- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
390 Section II / General Surgery |
|
Grey Turner’s sign |
Ecchymosis or discoloration of the |
|
flank in patients with retroperitoneal |
|
hemorrhage from dissecting blood from |
|
the retroperitoneum (Think: Grey |
|
TURNer TURN side to side flank |
|
[side] hematoma) |
Fox’s sign |
Ecchymosis of the inguinal ligament |
|
from blood tracking from the |
|
retroperitoneum and collecting at the |
|
inguinal ligament |
What are the significant lab |
Increased amylase/lipase |
values? |
Decreased Hct |
|
Decreased calcium levels |
What radiologic test should |
CT scan with IV contrast |
be performed? |
|
PANCREATIC ABSCESS |
|
|
|
What is it? |
Infected peripancreatic purulent fluid |
|
collection |
What are the signs/ |
Fever, unresolving pancreatitis, epigastric |
symptoms? |
mass |
What radiographic tests |
Abdominal CT with needle aspiration S |
should be performed? |
send for Gram stain/culture |
What are the associated lab |
Positive Gram stain and culture of |
findings? |
bacteria |
Which organisms are found |
Gram negative (most common): |
in pancreatic abscesses? |
Escherichia coli, Pseudomonas, |
|
Klebsiella |
|
Gram positive: Staphylococcus aureus, |
|
Candida |
What is the treatment? |
Antibiotics and percutaneous drain |
|
placement or operative débridement |
|
and placement of drains |
|
Chapter 55 / Pancreas 391 |
PANCREATIC NECROSIS |
|
|
|
What is it? |
Dead pancreatic tissue, usually following |
|
acute pancreatitis |
How is the diagnosis made? |
Abdominal CT with IV contrast; dead |
|
pancreatic tissue does not take up IV |
|
contrast and is not enhanced on CT scan |
|
(i.e., doesn’t “light up”) |
What is the treatment: |
|
|
Sterile? |
Medical management |
|
Suspicious of infection? |
CT-guided FNA |
|
Toxic, hypotensive? |
Operative débridement |
|
PANCREATIC PSEUDOCYST |
|
|
What is it? |
Encapsulated collection of pancreatic |
|
|
fluid |
|
|
Non-communicating |
|
|
pseudocyst |
|
|
|
‘07 |
|
f |
|
|
hr |
|
Communicating
pseudocyst
What makes it a “pseudo” cyst?
What is the incidence?
What are the associated risk factors?
What is the most common cause of pancreatic pseudocyst in the United States?
Wall is formed by inflammatory fibrosis, NOT epithelial cell lining
1 in 10 after alcoholic pancreatitis
Acute pancreatitis chronic pancreatitis from alcohol
Chronic alcoholic pancreatitis
392 Section II / General Surgery
What are the symptoms?
What are the signs?
What lab tests should be performed?
What are the diagnostic findings?
What is the differential diagnosis of a pseudocyst?
What are the possible complications of a pancreatic pseudocyst?
What is the treatment?
What is the waiting period before a pseudocyst should be drained?
What percentage of pseudocysts resolve spontaneously?
What is the treatment for pseudocyst with bleeding into cyst?
Epigastric pain/mass Emesis
Mild fever Weight loss
Note: Should be suspected when a patient with acute pancreatitis fails to resolve pain
Palpable epigastric mass, tender epigastrium, ileus
Amylase/lipase
Bilirubin
CBC
Lab—High amylase, leukocytosis, high bilirubin (if there is obstruction)
U/S—Fluid-filled mass CT—Fluid-filled mass, good for showing
multiple cysts ERCP—Radiopaque contrast material
fills cyst if there is a communicating pseudocyst (i.e., pancreatic duct communicates with pseudocyst)
Cystadenocarcinoma, cystadenoma
Infection, bleeding into the cyst, fistula, pancreatic ascites, gastric outlet obstruction, SBO, biliary obstruction
Drainage of the cyst or observation
It takes 6 weeks for pseudocyst walls to “mature” or become firm enough to hold sutures and most will resolve in this period of time if they are going to
50%
Angiogram amd embolization
|
Chapter 55 / Pancreas 393 |
What is the treatment for |
Percutaneous external drainage/ |
pseudocyst with infection? |
IV antibiotics |
What size pseudocyst should |
Most experts say: |
be drained? |
Pseudocysts larger than 5 cm have a |
|
small chance of resolving and have |
|
a higher chance of complications |
|
Calcified cyst wall |
|
Thick cyst wall |
What are three treatment options for pancreatic pseudocyst?
What are the surgical options for the following conditions:
Pseudocyst adherent to the stomach?
Pseudocyst adherent to the duodenum?
Pseudocyst not adherent to the stomach or duodenum?
Pseudocyst in the tail of the pancreas?
What is an endoscopic option for drainage of a pseudocyst?
1.Percutaneous aspiration/drain
2.Operative drainage
3.Transpapillary stent via ERCP (pseudocyst must communicate with pancreatic duct)
Cystogastrostomy (drain into the stomach)
Cystoduodenostomy (drain into the duodenum)
Roux-en-Y cystojejunostomy (drain into the Roux limb of the jejunum)
Resection of the pancreatic tail with the pseudocyst
Endoscopic cystogastrostomy
What must be done during a Biopsy of the cyst wall to rule out a cystic surgical drainage procedure carcinoma (e.g., cystadenocarcinoma) for a pancreatic pseudocyst?
What is the most common Massive hemorrhage into the pseudocyst cause of death due to
pancreatic pseudocyst?