< itI-Ii, Ii,a o 6ol,aipe pyccl,x >
2001 Kapan Med|ca (800) 533-B850 ў)r (949) 476-6282
GENERAL
SURGERY
KAPLAN

Table of Contents
General Surgery
I. Head and Neck Surgery
A. Oral Cavity Malignancies ............................................................................................................................ ]
B. Oropharynx ................................................................................................................................................ 5
C. Carcinoma of the ear pinna ........................................................................................................................ 7
D. Nasal cavity/paranasal sinuses ................................................................................................................... 7
E. Nasopharynx .............................................................................................................................................. 7
F. Oropharyngeal abscess ............................................................................................................................... 7
G. Foreign Bodies in Larynx and Esophagus ................................................................................................... /3
H. Cancers of the Neck .................................................................................................................................. /3
II. Cardiothoracic Surgery
A. Coronary Artery Bypass Grafting .............................................................................................................. 13
B. Coronary Angioplasty ............................................................................................................................... 13
C. Carotid Artery Disease .............................................................................................................................. 13
D. Disorders of the Pleura and Pleural Space ................................................................................................ 14
E. Bronchogenic Carcinoma ......................................................................................................................... 15
III. Gastrointestinal Surgery
A. Stomach ..................................................................................................................................................... 19
B. Duodenum ............................................................................................................................................... 23
C. Chronic Duodenal Ulcer .......................................................................................................................... 24
D. Upper GI Bleeding ................................................................................................................................... 26
IV. Small Intestine and Appendix
A. Meckel's Diverticulum ............................................................................................................................. 27
B. Malignant Tumors of the Small Intestine, Adenocarcinoma ...................................................................... 27
C. Mesenteric Vascular Insufficiency ............................................................................................................. 28
D. Small Intestine Obstruction ...................................................................................................................... 29
E. Acute Organic Small Intestinal Obstruction .............................................................................................. 30
F. Appendicitis .............................................................................................................................................. 31
G. Carcinoid ................................................................................................................................................. 33
H. Small bowel fistula .................................................................................................................................. 33
I. Short gut syndrome .................................................................................................................................... 33
V. Colon and Rectum
A. Polyps and Carcinoma ............................................................................................................................ 34
225813.0000260

Table of Contents - -
B. Ischemic Colitis ......................................................................................................................................... 34
C. Volvulus ................................................................................................................................................... 35
D. Rectal Prolapse ......................................................................................................................................... 36
E. Diverticular Disease .................................................................................................................................. 36
I=. Fistula-ln-Ano ............................................................................................................................................ 39
G. Cancer of the Colon and Rectum ............................................................................................................. 39
VI. General Abdominal Disorders
A. Peritonitis ................................................................................................................................................. 43
B. Intra-abdominal Abscess ........................................................................................................................... 43
C. Hernia ....................................................................................................................................................... 44
VII. Nutrition
A. Hyperalimentation ................................................................................................................................... 45
B. Nutritional Needs ..................................................................................................................................... 45
C. Parenteral Nutrition .................................................................................................................................. 47
VIII. Hepato-biliary Tract
A. Serum Markers of Hepatobiliary Disease ..................................................................................................
B. Cholecystitis/Biliary Colic ......................................................................................................................... 50
C. Obstructive Jaundice ................................................................................................................................ 51
D. Cholelithiasis ........................................................................................................................................... 54
E. Choledocholithiasis .................................................................................................................................. 54
F. Primary Sclerosing Cholangitis .................................................................................................................. 55
G. Recurrent Variceal Bleeding ..................................................................................................................... 56
H. Carcinoma of the extra-hepatic bi]iary tract ............................................................................................. 59
I. Hepatic encephalopathy ............................................................................................................................. 60
]. Primary hepatocellu]ar carcinoma ............................................................................................................. 60
K. Benign tumors of the liver ......................................................................................................................... 60
I_. Complications of liver resection ................................................................................................................ 61
M. Hepatic abscess ........................................................................................................................................ 61
IX. Pancreas
A. Physiology ................................................................................................................................................ 62
B. Pancreatitis ............................................................................................................................................... 62
C. Cysts and pseudocysts .............................................................................................................................. 65
D. Pancreatic Neoplasms .............................................................................................................................. 66
E. Pancreas divisum: failed fusion ..................................................... .. ........................................................... 67
F. Annular pancreas ...................................................................................................................................... 67
G. Islet Cell Tumors ...................................................................................................................................... 67

• Table of Contents  _
X. Breast
A. Benign Breast Masses ............................................................................................................................... 68
13. Breast Cancer ............................................................................................................................................ 68
XI. Adrenal Mass ...................................................................................................... 71
XII. Vascular Surgery
A. Venous Stasis Ulcers .................................................................................................................................. 72
B. Varicose Veins .......................................................................................................................................... 72
C. Deep veto thrombosis .............................................................................................................................. 73
D. Diseases of the Aorta ............................................................................................................................... 73
E. Chronic Arterial Insufficiency .................................................................................................................... 75
F. Acute Mesenteric Ischemia ........................................................................................................................ 76
X|II. Urology
A. Prostatic Carcinoma ................................................................................................................................. 78
B. Testicular Carcinoma ................................................................................................................................. 79
C. Fenal Cell Carcinoma .............................................................................................................................. B0
D. Pyelography .............................................................................................................................................. 82
E. Trans-urethral Iesection of the Prostate .................................................................................................... 82
F. Bladder cancer .......................................................................................................................................... 83
XIV. Pediatric Surgery
A. Congenital Diaphragmatic Hernia ............................................................................................................. 84
B. Congemtal Heart Disease ......................................................................................................................... 85
C. Tracheoesophageal (TE) Fistula ................................................................................................................. /38
D. Neonatal intestinal obstruction ................................................................................................................ 89
E. Duodenal Obstruction .............................................................................................................................. 90
F. Malrotation ...........................  ...................................................................................................................
G. Jejunoileal atresia ................. i ................................................................................................................... 90
H. Meconium Ileus .................. .. .................................................................................................................... 91
I. Gastrointestinal duplication ....................................................................................................................... 91
J. Hirschsprung's Disease .............................................................................................................................. 91
K. Necrotizing Enterocolitis .......................................................................................................................... 92
L. Mecomum plug syndrome ........................................................................................................................ 92
M. Colon atresia ............................................................................................................................................ 92
N. Omphalocele ........................................................................................................................................... 93
O. Gastroschisis ............................................................................................................................................ 93
P._ .Pyloric Stenosis ......................................................................................................................................... 93
Q. Intussusception ........................................................................................................................................ 94

Table of Contents o
R. Choledochal Cyst ..................................................................................................................................... 94
S. Atresia of the bile ducts ............................................................................................................................. 95
XV. Wounds
A. Stages ........................................................................................................................................................ 96
B. Classifications ............................................................................................................................................ 96
C. Factors Affecting Wound Healing ............................................................................................................. 96
19. Wound Care ............................................................................................................................................. 96
XVI. Infection
A. Etiology ...................................................................................................................................................... 97
B. Classifications According to Degree of Infection ...................................................................................... 97
C. Nanaement .............................................................................................................................................. 97

General Surgery
I. Head and Neck Surgery
A. Oral Cavlty Mahgnances
1. General Considerations
a. Etiology
1) Pipe smoking or snuff-dipping
2) Poor dental care or poorly-fitted dental plates
3) Syphilis
4) Leukoplakia (premalignant, should perform biopsy)
5) Related to tobacco and alcohol use
Synergistic and dose-dependent
6) Male predominance
b. Signs and symptoms
1) Chronic inflammation
2) Loose teeth
3) Impairment of speech
4) Difficulty in chewing
5) Difficulty in swallowing
6) Bleeding
7) Weight loss secondary to change in diet
c. Diagnosis
1) X-ray (mandibular)
2) Biopsy
a) Fine-needle asprauon
b) Excisional biopsy
3) Consider Panendoscopy
a) Bronchoscopy
b) Esophagoscopy
c) Laryngoscopy
4) With time, 15% develop second primary tumors in the same region
d. Histology
1) Mostly epidermoid
2) Minor salivary gland carcinomas - second most common
3) Sarcomas, lymphomas, melanomas - rare
4) Treatment - surgery and/or irradiation alone
.c...;::...::::::::::s:.:::.:-: ::..-.:.::: :::.?:,:...:..:..:.....-::-.:.;::.::.: .:;.:.:..::::::.:...,..-::::.:...:....-.::.:.-:--......::.:-. : :.< .-: .........
225813.0000260 3

General Surgery o Head and Neck Surgen/
2. Carcinoma of the tongue
a. Clinical findings
1) Usually squamons cell
2) Presents as ulcerating, infiltrating areas
3) 5-year survival 40%
4) 50% present with palpable ipsilateral cervical lymph node metastass
5) Chronic nonhealing ulcers considered premalignant change
6) If muscle invasion suspected MR/
7) Plummer-Vinson syndrome
a) Cervical dysphagia
b) Iron-deficiency
c) Atrophic oral mucosa
d) Brittle, spoon-shaped fingernails
b Treatment
!) Surgical excision
2) Radiation therapy for large tumors
3) Neck dissection - mandatory
4) If mandible is involved - partial mandibulectomy
3. Leukoplakia
a General Description
1) Literally a white patch of the oral mucus membrane
2) Occasionally is a sign of carcinoma and is seen in patients with AIDS
b Etiology
1) Most common causes
a) Epithelial hyperplasia
b) Hyperkeratosis
c) Usually in response to an irritant, i.e. dentures
2) Usually asymptomatic
3) The patient might feel a roughness in his or her mouth
c. Diagnosis.
1) Must be established only by histopathologxc examination
2) Cytologic smears and application of vital staining techniques
- a) Helpful in supplementing clinical information
b) Helpful in supplementing biopsy information
d. Treatment
1) If the leukoplakia is not reversible
Excision when feasible
2) Removal, using a CO 2 laser
Carcinonm of the buccal mucosa
a. Clinical findings
1) Squamons cell
2) Often preceded by leukoplalda
3) Usually slow-growing
4) Association with ingestion of tobacco and betel nuts
b. Treatment
1) Wide local excision
2) Through-and-through reseclaon
4 225813.000260.

General Surgery • Head and Neck Surgery  -
5. Cancer of the lips
a. Chmcal findings
I) On lower lip, malignant lesion usually squamous cell
2) Metastasis to regional lymph nodes in 10% of cases (in lower lip)
3) Upper lip has higher incidence of basal cell carcinoma when compared with lower lip
4) More common in light-skinned people
5) Most arise at skin
Vermilion border junction
6) Increased risk
a) Sunlight
b) Tobacco (pipe)
c) Syphilis
7) Increased risk of metastasis if lesion is greater than 2 cm
b. Treatment
1) Wide local removal, V-excision
2) If large or node positive, recurrent and bilateral:
Modified radical neck dissection
6. Carclnoma of floor of the mouth
a. Symptoms
1) Pain and swelling of tongue
2) Difficulty eating and spealdng
b. Clinical findings
1) Usually squamous cell
2) Most common in anterior floor of mouth
3) Metastasis first to submandibular nodes
c. Treatment
1) Resection of both mandibular rami
2) Small tumor
Surgery versus radiation alone
3) Large tumor
) Combined therapy
b) Radical neck dissection
(i) If crosses midline
(ii) If contralateral nodes involved
7. Ginval (alveolar) carcinoma
a. Symptoms
1) Tenderness in gums
2) Sometimes loosening of teeth appears
b. Clinical findings: Squamous cell
c. Treatment
1) Resection of involved mandible and overlying gum
2) Radical neck dissection
B. Oropharynx
1. General Considerations
a. Soft palate, pharyngeal wall. posterior one third of tongue
b. 5-year survival--20-30% (vs. 40% for tongue)
2258]3.0000260 

General Surgery • Head and Neck Surgery
-c. Etiology
1) Combined tobacco and alcohol consumption
2) Malnumtion
•
3) Immune defects
4) More common in males
5) Sixth decad
d. Signs and symptoms
1) Persistent sore throat
2) Cervical adenopathy
e. Diagnosis
1) Observation and palpation of tonsils and base of tongue; note..uvula
2) Panendoscopy
3) Often made after tumor metastasizes
4) If primary tumor not idenufied--biopsy neck mass
2. Tonsillm" carcinoma
a. Most common oropharyngeal tumor
b. Second only to laryngeal carcinoma of malignancies of the upper respiratory tract
l) Associated with alcohol/tobacco use
2) High frequency of cervical lymph node metastases
c. Symptoms
l) Sore throat (most common)
2) Tenderness
3) Neck mass
4) Otalgia (pain radiates to ear on same side)
d. Biopsy findings
l) Epidermoid
a) Less differentiated
b) Increased risk of early metastasis
2) Lymphosarcoma
e. Treatment
1) Radiation both pre- and postoperatively
2) Surgery
a) Resect tonsillar fossa
b) Hemimandibulectomy
c) Ipsilaceral radical neck dissection
If palpable neck metastases
3. Salivary gland cltrinoma
a. Major glands
1) Parotid-largest
2) Submaxillary-sialadenitis vs. lymphadenopathy
3) Sublingnal-floor of mouth
b. Clinical findings
1) Most common site of neoplasms is parotid gland
2) Pleomorphic adenoma (mixed tumor) usually found in superficial lobe of parotid gland
3) Often small outpouchings or satellite nodules present
4) Slow growing
5) Tumors are.muco-epidermoidal
6) 5% of all head/neck tumors
7) 70% of salivary gland tumors are parotid in origin, of these, 70% are benign
8) 60% submandibular tumors are malignant
225813.0000260.

General Surgery • I-lead and Neck Surgery
9) Parofid
a) Slow-growing
b) Pleomorphic
c) Including Warthin's tumor (papillary cystadenoma lymphomatosum)
d) Oncocytoma
e) If facial nerve involved, malignant
10) Tumors of minor salivary glands
a) Usually in palate
b) 75% malignant
C. Carcinoma of the ear pinna
1. Excessive sun exposure
2. Squamous cell/basal cell
3. Early lesions - surgery/irradiation
4. Invasion of cartilage - wedge excision
D. Nasal cavity/paranasal sinuses
• 1% of all malignancy
• 3:1 male:female predominance
• 50% epidermoid carcinomas; 20% minor salivary gland origin; 10% lymphomas: 20% sarcomas.
1. Presentation
a. Facial pain, nasal obstruction, persistent nasal discharge.
b. Maxillary antrum: most common location for paranasal cancer.
c. Ethmoid sinuses: most common sinus location.
2. Treatment
a. Epidermoid, carcinoma/minor salivary gland tumor
1) Maxillary antrum (ethmoid sinuses)
a) Surgical excision; consider radical neck -- palpable nodes
b) Radiation therapy: locally aggressive (bulky) tumors
2) Frontal and sphenoid sinuses
a) Radiotherapy (difficult location)
•
b) Lymphoma -- radiotherapy (only)
E. Nasopharynx
1. Squamous cancer; adenocarcinoma (minor salivary gland origin); lymphoma; melanoma.
2. Children: lymphoma
3. Adults: squmnous eel/
4. Epstein-Barr V'n'us: 50% of squamous cell carcinomas
5. Best treated with radiation.
6. Overall 5-year survival = 35%.
E Oropharynge! abscess
I. Peritonsillar _.10 years old.
• Antibiotics; surgery > 24 hours.
2. Retropharyngeal < 10 years old
• Lymphadenifis/pharyngitis
• Antibiotics; surgical drainage
3. Pharyngeal abscess
• Drainage through oropharynx; dangerous
• Drainage through lateral neck.
225813.0000260 7

General Surgery • Head and Neck Surgery
G. Foreign Bodies in Larynx and Esophagus
1. Larynx
• Care-coronary
• Heimlich maneuvez
• Infectious complications
• Retrieval via tracheal-bronchial endoscopy
2. Esophagus
• 95% immediately below cncopharyngeus
• Perforation (immediate vs. delayed)
• Diagnosis
• Endoscopic retrieval
3 Acute suppurative parotitis
• Can be severely life-threatening
• Dehydration, elderly or debilitated, poor oral hygiene
• Staphylococcus aureus
• IV antibiotics/hydration
• If unsuccessful, surgical drainage
H. Cancers of the Neck
1. Diagnosis
a. Chest x-ray
b. Panendoscopy
c. Biopsy
2. Euology
a. Metastatic adenocarclnoraa
b. Thyroid carcinoma
c. Breast, testis, lung, kidney, prostate, intra-abdominal origin
225813.0000260.

General Surgery • Head and Neck Surgery  _
Treatment
a. Radical
l) Removal of the following
a) Sternocleidal-mastoid
b) Internal jugular
c) Spinal accessory nerve
2) Treatment for squamous cell carcinoma with unknown 1 ° cancer
b. Modified radical
1) Removal of cervical lymphatics
2) Postoperative radiation
For node smaller than 3 cm
3) Spare sternocleidomastoid muscle
4) Spare spinal accessory nerve
5) May or may not spare internal jugular vein
Thyroid Gland
A Blood supply: artery
• Paired superior thyroid arteries: arising from external carotid
• Paired inferior thyroid arteries: arising from the thyro-cervical taut&.
• Thyroideaima artery: inconstant, arises from aortic arch
B. Venous Draining
• Super and middle thyroid veins: drains into internal jugular vein
• Inferior thyroid veins: drains into the innominate vein
C. Nerve Supply
• Innervation via sympathcuc (cervical ganglion); parasympathetic (Vagus via laryngeal nerves)
• Superior laryngeal nerve provides both sensory and motor functions to larynx.
• External branch innervates cricothyroid muscle: injury results in voice fatigue.
• Recurrent laryngeal nerve:
• Provides motor funcuon to the intfinslc laryngeal muscles
• Unilateral injury --) paralysis of vocal cords
• Bilateral injury --) severe airflow obstruction often necessitates traeheostomy
2251313.000020 9

< ZHMIa o 6olaDe pcczx >
General Surgery • Head and Neck Surgery
D. Hormonal Physiology
• Regulation of energy substrate metabolism
• Thyrotropin: releasing TRH from hypothalamus which regulates thyroid stimulating hormone
(TRH) release from anterior pituitary
• TSH release from anterior pituitary starnulates thyroid gland
• T4/T3 is responsible for end-organ effects
E. Thyroid Scan
• Technetium 99m pertechnetate, radioactive iodine
• Assess function of nodules within thyroid gland
• Identify ectopic thyroid tissue, distant metastases.
F. Ultrasonography
• Provides thyroid anatomic information as well as information on the solid or cystic nature of thyroid
nodules.
G. Fine Needle Aspiration
" Evaluation of thyroid nodules
• Determine need for operation
• May be used to treat cystic nodules
Hyperthyroidism
A. Causes
1. Graves' disease
2. Toxic multinodular goiter
3. Toxic adenoma
B. Treatment
1. Antithyroid drugs
2. Radioiodine ablation
3. Subtotal thyroidectomy
Thyroiditis
• Acute suppurative thyroiditis: acute illness, often bacterial origin
• Subacute (de Quervain's) thyroiditis: possibly viral origin
A Hashimoto disease: most common form, autoimmune, increase incidence of papillary carcinoma.
B. Riedel's thyroiditis may be assoc,ated with retroperitoneal fibrosis; frequently results in hypothyroidism;
operauon may be necessary to relieve tracheoesophageal obstruction.
lO 22581 ].0000260.

General Surgery • Head and Neck Surgery  _
Cancer of the Thyroid Gland
A. Medullary
• May be sporadic or familial
• Intermediate prognosis
• Associated with MEN Type I]
• Prognosis depends on nodal and disnt site mcstases - total thyroidectomy, plasma calcitonin level
--> diagnosis.
B. Papillary
• Best prognosis propensity for local or regional recurrence
• Survival  90%, subcoml thyrodectomy
C. Follicular
• Favorable prognosis, propensity for blood-borne distant metastases
• Total thyroidectomy: very responsive to radioiodine therapy
D. Anaplastic Carcinoma
• Extremely rapid growing
• Uniformly fatal
• Associated with tracheoesophageal obstrucuon
• Palliative surgery, radiotherapy, chemotherapy
E. Lymphoma
• Inmrmediate prognosis
• Regional radiation therapy, sysmmic chemotherapy
• May be cured by surgery alone (total thyroidectomy)
E PmthTroid GInds
• Parathyroid hormone is the principal mediator of calcmm homeostasis
• PTA: direct effects on bones and kidneys (reabsorption of filtered calcium, stimulates renal vitamin
D synthesis), indirect effect on the GI tract (increase absorption of dietary calcium).
G. Hyperparathyroidism: primary, secondary, tertiary
I. Diagnosis
• Increase parathyroid hormone
• Increase serum calcium (> 11 mg/dl)
• 80%: single adenoma
• 20%: multigiandular hyperplasia
• X-rays (sub-periosteal base resorption, bone cysts)
• Ultrasonography/CT scan
• Technetium: thallium scan
• Angiography/selective venous sampling
2. Cause of hypercalcemia: Vitamin D intoxication: milk-alkuli syndrome, multiple myeloma, metastatic
carcinoma, hyperthyroidism sarcoidosis.
3. Diseases associated with hyperthyroidism
• Hypertension, peptic ulcer disease, pancreatitls
• Pheochromocytoma (MEN Type H)
225813.00002f} 11

 General Surgery • Head and Neck Surgery
4. Treatment
° Single adenoma: excision of adenoma, biopsy of single normal gland
° Multiglandular hyperplasia: excision of three glands, partial excision of remamng fourth gland.
H. Esophagus
1. Gastroesophageai reflux: Evaluation
• 24-hour pH monitoring (most sensitive test)
° Barium swallow, esophagoscopy, acid perfusion (Bemstein) test, manometry
• Often associated with hiatal hernia
a. Complications: anemm, aspiration, Barrett's esophagus motility disturbance, lower esophageal
(Schatzki) ring, stricture, shortening
b. Hernia: Type I (Sliding)
• Symptoms of gastroesophageal reflux
• Cardia enters chest with G-E juncuon
• Presents in most patients with reflux
• Surgical repair if patient symptomatic (Nissen. Belsey, Hill)
2. Paraesophageal: Type II
• Presents as occult GI bleeding, or gastric volvulus
• Defect in phrenoesophageal membrane
• GE junction remains below the diaphragm
• Surgical repair mandatory
3. Esophageal Carcinoma:
a. Epidermoid cell cancer
° 2.5-140/100,000 patients males: highest in areas of Asia
• Risk factors: tobacco, alcohol
• Associated with achalasia corrosive esophageal stricture, celiac disease
• Higher incidence m black males in the U.S.
b. Adenocarcinoma
• Distal esophagus
• Barrett's esophagus: risk factor
• Colunmar epithelial junction; may be extension of gastric adenocarcinoma
• Higher incidence in white males in U.S.
4. Esophageal Diverticulum
a. Zenker's diverticulum: proximal esophagus
• Incomplete relaxation, discoordination or incomplete cricopharyngeal relaxation, halitosis
• ltl licd}thagia
• A pseudodiverticulum
• Treatment: excision, cricopharyngeal myotomy
b. Traction diverticulum
• Midesophagus, true chverticulum
• Caused by inflammation in adjacent mediasunal lymphnodule (tuberculosis, sarcoidosis)
• Treat underlying disease
c. Epphrenic diverticulum
• False diverticulum
• Operation if large, myotomy mandatory
5. Borhooeve's syndrome
• Perforation of distal esophagus
• 2 ° to violent vomiting
• Left-sided chest pain/effusion
• < 24 hours: thoacotomy, but stressed repair of esophagus, wide drainage of pleural cavity.
• > 24 hours: thoracotomy, esophageal exclusion, drainage of pleural cavity.
• Neck esophagostomy, gastostomy, feeding jejunostomy
12 225813.0000260.

< IHMIa o 5oDae pzcclt4x >
General Surgery • Cardiothoracic Surgery (2) -
II. Cardiothoracic Surgery
A. Coronary Artery Bypass Grafting
1. May significantly reduce angina but may not prolong life
2. Indications
a. Left main coronary occlusion of > 50%
b. Tkree-vessўl disease with occlusive lesions of > 66%
c. Left main equivalent (left anterior descending and circumflex) occlusive lesions near origin of > 66%
d. Left anterior descending disease which is technically not amenable to angioplasty
3. Other relevant criteria may be
a. Intractability to maximum medical treatment
b. Unstable angina
c. Patients needing other intracardiac surgery
4. Technique
a. Best choices
I) Left antcnor descending
Use internal thoracic arteries
2) Circumflex
Use internal thoracic ancnes
b. Right coronary artery
Use saphcnous vein grafts
c. Other vessels in patients nccding more than three grafts
Use saphcnous vein grafts
Results
a. Relief from angina
b. Increase in exercise tolerance
B Coronary Angioplasty
1. Indications
a. Proximal vessel disease in a single vessel
b. Stenosis in saphenous vein coronary artery bypass grafting
c. Selected multi-vessel disease
d. After acute MI (if angiogram indicates need) with 3 hours of infarction
2. Results
a. Relief of angina
b. Restenosis of 30% of cases in 3 years
c. Intimal dissection requiring emergency coronary artery bypass grafting
C. Carotid Artery Disease
1. Pathophysiology
Most commonly due to atherosclerosis
2. Signs and Symptoms may be the following
a. Asymlatomatic bruit
b. Amaurosis fugax
c. Transient ischemic attacks
d. Stroke

< iCHiaa o 6oiampeM pTcczx >
General Surgery • Cardiothoracic Surgery
3. Funduscopic exam
May show cholesterol plaque embolus to retinal artery
Diagnostic studies
a. Doppler echo
May reveal approx,mate degree of stenosis
b. Carotid arteriography
1) Better definition of the degree of stenosis
2) Better definiuon of the degree of ulceration
c. Brain CT scan may reveal infarct(s)
Treatment
a. Carotid endarterectomy
I) If the patient is symptomatic, and the carotid occlusion is > 50%
2) If there is an ulcerated plaque
3) If pauent ts asymptomafic but occlumon > 80%
b. Platelet inhibitors
The treatment in all other cases
D. Disorders of the Pleura and Pleural Space
1. The inner surface of each hemithorax has a mesothelial lining, the parietal pleura, which is invaginated at
each pulmonary hilum to form the visceral pleura
2. Pleural effusions
a. Definition: accumulation of fluid in the pleural space
b. Common cause of transudative effusion
1) CHF
2) Nephrotic syndrome
3) Cirrhosis
4) Hypoproteinemia
5) Myxedema
6) Characteristics
a) Straw-colored
b) Odorless
c) Low protein, LDH
d) Glucose two thirds plasma
c. Common cause of exudative plcural effusion
1) Malignancy
2) Infection
3) Infarction
4) Traumatic
5) Collagen vascular disease
6) Associated with diseased pleura with increased permeability to proteins or decreased
lymphatic clearance
7) pH < 7.2 (7.64--normal)
8) Glucose generally < 60
9) Bloody pleural effusion
Malignancy 90%
d. Treatment
1) Malignant pleural effusion treatment is palliative
2) Tube thoracostomy and pleural drainage; pleurodesis
1 4 225813.0oo0260

3. Pleural empyema
< lHraa o,i 6oa=rpel DMCCl4X >
General Surgery • Cardiothoracic Surge  _
a. Definition:
Pus in the pleurai cavity 2 ° to pulmonary infection
b. Diagnosis
1) Thoracentesis
2) WBC > 15,000
3) Protein > 3 g/dL
4) Low pH < 7.2
5) WW glucose 40-60
6) LDH > 1000
c. Treatment
I) Early stage
Antibiotics
2) Later stage
Closed tube/catheter drainage with antibiotic wrigafion until drainage ceases completely
3) Unresponsive
Formal open drainage with rib resection
d. Complications
1) Empyema necessitans
2) Bronchopleural fistula
4. Pleural tumors-Mesothelioma
a. Definition
Neoplasm originating in the mesothdial lining of serosal cavities
b. Etiology
1) Related to asbestos exposure
a) Chrysotile
b) Amphibole
2) Localized
a) Usually benign
b) Visceral pleura
c). Asymptomatic
d) Bloody pleural effusion
3) Diffuse
a) Any pleural surface
b) Sixth or seventh decade
c) Males > females
d) Malignant
c. Symptoms
1) Chest pain, dysanea
2) On x-ray
a) Pleural thickening
b) Lung nodules
c) Mediasfinal masses
d. Treatment
l) Benign mesothelioma: resection is the treatment of choice
2) Malignant
a) Stage I and II, pleuropneumonectomy versus pleurectomy with radiation implants and/or
combination chemotherapy
b) Stage III and IV, radiation and chemotherapy

< IHMIa o @oiaiipeM pTVcczx >
 General Surgery • Cardiothoracic Surgery
E. Bronchiogenic Carcinoma
1. Etiology and incidence
a. Leading cause of death from cancer in the United States (men and women combined)
b. Patients usually older than 40 years
c. Smoking is No.1 risk factor
d. Chronic exposures to environmental carcinogens
1) Vinyl chloride
2) Benzene
3) Especially asbestos
2. Types
a. Adenocarcinoma
1) Most common of malignant lung cancers
2) Associated with smoking
3) Increasing incidence in females
4) May be in response to chronic irritation
5) Slow growth/quick metastasis
6) 30% potentially resectable at diagnosis
7) 20% advanced local disease at outset
8) 50% disseminated disease when first seen
b. Squamous cell carcinoma
1) Second most common
2) Associated with smoking
3) Obstructs bronchi
4) Slow growth/quick metastasis
5) Tends to be central in location, i.e. perihilar
c. Oat cell carcinoma
1) Highly malignant via lymphatic and vascular systems
2) Poor prognosis
3) Pan of neuroendocnne tumors, Le. paraneoplastc syndromes
4) Only 10% surgically resectable
5) Overall 5-year survival < 5%
6) Postoperative chemotherapy effective
7) Radiation therapy postoperatively if completely unresectable and for mediastinal disease
d. Undifferentiated large cell carcinoma
1) Rare
2) Highly malignant
3) Poor prognosis
3. Signs and symptoms
a. Usually asymptomatic. Most often diagnosed by nodule on chest x-ray done for other purpose
b. Pulmonary symptoms
1) Dyspnea
2) Coughing
3) Wheezing
4) Sputum production
c. Nonpulmonary symptoms
1) Weight loss, malaise, hone pain (suggestive of metastases)
2) Paraneoplastic syndromes due to substances released by the primary tumor; not metastases,
i.e. ectopic ACTH, SIADH, hypercalcemia
4. Diagnosis
a. Chest x-ray
1) Benign nodule--smooth borders
2) "popcorn calcifications"
1 6 225813.0000260.

General Surgery • Cardiothoracic Surgery  _.
b. CT scan
Mediastinal nodes
1) < 1 cm benign
2) > 1.5 cm more likely to be malignant do preoperauve mediasunal biopsies
c. Bronchoscopy--proximal tumors
d. Mediastinoscopy
e. Biopsy
Percutaneous needle biopsy for peripheral tumors under CT guidance
5. Treatment
a. Surgical
1) Resection of lung, involved nodes, and surrounding aras
2) Extent of resection determined by extent of diseases
a) Lobectomy
b) Pneumonectomy (requires careful pre-op pulmonary function tests)
c) Vedge resection (for peripheral lesions)
3) Negative bronchial and vascular margins

General Sursery • Cardiothoracic Sursery
b. Radiation therapy
Postoperative for mediastinal metasmss
c. Chemotherapy
1) Does not improve survival
2) May help control oat cell carcinoma
225813.0000260.

< iў.I-Ii, Ii,a  6ol,a,iipeI pccii, ix >
General Surgery • Gastrontesunal Surgery
III. Gastrointestinal Surgery
A. Stomach
I. GI Physiology--Acid Production
a Cephalic phase
Sight/smell of food sumulates vagus nerve to increase acid producuon by parietal cells in fundus
b. Gastric phase
Antral distention, vagal stimulation, and presence of proteins stimulate gastrin production by G cells
in prepylonc antrum
c. Intestinal phase
Proteins and distention of the small bowel (proximally) promote gastric acid secretion (mechanism
remains unclear)
d Gastric acid inhibition
I) Luminal pH decrease inhibits gastrin release (negative feedback)
2) Secretin produced in the duodenum inhibits gastric acid secretion
::.:.-. (::,:::'  .... ::-:: ..... -:..I I hi,inside factor-
' .............  : -Psmogen
.
* Mucus: reted by surface epieal ce, n ce of e gic ds and by Bnner's glands.
e. Gasc Secretion
- 1) Cephalic, gc, intesfin phmes
2) Petal cells: ceptors for elcholine, gn, sne
3)' Inalumin protein
4) Gasmc distension
. Duen zcifion dec gtn lee
- An acififion ўre somatt, deces acid lee
f. Stomach and Duenum
1) Blo supply; Five nes
. Lett gtc
- ght gc
" ght, d
" Left gmtepiplok, d
" Sho gasc
2) Gmc esophageal plament
" ght gmoepiploic
225813.0000260

< zHza o oape p:wK.x >
General Surgery • Gastrointestinal Surgery
Figure 1-1
Left gastric arlery  Short gastric arteries
Inferior pBcreiduodenI de
Figure 1-2
Posterior vagus nerve --. 
Posterior nerve
of latarjet
Crow's foot
2 0 225813.0000260.

< Ha  oae p:vcc. >
General Surgery • Gastrointestinal Surgery
2. Acute erosive gastritis
Most common cause of upper gastrointestinal bleeding
a. Pathogenesis
I) Acid secretion
2) Rate of back-diffusion of the H + ions (the gastric barrier)
3) Gastric mucosal blood flow
4) Mucous and alkaline secretion
5) Submucosal buffers
6) Multiple superficial erosions
7) Cushing's (stress) ulcers
8) Curling's (burn-related) ulcers
b. Diagnosis
l) Clinical hallmark
Painless upper gastrointestinal bleeding
2) Endoscopic visualization
3) Bleeding only when erosion into submucosa
4) Characterized by:
a) Hematemesis
b) Bloody nasogastric aspirate
c) Melena or anemia
5) Pain
a) Uncommon
b) A sign of a penetrating ulcer when present
c. Treatment
1) Volume replacement
2) Gastric lavage with room temperature solutions
a) Water
b) Saline
3) Gastric lavage decreases ongoing fibrinolysis
4) 80% stop bleeding with lavage
5) Stomach must be completely evacuated of its blood
6) Intragastric neutralization
a) Cimetidine
Not helpful once bleeding has occurred
b) Antacids
c) Drugs: sucralfate, omeprazole
7) If bleeding persists or recurs
a) Transendoscopic bipolar electrocautery
b) Laser photocoagulation
8) If bleeding is severe
a) Fluid replacement of more than 3000 mL
b) Operation--treatment of choice
9) Anterior gastrotomy or partial gastrectomy and vagotomy
10) Medical treatment
a) H 2 antagonists
b) Omeprazole-reduces H+/K + ATPase
11) Splanchnic vasopressin administration
d. Prophylaxis
1) Antacids to maintain pH > 5.5
2) Sucralfate-mucosal barrier.
3) H 2 antagonist--continuous infusion

General Surgery • Gastrointestinal Surgery
3. Gastric carcinoma
a. Etiology
The following are associations of gastric cancer
1) Diet
a) Smoked food
b) Salted food
c) Pickled food
d) Nitrosamines
2. Blood group A
3. Patients with atrophic gastritis, achlorhydria, and gastric polyps larger than 2 cm,
pernicious anemia
b. Incidence
l) More common in older males (mean age, 60 years)
2) Men two rimes more likely than women
3) Common in Japan, Central and South American Andes
4) Decreasing in United States since 1950s without explanation
c. Pathology
1) More than 90% are adenocarcinomas. Others are lymphoma, leiomyosarcoma, carcinoid
2) Commonly found in the greater curvature of the stomach toward cardia which is not to
imply that lesions elsewhere are benign
3) The size of the tumor is greater than 4 cm with irregular margins and necrotic centers
4) Linitis plastica---types
a) Diffuse infiltrative
b) Polypoid
c) Ulcerative
d) Infiltrative and ulcerative
e) Superficial spreading
d. Clinical Findings
1) Weight loss and anorexia
2) Early satiety
3) Epigastric pain and discomfort
4) Iron. deficiency anemia (two thirds of patients)
e. Diagnosis
1) Barium studies
2)- Endoscopy
3) Biopsy
4) Document healing of gastric ulcers
f Therapy
1) Surgery (only chance of cure)
2) Radiotherapy
3) Chemotherapy
a) 5-FU
b) Doxorubicin
c) Mitomycin
d) Can follow CEA
4) Good 5-year prognosis
a) If disease confined to the stomach
b) Unfortunately this represents the minority, therefore., the prognosis is poor
5) Overall: 10-15% five-year survival in North America
22 225813.0000260.

< Ha  oae p:vcc. >
General Surgery • Gastro,ntestinal Surgery
4. Gastric ulcer
a. Etiology and pathogenesis
1) Most have below/normal acid secretion
2) Occur in areas of gastritis
3) Mostly along lesser curvature near incisura angularis
4) Peak incidence fifth decade, men > women
5) Back diffusion of hydrogen ions: mucosal barrier breakdown
b. Signs and symptoms
1) Pain in epigastrium, radiaung rough the back
2) Pain produced by eating
3) Weight loss
c. Diagnosis
1) Upper GI series
2) Endoscopy
3) Should also perform biopsy because of risk of malignancy mimicking gastric ulcer
d. Treatment
1) Brief, intensive medical management can be tried first: if endoscopic follow-up fails to
document rapid healing, the lesion is presumed to be malignant
2) Gastric resection is described by the amount of stomach removed and the method of
reconstruction
a) Billroth 1
(i) For bemgn ulcer of the stomach
(ii) Gastric remnant is anastomosed to the duodenum, i.e. normal configuration
b) Billroth II -Resection for neoplasm usually followed by a gastrojejunostomy
3) Antrectomy (one third)
4) Hemigastrectomy (one half)
5) Partial gastrectomy (two thirds)
6) Subtotal gastrectomy (three fourths)
7) Total gastrectomy
8) Indications for surgery
a) Intractability of symptoms despite compliance with intensive management
b) Hemorrhage
c) Perforation-wedge excision with omental patch closure
d) Obstruction
e) Rule out carcinoma in a non-healing gastric ulcer
B. Duodenum
1. Pathology/epidemiology of duodenal ulcer
a. Mean basal and maximal acid outputs 1.5-2 times normal
b. Increased parietal cell mass
c. Peak in fourth decade
d. 95% occur in duodenal bulb, rest in postbulbar or pylonc channel region
e. Associated with acid hypersecretion particularly in the inter-digestive phase
2. Signs and symptoms of duodenal ulcer
a. Burning epigastrie pain, accentuated by fasting
b. Pain relieved by antacid or eating
c. Pain may radiate to back
3. Treatment of duodenal ulcer
a. Maintain acid pH > 5.5 so proteolytic enzyme precursor pepsinogen remains inactive
b. Early operation to close a perforation with an omental graft
225813.0000260 23

General Surgery • Gastrointestinal Surgery
c. Operations designed to remove factors stimulating the gasmc juice production. (Duodenal ulcers are
believed to result from the actions of acid and pepsin from gastric juice)
1) Vagotomy-truncal, selective, highly selective
2) Removal of gastric antrum, i.e. antrectomy
3) Heineke-Mikulicz pyloroplasty
Used as drainage procedure for a vagotomized stomach
4) Truncal vagotomy with antrectomy
Achieves lowest recurrence rate but at a higher operative risk than other procedures
5) Operations ablating the pylodc mechanism, whether by resection or pyloroplasty, may lead to the
dumping syndrome
a) Characteristics
(i) Faintness
(ii) Sweating
(iii) Palpations
(iv) Nausea coming on during or shortly after the ingestion of food
b) Cause is related to rapid passage (i.e. "dumping") of hyperosmolar liquids into
duodenum or jejunum
5) Early post-prandial phase
6) Hyperosmolar solutions cause fluid shift into bowel lumen with resultant hypovolemia
7) 15-30 minutes of postprandially
8) Later phase
9) Glucose presented initially causes insulin surge with subsequent rebound hypoglycemia
10) 2-hours postprandially
d. Treatment of dumping syndromedietary manipulation
1) Increase fat
2) Decrease carbohydrate
3) Frequent small dry meals
C. Chronic Duodenal Ulcer
1, Diagnosis
a. Upper GI series
b. Endoscopy
c. Gastric acid analysis
.
2. Medical management
a. H, blocker or a proton pump inhibitor
b. Avoid foods that cause more acid secretion
c. Antacids
3. Surgical management
a. Indications for surgery
1) Intractable ulcer--failure of medical management
2) Persistent clinical symptoms
3) Persistent ulcer on endoscopic examination
b. Surgical options available
1) The aim is o reduce acid secretion
2) Vagotomy and antrectomy:
Procedure of choice (recurrence 1%)
3) Truncal vagotomy and pyloroplasty (recurrence 5%)
4) Highiy selective vagotomy
High risk of recurrent ulcerauon (10-15%)
24 2258! 30000260.

< rJ,a1a o o1ape p:vrJx >
General Surgery • Gastrointestinal Surgery
4. Complications of duodenal ulcer
a. Perfm:ationmanterior ulcer
1) Presentation
a) Acute epigastric or right lower quadrant pain
b) Free air under diaphragm, but only present 40-60% of the time
c) Chemical peritonitis which is usually sterile
2) Treatment
a) Just repair of perforation as with omental patch
b) May add truncal vagotomy and pyloroplasty as definitive therapy if patient is stable
b. Hemorrhage--posterior ulcer
1) Most common cause of death from duodenal ulcer
2) Usually resolves spontaneously
3) May be preceded by a small herald bleed
4) Presentation
a) Hematemesis and/or melena
b) Confirmation by testing for occult blood
c) Coffee grounds in nasogastric aspirate
d) Endoscopic visualization is definitive
5) Management
a) Nasogastric aspiration and lavage
b) H z blockers
c) Nonsurgical options
i) Endoscopic probe to bleeding vessel
ii) Endoscopic laser coagulation of bleeding vessel
d) Blood transfusion
e) Surgical options
i) Duodenal ulcer
ii) Over-sewing of bleeding ulcer with truncal vagotomy and pyloroplasty
iii) Vagotomy and antrectomy
c. Gastric outlet obstruction
1) Secondary to scarred duodenum/pylorus
a) Recurrent abdominal pain
b) Early satiety
c) Abdominal distension and vomiting, often of food eaten several days earlier
2) Physical examination
a) Look for epigastric fullness and peristaltic wave
b) Feel for epigastric mass
c) Listen for succussion splash
3) Complications
a) Poor nutrition
b) Dehydration
c) Hypokalemia
d) Hypochloremia
e) Metabolic alkaloss with paradoxic aciduria
d. Complications of vagotomy and gastric resection
• Dumping
• Diarrhea
• Retained antrum
• Afferent loop syndrome
• Blind loop syndrome
• Marginal ulceration
• Gastric malignancy (stump cancer)
• Vitamin B12 deficiency
225813.0000260 25

General Surgery • Gastrointestinal Surgery
e. Helicobacter pylor
• Diagnosis, urea breath test, ELISA, gold standard "endoscopic gastric biopsy"
• Gram negative microaerophilic spiral bacterium
• Gastric cancer 3x more common
• Associated wth antral gastritis duodenal ulcer, gastric ulcer chronic atrophic gastritis
• Colloidal bismuth in combination with antibiotics (tetracycline, Flagyl)
2 Hypergastrinemia
• Zollinger-Eilison syndrome: secretion stimulation test
• Antral G-cell hyperplasia: protein meal
• Retained antrum: Bombesin-stimulation test
• Renal failure
• Gastric outlet obstruction
• Short bowel syndrome
• Pernicious anemia
D. Upper GI Bleeding
1. Indications for emergency surgery
a. Bleeding vessel is visible in bed of ulcer
b. Two documented episodes of hypotension within 24 hours despite ongoing fluid resuscitation
c. Age older than 55 years
d. Rare blood group
e. Loss of 1.5-2 L of blood
f. Acute fall of Hct < 25
g, Acute blood loss, resulting in a syncopal episode
h. Blood loss requiring 4-6 L in a 24-hour period
2. Management
a. Nasogastric aspiration
1) To decompress stomach
2) To restore gastric tone
b. Correct fluid and electrolyte imbalance
c. Surgery
1) Duodenal ulcer
. a) Truncal vagotomy and antrectomy
b) Trncal vagotomy and pyloroplasty with stick tie of ulcer
c) Highly selective vagotomy with stick tie of ulcer
2) Gastric ulcers with hourglass stomach
a) Distal gastrectomy (Billroth I/II) including ulcer excision
b) Truncal vagotomy with stick tie of ulcer and pyloroplasty
3. Ulcer location and involved artery
a. Cardia of stomach --> left gastric artery
b. Lesser curvature of stomach --) right gastric artery
c. Greater curvature of stomach --) right gastroepiploic artery
d. First and second portion of duodenum --) gastroduodenal artery
2 6 225813.0000260.

General Surgery • Small Intestine
IV. Small Intestine and Appendix
A. Meckel's Diverticulum
I. Etiology
Remnant of the omphalomesenteric/vitelline duct which can also create a band, cyst, or umbilico-entenc
fistula
2. Rules of 2s
a. 2 inches long
b. 2 cm wide
c_ Male:female ratio is 2:1
d. 2 types of heterotopic tissue (gastric, pancreatic)
3. Signs and symptoms
a. Bleeding
1) Most common presentation
2) Ulcerauon of small bowel opposite divel-ticulum
3) Heterotopic gastric mucosa
b. Obstruction
Volvulus/intussusception (attached to anterior abdominal wall)
c. Diverticulitis-a true diverticulum
4. Diagnosis
"True" diverticulum may be diagnosed by Meckel's scan (specific for gastric mucosa) - Techneuum
99 m pertechnetate.
5. Relative indications for removal
a Palpable heterotopic mucosa
b, Narrow neck
c. Diverticulum > 2 inches
d. Younger than 40 years old
6. Absolute indications for resection
a. Diverticutitis
b. Bleeding
c. Obstruction
d. Perforation
e. Attached mesodiverticular or omphalo-diverticular bonds
h.- Surgery
1) Diverticulectomy
2) Segmental resection (may remove diseased adjacent ileal mucosa)
B. Malignant Tumors of the Sml Intestine, Adenocarcinoma
1. Incidence
a. Males > females
b. Sixth to seventh decade
c. Predisposing conditions
d. Villous polyps
e. Crohn's disease
f. Most common in duodenum
g. Cancer of the small intestine is rare
h. Most common type of small intestine cancer
2. Symptoms
a. Intermittent bowel obstruction
b. Partial small bowel obstruction

General Surgery o Small Intestine
3. Diagnosis
a, Occult blood in stool
b. Endoscopy
c. Enteroclysis
4. Treatment
a. Excision
b. Wide segmental resection, including draining lymph nodes
5. Sarcoma/lymphoma- less common
a. Lymphoma
I) Distal small bowel
2) Commonly presents as perforation
b Sarcoma
1) Evenly distributed throughout small bowel
2) Presents as obstruction or bleeding
C. Mesenteric Vascular Insufficiency
1. Chronic mesenteric vascular insufficiency
a. Synonym--abdominal angina
b. Causes of intestinal angina
1) Atherosclerosis of mesenteric arteries
2) Non-occlusive low-flow states
c. Signs and symptoms
1) Pain
a) Locahzed
b) Generalized
c) Postprandial
d) Lasting 2-3 hours
(i) Leads to diminished food intake
(ii) Leads to weight loss
2) Epigastric bruit
3) Severe peripheral vascular dtsease in multiple vessels
d. Laboratory diagnosis
1) Small bowel series
Shows motility disorder
2) Visceral angiogram
Shows narrowing of the celiac and mesenteric arteries
e. Treatment
1) Surgical revascularizauon of the bowel
2) Small frequent feedings
2. Acute mesenteric vascular insufficiency
a. General considerations
1) Acute mesenteric vascular insufficiency can be arterial or venous
2) Arterial occlusion is embolic or thrombotic
3) This presents as a sudden onset of pain in the setting of a recent myocardial infarction or m
the presence of an arrhythmia such as atrial fibrillation
4) Superior mesenteric artery is the most common artery involved
b. Buzz words
1) Severe abdominal pain
2) Unimpressive physical examination
28 2258] 3.0000260.

< iI-ii,[i,a  6oi,a,Ipei pyccxi.c.x > 'r'TI"'T''r 
General Surgery • Small Intestine  _.
3) History of vascular disease
4) Abdominal distention
5) Tenderness
6) Rigidity
7) Leukocytoss
8) Hemoconcentration
c. Signs and symptoms
1) Abrupt generalized abdominal pare that is intermittent
2) Nausea
3) Vomiting
4) Bloody diarrhea
5) Abdominal distention
6) Tenderness
d. Laboratory f'mdings
1) ttemoconcentration
2) Leukocytosis
3) Blood in the stool
4) Lactic acidosis
5) Imaging
Plain film of the abdomen shows a gaseous distention
6) CT scan
Shows atherosclerotic compromise of superior mesenteric artery and celiac axis
ў. Differential diagnosis
1) Acute panereatifis
2) Perforated viscus
3) Elevated serum amylase level
f. Treatment
1) Restore fluid, colloxd, electrolyte balance
2) Decompress the bowel
3) Prevent sepsis
4) Anglography wth transcatheter infusion of vasodilators
5) Laparotomy to resect bowel
6) Embolectomy/thrombeetomy
D. Small Intestine Obstruction
1. Mechanical (dynamic)
a. Any extrinsic or intrinsic factor encroaclfing on the lumen of the bowel
1) Tumors
2) Adhesions
3) Hernias
4) Volvulus
5) Intussusception
b. Obstruction may be either partial or complete
c. Patient suffers intermittent crampy abdominal pain
d. Peristalsis is visible and audible
1) Auscultation
a) Peristalsis in rushes
b) Note frequently is lfigh-pitched, metallic, and tinkling
2) Distension is evident
3) Vomiting is frequent
225813.3o0260 29

General Surgery • Small Intestine
e. Diagnosis
1) X-ray of the abdomen--reveals small bowel distension with presence of collapsed loops of
bowel
2) X-ray in the erect or lateral recumbent position
Reveals air and fluid levels in the gut
f. Treatment
1) Insert a tube into the stomach to decompress the stomach and jejunum
2) Intravenous infusion of isotonic sodium chloride, or Ringer's lactate solution and 5% glucose
3) Abdominal exploration
2. Paralytic (adynamic)
a From reflex loss of tone and peristalsis of the intrinsically normat intestinal tract
b Can occur following intraperitoneal operations, depending on the degree of trauma from handling,
drying .
c. Also results from the following
1) Compression fractures of the spine
2) Retroperitoneal hematoma formation
3) Pneumonia
4) Certain drugs inhibiting parasympathetic function
d. Hypokalemia also may produce adynamic ileus
E. Acute Organic Small Intestinal Obstruction
1. Buzz words
a. Colicky abdominal pain
b. Vomiting, Constipation, borborygmus
c. Tender, distended abdomen without peritoneal irritation
d. Audible, high-pitched, tinkling peristalsis or peristaltic rushes
e. X-ray shows dilated loops of small intestine with or without fluid levels
Inciting causes
a. External hernia
b. Postoperative adhesion
c. Gallstones
d. Neoplasms
e. ln.tussusception
L Foreign bodies
Symptoms and signs
a. Colicky abdominal pain
1) In periumbilical or central area
2) Constant
3) Diffuse
b. Fecal vomitus especially in well-established obstructions
c. Borborygmus, consciousness of intestinal movement
d. Restlessness, sweating, tachycardia
e Generalized abdominal distention
l) The higher the obstruction, the less the distention but the earlier the vomiting
2) The longer the obstruction, the greater the distention
f. Audible and visible peristaltic rushes
g. Low-grade fever
30 225813.0000260.

General Surgery
Small Intestine
Laboratory findings
a. Hemoi:oncentration
b. Leukocytosis
c. Electrolyte disturbances, especially acidosis
d. Abdominal x-ray
Differential diagnosis
a. Inflammation and perforation of a viscus or renal gallbladder colic
b. Ileus secondary to peritonitis (this would show rigidity and rebound tenderness)
c. Acute mesenteric vascular occlusion
d. Torsion of an organ
Complications
a. Strangulation necrosis
b. Perforation, peritonitis, sepsis
7. Treatment
a. Supportive
1) Decompression of intestinal tract
Place a nasogastric tube
2) Correct electrolyte imbalance
3) Antibiotics (chosen on empiric basis)
a) Gentamicin
b) Ampieillin
c) Clindamyein
b. Surgery
1) Relieve obstruction
2) Remove gangrenous bowel
Appendicitis
1. Buzz words
a. Early periumbilical discomfort followed by right lower-quadrant abdominal pain and
tenderness
b. Signs of peritoneal irritation
c. Anorexia, nausea, vomiting
d.. Low-grade fever
e. Polymorphonudear leukocytosis
2. General considerations
a. Appendicitis is initiated by obstruction of the appendlceal lumen
1) Fecalith
2) Foreign body
3) Neoplasm
4) Inflammation of wall
b. Necrosis and perforation occurs
e. Most commonly seen in males between 10 and 30 years
3. Signs and Symptoms
& Begins with epigastric pain associated with one to two episodes of vomiting
b. Pain later shifts to right lower quadrant
c. Pain associated with malaise and slight fever
d. Rebound tenderness, guarding and rigidity
e. Psoas, Rovsing's and obturator signs
f. Rectal tenderness or referred abdominal tenderness
225813.0000260 31

General Surgery • Small Intestine
4. Laboratory findings
a. Leukocytosis--usually with increase in neutrophils
b. Microscopic hematuria-beware a right ureteral stone
c. Pyuria without bactiurla
5. Imaging
a. Radiopaque shadow in right lower quadrant
b. Contrast enema: paracecal mass; obstructed appendiceal lumen
6. Vartauons from "'classic appendicitis"
a. Anatomic location of appendix: retroeecal, pelvic
b. Age
1) In infancy, more commonly leads to generalized peritonitis
2) In old age, prodromal symptoms are absent
3) In obesity, difficulty in evaluation
7. Differential diagnosis
a. Acute gastroenteritis
b. Mesenteric adenitis
c. Meckel's diverticulitis
d. Regional enteritis amebiasis
e. Perforated duodenal ulcer
f. Acute salpingitis/ectopic pregnancy--ruptured
g. Lobe pneumonia
h. Amebiasis
i CMV infection
1) AIDS
2) Transplant patients
8. Complications
a. Perforation
!) Can lead to generalized peritonitis
2) Can lead to appendiceal abscess
b. Phlebitis
c. Suppurative thrombophlebitis of the portal system with miliary liver abscesses
d. Other
1) Subphrenic abscess
2) Intestinal obstruction
32 225813.0000260.

< le/-ii,,ii,a o' 6ol,a,I=,,e pcci,x >
General Surgery • Small Intestine
9. Treatment
a. Preoperative care
1) No laxatives
2) Nothing by mouth
3) No narcotic medications
4) Abdominal and rectal examinations
5) Abdominal x-rays
6) Intubation
7) Antibiotics
a) Ampicillin
b) Gentamicin
c) Metronidazole or clindamycin
b. Surgery--appendectomy
c. Postoperative care
1) Ambulation
2) Change diet from clear liquids to soft solids on second to fifth postoperauve day
3) No enemas
4) Resume all activities in 2-3 weeks
d. Emergency nonsurgical treatment
Treat as acute peritonitis
G. Carcinoid
1. Kultschitzky cells
2. Prognosis is related to tumor size, location and histologic pattern
3. Multicentricity (30%)
4. Appendix > ileum (ileal tends to metastasize more common)
5. Produce serotonin, consume up to 60% of dietary tryptophan
6. Serum 5-HIAA - diagnostic
H. Small bowel fistula
I. Short gut syndrome
3.00o0260 33

General Surgery • Colon and Rectum
V. Colon and Rectum
A. Polyps and Carcinoma
1. Polyposis
a. Familial polyposis
1) Autosomal dominant inheritance
2) Innumerable polyps of the colon and rectum
3) Appear at puberty and cause bleeding from rectum, diarrhea, tcnesmus, intestinal
obstruction
4) Most serious complication is malignant change in the polyps
5) Treatment
a) Colectomy and ileoproctostomy
b) Total colectomy and ileostomy
b. Gardner's syndrome
1) Autosomal dominant inheritance
2) Associated with osteomas of the skull, multiple sebaceous cysts of the scalp, and desmoid
tumor
3) Involves both the large and small intestines
4) Risk of cancer almost 100%
5) Many extracolonic manifestations
6) Desmoid tumor 15%
c. Turcot's syndrome
l) Central nervous system tumor
2) Familial polyposis
d. Cronkhite-Canada syndrome
l) Hemaromaous polyps
2) Alopecia
3) Atrophy of the fingernails
e. Peuz-Jeghers
l) Familial disease
2) Polyps of the gastrointestinal tract associated with pigmented spots on the Hps, buccal
mucosa, and hands
2) Hamartomatous polyps
3) Not thought to be premalignant
4) Polyps in small bowel and colon
f. Nonfamilial polyps of the colon
1) Adenomatous polyps of the colon
a) May be single
b) May be multiple
c) May be pedunculated
d) May be sessile
2) Can be benign or malignant
3) Correlation between size and malignancy
4) Tubular 75% (5% malignant)
5) Villous 10% (40% malignant)
6) Tubulo-villous 15% (22% malignant)
7) > 2 cm, sessile more likely to be malignant
g Villous adenoma
l) Polyp of glandular origin
2) With great tendency to undergo malignant changes
34 22S8! 3.0000260.

< F/-Ma O 6olae p-cciix > 
General Surge D, • Colon and Rectum
B. Ischemic Colitis
I. General considerations
a. Caused by interference with blood flow to the colon but usually sparing the rectum lecause it has a
dual arterial supply
b. Seen in patients older than 50 years, usually with a history of peripheral vascular disease
c. Seen m women taking oral contraceptive pills
2 Clinical features
a. Lower abdominal pain of sudden onset
b. Fever, vomiting
c. Bright, red blood and clots per rectum
d. Sigmoidoscopy
1) Colon
2) Cecum
3) Splenic flexure
4) Sigmoid colon
e. X-rays
Show generalized dilation of the colon
L Barium enema
1) Involved areas
a) Splenic flexure
b) Sigrnoid colon
e) Ascending colon
2) Findings
a) Thumbprinting (edematous mucosal folds)
b) Saw-toothed mucosal irregularity
c) Tubular narrowing
d) Sacculafion
3. Treatment, if ischemia progresses to acute necrosis
a. Replacement blood
b. Antibiotics
1) Ampicillin
2) Clindamycin
c. Colectomy with colostomy
C. Volvulus
1. General considerations
& Twisting of a segment of the colon about its mesentery, usually the sigmoid
b. May spontaneously reduce and recur as a chronic problem
2. Symptoms
a. Acute abdominal pain
b. Distention
c. Tenderness
d. If gangrene is present
1) Fever
2) High white blood cell count
3. Diagnosis
a. X-ray shows markedly dilated loops of large bowel, the so-called bent inner tube or omega loop
zzssl 3.oooo26o 35

General Surgery • Colon and Rectum
b Air/fluid levels are almost always seen within the sigmoid loop
c "Bird's beak" deformity on abdominal plain films represents the place where the bowel's twisting
has narrowed the lumen
4. Treatment
a. If proctoscopic decompression and detorsion is successful, surgery should be considered
because of high recurrence rate
b Elective resection with primary anastomosis
c. In emergency situations, surgery is treatment of choice
5. Cecal volvulus
a. Secondary to "floppy" cecum (due to persistent cecal mesentery)
b. Either congenital or secondary to pregnancy (repeated) or previous surgery
c. Not amenable to rectal decompression
d. Surgery--axial cecopexy, cecostomy, appendicostomy, or colectomy
e. Cecal bastulc
2) Cecum is folded on itself rather than twisted
2) Rare
D. Rectal Prolapse
1. Definition: herniation of the rectum through the anus.
Associated with:
a. Parity
b. Straining at stool resulting from diet or abuse of laxatives
c. Institutionalization, i.e. personality disorders
d. Aging
Etiology
a. Weakening of the muscular and ligamentous support of the pelvic floor
b. Relaxation of the anal sphincters
c. Redundancy of the rectum and the sigrnoid
Treatment--surgical correction
a. Resection of the prolapsing and redundant Dowel
b. Plastic reconstruction of the perineal floor
c. Low-anterior resection
d. Rectal sling
E. Diverticular Disease
1. Definition
a. Sac-like herniations of mucosa/submucosa
b. 65% solely in sigmoid; 95% involve sigmold
c. Contain only outer submucosal and inner mucosal layer (false diverticulum)
d. Herniations at anatomic weak points where blood vessels (vasa recta) penetrate serosa
2. Etiology
a Diet-related
b. Low-fiber content, which increases intralummal pressure and results in muscular hypertrophy to
move low-volume residue
c. This.increased intraluminal pressure causes herniation of mucosa through muscularis at weak points
made by transversing blood vessels
36 225813.0000260.

< tcI-ii,a  6oi,a,Ipei pccti, ix >
General Surgery • Colon and Rectum
Presentation
a. Uncomplicated diverticular disease
b. Complicated diverticular disease
4. Uncomphcated dlvencular disease (diverticulosis)
a. Signs and symptoms
1) Asymptomatic
May be incidental finding at flexible sigmoidoscopy or lower GI studies
2) Diverticular pare
Chronic left lower quadrant abdominal pain without other pathological explanation
b. Differential diagnosis
1) Irritable bowel syndrome
2) Colon cancer
3) Pelvic inflammatory disease, ovarian cancer in females
4) Colitis
c. Diagnosis
1) Lower GI barium study
2) Colonoscopy
d. Treatment
1) Diet changes to increase fecal residue
2) Bulk laxatives, psyllium
3) Anuspasmodics
e. Complications
1) Painless hemorrhage
a) Massive lower GI bleeding
b) Differential diagnosis
i) Arteriovenous malformation
ii) Colon cancer
iii) Ischemic colitis
iv) Most common cause of massive lower GI bleed in U. S. (angiodysplasia)
c) Management
i) Initial fluid resuscitation/blood transfusion
ii) Rule out UGI bleeding
1) Nasogastric tube
2) Lavage/upper GI endoscopy in cases of massive hematochezla
iii) Proctosigmoidoscopy
iv) Continued bleed
d) Diagnostic studies (in order)
i) Proctosigmoidoseopy
ii) Bleeding scan (0.1 mL/min)
iii) Arteriogram (0.5 mL/min)
e) Therapeutae options
i) Most of the bleeding stops on its own
ii) Nonsurgical
iii) Intra-arterial vasopressin infusion
iv) Angiographic embolization of bleeding
f) Surgical-Localization of bleeding area and resection of involved colon
2) Bleeding usually from left side
3) 75-80% will cease bleeding on their own
225813.0000260 37

General Surgery ,, Colon and Rectum
5. Diverticulitis
a. Pathogenesis
1) Obstruction at neck of diverticulum leads to inflammation
2) Obstruction of diverticular neck secondary to inflammation
3) Micropefforation ensues
4) Bacterial invasion of pericolic tissue with resulting pericolitis, abscess formation
b. Clinical presentation
1) Left lower quadrant pain with fever and chills
2) Classic left lower quadrant tenderness and mass
3) Localized left lower quadrant peritonitis
4) Elevated WBC with left shift
5) Abdominal x-ray shows ileus and possible sigmoid obstruction
c. Differential diagnosis
1) Cancer
2) Colitis
d. Complications
1) Free perforation and peritonitis
2) Abscess (most common)
3) Perforation, confined
4) Fistula (especially colo-vesicular)
a) Internal-common
b) External-rare
c) Enterocolic
d) Vesicocolic
5) Obstruction
6) Intractability
Note: avoid barium enema (increased hydrostatic pressure) and endoscopy during acute attack
may result in free perforation
e. NIanagemen!
1) Initial stabilization
a) Fluids
b) Bed rest
c) Fasting
d) Antibiotics
" e) Pain control
2) Avoid endoscopy or lower GI study during acute attack
3) Confirm diagnosis with endoscopy and lower GI study after resolution of inflammation
f. Indications for surgery--intractable diverticular pain
1) Failed medical management with dietary modulation
2) Resection of involved segment of colon
g Complicationsperforation with peritonitis
1) Two-stage procedure
a) Hattmann's resection
b) Elective reversal of colostomy
2) Three-stage procedure
a) Emergent proximal colostomy
b) Elective resection of diseased colon with reanastomosis
c) Reversal of proximal colostomy
3) One-stage procedure-only if process is very localized
38 225813.00002G0.

< leIila o 6olalpeli pyccii, tx >
Genera] SurBer Y • Colon and Rectum
6. Diverticular abscess
a Options (as in perforated diverticulitis)
1) CT-guided percutaneous drainage of abscess followed by elective one-stage colon resection
2) Contraindication
a) Perforation
b) Peritonitis
c) Multiloculated abscess
b. Obstruction
Surgical option essentially as above, i.e., two-stage, or three-stage colon resection after initial
stabilization of pauent
F. Fistula-In-Ano
1 Defimtion
An abnormal passage between the anal canal and the skin surface
2. Pathogenesis
Begins with anorectal abscess which then tracks through perianal fat to the skin
3. Signs and symptoms:
Recurrent acute episodes of rectal pain, purulent drainage, and constipation
4. Diagnosis
a. Inspection, digital examination, anoscopy
b. Palpation
c. Insert probe through skin opening
5. Management
a. Antibiotics
b. Exclude other diagnoses: Crohn's disease, lymphoma, cancer
c. Low-residue diet
d. Operation to lay open fistula tract and drain abscess
G. Cancer of the Colon and Rectum
1. Buzz words
a. Altered bowel function (constipation)
b. Bright red rectal bleeding in distal lesions
c. Occult blood in the feces, unexplained anemia, weight loss in right-sided carcinomas
d. Palpable mass involving colon or rectum (valuable when present)
2- General
a. Carcinoma is the only common malignancy of the colon and rectum
b. 15% of all cancer deaths
3. Predisposing causes of carcinoma
a. Older than 40 year
b. Rectocolonic polyps I
1) Familial polyp0sis
2) Villous adenomas
c. Hereditary non-polyposis cancer (Lynch syndrome)
d. Prior colon cancer (5-8% of patients will develop a second metachronous tumor)
e. Crohn's disease
f. Ulcerative colitis
g. Males arc affected more than females
h. Highest incidence is in persons older than 50 years
i. • 50% occur in the rectum, 20% in the sigmoid
j. Women with a history of breast, ovarian, or cndomclaial cancer
k. Strep boris in elderly associated with colonic polyps

General Surgery • Colon and Rectum
4. Clinical features
Depend on whether the lesion is in the right or left side of the colon
a. Carcinoma--right side
1) Vague abdominal pain
2) Progresses to crampy pain
3) Secondary anemia-microcytlc
4) Stools positive for occult blood
5) Complains of diarrhea
6) Palpable mass--late
7) History of weight loss
b. Carcinomamleft side
1) Obstructive symptoms predominate
2) Acute colonic obstruction
3) May or may not find anemia
4) Bright red blood--stool
5) Complains of constipation
5 Differential diagnosis
a. Diverticulitis
b. Functional bowel disease
c. Hemorrhoids
6. Work-up
a. Proctosigmoidoscopy/colonoscopy
b. Carcinoembryonic antigen (CEA)
c. Barium enema
7. Treatment
a. Curative treatment
Wide surgical resection of the lesion and its regional lymphatics
b. Preliminary transverse colostomy or cecostomy if obstruction is present
c. Preoperative irradiation of 2000-2500R in 10 fractions over 10-12 days
1) Helps increase resectability
2) Improves survival
d. Chemotherapy: 5-FU
8. Prognosis
a. 5-year survival rate after resection is 50%
b. Local recurrence occurs in 10-15%
c. Early identification can be detected by high levels of carcinoembryonic antigen (CEA) every 3
months for the first year (increased in smokers)
d. Sigmoidoscopy/colonoscopy every 6 months for 2 years
9. Screening
a. Rectal: older than 40 years, yearly
b. Hemoceults older than 50 years, yearly
c. $igmoidoscopy every 3 to 5 years, or colonoscopy older than 50 years
10. False positive hemoccults
a. Rare
b. Meat
c. Iron
40 225813.0000260.

< leii,{i,a o, ,ol,a,,iipe pxjcclo, lx > 
General Surgery • Colon and Rectum  _.
After age 40 (both m.ni":::iliiR[n! :!y.i!i[familial polyposis, villous po|;p
Z25813.0000Z60 41

General Surgery • Colon and Rectum
Figure 1-3
11. Pseudomembranous enterocolitis
a. Ciostridium difficile
b. Antibiotic-related
c. Therapy
1) Metronidazole
2) Vancomycin
d. Surgery rarely necessary
1) Toxic colius
2) Perforation
42 225813.00o0260.

General Surgery • General Abdominal Disorders  __
VI. General Abdominal Disorders
A. Peritonitis
1. Etiology
a. A wide variety of acute abdominal disorders can be complicated by the most important complication
localized or generalized peritonitis
b. Peritonitis may be caused by infectious or chemical agents
1) Perforation or necrosis of the gastrointestinal tract, the usual source of infection
2) Chemical peritonitis occurs in acute pancreatitis and in early stage of gastroduodenal
perforation
2. Signs and symptoms
a. History of abdominal illness
b. Abdominal pain, vomiting, fever, and prostration
c. Abdominal rigidity and diffuse or local tenderness
d. Later, abdominal distention and paralytic ileus
e. Leukocytosis
3, Diagnosis by x-ray
Plain films and contrast studies appropriate to diagnostic suspicion
4. Treatment
a. Surgical: close perforation and drain purulent collections
b. Control of infection-antibiotics: empiric then culture-specific
c. Correct fluid and electrolyte imbalances
B. Intra-abdominal Abscess
1. Definition
Localization of pus walled off from the rest of the peritoneal cavity by inflammatory adhesion to adjacent
viscera
2. Etiology
a. Arises during resolution of generalized peritonitis, following complication of spontaneous intra-
abdominal disease
1) Appendicitis
2) Diverticulitis
3) Perforated ulcer
b. Polymicrobial, both aerobic and anaerobic
1) Bacteroides species
2) Peptostreptococcus
3. Signs and symptoms
a. Abdominal pain, fever
b. Recurring or worsening jaundice is also an important nonspecific hallmark
c. Leukocytosis
4. Diagnosis
a. X-ray
b. CT scan
c. Index of suspicion
225813.0000260 43

< 10/-mta o, 6ol,a,Ie pTVcct{x >
General Surgery • General Abdominal Disorders
Treatment
a. Pemutaneous drainage
b. Open surgical drainage
c. Antibiotic therapy
Hernia
1. Etiology and pathogenesis of inguinal hernia
a. Indirect inguinal hernia results from a persistently patent process vaginalis
b. Begins at the internal inguinal ring and passes through the inguinal canal
c. Contents of the hernia can extend into the vaginalis of the testes into the scrotum
d. Most common groin hernia is the indirect inguinal hernia. Indirect inguinal hernia is 10
times more common in males
e. Incarceration less likely with direct hernia
f. Direct inguinal hernia is a defect in the posterior inguinal wall within Hasselbach's uiangle,
whose borders are:
i. Inguinal ligament
ii. Inferior epigastdc artery
iii. Lateral border of rectus muscle
g. Repair
i. Indirect
ii. High hgafion of sac
iii. Recreate internal ring
iv. Recreate floor of inguinal canal
v. Direct--repair fascial defect in posterior wall
h. Most common hernia in females is indirect inguinal hernia
2. Femoral hernia
a. Results from a defective femoral ring associated with increased abdominal pressure as in pregnancy
or obesity. The main sac extends into the femoral canal
b. More common in females (80% of all femoral hernias)
c. Requires Cooper's ligament repair
3. Umbilical hernia
a. Defect in the region of the umbilicus
b. In children especially, umbilical hernia often is associated with separation of the rectus muscle,
known as diastasis recti
c. Treatment
1) Allow to close spontaneously in young children
2) Fascial repak if still present at 4 years of age
4. Incisional hernia
a. Occurs at the site of previous operative wound
b. Frequently is the result of postoperative infectton
5. Diaphragmatic hernia
a. Protrusion of abdominal contents upward through the diaphragm into the thorax
b. May be congenital or acquired. Trauma is the most common cause
c. Most commonly on left side
d. May be diagnosed by air fluid levels in thorax in chest x-ray
44 225813.00OO260.

< i.I-ii, ii,a  6ol,a,iipe pccii, ix >
General Surgery • Nutrition
VII. Nutrition
A. Hyperalimentauon
1. History
a. Risk Factors
1) Poverty
2) Alcoholism
3) Age
b. Unexplained weight loss
c. Diminished intake
d. Catabolic Medications
1) Steroids
2) Immuno suppressant therapy (i.e., chemotherapy)
e. Supranormal nutritional requirements
1) Trauma
2) Burns
3) Fever
4) Sepsis
2. Anthropometnc Measurements
a. Height and weight
b. Triceps skin fold
c. Serum measurements
1) Albumin (half-life: 17 days)
2) Pre-albumin (half-life: 48 hours)
3) Retinal binding protein (half-life: 12--18 hours)
d. Creatinine--height index
e. Nitrogen balance (nitrogen intake minus nitrogen loss: Grams of protein intake divided by 6.25
Urine urea nitrogen (LrUN) minus 3- grams (sweat, stool, nitrogen losses)
3. Immunologic Measurements
a. Total lymphocyte count. Normal value 1500 cells per ml.
b. Delayed hypersensitivity skin test: mumps, purified protein derivauve, SK-SD
(streptokinase-streptodornase), Candida, histoplasmin
I) Normal response is a 5 mm area of induration. Examine for response to at least one antigen at 48
hours.
2) Mild response: paxttal immunocompromise
3) No response: Anergy
B. Nutritional Needs
1. Protein
a. 0.9-1.5 grams proteins per kilogram body weight daily (6.25 grams protein = 1 gram of nitrogen)
1) Protein sparing achieved when 150-200 grams (700 K cal.) of intravenous glucose provided
daily
2) Nitrogen balance improves to a maximum as caloric intake increases from an inadequate level to
that which meets basal energy requirements.

 General Surgery • Nutrition
2. Calories
a. Harris Benedict equation for resting metabolic rate (RME)
1) W = weight in kg; H = Height in cm, A= age in years:
Males (Kcal/day) = 66.47 + 13.75 x W + 5 X H - 6.76 x A
Females (Kcal/day) = 655.1 + 9.56 x W + 1.85 x H -4.68 x A
2) Activity adjustment factors
a) Bed rest, 1.2
b) Ambulation, 1.3
c) Trauma and fractures, 1.8
d) Severe sepsis and burns, 2.0
e) Per 10 Celsius fever, 1.13
3) Parenteral formulation with > 10% glucose concentration (> 10 gnVdl) require central vein
administration. A maximum of 60%, but usually only 40% of calories should be provided as lipid
emulsions.
b. Caloric requirements: 30-80 K cai per kg. per day
3. Fat
a. A minimum of 500 ml of 10% lipid emulsion may be given twice per week to prevent fatty acid
deficiency (principally linoleic acid).
b. Essential fatty acid deficiency
Dry scaly skin and hair loss
Micro Nutrients: Vitamins and Trace Elements
a. Vitamins
1) Essential vitamins
a) 4 fat soluble
b) 9 water soluble
2) Fat soluble (A, D, E and K); water soluble (e.g., Fohc acid, B complex)
a) VITAMIN A
Essential component for visual cycle (deficiency: night blindness)
b) VITAMIN D:
Enhances calcium gastrointestinal absorption and resorption from bone of both calcium and
phosphorus (deficiency: Rickets)
c) VITAMIN E:
Antioxidant
d) VITAMIN K:
Cofactor for coagulation factors H, VII, IX and X
e) B COMPLEX:
Cofactor for several metabolic enzymes (deficiency: Beri-beri)
f) FOLIC ACID:
Co-factor in DNA synthesizing (deficiency- megaloblastic anemia)
b. Essential Trace Elements
1) Iron, Zinc, Copper, Selenium, Chromium, Iodine
a) Iron deficiency
Microcytic hypochromlc anerma
b) Zinc deficiency
i) Diarrhea
ii) Central nervous system chsturbance
iii) Eczematoid dermatitis
c) Copper deficiency
i) Anemia
ii) Leukopenia
iii) Bone demineralization
d) Selenium deficiency -skeletal myopathy or cardiomyopathy
46 225813.OO0O260.

General Surgery • Nutrition
e) Chromium deficiency
i) Weight loss
ii) Glucose intolerance
iii) Peripheral sensory neuropathy
f) Iodine deficiency
i) Thyroid goiter
ii) Hypothyroidism
C. Parenteral Nutrition
1. Indications
a. Gut Unavailable
1) Prolonged paralytic ileus or obstruction
2) Short bowel syndrome
3) Enterocutaneous fistula
4) Necrotizing enterocolitis
5) Malabsorption syndromes
6) Esophageal benign stricture or malignancy
b. Inadequate Oral Intake or "Bowd Rest" Indicated
1) Severe acute pancreatitis
2) Catabolic state
a) Bums
b) Sepsis
e) Polytrauma
3) Extreme prematurity
4) Tracheoesophageal fistula (infants; until gastrostom.v performed)
22se3.oooo2o 47

General Surgery • Nutrition
5) Hyperemesis gravidarum
6) Intractable diarrhea
c. Adjunctive to Other Therapy
1) Cancer chemotherapy
2) Cancer radiotherapy
3) Inflammatory bowel disease
4) Perioperative nutritional repletion
2. Categories
a. Peripheral Parental Nutrition
Utilizes a 3% amino acid solution in 10% dextrose with electrolytes, plus a liquid emulsion supplying
up to 60% of estimated energy (caloric) needs.
b. Total parenteral (central vein) nutrition
Will provide all energy and nitrogen needs
1) Parenteral caloric reqmrements provided with standard 20-25o dextrose solutions ranging from
100-1500 mOsm per liter
2) Nitrogen administered as L-amino acids
3) Standard formulations: 25% dextrose and 4.25% amino acids, supplying 2700 non-nitrogen
calories, 18.75 grams of nitrogen in 3 liters/per day volume.
3 Complications
a. Metabolic
1) Hyperglycemia
2) Hypoglycemia
3) Electrolyte imbalances
4) Trace element deficiency
5) Vitamin deficiency
6) Hypo-proteinemia
7) Hyper-cholesterolemia
8) Abnormalities of liver function (elevation of liver transaminases)
9) Pancreatitis
b. Central Venous Catheterization
1) Simple pneumothorax
2) Tension pneumothorax
3) Subcutaneous emphysema
4) Subclavian artery injury
5) Hemothorax
6) Brachial plexus injury
7) Improper catheter position
8) Septicemia
c. Enteral Therapy
1) Recurrent pulmonary aspiration
2) Esophageal reflux
3) Esophageal erosions
4) Feeding tube obsu'uction
5) Refractory diarrhea
6) Malabsorption
7) Fluid and electrolyte abnormality
8) Hyperglycemia
9) Hyperosmolarity
48 28 3.oooo2Eo.

< F./-Ii, Ii,a o, 6ol,a,hlpe pccle/6x >
General Surgery • Hepato-biliaryTract
VIII. Hepato-biliary Tract
A. Serum Markers of Hepatobiliary Disease
1. Tests of Liver Function
a. Serum Bilirubin
1) Total--nl range: 0.1--1.0 mgldl
2) Direct--nl range: 0.0--0.4 mg/dl
3) Indirectmnl range: 0,0 0.1 mdl
4) Unconjugated bilirubin (indirect bilirubin)
Increases in serum with increased hemolysis
5) Primarily the direct conjugated bilirubin is elevated with extra-hepatic biliary obstruction
(cholestasis)
t5) Both direct and indirect (conjugated and unconjugated) bilirubin are -increased in the
serum with hepatic disease
b. Albumin--nl range: 3.54.7 g/dl.
c. Prothrombin time (PT)mnl range: 9.2-13.0 sec
d. Serum markers of Hepatocellular necrosis (transaminases)
1) Serum glutamic oxaloacetic transaminase (Aspartate aminotransferase)
a) (SGOT/AST)mnl range: 5-40 IU/L
b) (SGOT) are released from the hepatocyte and are increased significantly in hepatitis of
various etiologies.
2) Serum glutamic pyruvate transarmnase (SGPT)
a) (Alanine aminotransferase) (SGPT/ALT)--nl range: 7--56 IU/L
b) These are also released from the hepatocyte and are increased significantly in hepatitis of
various etiologies.
3) Lactate dehydrogenase (LDH)nl range: 313618 IU/L
Serum markers of extra hepatic/Intrahepatic bile duct obstruction (cholestasis)
a. -Glutamyl transpeptidase (GGTP)mnl range: 7-46 IU/L.
b. Alkaline phosphatase (ALKF)---nl range: 38-126 IU/L
1) An elevated Alkaline phosphatase and U-Glutamyl transpeptidase (GGTP) confirms biliary
tract obstruction
2) Released by the bile canalicular cells; therefore, provide a sensitive test for different causes of
bile stasis
a) Extra hepatic biliary obstruction
b) Cholestasis
(i) Caused by drug reaction
(ii) Primary biliary cirrhosis
c. Leucine aminopeptidase (LAP)--nl range: 12-33 IU/L.
3. Other Diagnostic Procedures
a. Ultrasonography
1) Has become the initial study in evaluating many patients with suspected biliary tract
disease.
2) Painless, relatively inexpensive, and does not entail lethal radiation, nor require any specific
preparation of the patient
3) Computed tomography
Provides noninvasive, detailed imaging
a) Hepatobiliary tree
b) Periampullary region
225813.0000260 49

General Surgery • Hepato-biliaryTract
b Percutaneous Transhepatic Cholangiogram
l) Obtained by percutaneously sticking a thin needle through the liver and injecting contrast
medium directly into an intra-hepatic bile duct
2) Particularly valuable in demonstrating the upper ductai system
c. Endoscopic Retrograde Cholangio Pancreatogram
I) Requires a skilled endoscopist, who endoscopically injects contrast agent to obtain a radiograph
of the pancreatic and biliary ductal anatomy.
2) Of particular value in patients with normal size bile ducts and in those with suspected
periampullary cancer, particularly when a biopsy can be obtained for diagnosis
d Urinalysis
l) A characteristic feature of the jaundice associated with common bile duct caliculi lS its
fluctuating nature wh]ch may progress to non-fluctuating jaundice if complete obstruction occurs,
similar to biliary obstruction associated with malignant disease.
2) Bile in the urine has diagnostic implications
a) Conjugated bile is water soluble so excreted in the urine
b) Unconjugated bile is water insoluble so not excreted
c) If urobilinogen is present, complete biliary obstruction is not present (unnobilogen is
formed in the gut by the action of bacteria on conjugated bilirubin)
B. Cholecystitis/Biliary Colic
1. Etiology
a. Associated with gallstones in more than 90% of cases
b. Acalculous cholecystitis not uncommon after surgery and prolonged bed rest
c. May result from "sludge"
2. Pathogenesis
a. Occurs with impacting of stone in Hartmann's pouch
b. Results in ischemia, necrosis, and ulceration with swelling and impaired venous return from
gallbladder wall with further ischemia (acute cholecystitis)
c. Acute attack often precipitated by a large, fatty meal
3. Signs and symptoms
a. Steady, severe pain and tenderness in the right upper quadrant (RUQ) eplgastrium, may
radiate to right scapula. Pain usually presents postprandially and often resolves within hours (if
biliary colic)
b. Nausea, vomiting
May actually relieve pain (if bfliary colic)
c. Jaundice
Common bile duct (CBD) stone
d. Fever, leukocytosis
e. Murphy's sign is present
Attenuation of inspiration with palpation of RUQ
4. Diagnosis
a. Ultrasound reveals presence of gallstone, thickened gall- bladder with pericholecystic fluid
1) "Headlight"sign
2) Look for dilated CBD
3) Air in the gallbladder wall
b. HIDA scan
False (+) with prolonged fasting state and liver disease
..0 225813.0000260.

< F./-Ii, Ii,a o, 6ol,a,Ie pccmix >
General Surgery • Hepato - biliary Tract  _
5. Treatment
a Conservative with delayed elective cholecystectomy
Rare
1) Rationale
a) Most cases resolve with antibiotics and conservative management
b) Surgery technically more difficult in acute cholecystitis, therefore higher risk of operative
injuries
2) Management
a) Antibiotics
b) Pain control
c) Parenteral fluids
d) Frequent assessment to assess progression of disease
b. Early cholecystectomy
Usually within 72 hours of presentation
1) Rationale
a) 5% fail to respond to conservative management
b) 25-50% have exacerbation while waiting for elective cholecystectomy
2) Options
a) Open cholecystectomy (rarely done
b) Laparoscopic cholecystectomy
Shorter postoperative stay with less postoperative pain and early recovery
c) Cholecystostomy (rarely done)
d) Elective cholecystectomy should be performed even with asymptomatic cholelithiasls in
high-risk patients
3) Brittle diabetic (controlled diabetics are no different than the general populaUon)
4) Immunosuppressed
6. Complications
a. Mucocele
1) 2 ° to gallstone impacting at Hartmann's pouch. Bile accumulates in gallbladder and pigments are
reabsorbed through gallbladder mucosa. Mucus secretion from gallbladder further distends the
gallbladder to form mucocele
2) Treatment---cholecystectomy
b. Empyema
1) Pus in gallbladder
2) Patients usually very ill with increased temperature, rigor, and chills. Persistent and progressive
rise of WBC
3) Treatment
a) Parenteral antibiotics
:
b) Urgent cho..cystectomy or cholecystostomy, depending on medical condition of patien|
c. Gallbladder perforation
1) Uncommon
2) Perforation usually at fundus or erosion of gallstone n Hartmann's pouch
3) Presentation--as in peritonitis
4) Management
a) Fluid resuscitation
b) IV broad-spectrum antibiotic coverage
c) Exploratory laparotomy with cholecystectomy or cholecystostomy
225813.0000260 51

 General Surgery • Hepato-biliaryTract
C. Obstructive Jaundice
l. Etiology
a. Choledocholithiasis
b Biliary stricture
1) Benign
a) Postoperative-injury to CBD
b) Papillary stenosis
c) Sclerosing cholangitis
2) Malignant: Cholangiocarcinoma
3) Postoperative--injury to CBD
a) Biliary tract surgery
b) Hepatic lobectomy
c. Ampullary carcinoma (10%)
d. Carcinoma head of pancreas (85%)
e. Duodenal mass (< 5%)
f. Distal biliary tract carcinoma (< 5%)
2. Diagnosis
a. History and physical examination pointers
1) Previous biliary surgery
a) Duct stone
b) Duct stricture
2) Inflammatory bowel disease: Sclerosing cholangitis
3) Travel to underdeveloped countries: Parasitic infestation, e.g., ascariasis
b. Physical examination
1) Palpable gallbladder (Courvoisier's sign)
a) Pancreatic malignancy
b) Ampullary carcinoma
c) Dilatation secondary to mass
d) No previous scarring because there is no chronic inflammation
c. Laboratory findings
1) Elevated SGOT/SGPT
2) Elevated bflirubin
3) Conjugated bilirubinemia
4) Unconjugated bilirubin--fat soluble; conjugated--water soluble. With biliary outflow
obstruction, the conjugated (direct) fraction "backs up" into the blood stream and is filtered by
the kidneys. This will manifest as a darkening of the urine (hyperbilirubinemia). The failure
of bile to reach the colon will result in gray-colored (acholic) stools
5) Elevated alkaline phosphatase
6) U/S scan
a) Bile duct dilatation
b) Visualization of stone
c) Pancreatic mass
Better visualized at CT scan abdomen
7) ERCP
a) Suitable for distal biliary obstructaon
b) Visualizes ampulla
c) Better assessment of level of dilatation
d) Simultaneous brush cytology
e) Risk of inducing pancreatitis
8) Percutaneous transhepatic cholangiogram (PTC)
a) Suitable for proximal biliary obstruction or in cases of failed ERCP
b) Risk of biliary leak and bile peritonitis
52 225813.0000260.

General Surgery • Hepato - biliary Tract
9) CT scan of abdomen
a) Assessment of pancreas
b) Better in obese patients or patients with prior biliary enteric anastomosis
3. Treatment
a. CBD stone
I) Cholecystectomy and CBD exploration and stone extraction
2) Other option
Preoperative ERCP and papillotomy with duct stone clearance followed by subsequent
laparoscopic cholecystectomy
b. Retained stone (options)
1) Early postoperative--T-tube irrigation with:
a) Monooctanoin
b) Hep.qrin (250,000 U in 250 0.9 NS q x 5 days)
c) Has to be cholesterol stones
2) Late postoperative but intact T-tube
a) Radiological manipulation of stone through tube
b) T-tube is usually left for at least 4 weeks to form maure T-tube track
3) Late postoperative without T-tube options available
a) ERCP with papillotomy and stone extraction. Failure rate high if: stones > 2 cm or if more
than five stones
b) ERCP-guided laser lithotripsy
c) Extracorporeal shock wave lithotripsy (ESWL)
Role of surgery
a. Failed nonsurglcal measures
b. Options available
1) CBD stone extraction
a) Exploration of supraduodenal CBD
b) Transduodenal exploration with sphincteroplasty where supraduodenal exploration fails.
Riskcluodenal leak and acute pancreatitis
2) Biliary enteric bypass
a) Choledochoduodenostomy indication
b) Stone in distal CBD-failed extraction
c) Very dilated CBD
To provide a channel in event of recurrent stone
3) Carcinoma head of pancreas
a) Curative: Whipple's resection
b) Palliative: Biliary enteric bypass
(ii) Cholecystojejunostomy
(iii) Choledochojejunostomy
(iv) Gastrojejunostomy
c. Ampullary carcinoma
Whipple's resection
d. Biliary stricture
1) Bemgn
a) Small segment:
Resection of stricture with primary duct anastomosis
b) Large segment:
Resection with biliary enteric anastomosis
2) Malignant
a) Resection and biliary enteric anastomosis
b) Palliative
Endo-biliary stent

General Surgery • Hepato- biliaryTract
D. Cholelithiasis
1. Etiology
a. More common in women than men
b. Increase in incidence In both sexes and all races wth age
c. Often follows pregnancy
1) Stasis and infection probably predispose to gallstone formation
2) Perhaps of greater importance are abnormalities in the composition of bile caused by
hyperestrinism
d. Associated risk factors (common denominator) is excess circulating iipids and free-fatty acids
1) Obesity(fat)
2) Female (increased estrogen causes peripheral mobilization of free fatty acids via lipolysls)
3) Elderly 
4) Fertile (high circulating estrogen)
5) Hereditary (Pima Indians)
2. Pathogenesis
a. Most mportant is maintenance of a normal ratio betveen bile salts and phospholipid (lecithin) and
cholesterol
b An increase in cholesterol or reduction in the bile salt pool is a potential cause of derangement
c. Composition
1) Cholesterol (common)
2) Pigment
Seen with hemolysis or with inability to conjugate bilirubin (cirrhosis)
3) Mixed (most common)
3. Signs and symptoms
a Cholelithiasls is frequently asymptomatlc and is discovered in the course of routine radiographic
study (or autopsy). Cholecystectomy not indicated
b Cholecystitis
1) Pain becomes constant
2) Nontransient obstruction of cystic duct
3) Nausea/vomiting do not provide relief
4) Temperature, leukocytosis
4. Treatment
a. Diabetic patients should undergo cholecystectomy to avoid complication since disease course is so
accelerated in the diabetic
b. Operation is mandatory for symptomatic cholelithiasis
E. Choledocholithiasis
1. Symptoms
a. Often a history of bHiary colic or jaundice
b. Sudden onset of severe RUQ or epigastric pain that may radiate to the right scapula or
shoulder
c. Nausea and vomiting
d. Jaundice
e. Lcukocytosis
f. Abdominal films may reveal gallstones
g. Laboratory values
1) . Elevated alkaline phosphatase
2) Elevated 5' nucleotide
3) Elevated total bilirubin
54 225813.0oo0260.

< ,Hxa o ovae pTvcc,z.n  '_l|.I
General Surgery • Hepato - biliary Tract
4) F.levated SOOT
5) Elevated SGPT
2. Diagnosis
a. Uitrasonography
b. CT scan
c. Percutaneous transhepatic cholangiography may provide information regarding the cause,
location, and extent of biliary obstruction
d. ERCP with cholangiogram allows for visualization of distal hepatobiliary anatomy
3. Treatment
a. ERCP with papiliotomy may allow CBD stone to pass
b. Cholecystectomy
Done selectively. Wait until gallstone pancreatitis, if present, resolves
c. Intraoperative cholangiography indications
1) CBD > 10 mm by ultrasound
2) History of jaundice
3) History of pancreatitis
4) Recurrent stones
5) Palpable stones in gallbladder
F. Primary Sclerosing Cholangitis
1. General Considerations
a. Possible autoimmune etiology
b. Rare
c. Nonspecific inflammatory
d. Involving both intra- and extra-hepatic biliary ducts
2. Symptoms
a. Intermittent jaundice usually presenting in fourth or fifth decades
b. Pruritus
c. Anorexia
d. Indigestion
.
3. Diagnosis
a. Progressive obstructive jaundice
b. Absence of caliculi in the gallbladder or biliary ducts
c. Absence of disease-causing cholangitis
d. Thickening and narrowing of the biliary ductal system
e. ERCP and cholangiogram will reveal a "beaded" appearance of intra- and extra-hepatic bile ducts
f. Associated conditions
1) Ulcerative colitis/Crohn's
2) Panereatitis
3) Diabetes mellitus
4. Treatment
a. Surgical bypass such as cholecystoduodenostomy
b. Poor prognosis
c. Candidates for liver transplant
d. 4-week trial on prednisone
225813.0000260 55

 General Surgery • Hepato-biliaryTract
G. Recurrent Variceal Bleeding
1. DefinlUon: abnormal elevation in portal venous pressure
2. Etiology
a. Increased pressure due to increased flow and/or increased resistance
b. Increase in portal pressure to > 20 mm Hg leads to development of vances
c. Intrahepatic obstruction
1) Cirrhosis
a) Nutritional
b) Postnecrotic
c) Bfliary
2) Conditions causing hepatic fibrosis
a) Hemochromatosis
b) Wflson's disease
c) Congenital hepatic fibrosis
3) Infiltrative lesion
4) Veno-occlusive lesions: Schistosomiasis
d Extrahepatic obstruction of portal venom system
1) Congenital obstruction
2) Cavernomatous transformation of portal veto
3) Infection (i.e. appendicitis)
4) Trauma
5) Extrinsic compression
e. Extra-hepatic outflow obstruction
1) Budd-Chiari syndrome (hepatic vein occlusion)
2) Right heart failure
3) Neonatorum omphalitis
f Increased hepatoportal flow without obstruction
1) Hepatic A-V fistula
2) Splenic A-V fistula
3. Dmgnoss of variceal bleed
a. Esophagogastroduodenoscopy (EGD)
1) Confirm presence of varices and demonstrate bleeding from varices or demonstrate stigmata
of recent hemorrhage
2) Exclude other causes of upper GI tract
b. Check
1) CBC
2) Blood chemistry
3) Liver function tests
4) PT/PTT
c Areas of collateralization (porto-systemic communications)
1) Esophagus (coronary vein)
2) Hermorrhoidals
a) Superior--inferior mesentefic
b) Middleminferior mesenteric + hypogastric
c) Inferior--hypogastric
3) Retroperitoneal veins of Retzius
4) Umbilical veins (caput medusae)
56 225813.000020.

General Surgery • Hepato - biliary Tract  _
4. Management
a. General
1) Fluid resuscitation
2) Blood transfusion
b. Acute
l) Pharmacologic
a) Vasopressin infusion (initial management for gastric varices)
b) Side effect: risk of producing myocardial ischemia. Addition of NTG (nitroglycerin)
alleviates angina
2) Mechanical
a) Sengstaken-Biakemore tube to produce tamponade and arrest variceal blood. Good
temporary measure until definitive treatment initiated
b) Temporizing (24-36 hours) procedure
c) Risks: aspiration and esophageal perforation
3) Sclerotherapy (initial management for esophageal varices)
a) May be done prophylactically (chronic sclerotherapy)
b) Injection of sclerosing agent
c) Intra-variceal--in US and UK
d) Para-vanceal--in Europe
e) Intra-variceal sclerosis induces thrombosis in the vein and prevents bleeding
0 Para-variceal sclerosis induces inflammation around varices and this prevents leakage
g) Rsks
(i) Stricture
(it) Extra-luminal leakage of sclerosing agent
c. Endoscopic variceai banding
1 ) New technique
2) Shown to have good results
3) No risk of leakage of sclerosant
4) Minimal risk of smcture formation
d. Emergency surgery
I) In event of failure of nonsurgical options (at least two attempts at sclerotherapy)
2) Options
a) Devascularization procedures
i) Esophageal transection and reanastomosis: the esophagus is transected and
reanastomosed. This is done with an EEA gun. This obliterates the varices
it) Transluminal ligation of vm-ices may also be undertaken
iii) Surgical procedures: extensive portazygos disconnection with esophageal transection is
performed
b) Emergency shunt: emergency portacaval shunt s not usually preferred because of hgh
operativelmortality rate (30-40%)
5. Prevention of recurrent bleeding
a. Sclerotherapy
1) Achieves bleeding control in approximately 90% of patients
2) Does not change survival outcome
b. Surgery
1) Shunt procedures
a) Nonselective shunt
Causes nonselective decompression of portal clrculatmn
b) Portal vein
Side to side versus end to end; Disadvantage: increased risk of hepatic encephalopathy
c) Splenorenal shunt
225813.0000260 5 7

General Surgery • Hepato-biliaryTract
d) Selective shunts
Selectively decompresses porto-azygos circulation and reduces intra-variceal pressure
i) Distal splenorenal shunt (DSRS or Warren shunt)
ii) Coronary vein-IVC shunt (Inokuck shunt). Less risk of hepauc encephalopathy
Figure 1-4: Types of Shunts
//,, ....... , //\ ......
Interposition
3. Mesorenal
Figure 1-5: Sengstaken-Blakemore Tube
C,atrlc A_llralion Tube
Balloon .  
S8 225813.0000260.

General Surgery • Hepato - biliary Tract
2) Shunt has some survival advantage over sclerotherapy
3) In selective shunts, noncirrhotics have survival advantage over cirrhotics
4) Nonshunt procedures
a) Esophageal transection
b) Esophageal gastric devascularization
c) Pharmacologic:
Propranolol has been shown to reduce portal pressure
d) Somatostatin
• Tale.:l+l. Child's Classification (Cooperative Risc)
 ,bi,i. .......................... : -.:! . -..S '. ..... i: - !i ::-:.i . 
.- , ........  .
• -:.:saa,- :iiii, /) • ,) .... /:..L;.:.; .:: :.)t . -
.......
. :?  .  ........;-:;:::,--  ........... :.-.-.. ....... ..ў.,..:..... ,:...:...;.....:. ,:.-.::. ........
:.5:::utrtidh:: .........  ....... ::.::. ...:..::.:Good Fair. ..... . " ..... :Oor:.,
5) Transjugular intrahepatic portal systemic shunt (TIPS)
Temporary bridge to definitive shunt procedure.
6) Transplantation
H. Carcinoma of the extra-hepatic biliary tract
1. Etiology and incidence
a. Occurs in approximately 2% of all people operated on for biliary tract disease
b. It is insidious and diagnosis is usually made unexpectedly at surgery
e. Spread of the cancer is by direct extension into the liver or to the peritoneal surface
d. Carcinoma of the extrahepatic bile ducts accounts for 3% of all cancer in the United States
e. More common in males
f. Association with gallstones
g. Chronic typhoid carriers
h. Choledochal cyst
i. Hemochromatosis
j. Location
1) 60% proximal one third (Klatzkin tumors)
2) 20% middle one third
3) 20% distal one third

< ic-ii, ii,a  5ol,a,ioipel pyccii, ix >
General Surgery • Hepato - biliary Tract
2. Signs and symptoms
a. Progressive jaundice
b. Pain in the fight upper abdomen
c. Weight loss
d. Anorexia
e. Physical examination
1) Palpable gallbladder with jaundice usually signifies malignant disease
2) Hepatomegaly
3) Ascites may occur
3. Diagnosis
a. Percutaneous transhepatic cholangiogram (PTHC)
b ERCP
Ductal dilatanon proxxmal to tumor
c. Selective celiac angiography
May document vascular invasion
4. Treatment
a. Palliative surgery is indicated to decompress the hepatobiliary system and relieve jaundice
b Also cholecystoduodenostomy
c. Nonresectable
1) Metastatic disease
2) Extensive vascular invasion
3) Bilobar or secondary radical involvement
d. Surgery
1) Middle/lower one third
WhJpple's procedure
2) Upper one third
Resection, lobectomy versus palliative U-tube stenting
e. 5% 2-year survival with hepaticojejunostomy if positive nodes
Hepatic encephalopathy
I. Etiology
2. Blood flow features of liver with cirrhosis
3. Treatment
a. Nutrition
b. Lactulose/neomycin
c. Oral protein restriction
d. Systemic antibiotics
Primary hepatocellular carcinoma
1. Most common gastrointestinal malignancy in the world (Africa, southeast Asia, Japan)
2. Hepatitis o most common etiologic factor
3. Other factors
a. Environmental toxins (dietary atlatoxin-B, nitrosamines)
b. Exogenous steroids (anabolic, oral contraceptives)
c. Hepatic cirrhosis
60 225813.00O0260.

General Surgery • Hepato - biliary Tract
K. Benign tumors of the liver
•
1. Cavernous hemangiomas: contrast CT, MRI, radio-labeled RBCs, percutaneous biopsy contraindicated,
resection for symptoms only
2. Hepatic adenoma
a. Associated with oral contraceptives and other oral exogenous steroids
b. Symptomatic in 80% of patients
c. High risk of hemorrhage
d. May be seen in glycogen storage disease
e. Malignant potential
f Characteristic angiography
g. Treatment: hepatic resection
3. Focal nodular hyperplasia
a. Central stellate scar
b. Possible relationship to steroids
c. Observation only
d Discontinuation of oral contraceptives
L. Complications of liver resection
1. Post-surgical
a Bleeding
b. Bile leak
c Abscess
2. Metabolic
a. Liver failure
b Renal failure
c. Hypoglycemia (10% dextrose)
d Hypoalbuminernia
e. Coagulopathy (fresh frozen plasma, platelets, packed RBC)
M. Hepatic abscess
1. Cause
a. Biliary
b. Portal venous circulation
c. Hematogenous
d. Cryptogenic
2. Pyogenic (Gram-negative)
3. Amebic (Entameba histolytica)
a, Casoni test
4. Right lobe most commonly involved
a. Echinococcus
b. Pericystcctomy
c. Hypertonic saline

General Surgery • Pancreas
IX. Pancreas
A. Physiology
1. Exocrine pancreas
a. Bicarbonate / water digestive enzymes
b. Trypsinogen --> trypsin (duodenal enterokinase) --> activates inactive forms of pancreauc enzymes.
2. Endocrine pancreas
a. Insulin --> beta cells (75% of the islet cells)
b. Glucagon - alpha cells
c. Gastrin, somatostatin - delta cells
d. Diabetes _> 85% pancreatectomy
e. Somatostatin, pancreatic polypepdde
f. Exocrine pancreatic insufficiency > 95% pancreatectomy
B Pancreatitis
1. Acute pancreatitis
a. Mechamsms that cause acute pancreatitis involve intrapancreatic activation of enzymes, resulting
in autodigestion
b Most common cause in U.S. is alcoholism; then biliary tract disease
c. Other risk factors
I) Abdominal trauma
2) Viral infection
a) Mumps
b) Hepatitis
c) Coxsaclde
3) Hyperlipoproteinemia
4) Hypercalcemia
5) Posterior penetration of a duodenal ulcer
6) Use of certain drugs:
Especially corticosteroids, diuretics, immunosuppressives, isomazole
d. Etiology
1) 70% of cases are related to biliary tract disease (gallstones) or heaw alcohol intake
2) Hypercalcemia
3) Hyperlipidemia
4) Abdominal trauma
5) Drugs (prednisone and thiazide)
6) Vasculitis
62 225813.0000260.

General Surgery • Pancreas
Pathogenesis
Exact pathogenesis is not known but may include edema or obstruction of the ampulla of the Vater
with resultant reflux of bile into pancreatic ducts, stenosis of the accessory pancreatic duct
Signs and symptoms
1) Severe abdominal pain with radiation straight through to the back and relieved by sitting
upright
2) Severe abdominal tenderness
3) Fever, dehydration, prostration
4) Shock
5) Red, subcutaneous nodules resulting from wdespread fat necross
6) Grey Turner's sign
Hemorrhagic ascites that produce discoloration of the flanks
7) Cullen's sign
Discoloration around the umbilicus
8) Phlegm
9) Abscess formation
I 0) Obstruction of the common bile duct causing jaundice
1 I) Fox's sign
Discoloration along inguinal ligaments
12) 5-10% develop necrotizing pancreatitis
g. Diagnosis
1) Severe upper abdominal pain with history of above risk factors
2) Elevation of serum amylase or urinary amylase clearance (more than 4% of creatinine
3) Abdominal x-ray
a) Sentinel loop
b) Psoas border blunting
c) paralyuc ileus
d) gallstones
4) Chest x-ray
a) Elevated hemidiaphragm
b) Left pleural effusion (sympathetic)
5) Ultrasound: gallstones, dilated CBD, enlarged pancreas
6) CT scan: pancreatic edema, peripancreatic fluid
7) ERCP: not indicated in acute phase unless documented stone by ultrasound and papillotomy
required
8) Laboratory finding: Increased amylase
a) Fallopian tubes
b) Pancreas
c) Small bowe.:l
d) Salivary gl_nds
h. Treatment
1) Nasogastric suciion
2) Vigorous fluid 'eplacement
3) Relief of pain
4) Nothing by mouth
5) Analgesia
6) Bowel rest
7) Treatment of complications
8) Hyperalimentation
9) Incentive spirometry
10) Role for antibiotics uncertain
225813.0000260 63

General Surgery • Pancreas
2. Chronic pancreatkis
a. Etiology
1) Gallstone
2) Most commonly alcohol-related
3) Metabolic--hyperlipemic
b Signs and symptoms over time:
1) Abdominal pain, unresponsive to therapy, may be aggravated by eaung
2) Nausea
3) Vomiting
4) Features of varying degree of shock
5) Upper abdominal tenderness and guarding
6) Weight loss, malabsorption
7) Jaundice
c. Diagnosis
1) Hyperamylasemia during exacerbation
2) Amylase levels may be deceptive depending on amount of pancreas that has "'burnt out'"
3) Elevated lipase
4) Painful episodes
5) Presence of risk factors
6) X-ray of abdomen
Documentation of calcifications 95% sensitive for chronic alcoholic pancreautis
d. Complications
1) Necrotizing pancreatitis
2) Pancreatic pseudocyst
3) Pancreatic abscess
4) Shock
5) Adult respiratory distress syndrome
6) Acute renal failure
7) UGI bleeding
a) Therapeutic decisions
b) Relief of pain
c) Fluid replacement
64 225813.0000260.

General Surgery • Pancreas
Treatment in uncomplicated pancreatitis
a. Fluid resuscitation
b. Pain control
c. General supportive measures
d. Debatable role of
1) Antibiotics
2) Nasogastric tube drainage
Indicauons for surgery
a. To treat causative factors
b. Failure to improve despite intensive treatment
c. In cases of difficult diagnosis where cause of peritonitis is not resolved
d. Complications occur which require suical management
5- Necrotizing pancreatitis
a. Presentation
1) Decreasing Hct if hemorrhagic
2) Fulminant clinical course
3) Necrosis visualized or dynamic contrast enhanced CT scan
4) Sequential multiple organ failure
b. Management
1) Antibiotics
2) Fluid resuscitation/total parenteral nutrition
3) Serial dynamic CT scan to assess extent of pancreatic necrosis
4) Surgical indication: Needle aspirate documenting infected peripancreatic fluid collection and
ongoing sepsis
5) Surgical option
a) Pancreatic debridement lavage; opponents state that a lavage "tract" forms and this is not
useful
b) Pancreatic debridement with laparotomy
Leave wound open and regular dressing changes
c. I=Iigh mortality rate
C. Cysts and pseudocysts
1 True cysts
a. Congenital cysts of the pancreas
b. Parasitic cysts
c. Retention cysts are caused by panereatitis
d. Neoplastic cysts
2. Pseudocysts
a. Pancreatitis and trauma are the most important causes of pseudocysts
b. Signs and symptoms
1) Persistent pain, fever, ileus appeanng 2-3 weeks after an attack of pancreatitis or trauma to the
pancreas
2) Persistent hyperamylasemia
3) Epigastric mass (tender/nontender)
c. Diagnosis
1) Ultrasound
2) CT scan of abdomen
3) Upper GI series
225813.0000260 65

General Surgery • Pancreas
d. Treatment
1) Total parenteral nutrition nothing by mouth
2) Serial follow up with CT scan or ultrasound scan to assess change m size of pseudocyst
3) Size < 6 cm usually conservative management gives good chance of resolution; > 6 cm, less
likely to resolve
e. Indcauons for surgery
I) If the psuedocyst does not resolve m 6 weeks, an operauon is indicated
2) Hemmorhage
3) Presence of infection
4) Fistulization (pleura, mediastinum)
f. Surgical options
I) External drainage
a) Immature cysts with thin wall (< 4 weeks)
b) Presence of infection
2) Internal drainage--mature noninfected cysts
a) Cystogastrostomy
b) Cystojejunostomy
c) Cystoduodenostomy
3) Distal pancreatectomy for pancreatic pseudocyst associated with tail of pancreas
g. Nonsureal options
1) Percutaneous cystotomy; 25-30% early recurrence
2) Endoscopic eystogastrostomy
D. Pancreatic Neoplasms
1. Incidence
a. Fourth most common cause of cancer deaths in United States: incidence actually increasing
b. Male: female 2:1
c. Risk factors
1) Smoking
2) Diabetes mellitus
3) Alcohol consumption
4) Increased consumption of animal fats and coffee
5) Increasing age
d. Sixth-seventh decade
e. More common in blacks
f. Increased incidence after gastric resectaon
2. Pathology
a. Ductal cells--5% total cell mass, yet majority of tumors
b. Permeural invasion up to 90% of the time
3. Signs and symptoms
a. Usually vague and nonspecitic until the disease is advanced
b. Persistent epigastric pain with radiation to the back
c. Anorexia, weight loss
d. Obstructive jaundice often painless
e. Migratory thrombophlebitis (TrousseauSgn)
f. Paraneoplastic syndromes (Cushing's syndrome, hypercalcemia)
g. Hepatomegaly
h. Ascites
i. Pleura] effusion

< ic-ii, ii,a  5ol,a,iel pyccii, ix >
General Surgery • Pancreas
4. Diagnosis-
a Demonstration of enlarged pancreas by ultrasonography or CT scan
1) Stage and extent of tumor
a) Ascites
b) Metastases (May miss if < 2 cm)
2) Nonresectable
a) Portal/superior mesenteric invasion
b) Nodes outside of dissection area
c) Obvious metastases
b. Serum tumor markers
(carcinoembryonic antigen, a-fetoprotein)
c. Needle biopsy
d. Alkaline phosphatase and direct bilirubin increase
e. Elevated tumor markers
I) CA 19-9
2) CA 50
3) C-K-RAS oncogene
5. Treatment
a. Surgery is rarely curative but palliative biliary drainage may be useful
I) 1% survival at 5 years
2) Mean survival--I year
3) Only 10-20% with planned resection undergo actual procedure after intraoperative evaluation
4) Whipple procedure: radical resection of GB. CBD, distal stomach, and pancreatic head
a) Gastrojejunostomy
b) Choledochojejunostomy
c) Pancreaticojej unostorny
5) Post-Whipple complications
a) Necrotizing retroperitoneal infection
b) UGI bleeding
c) Marginal ulcer
d) Biliary fistula
e.) Pancreatic fistula
6. Prognosis
a. 70% head of pancreas
b. 15% body
c. 10% tail (worst prognosis secondary to late presentataon)
E. Pancreas divisum: failed fusion
1. 10% of population
2. Duct of Santorini > duct of Wirsung
E Annular pancreas
1. Downs syndrome
2. Duodenal stenosis
3. Peptic ulcer disease
G Islet cell tumors:
1. Insulinoma
"2. Glucagonoma
3. Gastrinoma

General Surgery • Breast
X. Breast
A. Benign Breast Masses
1. Fibrocystic disease
a. Incidence and etiology
l) Most common lesion of female breast
2) Typically occurs between 30-50 years of age
3) May be due to menstrual cycle hormonal changes
4) Can occur as single or multiple cysts; is frequently bilateral
b. Signs and symptoms
l) Monthly cyclic tenderness
2) Palpation of fibrous and cystic areas; no dominant mass
c. Treatment
1) Aspiration or observation
2) Excisionai biopsy if no fluid is aspirated or unusual aspirate
2. Fibroadenoma
a. Incidence
l) Typically occurs late teens to early 30s
2) Occasionally multiple
b. Signs and symptoms
1) Palpation of a smooth, round, firm, discrete, non-tender mass that is movable
2) Rapid growth during high estrogen periods
a) Pregnancy
b) Lactation
c) Premenopause
c. Treatment: Complete excision
B. Breast Cancer
1. Incidence an d epidemiology
a. Most common malignancy in women, second only to lung cancer for cancer-related deaths
b. Leading cause of death in women 40-44 years of age
c. One in nine U.S. women will develop a breast malignancy
d. Ductal carcinoma (80%)
1) 75% of case of breast are infiltrating
2) Scirrhous pattern predominate
3) Anaplastic tumor and those with vascular invasion have poorer prognosis
4) Microscopic invasion of the nipples will occur
5) Medullary, comedo papillary, colloid, and tubular carcinomas (all of duct call origin) are less
common and have a more favorable prognosis)
e. Paget's (not related to bone disease)
I) Presents as excoriation or sore
2) Breast mass may not be palpable
f. Lobular carcinoma in situ (LCIS)
I) 10% overall; 15-20%/ar bilateral
2) Infiltrating lobular carcinoma
3) Slightly more favorable prognosis than for duetal carcinoma
g. Inflammatory (breast looks infected, but tumor blocks lymphatics and causes acute sterile
lym.phangitis)
h. Duct carcinoma in situ (DCIS)
68 225813.000026

< a o orae pycc >General Surgery • Breast  _
2. Risk factors
a. Older than 20 years
b. Family history
1) 30% increased if mother with cancer
2) 50% increased if sister with cancer
c. Nulliparity
d. High SES
e. Females > males (100:1)
f. Estrogen or birth control pills do not increase risk
g. Fibrocystic disease may not increase risk significantly
h, Prior breast cancer
3. Signs and symptoms
a. Breast lumps
b. Pain (more common with fibrocystic disease)
c. Metastases (lung, bone, liver, adrenals)
d. Most frequent presentation: asymptomatic patient with positive screening mammogram
4. Diagnosis
a. Risk factor analysis
b. Physical examination
1) Self-examination
2) Physician
c. Mammography
1) Baseline 35-40 years old (earlier if positive family history)
2) Every 2 years, 40-50 years old
3) Every year if older than 50 years
4) Popcorn micro-calcifications (30% are cancer)
5) Stellate appearances
6) Most commonly upper, outer quadrant
d. Needle aspiration
e. Biopsy
,:.::. ...... .:............::., :::,...:.::...::;....<:..,<. ::.:::....-,;:,_.,-.:.:.,:..-:::::;..:::::.::,...:..:::.:: ,.-_., , .,.- , , ,..... ,.., __., _ , ....
.=-:-: ............ :,. :;..:L:.:c.:-:::t::.Y.::-:: ........... :-,--.:..., ....... :<.-:-'::: :.::.-,"-: ....... )! :-
,
225813.0000260 69

General Surgery • Breast
Treatment
a. Stage I (T1 NO or N1 or MO)
1) Surgery
a) Modified radical mastectomy "gold standard" (for all infiltrating adenocarcinoma of the
breasO
b) For earlier stages, potentially curative
2) Radiation therapy
a) Wide local excision
b) Complete axillary dissection
c) Radiation therapy to the residual breast
3) Chemotherapy
a) Pathologically (+) lymph nodes in axilla
b) Post menopausal patients with positive nodes ER (+)
4) Hormonal therapy
a) Tamoxifen is administered for two years to post-menopausal women wxth (+) nodes who are
ER (+)
b. Stage II (TO Nlb: T1 Nlb M0; T2 N0,1a, lb M0)
1) Surgery
a) Modified radical mastectomy
b) The majority will have (+) axillary nodes
2) Radiation therapy
a) Wide local excision
b) Complete axillary dissection
c) Radiation therapy to the residual breast (acceptable for tumors less than or equal to 4 cm
in diameter)
3) Chemotherapy/hormonal therapy
a) Recommendations are similar to those for Stage I cancer
c. Stage III - Locally advanced (T1 N2 M0; T2 N2 M0; T3 N0,1,2 M0)
1) Surgery
a) Resection with wide marn
b) Modified radical mastectomy may not be adequate
c) Resection of underlying muscle may be indicated if tumor abuts pectoralis muscle
d) If axillary nodes not fixed to adjacent structures, an axillary dissection is indicated
2) Radiation therapy
a) May be preferable to excision as iniual therapy for large tumors (i.e., > 4 cm. in diameter)
b) Fixed axillary nodes are irradiated
c) Radiation followed by surgical resection (if feasible)
3) Chemotherapy
a) Combination of surgery, radiation therapy, and chemotherapy often indicated
b) Induction chemotherapy or radiation therapy or both prior to surgery
c) If not, postoperative agents frequently administered
70 225813.0000260.

< F./-Ii, Ir,a o,r 6oi,a,rbrpel pcc:i6/( >
General SurBery • Adrenal/Vass
4) Hormonal therapy
a) Tamoxifen may be added in the ER (+) post-menopausal patient
d. Stage IV (T4 Any N Any M; Any T N3 Any M; Any TAny N MI)
I) Surgery
a) Goal is pal]muon
b) Local therapy (palliative resection)
c) Disseminated tumor treated with systemic therapy (chemotherapy, hormonal manipulation)
d) Sequential therapy preferred (chemotherapy/radiation therapy --> surgery)
e) Visceral malignancies don't respond as well
f) Chemotherapy is more efficacious
2) Radiation therapy
a) Control of inoperable cancer
3) Chemotherapy
a) Multi-agent chemotherapy
b) Most likely a combination of Cyclophosphamide, Methotrexate (or Adnamycin),
Fluorouracil
e. Ductai cell origin (intraductal carcinoma)
I) Modified radical mastectomy
2) Wide excision
3) Radiation
4) Axillary node dissection
f. Lobular carcinoma
1) Options include mirror image biopsy, serial mammograms, bilateral mastectomy
g. Breast cancer in men
1) 1% of all cases of breast cancer
2) Poorer prognosis
3) Radical mastectomy (best curative rate)
XI. Adrenal Mass
Figure 1-6
• 1-2% at abdominal CT scans will show adrenal moss {'inўidenralomas']
>6era 6em
lid cys .li.c biochemical, assay
otlve tnacve
r ca! dear solid
ollow as r
assay ± *olv
srer,
*NOTE- if • 2 cm, no lurlher workup needed, excepl for blachem,cal assay
22S813.0000260 71

General Surgery • Vascular Surgery
XII. Vascular Surgery
A. Venous Stasis Ulcers
1. Venous anatomy (lower extremity)
a. Lower leg (deep)
Posterior tibial and peroneal veins empty into popliteal vein femoral primary drainage
b. Superficial system
1) Greater saphenous
2) Lesser saphenous
3) Communicating branches (perforators)
2. Pathophysiology
a. Venous stasis ulcers secondary to incompetence of perforating branches with back-up of deep
venous return into superficial system
b. Skin and subcutaneous tissue become edematous with overlying ulceration
c. Most commonly over medial malleolus
Treatment
a. Infected ulcer
1) Strict bed rest
2) Elevate extremity
3) Wet to dry dressings
4) Antibiotics if cellulitis present
b. Clean ulcer
1) Exercise lower extremity
2) Elevate lower extremity when resting
3) Compression boots
4) Zinc-oxide glycerin
4. Surgery
a. Ligate incompetent perforators
b. Major vein--valvuloplasty or valve transplant
B. Varicose Vins
1. Classification
a. Primary
Congenital; saphenofemoral valve incompetence and valves of greater and lesser saphenous
vein
b. Secondary
Previous phlebitis or trauma
1. Pathophysiology
a Reversal of flow causes "backflow" in superficial system
b. Part of deep venous return "circulated" through superficial system
c. Results in tortuous, dilated superfidal veins
2. Diagnosis--Trenddenburg test
3. Therapy
a. Stockings
b. Surgery
1) Saphenous vein stripping
2) Sclerotherapy
3) Saphenofemoral ligation
72 225813.000026

General Surgery • Vascular Surgery
C. Deep vein thrombosis
1. Cytology / risk factors - Virchow's triad
2. Evaluation - I 2s human fibrin scanning. Doppler ultrasound, duplex scanning, IPG, venography
3. Treatment - Streptokinase, urokinase, anticoagulation (heparin, coumadin), Greenfield f'dter
4. Complications
a. Pulmonary embolism
b. Phlegmasia ceruleus dulens
c. Phlegmasia ceruleus albican
d. Post-phlebitic syndrome
D. Diseases of the Aorta
Figure 1-7
Type I Type II i'ype III
1. Aneurysm of the Thoracic Aorta
a. Occurs in any segment of the thoracic aorta
b. Atherosclerosis, medial degeneration, and previous aortic dissection are the most frequent causes
c. Aortitis, syphilis (aortic root), and trauma are rarer causes
d. Regardless of the underlying etiology, hypertension is a prominent predisposing factor
e. In addition to developing saccular aneurysms, the ascending aorta is also subject to diffuse fusiform
dilatation
1) Fusiform dilatation that is associated with aortic valvular regurgitation is known as annuloaortic
ectasia
2S813.00260 73

General Surgery • Vascular Surgery
2) Synthetic graft replacement of the ascending aorta, with aortic valve replacement if necessary, is
indicated when the disease causes local pressure symptoms (chest pain or back pain), when great
or progressive enlargement of the aneurysm occurs, or when severe aortic regurgitation is present
3) Atherosclerotic aneurysms involving the descending thoracic aorta are often asymptomatic
4) Because surgical removal is a formidable task, such aneurysms are usually managed
conservatavely, unless they are greater than 6 cm in size (increased risk of rupture), are
progressively enlarging, or are causing symptoms
5) Because the aorta is fixed at a point distal to the origin of the left subclavian artery, most post-
traumatic aneurysms arise at this site
a) When the aorta is sheared by an abrupt deceleraaon trauma (usually as a consequence of an
automobile accident), a tear may develop in the intima just beyond the mouth of the left
subclavian artery
b) The resulting lesion is a false aneurysm produced by extravasatlon of blood into the media
and subclavian areas
c) This type of aneurysm usually causes symptoms and should be repaired electively
2. Aneurysm of the Abdominal Aorta
a. Are much more common than in the thoracic aorta
b. Abdominal aneurysms are usually considered to be atherosclerotic lesions
c. Also, a genetic predisposition is consistent with the observation that abdominal aneurysms are much
more common in men, exhibit a familial clustering, and are associated with other types of aneurysms
i.e. visceral arteries
d. Clinically, the aneurysm appears as a pulsating abdominal mass, and can usually be detected on
physical examination before any symptoms develop. Ultimately, as the aneurysm enlarges, it
causes abdominal pain; however, many aneurysms rupture before any symptoms appear.
e. Lateral-projection plain roentgenograms of the abdomen reveal the lesion in more than one half of the
cases
f. Ultrasound examination identifies virtually all lesions and accurately indicates their size
g Magnetic resonance imaging can be used to depict involvement of the renal or iliac arteries
h. Long-term oral therapy with a beta-adrenergic bloclong drug may retard the expansion of a small
aneurysm
i. Elective surgery is advisable, in the absence of other medical contraindications, for all
abdominal aneurysms larger than about 5 cm in diameter to avoid rupture
j. Resection of abdominal aneurysms and replacement with a prosthetic graft has a low mortality risk if
dohe electively
3. Dissecting Aneurysm
a. More accurately termed aortic dissection or dissecting hematoma, arises through a spontaneous tear
in the intima, which results in extravasation of blood into a false channel within in the media
b. The intima may rupture initially at any point along the aorta, but the most frequent sites are the
proximal ascending aorta and the descending thoracic aorta just distal to the origin of the left
subclavian artery
c. Classification
1) TypeI
Primary tear in ascending aorta and dissection involving aortic arch and distal aorta
2) Type It
Dissection involving only ascending aorta
3) Type rrl
Primary tear in subclavian artery, extending distally
4) For clinical purposes, since types I and II have a similar prognosis, there are really only two
types; those with the tear in ascending aorta and those with the tear in the descending aorta, also
called "proximal" and "distal," respectively
74 225813.0000260.

General Surgery • Vascular Surgery  _.
5) Tile underlying cause of proximal dssection is loss of integrity of the elastic and connective
tissue in the aortic wall
6) Although this condition is often referred to a cystic medionecrosis, it is better termed medial
degeneration
7) Persons afflicted with Marfan's syndrome are particularly prone to this type of dissection
8) The peak incidence is in the fifth to seventh decades, and it is more common in men than in
women, although the incidence is equal in persons younger than 40 year due to the occurrence of
aortic dissection occurring m women during pregnancy
9) Retroade dissection into the sinus of the Valsaiva with rupture into the pedcardial space,
leading to cardiac tamponade, is a-major cause of the high mortality associated with this type of
dissection
10) Distal dissection most commonly develops in elderly patients with hypertension and
atherosclerosis
d. Clinical manifestations
1) The classic presentation is a sudden onset of excruciating chest pain ("ripping," "tearing,"
or "stabbing"), usually beginning in the anterior chest radiating to the back and moving
distally as the dissection progresses
2) Cardiac murmurs are usually heard at the base of the heart and may be systolic, diastolic, or both
3) A diastolic murmur of aortic regurgitation indicates involvement of the ascending aorta and is
heard in more than 50% of patients with type I dissection
e. Diagnosis
1) Transesophageal echocardiography is now the most accurate imaging method
2) Contrast aortography detects the two channds in the aorta and thereby confirms the diagnosis
f. Treatment
1) The management of acute aortic dissection is basically surgical
2) Medical therapy is directed at reducing the physical stress on the wall of the aorta
3) Combination therapy is usually used: sodium nitroprusside (or Trimethaphan) to reduce the
blood pressure and intravenous propranolol to decrease the left ventricular contractile force
E. Chronic Arterial Insufficiency
1. Aortofliac disease
a. Pathophysiology
1) Inflow--obstruction to the groin
2) Outflow---obstruction leaving the groin
3) Most commonly resultant from atherosclerosis
b. Signs and symptoms
1) Intermittent claudication in hip, thigh, or buttocks
2) Male impotence
3) Absent/distantifemoral pulses
4) Femoral bruits -
5) Rest pain
6) Gangrene/ulceration
7) Leriche's syndrome (buttock claudication)
Results from atherosclerotic occlusion of distal aorta and proximal iliac vessels
a) Pallor
b) Impotence
c) Fatigue
d) Trophic changes
e) Atrophy of muscles
225813.0000260 75

 General Surgery • Vascular Surgery
c. Diagnosis
i) Doppler ultrasound
2) Ankle/brachial index (ABI)
a) Norm--I.0
b) 0.6-0.9--claudication
c) < .5--rest pain or ulcerations
d) Falsely elevated in diabetics
3) Arteriogram
d. Treatment
1) Ciaudication
a) Stop smoking
b) "Walk through" claudication
c) Treat cholesterol and diabetes
2) Rest pain/ulceration--threatened limb loss
a) Aorto-bifemoral bypass
b) Femoral
Femoral crossover if good circulation in one extremity
c) Axillo-bifemoral bypass
i) Avoid abdomen
ii) Considered "extra-anatomic"
iii) Shorter long-term patency
iv) Balloon angioplasty
Isolated stenotic lesion
2. Femoropopliteal occlusive disease
a. Etiology and pathogenesis
1) Atherosclerosis
2) Most common location is at the adductor (Hunter's) canal
3) Also lesions at profunda femoris takeoff, popliteal artery, tibioperoneai trunk
b. Signs and symptoms
1) Intermittent daudication of calf
2) Rest pain in foot
3) Trophic changes in pretibial region
4) Thickening of nails
5)- Shiny, hairless skin
6) Ulceration and gangrene at end-circulation (toes)
c. Treatment
1) Claudication---same as aortoiliac disease
2) Rest pain]ulceration
a) Laser balloon--angioplasty
b) Femoral
i) Popliteal bypass
ii) Synthetic graft
iii) Autologous vein
(a) Higher 5-year patency
(b) Reversed saphenous (ex vivo) technique
(c) In situ bypass
iv) Femoral-tibial bypass
76 225813,0000260.

< leIi,,zr,a o, 6oi,a,I,e pcci(:i, zx >
General Surgery • Vascular Surgery  _.
F. Acute Mesenteric Ischemia
I. Etiology and pathogenesis
a. Small bowel and colon with extensive collateralization
b. Most commonly related to atherosclerosis
c. Thrombosis
Most commonly at origin of superior mesenteric artery (SMA)
d. Embolus
6-8 cm after takeoff of SMA, distal to middle colic artery takeoff
e. Embolus most commonly originates from heart
1) Related to atrial fibrillation
2) Myxomatous cardiac disease
3) May also arise from atherosclerotic aorta
Signs and symptoms
a. May give history of recurrent postprandial abdominal pain (intestinal angina)
b. Cardiac disease coexistent
c. May follow hypotensive episode (non-occlusive ischemia)
d. May ingest digoxin (unknown relationship)
e. Sine qua non
Pain out of proportion to physical examination
f. May have gastrointestinal evacuauon
Diagnosis
a. High index of suspicion
b. Selective mesenteric angiography
c. Leukocytosis
d. Metabolic acidosis
e. Air in wall of bowel (plain film)
Therapy
a. Papaverine infusion into mesenteric circulation
b. Embolectomy
c. Aorto-mesentenc bypass
d. Look for bowel viability
1) Color
2) Intestinal peristalsis
3) Venous engorgement
4) Fluorescein beads
5) Doppler examination
6) "Second-look" operation
225813.0000260 77

I General Surgery • Urology
XIII. Urology
A. Prostatic Carcinoma
1. General Considerations
a. Rare in men below 50 and incidence increases with age
b. Most common malignancy in older men
c. Second most common cause of death in men over 55
d. Incidence rate of 130,000 per year
e. Death rate of 30,000 per year
f. More common in African Americans than Whites
Etiology
a. Unknown !
b. Both hormonal influence (testosterone:estrogen ratio) and environmental factor are suspected
c. Association with au'ophy of prostate noted
d, No association with benign prostatic hyperplasia (BPH) and they may even coexist
Pathophysiology
a. Most of the cases arise from the peripheral zone
b. At early stages, it is confined within gland, then invades capsule and into the seminal vesicles
c. Local extension to the pelvic and ischial bones
d. Metastases by hematogenous route to the lungs, liver and adrenals.
Signs and Symptoms
a. Obstructive voiding symptoms
1) Retention
2) Frequency
3) Urgency
4) Hesitancy
b. If with metastasis:
1) Bone pain
2) Weight loss
3) Ureteral obstction
4) Fatigue
Diagnosis
a. Regular rectal examination for men over 50
1) Finding areas of induration and irregularity suggest diagnosis
2) If I cm nodule detected, there is S0 % chance of cancer
b. Prostate-specific antigen
1) Tumor marker
2) Produced ordy by prostate, but not cancer specific
3) Also used for monitoring purposes after radical prostatectomy; elevation suggests
recurrence
c. Prostatic acid phosphatase
1) Not specific for prostatic cancer
2) Significant elevation suggest metastasis
d. Definitive diagnostic procedure
1) Transperineal or transrectal needle biopsy
2) Transurethral biopsy
78 225813.0000260.

7. Prognosis
Both stage and grade of tumor determine prognosis
B. Testicular Carcinoma
1. General Considerations
a. Relatively rare
b. Incidence rate of 2/100,000 men/year
c. Most common solid tumor of young men age between 20-40
d. Rare in African Americans
2. Etiology
 Unknown
b. More common in undescended testes
3. Signs and symptoms
a. Painless scrotal mass, which increases in size; discomfort
b. In late metastasis
Weight loss, fatigue, enlarged regional lymph nodes
4. Pathology
a. Usually of germ cell origin (95%)
b. From the primordial germ cells of testes
e. Most are seminomas (40%)
d. Teratoearcinomas and embryonal cell carcinomas account for 25% each.
5. Diagnosis and differential diagnosis
a. Transillumination and serotal ultrasound
b. Differentiates between spermatocele and hydrocele
c. EpididymRis is most common misdiagnosis
d. Tumor markers
225813.0000260 79

 General Surgery • Urology
I) Alpha-fetoprotein (AFP)
Increased in embryonal carcinoma and yolk sac tumors
2) b-hCG
a) Increased in choriocarcinoma, pure seminoma and in embryonal carcinoma
b) definitive diagnosis:
c) Inguinal exploration and microscopic identification of tumor cells
6. Management
a. Seminomatous
1) StageA, B1
Inguinal orchiectomy and radiation therapy
2) Stage B2 and B3
Chemotherapy
b. Non-seminomatous
l) Low stage
Orchiectomy and retropntoneal lymph node dissection
2) High stage
Orchiectomy and chemotherapy
7. Prognosis (5-year survival)
a. Highly malignant choriocarcinoma almost zero %
b Seminoma localized in testes = 90%
C. Renal Cell Carcinoma
1,. General Considerations
a. Most common malignant tumor of the renal parenchyma
b Men:women (2:1)
c. More common in 50-70 year age group
d. No racial difference
2. Etiology
a. Unknown
b. Association between muitifocal bilateral tumor and von Hippel-Lindau disease
c. Cigarette smoking is implicated
3. Signs and symptoms
a Clinically silent until late stage
80 225813.0oo0260.

General Surgery • Urology  _
b. Late symptoms
1) Flank pain
2) Gross hematuria
3) Palpable mass
4) Weight loss
5) Hypertension
6) Anemia
7) Lethargy
8) Fever
4. Types
a. Foamy (granular) cell carcinoma and tubular adenocarcinoma
b Wilm's tumor
c. Renal sarcoma
5. Differential Diagnosis
a. Polycystic disease
b. Hydronephrosis
c. Metastatic disease from:
1) L.vmphosarcoma
2) Leukemia
3) Renal tuberculosis
4) Breast cancer
6. Diagnosis
a IVP
b. Ultrasound
c CT scan
d. Serum calcium
e. Liver function test
f. Bone scan
g CT scan of liver
h. Chest X-ray
7. Management: Radical nephrectomy with excision of affected adrenal gland and hilar nodes
8. Prognosis
a. Depends on the stage once diagnosed
b. Without metastasis, 5-year survival rate greater than 50%
225813,0000260 81

i[ General Surgery • Urology
D Pyelography
1. Intravenous Pyelography (IVP)
a. General Considerations
1) Excretory urography
2) Used as initial study for evaluating the kidneys and ureters
3) Uses intravenous administration of a radiographic contrast agent
b. Indcataon
1) locate stones
2) determine presence of obstruction, hydronephrosis, and caliectasis
3) renal/ureteral anomalies.
4) stab or gun shot wounds to flank or upper abdomen
5) identify anatomic abnormalities causing stone formation
c. Contraindications
1) allergy to contrast media
2) contrast toxicity
3) cardiac disease
4) pregnancy
2. Retrograde Pydography:
a. General Considerations
1) Contrast media injected through a catheter into the ureteral orifice
2) To demonstrate the ureteral lumen and the upper collecUng system of the kidney
b. Indications
1) Locate stones
2) Determine presence of obstruction
3) Identify anatomic abnormalities
4) In high-grade obstructions due to impacted ureteral stones
5) In defining necessity for pre-op drainage with ureteral catheter or
6) Percutaneous nephrostomy tube
7) Ureteral disease such as stricture or retroperitoneal fibrosis
c. Contraindication
1) Allergy to contrast media
2) Urinary tract infection
d. Complications
1) Ureteral perforation
2) Calyceal rupture
3) Bacteremia and sepsis
82 225813.0000260.

< F.z-Ii, Ii,a o, ,oi,a,Ie pTVcc1KIX >
General Surgery • Urology
E. Trans-urethral Resection of the Prostate
1. Indication
a. Gold standard in treating benign prostatic hyperplasia (BPH)
2. Complications
a. Bleeding
b. TURP Syndrome
Due to excess irrigation fluid absorption leading to.
1) Hyponatremia
2) Water and ammonium intoxication
c. Urinary tract infection
d. Epididymitis
e. Urinary retention
f. Incontinence
g. Urethral stricture
h. Impotence
i. Retrograde ejaculation
E Bladder cancer
1. Peak incidence 50-70 years
2. Males > females
3. Transitional cell type 90% >> squamous cell >> adenocarcinoma
4. Painless hematuria > bladder irritability
5. Prognosis based on histologic grade of cancer and presence of muscular invasion
6. Metastases via both lymphatic and hematogenous route (bile, liver and bone)
7. Endoscopic ablation (superficial lesions)
8. Radical cystectomy, _ pre-op RT (invasive lesions)
225813.0000260 83

 General Surgery • Pediatric Surgery
XIV. Pediatric Surgery
A. Congenital Diaphragmatic Hernia
1. Failure of complete formation of the diaphragm. Results in a defect through which abdominal
organs herniate into the chest
2. Types
a. Bochdalek Hernia
l) Epidemiology
a) The most common congenital diaphragmatic hernia
b) Incidence is 1 in 4,000 live births
c) More common in males
2) Signs and Symptoms
a) Cyanosis
b) Dyspnea
c) Dysphagia
d) Tachycardia
e) Respiratory difficulty
f) Dull to tympany on percussion of chest
g) Decreased respiratory movement on affected side
h) Right-sided heart sounds
i) Breath sounds diminished to absent
j) Occasional peristalsis in chest
3) Pathophysiology
a) Failure of complete formation of the diaphragm
b) Results in a lateral defect through which abdominal organs herniate nto the chest
i) This prevents normal lung development
ii) Affected lung and pulmonary arteries become hypoplastic
4) Diagnosis
a) Pre-natal ultrasound
b) Chest X-ray
5) Management
a) Stabilization and pre-op preparation
b) Operative treatment
i) Substernal approach
2i) Reduce hernia
iii) Repair diaphragm
c) Post-operative respiratory, circulatory, metabolic, and nutritional support
6) Prognosis
a) Depending on severity of pulmonary hypoplasia
b) Has b_igh pexi-natal mortality
b. Morgagni Hernia
1) Epidemiology
a) Less common than Bochdalek
b) Females more affected than males
c) Mostly older patients than Bochdalek
d) Occasionally seen in infants
2) Signs and Symptoms
a) Most asymptom, atic
b) Occasional epigastric or lower chest pain
c) Intermittent constipation
d) Flatulence

General Surgery • Pediatric Surgery
3) Pathology
a) Results from a defect in the anterior midline retrosternal muscle
b) Occurs behind sternum through the foramen of Morgagni
c) Most often contain the liver
d) Occasionally including stomach, intestines
e) Incarcerated hollow viscera usually account for symptoms
4) Diagnosis
a) Chest x-ray: Anterior mass with air-fluid level
b) Barium studies: Visceral herniation
5) Management
a) Children
i) Early intervention
(a) Due to increased rate of strangulation
(b) Open, reduce and close defect
b) Adults
i) Observation
If simple omental herniation
ii) Surgical repair
If symptomatic or containing viscera
B. Congenital Heart Disease
1. Tetralog.v of Fallo!
a. General Considerations
1) One of the most common congenital heart malformation (10-15 %)
2) The most common cyanotic malformation (>50%)
b. Signs and Symptoms
1) Dyspnea
2) Cyanosis
3) Cyanotic spells = hypoxemic spells
a) Sudden onset of dyspnea
b) Sudden onset of cyanosis
c Altered consciousness
d) Decrease intensity of systolic murmur
. 4) Squatting
5) Usually small and thin
6) Cyanosis of nail beds, lips, oral mucosa
7) Clubbing of fingers and toes
c. Pathology
1) Consists of
a) Right ventricular hypertrophy
b) Ventricular septal defect
c) Pulmonary stenosis
d) Overriding aorta
d. Diagnosis
1) Chest x-ray
a) Small "boot-shaped" heart
b) Decreased pulmonary blood flow
2) ECG
a) Always abnormal
b) Right vcntricular hypertrophy with right axis deviation

< Hia om 6omao)e pyccx >
 General Surgery • Pediatric Surgery
3) Echocardiography
a) Reveals thickening of the free right ventdcular wall
b) With overriding aorta and a membranous venmcular septal defect
c) Important in establishing the diagnosis
4) Cardiac Catheterization
a) Reveals right-to-left shunt
b) Definitive
5) Angiocardiography: definitive
e. Management: Surgical correction
1) 2-stage repair
a) Shunt procedure in infancy
i) Blalock-Taussig shunt
(a) More common
b) Complete repair at 3-5 years of age
i) VSD closure
ii) Excision of hypertrophied infundibular muscle
iii) Enlargement of pulmonary artery
2) Complete repair during infancy
A more recent trend
f. Prognosis-good success rate for surgical correction
2. Patent Ductus Arterlosus
a. General Considerations
1) One of most common congenital heart disease (10%)
2) Incidence rate of 1 per 2,500 live births and increases:
a) With prematurity and with decreasing birth weight
b) In children born to mothers who had rubella during first trimester of pregnancy
c) In babies born at higher altitudes (over 10,000 fee0
3) More common in females (2:1)
b. Signs and Symptoms
1) Often asymptomatic
2) Poor feeding
3) Respiratory distress
4) CHF with respiratory infections
5)" Acyanotic unless other cardiac lesions are present
6) Characteristic continuous harsh "machinery" murmur at left precordial area
Establishes diagnosis in 95% of cases
c. Pathology
1) Physiologic right to left shunt in fetal circulation
2) Connecting the pulmonary artery to the aorta
3) Bypassing the fetal lungs
4) The ductus closes within a few hours to a few days after birth
5) However, in some this does not occur
d. Diagnosis:
1) Physical examination: "Machinery" murmur
2) Doppler echo
a) To rule out associated defects
b) Outlines size and shunt pattern accurately
3) Cardiac catheterization
4) Chest radiograph
5) ECG
86 225813.0000260.

< iHIa oT 6oaTspeH pycclqx >
General Surgery •
e. Differential Diagnosis
1) Abrucopulmonary septal defect
2) Sinus of Valsalva that has ruptured
3) Truncus arteriosus
4) Pulmonary branch stenosis
5) Peripheral arteriovenous fistula
6) VSD with aortic insufficiency
f. Management
1) Medical
a) Indomethacin
b) Prostaglandin inhibitor
2) Surgical
a) Ligation at 1-2 years of age
b) Except when CHF present, must ligate immediately
g. Prognosis
1) Small PDA
Patient may live normally with few cardiac symptoms
2) Large PDA
CHF most likely to occur early infancy
3) Infectious endarteritis may be present
h. Complications
1) Pulmonary hypertension can occur wth large PDA if without surgery
2) Rare
a) Aneurysmal dilatation of the pulmonary artery or duct
b) Calcification of the ductus
c) Non-infectious thrombosis of the ductus with embolization
d) Paradoxic emboli
3. Atrial Septal Defect
a. Epidemiology
1) The third most common congenital cardiac anomaly
2) More common in female (2:1)
3) Seeundum defect is the most common type
b. Signs and Symptoms
1) Most patients are asymptomatic
" 2) Systolic murmur
3) Fatigue
4) Exertional dyspnea
5) Palpitation
6) Frequent respiratory infection
7) Fixed widely split, second heart sound almost pathognomonic
8) Short early diastolic murmur diagnostic
9) May have growth and development retardation
Gracile habitus
c. Pathophysiology: ASD results in a left-to-right shunt
d. Diagnosis
1) Auscultation
a) Systolic murmur with fixed widely split second heart sound
b) Short early diastolic murmur
2) Chest x-ray: prominent pulmonary shadow
3) ECG
a) Right bundle branch block
b) Right ventricular hypertrophy
Pediatric Surgery  _
225813.0000260

 General Surgery • Pediatric Surgery
4) Radionuclide Scan
5) Echo
6) Catheterization
e. Differential Diagnosis
Partial anomalous pulmonary venous return
f. Management
Surgical closure of defect
g. Prognosis
1% operative mortality
4. Ventricular Septal Defect
a. The most common congenital heart defect (25%)
b. Signs and Symptoms
1) Failure to thrive
2) Difficulty feeding
3) Respiratory infection
4) CHF
5) Hemolysis
6) Parasystolic murmur
7) Palpable thrill
c Pathology
1) Failure of the ventricular septum to completely close
2) of cases involves membranous septum
3) Left-to-right shunt
4) CHF
5) Increase in pulmonary blood flow
d. Pathophysiology
1) Cardiac failure
2) Pulmonary hypertension
e. Diagnosis
1) Chest x-ray
a) Cardlomegaly
b) Increase in pulmonary vasculature
2) ECG
- a) Left atrial enlargement
b) Left ventricular enlargement
3) Echocardiography
4) Catheterization
f. Management
1) Small defect
a) Observation
b) More than 90% undergo spontaneous closure by age 8
2) Large defect: Surgical closure of defect
g. Prognosis: 1-10% operative mortality
C. Tracheoesophageal f/E) Fistula
1. Signs and symptoms (with associated esophageal atresia)
a. Respiratory distress
b. Excessive salivation
c. Cyanosis with first feeding
d. Distention
e. Aspiration pneumonitis
f. Most commonly proximal esophageal atresia with distal tracheoesophageal f'tstula
88 225813.0000260.

< F/-mIa o Oola=pe pJcCIWx >
General Surgery * Pediatric Surgery
2. Etiology
a. Males = females
b. Associated with polyhydramnios
c. Majority of infants have assocmted abnormaliues
3. Diagnosis
a. Inability to pass nasogastric catheter with follow-up chest x-ray
b. Abdominal f'dm with gas pattern
c. Bronchoscopy
d. Contrast study
4. Treatment
a. Catheter in esophagus
b. IV antibiotics
c. Immediate repair if no other major abnormalities
1) Suture close TE fistula at tracheal end and cover with pleura
2) Single-layer-end-to-end esophagus and/or proximal myotomy
D. Neonatal intestinal obstruction
1. Cardinal signs
a. Maternal polyhydramnios
b. Bilious or nonbilious vomiting
c. Abdominal distension
d. No meconium passage (Ј 48 hours)
e. Atresia - complete obstruction
f Stenosis - residual lumen present
2. Physical examination
Flat or distended abdomen, tender erythematous abdomen, shock
3. Diagnosis
Electrolyt imbalance; abdominal x-ray shows quantity and location of distended loops; calcification;
alkalosls vs. acidosis; sonography, CT scan
.
4 Treatment
a. Duodenal obstructmn: duodenoduodenostomy
b. Annular pancreas: duodenoduodenostomy
c. Malrotation: drotation, division of bands, appendectomy
d. Jejunoileal atrCsia: exteriorization or anastomosis
e. Colon atresia: colostomy
f. Meconium ileus: Gastrograffin (Conray) enema and staged anastomosis
g. Necrotizing enterocolifis: bowel rest, hyperalimentation, anastomosis or resection and
exteriorization
5. Supportive measures
a. Nasogastric suction
b. Appropriate fluid replacement and maintenance
c. Antibiotics if needed

 General Surgery • Pediatric Surgery
6. Gastroesophageal reflux
a. Work-up
1) Barium enema, upper GI series
2) Radionuclide milk scan
3) Manometry
4) Midesophageal pH monitonng
b. Treatment: Nissen fundoplication
E, Duodenal Obstruction
1. Etiology and pathogenesis
a, Most commonly secondary to duodenal atresia of mucosa
b. Duodenal web
ў. Associated with polyhydramnios
d. Majority distal to ampulla of Vatr
e. Annular pancreas
2, Diagnosis
a. Intolerance to feeding
b, Association with Down's syndrome
c. Bilious vomiting
d. Roentgenograms"double-bubble" sign
e. Contrast study rarely required
3 Treatment
a. Laparotomy within first 48 hours
b. Duodenoduodenostomy versus duodenotomy and web excision (if present)
c. Side-to-side duodenojejunostomy
d. IV antibiotics
F. Malrotation
1. Pathology
a, Incomplete rotation with lack of fixauon
b. Complete obstruction (mid-gut volvulus)
c. Partial obstruction (Ladd bands)
Ladd bands
a. Peritoneal bands
b. Baby looks healthy
c. Intermittent bilious vomiting
d. Upper GI series and barium enema are suggestive
Midgut volvulus
a. Complete obstruction
b, Baby looks ill
c. Abdominal distension
d Upper GI series and barium enema are diagnostic
Treatment
a. Derotation
b. Division of Ladd bands
c. Resection of devitalized bowel
90 225813.0oo0260.

< Hma o, 6oamlpe pyccwx >
General Surgery • Pediatric Surgery  _
G. Jejunoileal atresia
1. Pathophysiology
a. Intrauterine mesenteric vascular accident
b. Polyhydramnios not present
c. Variable deee of abdominal distension
d. No passage of meconium
2. Management
a. Exteriorization
b. Elemental diet
c. Resection with anastomosis
d. Overall monahty: 15%
e. Parenteral nutrition
H. Meconium Ileus
1. Affects 10-20% of infants born with cystic fibrosis
2. Signs and symptoms
a. Vomiting
b. Distention
c. Failure to pass meconium
d. Abdominal x-ray
1) Distended loops of bowel
2) Minimal air fluid levels
3) Right lower quadrant (RLQ) "'ground glass" appearance
e. Treatment for uncomplicated meconium ileus
1) Gastrografin enemas
2) If above fails, operation enterotomy and imgatmn versus resection and enterostomy
I. Gastrointestinal duplicataon
1. Pathophysology
a. Can occur anywhere along GI tract
b. May contain all layers of bowel wall
c. If gastric mucosa present - bleeding may occur
d. Other presentations: obstruction, perforation
2. Diagnosis
a. Clinical grounds
b. Conventional x-rays
c. Contrast studies (upper GI series, barium enema)
d. Abdominal ultrasound
3. Types/treatment
a. Esophageal duplicataon - resection, repair
b. Small bowel - resection, repmr
c. Stomach/duodenum - excision of the common wall
225813.0000260 91

< le/-Iiўr,a o, 6ol,a,BrDeli pcc:i, tx >
General Surgery • Pediatric Surgery
1. Hirschsprung's Disease
1. Etiology and pathogenesis
a. Absence of Auerbach's and Meissner's ganghon cells (no parasympathetic innervation)
b. Functional obstruction of rectosigmoid colon due to lack of peristalsis
c. Usually involves distal colon; variable proximal involvement
d. Males > females
e. Familial pattern
2. Signs and symptoms
a. Delayed meconium passage
b. Abdominal distention
c. Vomiting presents later
d Alternating diarrhea and constipation may be present
e. Abdominal plain films with distended loops small/large bowel
f. Contrast studies
g. Diagnosis confirmed by rectal biopsy and acetylcholinesterase staining of neurofibrils
3. Therapy
a. Neonates---diverting colostomy
b Delayed "pull-through'" anastomosis after 1 year
K. Necrotizing Enterocolitis
1. Euology and pathogenesis
a. Usually premature infants
b Unknown etiology
c. Splanchnic vasoconstriction results in mucosal injury
d. Bacterial overgrowth
2. Signs and symptoms
a. Distention
b. Vomiting
c. Rectal bleeding
d. Possible mass (abscess)
e. Abdominal wall erythema
f. Abdominal plain f'flms
1) Dilated loop of bowel
2) Pneumatosis intestinalis
3) Air in hepatobiliary tract
4) Free air under diaphragm
5) Ascites
g. May result in DIC
3. Treatment
a_ Supportive therapy
1) Hyperalimentation
2) IV antibiotics
b. Surgery
1) Resection of devitalized bowel
2) Ostomy
3) Second-look laparotomy
4) 50% mortality correlates with gestational age
92 "-
225813.0000260.

< F/-mIa o Oola=pe pJCCMX >
General Surgery *
L Meeonium plug syndrome.
1. Colonic meconium ileus
2. 20%: Hirschsprung's disease
3. Gastrografin enema
4. Operation (rare) when?: perforation
M. Colon atresia
1 Pathophysiology
a. Slow progessive abdominal distension
b. Failure to pass meconium
c. Associated congenital deformities
d. Abdominal wall defect
e. Bladder exstrophy
2. Treatment: staged colostomy with anastomosis
N. Omphalocele
1. Defect of the umbilical ring with investing peritoneal sac
2. Association with premature infants and other GI abnormalities
3. Viscera herniate through sac
a. Small bowel
b. Liver
c. Malrotation often present
4. Treatment
a. Nasogastriў tube
b. Early operative intervention
1) Small defects
Primary closure
2) Larger defects
a) Staged closure
b) Dacron-silo
c) Delayed closure
d) Agents causing eschars
O Gastroschisis
I. Males = females
2. No peritoneal sac
3. Defect lateral to the unbilicus, usually to the right of the umbilical cord
4 Intrauterine peritonitis
5. Usually without associated anomalies
6. May have intestinal atresia
7. May involve genitourinary organs in females
8. Treatment
a. Nasogastric tube
b. Vigorous IV resuscitation
c. IV antibiotics
d. Surgery
1) Attempts at primary reduction of viscera
2) Staged procedure using Dacron silo and delayed closure
Pediatric Surgery
225813.0000260 93

General Surgery • Pediatric Surgery
P. Pyloric Stenosis
1. Etiology and pathogenes,s
a Unknown etiology
b. More common in firsbborn, males > females
c Increased smooth muscle of pyiorus
2. Signs and symptoms
a Projectile vomiting after feeding (nonbilious)
b. Usually presents between second and fourth weeks of life
c Palpable mass in epigastrium ("olive")
 d. Visible peristalsis
 e. Failure to thrive
 3. Diagnosis
 a. Ultrasound may show hypertrophied muscle and lengthening of pyloric channel
 b Barium contrast study
v 4. Therapy
i a. Vigorous fluid resuscitation
b. Nasogastric tube/oro-gastric tube
 c. Extramucosal pyloromyotomy
v Q. Intussusception
1. Etaology and pathogenesis
a. Most common before the age of 2 years
b. Males > females
c. Often follows viral infection with hypertrophy of submucosal lymphoid tissue
1) Gastroenteritis
2) Upper respiratory infection (URI)
d. Most commonly at ileocolic junction
2. Signs and symptoms
a. Colicky abdominal pain of sudden onset
b. Nausea and vomiting
c. Currant-jelly stool intermixed with mucous and blood
e. "Sausage" palpable in RLQ
3. Diagnosis
a. Abdominal films
1) Dilated loops of small bowel mr
2) Air fluid levels
b. Barium enema
"coiled-spring" appearance
4. Treatment
a. Nasogastric tube
b. IV antibiotics
e. Attempts at hydrostatic reduction (barium enema) successful 70% of the lame
d. Surgery
1) "Milk the intussusceptum"
2) If unsuccessful, bowel resecuon
Look for "lead-point"
94 225813.0000260.

General Surgery • Pediatric Surgery  _
R. Choledochal Cyst
1. Etiology and pathogenesis
a Cystic outpouching of intrahepatic or extrahpatic bile ducts
b. May be secondary to pancreatic enzyme degradation of canalicular endothelium and ductal wall
c. Females > males
d. Most commonly cystic dilatation of common bile duct
2. Signs and symptoms
(Intermittent)
a. Jaundice
b. Pain in RUQ
c. Palpable mass
d. Pancreadtis
3. Diagnosis
a. Ultrasound
b. PTHC
c. ERCP
4. Increased risk of malignant degeneration
a. Cyst resection
b. Roux-en-Y hepatmojejunostomy
S. Atresia of the bile ducts
1. Etiology: congemtal abnormality
2. Diagnosis
a. Jaundice Ј 2 weeks of life
b. Progressive dark urine
c. Acholic stools
d. Exclude
1) Neonatal jaundice
2) Hepatitis
3) Alk phos, SGPT/SGOT
3. Treatment: Roux-en-y portoenterostomy
4. Problems
a. Post-operative cholangids
b.. Biliary cirrhosis/portal hypertension (50% of survivors)

General Surgery • Wounds
XV. Wounds
A. Stages
1. Subacutc phase
a. Inflammation
1) Polymotphonuclcar lcukocytcs
2) Macmphages
b. May bc difficult to distinguish from infection
c. No increase in wound strength
2 Proliferative phase
a. Begins when wound covered by epithelium
b. Collagen production
c. Fibroblasts and capillaries to the wound
d. Scar appears red, raised, and hard
e. Wound sWength increases
3. Maturation phase
a. Maturation of collagen
b. Scar flattens
c. Continued wound strength gain
B. Classifications
1. Healing by first intention/1 ° healing
a, Closed with sutures or tape
b. Skin grafts can also be considered 1 °
2. Healing by second intentionl2 ° healing
a. Wound left open to allow spontaneous healing
b. Used with gross contamination
3. Healing by third intention/3 ° healing
a. Closure after infection is gone
b. Interrupts 2 ° healing
C. Factors Affecting Wound Healing
1. DID NOT I-AL
Drugs
Infection
Diabetes
"N" adequate Nutrition
Tissue necrosis
Hypoxia
Excessive tension on wound edges
Another wound (competition for substrates)
Low temperature
2. Acute problems
 Infection
b. Dehiscence
3. Chronic problems
a. Hernia formation
b. Excessive fibrosis
96 225813.0000260.

< F/-mIa o, Oola=pe pI/cciw,,x >
General Surgery * Infection
D Wound Care
1. Cleanly incised wounds that are properly sutured will heal unless infection supervenes
2. Bleeding points must be ligated carefully because development of a hematoma predisposes to infection.
Careful obliteration of dead space is necessary to minimize the collection of serum in the wound
3. Traumatic wounds that are associated with large amounts of contamination and destruction of soft tssue
should be debnded
4 The use of antibiotic therapy in conjunction with debridement has markedly reduced the massive infection
rates
XVI. Infection
A Etiology
1. Infection of surgical wounds is the result of bacterial contamination, either from the patient's internal
environment or from breaks in surgical technique
2. Two primary factors are significant in the pathogenesis of infection
a. Dose of bacterial contamination
b. Resistance of the patient
B. Classifications According to Degree of Infection
1 Clean wound
Only source of contamination from within the patient is the skin
2. Clean/contaminated
a. Contamination is from the skin plus an additional source such as opening the appropriately prepared
colon or small intestine
b. In current practice, contarmnated prophylaxis is indicated in clean/contaminated wounds only when
foreign bodies are deliberately inserted or for anticipated prolonged procedures
c. Consists of the preoperative intravenous administration of broad-spectrum agents, Additionally, the
antimicrobial must be given during the operation in dosages sufficient to maintain a blood level
considered sufficient for that agent. Postoperative administration is not indicated
3. Heavily contaminated
4. Infected
C. Management
I. Cellulitis: Penicillin or erythromycin
2. Clostridial infections
a. Surgical debridement
b. Antibiotics
c. Blood volume replacement
3. Necrotizing fasciitis
a. Surgical debridement
b. Antibiotics
c. Blood volume replacement