- •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
394 Section II / General Surgery
PANCREATIC CARCINOMA
What is it?
What are the associated risk factors?
What is the male to female ratio?
What is the African American to white ratio?
What is the average age?
What are the different types?
What percentage arise in the pancreatic head?
Why are most pancreatic cancers in the tail nonresectable?
What are the signs/ symptoms of tumors based on location:
Head of the pancreas?
Adenocarcinoma of the pancreas arising from duct cells
Smoking 3 risk, diabetes mellitus, heavy alcohol use, chronic pancreatitis, diet high in fried meats, previous gastrectomy
3:2
2:1
60 years
80% are duct cell adenocarcinomas; other types include cystadenocarcinoma and acinar cell carcinoma
66% arise in the pancreatic head; 33% arise in the body and tail
These tumors grow without symptoms until it is too late and they have already spread— head of the pancreas tumors draw attention earlier because of biliary obstruction
Painless jaundice from obstruction of common bile duct; weight loss; abdominal pain; back pain; weakness; pruritus from bile salts in skin; anorexia; Courvoisier’s sign; acholic stools; dark urine; diabetes
Body or tail? |
Weight loss and pain (90%); migratory |
|
|
thrombophlebitis (10%); jaundice |
|
|
( 10%); nausea and vomiting; fatigue |
|
What are the most common |
1. |
Weight loss (90%) |
symptoms of cancer of the |
2. |
Pain (75%) |
pancreatic HEAD? |
3. |
Jaundice (70%) |
|
Chapter 55 / Pancreas 395 |
What is “Courvoisier’s sign”? |
Palpable, nontender, distended gallbladder |
What percentage of patients |
33% |
with cancers of the pancreatic |
|
HEAD have Courvoisier’s |
|
sign? |
|
What is the classic |
Painless jaundice |
presentation of pancreatic |
|
cancer in the head of the |
|
pancreas? |
|
What metastatic lymph nodes described classically for gastric cancer can be found with metastatic pancreatic cancer?
Virchow’s node; Sister Mary Joseph’s nodule
What are the associated lab |
Increased direct bilirubin and alkaline |
findings? |
phosphatase (as a result of biliary |
|
obstruction) |
|
Increased LFTs |
|
Elevated pancreatic tumor markers |
Which tumor markers are |
CA-19-9 |
associated with pancreatic |
|
cancer? |
|
What does CA-19-9 stand for?
What diagnostic studies are performed?
What are the pancreatic cancer STAGES:
Stage I?
Stage II?
Carbohydrate Antigen 19-9
Abdominal CT, U/S, cholangiography (ERCP to rule out choledocholithiasis and cell brushings), endoscopic U/S with biopsy
Tumor is limited to pancreas, with no nodes or metastases
Tumor extends into bile duct, peripancreatic tissues, or duodenum; there are no nodes or metastases
Stage III? |
Same findings as stage II plus positive |
|
nodes or celiac or SMA involvement |
396 Section II / General Surgery |
|
Stage IVA? |
Tumor extends to stomach, colon, spleen, |
|
or major vessels, with any nodal status |
|
and no distant metastases |
Stage IVB? |
Distant metastases (any nodal status, |
|
any tumor size) are found |
What is the treatment based |
|
on location: |
|
Head of the pancreas? |
Whipple procedure |
|
(pancreaticoduodenectomy) |
Body or tail? |
Distal resection |
What factors signify |
Vascular encasement (SMA, hepatic artery) |
inoperability? |
Liver metastasis |
|
Peritoneal implants |
|
Distant lymph node metastasis |
|
(periaortic/celiac nodes) |
|
Distant metastasis |
|
Malignant ascites |
Is portal vein or SMV |
No—can be resected and reconstructed |
involvement an absolute |
with vein interposition graft at some |
contraindication for |
centers |
resection? |
|
Should patients undergo |
No (exceptions for symptoms/ |
preoperative biliary |
preoperative XRT, trials, etc.) |
drainage (e.g., ERCP)? |
|
Define the |
Cholecystectomy |
Whipple procedure |
Truncal vagotomy |
(pancreaticoduodenectomy). |
Antrectomy |
|
Pancreaticoduodenectomy—removal of |
|
head of pancreas and duodenum |
|
Choledochojejunostomy—anastomosis of |
|
common bile duct to jejunum |
|
Pancreaticojejunostomy—anastomosis of |
|
distal pancreas remnant to jejunum |
|
Gastrojejunostomy—anastomosis of |
|
stomach to jejunum |
What is the complication rate |
25% |
after a Whipple procedure? |
|
What mortality rate is associated with a Whipple procedure?
What is the “pyloruspreserving Whipple”?
What are the possible post-Whipple complications?
Chapter 55 / Pancreas 397
5% at busy centers
No antrectomy; anastomose duodenum to jejunum
Delayed gastric emptying (if antrectomy is performed); anastomotic leak (from the bile duct or pancreatic anastomosis), causing pancreatic/biliary fistula; wound infection; postgastrectomy syndromes; sepsis; pancreatitis
Why must the duodenum be removed if the head of the pancreas is resected?
What is the postoperative adjuvant therapy?
What is the palliative treatment if the tumor is inoperable and biliary obstruction is present?
They share the same blood supply
Chemotherapy /– XRT
PTC or ERCP and placement of stent across obstruction
What is the prognosis at 1 year after diagnosis?
What is the survival rate at 5 years after resection?
MISCELLANEOUS
Dismal; 90% of patients die within 1 year of diagnosis
20%
What is an annular |
Pancreas encircling the duodenum; if |
pancreas? |
obstruction is present, bypass, do not |
|
resect |
What is pancreatic divisum? |
Failure of the two pancreatic ducts to |
|
fuse; the normally small duct (Small |
|
Santorini) of Santorini acts as the main |
|
duct in pancreatic divisum (Think: the |
|
two pancreatic ducts are Divided |
|
Divisum) |
398 Section II / General Surgery |
|
What is heterotopic |
Heterotopic pancreatic tissue usually |
pancreatic tissue? |
found in the stomach, intestine, |
|
duodenum |
What is a Puestow |
Longitudinal filleting of the pancreas/ |
procedure? |
pancreatic duct with a side-to-side |
|
anastomosis with the small bowel |
What medication decreases |
Somatostatin (GI-inhibitory hormone) |
output from a pancreatic |
|
fistula? |
|
Which has a longer half-life: |
Lipase; therefore, amylase may be normal |
amylase or lipase? |
and lipase will remain elevated longer |
What is the WDHA syndrome? |
Pancreatic VIPoma (Vasoactive Intestinal |
|
Polypeptide tumor) |
|
Also known as Verner-Morrison syndrome |
|
Tumor secretes VIP, which causes: |
|
Watery |
|
Diarrhea |
|
Hypokalemia |
|
Achlorhydria (inhibits gastric acid |
|
secretion) |
What is the Whipple triad of pancreatic insulinoma?
1.Hypoglycemia (Glc 50)
2.Symptoms of hypoglycemia: mental status changes/vasomotor instability
3.Relief of symptoms with administration of glucose
What is the most common |
Insulinoma |
|
islet cell tumor? |
|
|
What pancreatic tumor is |
Somatostatinoma (inhibits gallbladder |
|
associated with gallstone |
contraction) |
|
formation? |
|
|
What is the triad found with |
1. |
Gallstones |
pancreatic somatostatinoma |
2. |
Diabetes |
tumor? |
3. |
Steatorrhea |
What are the two classic |
1. |
Diabetes |
findings with pancreatic |
2. |
Dermatitis/rash (necrotizing migratory |
glucagonoma tumors? |
|
erythema) |