GS ‘Ante Doan, Peter Sears and Nathalie Woug-Chong, cept editors Alcina Garbent end Modupe Oyewam aoa etre Adam Gindwish, EBM editor Dr. Tuli Gil and Dr. David Ucbach,siaffedtors Basic Anatomy Review Diferemtiet Diagnoses of Common Presontatlons, Aaute Abdominal Pain ‘Abdominal Mase GIBloeding sJaundlea Preoperative Preparations . Thoracie Surgery Esophagus ‘Chet Wall laura, Lung, and Mediastinurn ‘Stomach and Duodenum .. Peptic Ulcer Disease Gastric Carcinoma Gastric Sarcoma Bariatric Surgery Complications of Gastrie Surgery ‘Small Intestine. Meckat's Divericulurn Tumours of Smeal Intagtine Hernia Groin Hernias Bowel Obstruction, ‘Small Bowel Obstruction (SBO) Large Bowel Obstruction (LB0) Pseudo-Obstruction ‘Taxic Megacaton Porolytic lous Ogilie's Syndrome Intestinal Ischemia, Appendix Appendicitis ‘Tumours of the Appondix Inflammatory Bowel Disease (IBD) Grohtre Disease Ulcerative Colle Diverticular Di Divartculosi Divarticuttis 2 4 2 16 20 a a cy a a 28 20 Colorectal Neoplasms. Colorectal Screening Guidelines Colorectal Polyps Familial Colon Cancer Syndromea Colorectal Carcinoma (CRC) Other Conditions of the Large Intestine . Angiodysplasia Valvulus Fistula. . Ostomies Anorectum Hemorrhoids ‘Anal Fiseures: ‘Anorectal Abscosa FlatulaIn-Ano Pllonidal Disease Rectal Prolepse Anal Neoplasms Liver ver Cysts Liver Abscooses Neoplosms LUver Transplantation Biliary Tract Cholelthiasis: Biiary Colic Acute Cholecysitio ‘calculous Cholecystitis: Choledocholthlasis ‘Acuta Cholangitis Gallstone ileus Carcinoma of the Gallbladder Cholenglocarcinome Pancreas... ‘Acs Pancremtis, Chronle Pancreat Panereatio Cancer Spleen, Splenic Traurna Splenectomy Broast ‘Benign Breast Lesions Breast Cancer Surgical Endocrinology... “Thyroid and Parathyroid Adrenal Gand ‘Skin Lesions. Common Medications. References 32 36 37 37 38 a “4 4 52 52 58 “Toronto Notes 2011GS General Surgery ‘Basic Anatomy Review Toronto Notes 2011 Basic Anatomy Review iota — Lower ine ccm pe me, am Pears et = Nesey desma ee = ects abdomnions sms: in rectus sheath, divided by Linea alba + above arcuate line (semicircular line of Douglas), which fs midway between symphysis pubis ‘and umbilicus “anterior rectus sheath = external oblique aponcurosis and anterior laf of internal oblique sponeurosis + posterior rectur sheath = posterior leaf of internal oblique apaneurodi and transverrut usc sponeurocis + below arcuate line iraneversais + arteries: superior epigastric (branch of interna] thoracic), inferior epigetric (branch of external iliac); both arteries anastomoee and le behind the rectus muscle‘Toronto Notes 2011 ‘General Surgery G83 [Above Arcus ine = oe Sr) i I cst igre 4, Red Sapp to th 6 Toat eed Sate = Venus Flow roti + end pelt Inthe portal vet uo gem Pela) SS Figs 6, Venoun Drainage of the 1 TetGSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 Differential Diagnoses of Common Presentations Acute Abdominal Pain oss of Acute Abdominal Pain eroNsTnE m7 Ses rt 4 tend RA ee cae Fy ae ony i foto Oetinter it urct) Gers nian oe io cone rae Bo eee ed teede aearheee sua Same ester Thaw ben ne ioe = Reo same) Bo cece Soper son 7 Toes tiectonne Seen a Sekar Spt ote pce Sedeptreey Red imei Sere Secon amy) oan a ater Fan ‘lie boned sci aa BES renters a a eee Feces tock En graces orc ee eee Soeur Py im Pret 2 ie ne oa Ser emeridot mate, lero Seperate = Epos! edeToronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Abdominal Mass: Tae 2 itforon ii Ure Te pa dat UO) recuperate admeariane, Sibee— sdnmnog, wna dee, FMC obepecmtcrca piece ebook atin on ‘Sopot itm Tete shone Abort ABR wo) Src sot a Se ue eran, (teri srve tr acd Indcaons er Uget Opt Sed AT hoe cD Toe ine Tet ar Oran Oh lees Famer tenes ST — sce cpeacionees een (U_bstiedsten tn Deco reac, mer ' ah Iedizations for 1 re ofmedic 1 prolonged bling sgecet bod loss (eqsring>6 units of pRBCs ins short prod of tim) high rat cf eating hypeteen « heding tr prs dps lndonnpr and engogapic rspenic mane ‘Surgical Management of GI Bleeding = upper Gi SHleeding from source proximal to the igaenent of Tritz + often presents with hematemesis and melena unless very brisk (then can present with ‘BRBPR, * intial manegement with endoscopy; i fal, then consider surgery = lower Gt eedling Tlceding from a source distal to the ligament of Tete * often presents with BRAPR unless proximal to tensverse colon '¢ may occaricnally preset with melera initial management wits colonoscopy to detect and potentially stop source of bleeding * angiography, RBC scan to determine sourceas indicated ‘rurgcal mervemion tf wnarce Fund “Table 3. Dierenil Dhapasels of G1 Booting 7 eae tapi cor = konto) Cel ean Serre Nese pss 1 Esonhoqes Faia cs ‘ocx fds tg Saas Sooceane mes Eee Eimer Stomich eu tame em cancer abd Diora a ceed ct Patent Jian Taare ene hewlett bem ab at ‘aoradeactbocrtnctin peruse Ga SlenetnSe Geom targery _ Difereaignsinl oganenitGoninan Paapatiindecprntons Some Note 207 “Tabla 2 Dtoentl Dingoes of 61 mleeding (commun) Pemmmie ores iy “oho ae Se Secreta! Aten deen mtn ee i Ageia ‘Ainecing port gmetranrecitel snacorrnsie ie even Sperone an, tuoi ttn Ne pam tem = octet = So acssr = Shecor —— O-; Jaundice + ee Gmamacon et =of§ eran Diagnote Se eee — Serf Seeger Nar dae St tf | ila ecm meaereme hae 24 tm | Seeley td ap SUnipinicd beet euminophes,eytronyin sei valpoc ac —— "Sue sa | oem pa "Ey get hn aint ee “benign biliary stricture ve ‘> carcinoma — bile duct, head of pancress, ampulla of Vater, dvodenm O_o Preoperative Preparatio' owas ray Seal ama Pao Considerations gerne informed consent ce hcl Legal end Organizational Aspects of Medicine, ELOAMS) Te ccumetnelvswmnns |» Gamuls—enenteta, medi, canligy tr tpemed teen RPO ater mung AAT acy totes) VSR ee gn oui) Hwan 606.86 | IV balanced crysalod at maintenance ate (42:1 rule -* roughly 100-125 er} noma F Fosycani ireameise |” sale or Ringer lactat; bolus to catch up on estimated lorses cing losses rom bowel prep + petits regular meds inchdiog predolsane ~ connider pre-op sees dose Lfpredalsane used 18 est year i + prophylactic antibiotics (within I hour prior to incision) usually efazolin (Aneet™) x rman {Fmetroni « bowel prep: cleans out bowel and decreases bacterial population tse eg Hest Panos) ting vas Q 1 SRIEe esd ota eect Goa cate end pba were) inter raking concent reap an ign decreas postop complatons ne Invention Actity '« blood components: group and screen or cross und type depending an procedure ere 1 Gieh eeepc Bon mine eae UNMET FT Teh ery of eding doer a ANGspedose out ste [sees | 2 een enaeeth gabe say abnemal win ps 6 onthe 1G if >50 years old ora indicated by history g Drains fear * aerogenes decompresion ans of guste contents gto gn fe hiro cece eign onc koe nul ae srscecn + conlsindications eupected bed sul rector obruction of taal psseges do 0 Cat reves + Fale gather sis toscana moniter win cute daconenion of bade rane cea Soriano nped cial hry eat ian fotToronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Surgical Complications or Postoporative Faver + Seer dae ct neces py infection 1 ing of eve aay beet erese i poDsex > setae net common cute fever on POD 41) + cay wsdl intone Gcratu, Gro A Spaces ft foccnpmussnd @ {ook forse dranage) Swe a rattorer + apratin poenmoniie sre + other Addsonian cis thyroid storm transfusion reaction Mewar + Pons Moot ovire ‘nfectoas more bkely oe ae SUTT wound infection IV ste neton, sep thombophiebis eae + POD #5. een * Tesage at bowel anastomosis (tachycardia, hypotension, oliguris, abdominal pain) * ftra-sbdominal abacea (xsusDy POD 45-10) = DVTIPE (can be anytime postop, most commonly POD #7-10) * drug fone (POD $6-10) + other: choleystitis,per-rctlcbscess, URI infected seroma/biloma/hematom, parti, .dificte colts, enocardtss Trostent 1 inpyeeie aetaminophen) Wound Complications WOUND CARE spithelsiation of wound occurs 48 hours after dosure 1 dressings applied inthe operting room can be removed POD #2-4 + eare unconeredtfwoumdia dey jemove dressings i wet, sgns of infection (fever, tachycardia, pai) + examination ofthe wound: inspect, compres adjacent areas, swab drainage for C&S and ‘Grom sal + skin grtres and capes can be removed POD #5: - mesem cromes crease (rein), cased mnder tensa, in extremeiticn Quand) er patent factors (elderly, corticosteroid use) removed POD #14, earlier if sigs of infection + can bathe POD 42:3 1 negative presre dressings consiat of gl faam and suction, ‘Fidel for large (grafed sites) or aonealng wounds (eraiated ski, ulcer) DRAINS += Placed ints operatively to peovest lid eccumolation (ood, pus, serum blk wine) + potenil oute of infection, ring eu Unrough separate incision (s- operative wound} to ‘decrease nak of wound fection. + ypeofdmine * open (Pennote, higher rik of infection owed Gacnen Pe Hak) coneced to mcion + sump (Deval) suction with sttlow system to prevent obstruction + router desi outputs dally 1 tains shouldbe removed once drainage s minimal (usually less then 30-50 cc!24ht) WOUND INFECTION Etiology +S. aureus, E.coli, Enterococcus, Steptococ wp, Clare a. Fisk Factors + ype af procedure: clean (lective, not emergent, not traumatic, ne acute inflammation, ‘ence not entered) <1 S% + clean-conteminated (elective entering of resp/Glibilary/GU tact): <3% * contamina (npurlest nanan gro pag om ie cy nolo ‘wacts with infected ilelurine, penetrating trauma <4 hrs oa): 5% s/GLiaryiGUGSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 * digty (purulent inflammation, pre-op perforation of esp/GUib ‘smu > sold) 3598 + increased risk with procedures >2 hrs ong, ust of drains + patent charset age, DM, steroids, immunosuppression, obesity burn, malnutrition, Infections, traumatic wound, radiation, chemotherapy + ether Sectors "prolonged preoperative hospitalization, reduced blood flow, breakin sterile technique, Jhemafams, seroma, farcign bodies (drains, entares rai) Ctnleal Presentation + typically ier POD #3-6 (Streptovocc and Clot dln can peesnt In 24 hrs) 1 pul, blanchable wound erythema, induration, fank pas or purulosanguinous discharge, ‘warmth + complications: fistula, sinus acts, sepsis absces, suppressed wound healing, superinfection, Spreading infection to myonecross of fascial necrosis (neeeatlzngfascllis, wound dehiscence, visecraion, bezale ary/GU tracts, peneteaing Prophytexis + pre-op antibiotics forall surgeries [ceftaolin (Ance"Yanetromidaaale * within 1 hour preincsions can ze dase with Ancel® afer her he OR + pastap snthiete for enrarinated and der murgerien ‘no evidence supporting more than 24 hrs of postop entimicrobial prophylaxis for any case = generally no nced for port-op ndbiotics unio + normothermia (maintein patient temperature >36°C during OR) ‘ fyperenyzenation (eonsder IO, >80%9 08) Treatment + reopen aflected part of incision, culture wound, pack, heal by secondary intention + acetic only celle or smimeanodefictency 1 debride necrotie and non-oableteme tnttcperstiely WOUND HEMORRHAGE/HEMATOMA + secandary to indents sori contra af emosinsc Fisk Factors: + antknagulant therapy coagalopathie,thrombocjtopenta, DIC sever liver disease, _myeloproMferatlve Gsorder cevere arterial hypertension, eevee cough Clinical Features + pan, swelling discolouration of wound edges leakage { fpidly expanding neck ematonsa can compromise srw and i surgical emergency Teartmen 1 iguana may aed open to fd some ‘SEROMA, * fluid collection ether then pus or blood 1 secondary to transection of fangh wees + delays healing ‘Tremment 1 pressure droming + nendle dretnage 1 ifeignicant may need to e-operate ‘WOUND DEHISCENCE += disruption of fecal lope, sbdoazinal contents contained by chin only Clinical Features + typically POD 41-3, most common presenting sign is serosanguinous drainage from wound, ‘2 evisceration (2stuption of all abdominal lagers and extraston af ebdamfaal contents — mortality of 15%) «+ palpation of wound edge: should normally fel a “healing ridge fom abdominal wll osure ‘Gale area of torae under inion)“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Fisk Factors + local: technical falre of closure, increased intra-abdominal pressure (eg. COPD, ileus, bowel ‘hetraction), hematoma, tnfectian poor blood supply, rastion «+ optemsic: aking, malbutriton (bypocl>uminease, vitumin C), connective ioe Gioeess, ‘immunosuppression (disease, steroid, chemotherapy), other (age DM, sepsis, uremia) Urinary and Renal Complications URINARY RETENTION ay occur after any operation wth general anesthesia or spinal anesthesia + more likely in older males with history of benign prostate hyperplasia (BPH), patents on smtichobncryice Cinteat presentation Ibdominel discomfort, palpable bladder, overflow incontinence ‘Trastment «Foley catheter tn ret bladder, then trial of void ‘OLIGURIA/ANURIA (sce abo Nerolags, NP20) Edolony + peecomal ve renal ve post rea most common postop causes pre-rnal + ischemic AUN ‘external rid lose: hemorrhage, dhyfaton, deren ‘interval ud oss third spacing de to bows obstruction, pancreatitis, post-op (Cintaa! Prasamtation + urine output 0.5 celkg/,ineressing Cr, increasing BUN Treatment + according to underlying cause fuld deficit Is rated with crystalloid, [normal saline (NS) or ‘Ringer lactate (203) Postoperative Dyspnea + sc sary Gaping 9 en ara Competions St (ARDS), asthma, pleural ef (PBs Respiratory Complications ATELECTASIS + comprises 90% of post-op pulmonary complications Clinical Features Tove grade fever on POD #1, tach. ‘wchrpace Flak Factors + COPD, smoking, obesity, eldety pens * upper abdominathoraci segery ovesedatin significant postop pi effort dia, crackles, decreased breath sounds, bronchial breathing, oor inspiratory ‘Trootmont, ‘= stoking cesalion [most beneficlif>6 weeks pre-op) + postopenste} ‘ oinimize use of espeatory depressant drugs + pad pein coool Econ cre epee an gh cit ptr cage(C910 Glnneabingeery Differential ISingfioe Cottman resentations "Toronto Notes 2011 PNEUMMONIA/PNEUMONITIS. += may be secondary to aspiration of gocric contents daring anesthetc tnduction ‘ermbetion, causing a chemical pneamontis Fisk Factors + aspiration: general anestheie, decreased LOC, GERD, fil stomach, bowel/gastric outlet obstruction + non-functioning NG tube, pregnancy, seizure disorder + now aspiration: atlectas imme, pre-exstog eplratary dlease ration prophylaxis pre-op NPO/NG tube, rpid sequence anesthetic induction immediste removal of debris and fuk fom sieway + consider endotracheal intubation and fextle bronchoscopic asplration 11 antibioties to caver oral nosocomial aerabes and anaerobes (eg, cefotaxime, metronidazole) PULMONARY EMBOLUS (se Respislagy- RLS) Clinical Features + unilateral leg swelling ind pain (DVT asa source of PE), sudden onset SOR, tachycardia, Fever (oD #7.10) Treatment + IV par » Greenfidd (IVC) fer Lfcootrindlestions to eaticumpation + prophylaxis: subcutaneous heparin (3000 unit bid) or LMW heparin, compression stockings (TED wocking») longterm warfarin (INR _ 2-3) for 3 months PULMONARY EDEMA Evology 1 relator enon dence ole replacement, LY flr, sh of i from perierato pulmonary vascular bed, negative airway pressure, alveolar injury dueto toxins (eg, ARDS) more common with pre-existing cardi dsetse «+ negative pres pulmonary edema de to ipapirtary cfr gxint a Gosed pti upon ‘neatening fram generdl anaesthesia Ctincal Features = 90 B,cracRer ot lng boven, CXR sboormal ‘Treatment {LMINOP = Lants 1 Maplin (decreanessymptems of dyspnea, reader and sfelead reduction) RESPIRATORY FAILURE Clinical Features + dspace, cyanosis evidence of obstructive bang dioeave alist manifestations. tachypnea and hypoxemia (RR >25, pO, <60) > pulmonary edema, anciplained decreas In $20 + squat bod posure oman pulmonary pertuan 1 these mentees lta kacp PaO > comalder ARDSToronto Nowe 2011 Dilcal Diagnoses of Common Prictations General sarpey O55 Cardiac Complications ¢ inc 3 cme npn Comp weep) 1 amen aay ahi tsico| sit yee (evcandey MVOCARDIAL INFARCTION gan, + see Catdlology and Cardiovascular Surgery, C25 > super increases isk af MI. + Inddence * 0.5% in previowsly asymptomatic men >30 years old * 40-fold increase in men >50 years old with previous MI lek Foctore = oop! com + previous Mt (highest sk <6 months, but risk never returns to baseline) Imcrerd age yeni =o Clinical Features + majority of cases on day of operation or POD #1-4 en silent without chest pain, may only present with new-onset CHF (dyspnea), archythmias, Dypemndien Intra-abdominal Abscess Definition » collection of pus walled-off from rest of peritoneal cavity by inflammatory adhesions and viscera Etiology : Gem anaerobes + weal ptm Gram aoa bate, Fisk Factors ost op cuntentnsted OX Grimegery with anestomones oor healing risk factors (DM, poor nutrition, etc} + nay occur POD #3 ster laparotomy when fli re-distribution occurs Clinical Features + persistent spiking fever, dull pain, weight loss 1 hue dificso palpate + Eibeoestorledopet2 Cammaempenied : cr nanmocmpenmibel 5 coveisting esi (Pleural effusion wil subphresic abscess) + common sites: pel, Morrisons pouch (space between duodenum and lve) subphrenic, ‘paracelc tes, esse ac per-appendical, postsurgical anastomoeis, vertical, Pooas Treatment 1 Uokidemen etd 8 tae soon incon + antibiotics to cover aerobes and anaerobes (ampicilin/gentamicin/ metronidazole o ‘Sprofloxacin metronidazole or clindamycin gentamicin r eloteten) Paralytic Ileus + sc Bowel Oetretion, C523 + see Bepchitry. 7517 and Pearology: N10GSE General Surgery fre ‘tkeroare Daren Dingo es hs, Dilfrential Diagnoses of Common Presentations Toronto Notes 2011 Bele Surgery Esophagus ‘SUDING HIATUS HERMA (Type I (sce Figure * bernation of both the samach and the gattroesophngea! (GE) junciom ita thorax + 9036 of exophagea hernias Risk Factors ca ‘Snoressed int-abdominal presmre (og abesiy, pregnancy, conghing, heary iting, straining ‘wih cansipstian) + smoking, Chineal Faaturee * gjrty ate aeymptomatic - “Tanger hernias frequently astociated with GERD due to disruption of competence of GE junction sod prevention of cid dearance ance refi: has ccearred Complieations + noeteoemen eomptation GERD 1 ic complications aera snd age ested et: : tana) ‘coophegitin epg ‘+ consequences of csophapis (peptic stricture, Barret caophags, esophageal carcinoma) ‘+ exir-esopbagaal complication: (aspiration paeumonia, asda, cough, yng) Investigations + atu swallow, endoscopy, or esophageal manometry (technique for measuring LES pressure) eee larger hernias + darhour esophageal pH monitoring to quantify reflux + gastroscapy with biopsy to document type and extent af ssue damage and rule out esophsgs, Beret nd cancer + CXR: globular shadow with air uid level visible over cardiac shadow Trectment TTetoympom of GERD: Tayi ediicnon rtp ming ght om clothed ofbed, no mea 3s pro espn, male tol ues mals ead doo coi tant + mela + ape ie? . “re ompatim rife mid meget SNison hasan suehy peop andus of stomachs wrapped eround the lower esophagus and sutured in place soca ne“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS PARAESOPHAGEAL HIATUS HERNIA (Type lt) (= Figaze) + herniation ofall or part ofthe stomsch through the esophageal hats into the thorax with an ‘undiphoed GE Juncion + Hust donsmon evga hela (0%) = soualy seyorptomatc due to normal GB junction, + pressure sensction in lower ches, dysphagia ‘Complications += hemarthage, incarceration, strangulation, chsractian, gastric msi wloee Treatment 1 Surgery to prevent severe = reduce hernia and excise hernia sac, repair defect at hiatus, and Nissen fundoplication + may consider suturing stomach o anterior abdominal wal (gastropexy) = invery elder patients a igh rorgcal isk conser PEG ‘pewonomy) MIXED HIATUS HERNIA [Type Ill) = combination of Types and TYPE IV HERNIA + herniation of other abdominal organs into thorax colon spleen, small bowel ESOPHAGEAL PERFORATION *SEndoscope, dilaton, bop, intubation, operative, NG tbe placement 1 Derngenie: = repeated, Gorcefel vomiting (Bocchaaw's apndrome} * ether ennralsions defecation bens (re) el poran + ingestion Lory: oe tl re * forego body, conrcir substance Semaine fect + carcnome cnn Clinical Features = neck or chest pata ‘ores mchycartl,lnypotenton, dyspnea, replrtory compromise + subcutaneous emphysema, purumothorer, bematemesis Ivostignti 1 CX paeumentoom, pesntomedaioun, pln elon eabdapheagmate at £'Cr chert widened mediastinum, pneumomedistin + contrast swallow water-soluble then thin berium): contrast extravesstion Treatment + supportive ruptareis contain ‘= NPO, vigorous fluid resuscitation, broad-spectrum anibiotis =a hoe * primary dosure of «heal ceopbagus or rection of scared cxaphigus = >2hrsor on viable woand edges ‘* diversion and exclusion followed by delayed reconstruction (ie esophagostomy ‘proximally, close esophagus distally, gastrostomyjejunostomy for decompression! feeding) septs, sbeces, ital mediastinitis, death Sicpan coe aaa egy. post-op esophageal leak + mortality 10-50% dependant on timing of diagnosisGS General Surgery Differential Diagnoses of Common Presentations “oronto Notes 2011 ESOPHAGEAL CARCINOMA Sfomteels 31 + cave 50-60 years of age + upper (20-33%) middle (33%), lower (33-50%) + squamous ell carcinoma (SCC) and adenocarcinoma occur with equal frequency, with enocerinoma beemming more commen Sorenie incidence sitio i ‘squamous cell carcinoma (SCC): * 4S Seating Spi ll, Sd Bet mt), clog (hot Mel) = andelying esophages) disease such os strictures verticals, ssenocardngm: ‘Barret cophagus (moet important), smoking, obesity iocessd refluz), GERD Clinical Features + Irequenlly asymptomatic Ite presetalon progrensive dysphagi (mechanical) ~ fel elids hen Repke Simin fm cnet ps Seog seit nen) Investigations terns cee a acta aimee coca Staging workup (adrenal liver, ung, bone metastases) regional nodal involvement (most accurate way to stage the cancer) + teonchosoopy: * rule out airway invasion in tumours ofthe upper end mid esophagus Troatmem + hepato emery irre deme odie mea ‘aulimedal heap. * concorent eral beam radiation nd chemotherapy (cplatin and 57T) posobiityofcureuve sophogectomy afer chemoredttion if escsereopords wel + Sfonae to tlente maltmoda neapy or highly dynoed dies, comer ative resection, brachytherapy, or endoscopic dation temtngaser sation for pallition + topenbie . (Grnsthoracic or taht proach) and iymphadenectomy ‘acastomods ia chest or neck eae en cela remem wen ad raion ee conten 1 tat chemethoupy + dation analy tcommended x pot

pecuexorvatorn,pectuscarnstom, sternal fasures + surgery for: comes pychosocal factors respiratory or cxiowascula insaficieney ‘THORACIC OUTLET SYNDROME + mpingement of rabclavian vowed snd brachil plemae cre trunk Etiology cogent ~ cervical ib + degenerative ~ osteoporosis Clinical Fowtures ‘= neurogent ~ ulnar and madian nerve motor snd sensoey function * arterial fatigue, wesknes,cldnes, ischemic pain paresthesia * venous” edema, enautditenton, colteel Greaison, eyanodt ‘Treatment + conservative (5010 90%) * plyslotherapy, posture and bebo modification + surged if conservative treatment fla removal of frst r cervical ib (if applicable) ‘Tumours ‘bemige frou dyeplmn, conmophubc gamulome,cxtenchoodrams + malignant: fbrosarcoma, chondrosarcoma, osteogenic sarcoma, Ewing’ sarcoma, enyeloma Pleura, Lung, and Mediastinum = see Respirology 21 ‘Tuse THORACOSTOMY drain abnormal large-vehuoe ai ar fii cxllections in the pleural space +t dra sian tons in * hematheres, drpatharsz, exrpyema * paeumathara if acuredaae "fe alta fi eu pty ling loc eye 1 cou as od Saicene ofp fad vince arn ° + ated nr curt pour ea (ea ist) + frlng nm droge aligns Procedure tbe size _ varies according to indication larger tube for more viscous drainage + insertion Ste _ typically thor Sth intercostal space in anterior axillary or mid-aillary line 1 technigpe: ™ local enaethete = -2emshinineidon * Kelly clamp for blunt dissection tothe pleural spacs, taking care to pass over the top ofthe ‘bt avoid neuromsacuar anle 1 be is inert mod mature in place ‘tube is attached tox pleural drainage system (suction/ underwater seal, usualy -20 mm * post-imertian CER to ensure proper tube picement (posterior apex cf kang) ‘MPnen drainage <100-200clday, no sr leak and Lungs uly expanded + consder clamping tube for 4-6 ars then obtaining CXR to ensute ung remains expanded ‘tak emoral afer patent exces and hold brexthGSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 crept are 98) : cree 9% 1 asta ont comme option), pel by tubes may disect along the external chest wall, of may be placed below the diaphragm = Bes aes sa ratve contraindication) 3 pesfoaton ating + fisk of re-expansion pulmonary edema when large volumes ofa or hid are drawn of quickly (Lot 151) taum Stomach and Duodenum Peptic Ulcer Dissase asic uLcERs + soe Gostroenteralogy, G11, Gz? ‘Surgical Treatment + tnermacngly rare due to. pylor/ eradication snd medical treatment ‘Surgery ‘unresponsive fo medical retina * always operate fills to heal completely, even ibiopsy negative _ could be primary gastric Iympbome or sdenocarcinama popes or ccinome, * anys bop ulcer for malignancy + hemorshnge ~3x pester ak af bleeding compared to duodenal ulcers * complications obstruction, perforation, bleeding Procedures «distal gastrectomy with ulcer excision _Billoth I or Billoth I (sce Figure 8) + wayne ana ploropny onl act kypemecretion — rant 1 srege rexel if posible or bopsy wilh primary repair DUODENAL ULCERS + see Gaoenterogh C12 1 tmost wits 2 em of pylorus (duodenal bulb) Complications + perforated ulee (yc on sntecoreurfce) cline Sotscce ‘¢sudden onset of pain (possibly in RLQ due to track down right paracolic gutter) * acute shdemen ~ eid, difase guending tee ‘intial chemical peritonitis followed by bacterial peritonitis TTEXR re airunder diaphragm (70% of paints) * oversew ulcer (plication) and omental (Graham) patch _ most common treatment + poner poco! + Span td 1S ap porting it back nt oes : npr a ula ny ones ia Stourton nti wth css lod wansfson i ee 5 Ragen enor pec enonnpy on try or nfo resi may have 2nd seope ° surgery if severe ar eeurrent bleeding, hemodynamically unstable or falture of endoscopy ~ overveing of ulcer, pyloroplasty «+ guaric tlt obstruction: etiology: leer can lead to edema, fibrosis of pyloric channel, neoplasm = clinical presentation: ngs rong (onde od com ir) ined etme mp abn ‘ssuccusion spash (splashing noise heard wien patient i shaken) + anacotate pan fuid movement in obetucted organ“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS NGA pression and correction of hypochoremichypokalemic metabolic llalois medical managenest ally high doe PET therapy * een ot oir ces open nc er ih ray cx pte ‘Surgical Trestment + eugielincetone “TRebartng ceed into pcnton, uit cetton vedas to operate based on amount of band les usually >8 unit), ete of bleeding and Thersodyaamicstabity Lehi ee elt anagram) "Tepe ae. poe "Sime done nom dv to Fy exdstion Complications of Surgery + retained entra + fla (gntrocaicpsjnal) {= damping symirams, postvagntomy darches, afferent loop synrome (see Completions of Gastre Surgery G5I9) Gastric CareInoma Epkdendology + nalefemale = 32 + incidence for adenocarcinoma _ 10 per 10,000, inidence highest in Asia (Japan 8 times ‘higher tea in US) 4 most commun ag group = 50-59 years + incidence bas decreased by 23 in past 50 years 1 pernicious anemia arsociated with chlorhydria and chronic atrophic gstritis ‘patric denen polyps + previous partial gastrectomy (>10 years post gastrectomy) Jeske un greater curvature of stomach er carla + ssyupomatis tiions a late amet of ermpeerne mas (25%) 2hematemels, eal oceuit Hood, melena, lean decency anemia + signs of metastatic discae: 7 Virchows node left eupraclavcalar node ‘+ Blomersshef- maar in pouch of Douglas + Keukenberg tumour - mefashes to omy 4 Sister Mary Joseph node umbilical metastases * tris node left anllery nodes + metas * lve hangin Investigations + OGDand biopey 1 ebesebdovpetis CT 1 CT for metastatic work-up (te Tle 4)GS General Surgery Differential Diagnoses of Common Presentations “oronto Notes 2011 ‘Tabla 4 Stagg of este Cartsom Sige tore ir Wars cd amos 7 Dwmontomscuars pee Fe athe wns ono apne es Ht ate v Osteen cr nodemint eos snetees + Ob ‘ ‘Treatment + sdenocarcioome: proximal eso * toll gectreciomy and esophagnejunostomy Roux-en-Y (see Figure 8) + diaallesione ‘distal gestrectomsy wide margins, en bloc moval of omentum and lymph nodes = palliation: * autre revectan to decrease bleeding and relleve obstractian, enables the patient 0 eat ‘radiation therapy 1 Rades ate showing larger role for chemotherapy * Spy «rte, ngey ned coe (pectin, etn, cuss) Gastric Sarcoma Gastrointestinal Stromal Tumour (GIST) + mort commen mesenchymal neoplasm of GI tract 1 decved fom interstitial cells of Cael (ells associated with Auerbach’ plexus that have ‘sttonomaras pacer function eo andints arial tomo the Gi trac) + 75-8086 associated with tyrosine kinase (e KI") mations + most common in stomach (30%), and proximal small intestine (25%), but can accu anywhere ‘song Gl tact + typically present with vague abdominal mas, f ‘Spmptems of bleding and anemia + cen discovered incidentally on CT, laparotomy ex endoscopy ling of abdominal fullness, or with secondary Pen Triad: GIST, and ‘chondroma oa ppg, ond oma. Management + surgical section if>2 cm: follow with serial endoscopy <2 cm then resect if growing or 1 farcnaneous biopsy NOT recommended due to hike alt and rik of peritoneal Ipread + locale GIST: surgical esetion wit preservation of ntact preudocpsue *ymphadenecorty NOT recommended as GISTs rarely metas ph nodes + advanced diseases metastases fer arr peritoneal cyt * chemotherapy with natin mesylate (yosineKnse inhibitor) + caer rsarh Joking ino sl ato jer cr aoa esi far bained GST og ee "cuore as ee “doen Carmi be vm - Satna etna nae oti figures or 0/hpf) Bariatric Surgery «weight reduction surgery for morbid obesity ‘indications, BMI >40 or BMI >35 with related comorbidity (eg. DM, CAD) 1 requires multdisciplinary evaluation and fllow-up“Toronto Notes 2011 Differential Diagnoses of Common Presentations ‘Surgical Options = malabeonpireteetrctve: ‘ isparsecopie Rovs-en-¥ gar: bypars (most common) ‘staple off smal gasizic pouch (restrictive) with Roux-en-Y limb o pouch (malabsorptive) ‘th dumping syndrome plytology * most elertie, higher eamplicatian rates sect: "Piao od und fn cet pouch oj able hough por under hin «= laparoscopic verttcal banded geatroplesy pa The saped al gti onc placement fas rng band * "Doiliopancreatic diversion with duodenal switch + peony conmseumennetns ode iain dou end duodensenireamy Complications + perioperative mortality 1% (anastomotic leak with peritoneal sigs, PE) ' chutruction at enteroenterosto (see Comphoatons of Gastric Surgery below) 1 staple ine dehiscence umptng syndrome 4 Ghoti due to rapid weight loss (20-30%) ‘naan Complications of Gastric Surgery ‘+ mat resolve within L year (ace Page 9) Alkaline oflux Gastrtis (see Figure 9A) + duodenal contents (blhons) refx mt rtamach cancng putin + esophagitis + teatment ‘medial H Hocker, metocpamie,choleryramine (hile cid seqpestrans) {= eurgieal: conversion of Blot | arta RowseneY ‘Aferent Loop Syndrama (see igure 38) + sccumlation afbile and secretions causes intermittent mechanical obstraction and ‘Eatonton of afizent ln += dincal features: = ealy postprandial dlstention, RUQ pet, nasa, bio vorfing, anemia + treatment surgery (conversion to Roux-en-Y increnesallerent loop drainage) omar ng a Tale = A, a = it oo eae ve Saag = edology: large: Josd leads to lange insntin release and hypoglycemia “emanate: Syndrome (so Fgme 9D) + bacterial overgrowth of colonic Gram-negative bacteria in afferent limb elite) seus: *anemia/weakness, diarrhea, malnutrition, abdominal pain and hypocalcemia + teeatment broad spectrum antbotis, surgery (coaversion to Biloth 1) Postvagotamy Diarrhea (see gure 9E) = apmase + bile salts in colon inhibi wate resorption ‘+ textment: medical (cholestyramine) sarge (severad interposition jejunal ecgrent) General Surgery GSS me mite Pewee a di Galehetr Parcins secon 1 Ateve oes frac Femme bia Fg 8. Comlicetans of Baars samyGSE General Surgery of 2 asia Girriaen 1 Srasumae nN css 1 Read e605 ee tte Feecee hee Feces erent Eye ge Cte erin Lain Differential Diagnoses of Common Presentations Toronto Notes 2011 RUE LUSh LCd Meckel’s Diverticulum «+ remnant ofthe embryonic vitelline duct on antimesentric border of eum [heterotopic - several types of mucosa including gastric, pancreatic, cola moet common true dertculum of GI tract (Clnkeal Features 2 GI bleed, small bowel obstruction (SBO}, diverticulitis (mimics appendicitis) * patois bleeding ~ ulceration caused by ectopic gutric emcosa 50% of patients with this presentation are <2 years old Investigations + technetium-9 to identify the ectopic gastric mucosa (Meckel’ sean) (Complicstions Geta urnshiar eum, wanhtel eins brows cord between umbilicus and ileum + SHO doe to valvalus intuanuseption.perforetion Tresmont “incidental finding conalder mga resection symptomatic _ fluid and electrolyte stabiliaation and surgical resection ‘+ baoad baued segmental ection to remowe all mcasl types and alcerated mons opposite ‘he diverticulum (Le not simple dverticalectomy) Tumours of Small Intestine lok Factors expomure (red mest in diet) unilie adenomatous polyposis (FAP), Petr Jegher syndrome, Gardner syndrome ‘Ceahni disease, celle disse 1 ietmnunedefciency, antaimmune dserdert Clinical Features * ssullyeapmpiometicunil advanced * Yoterm ent obstruction, Iniseascepton, occult bleeding palpable abdominal mass sbdornal += femal adenomatous polyposis (FAP) (sce Peel Colon Cancer Syndromes, GS33) omarion » juvenile polyps + the: lelomomas, lpomes, henanglomas MALIGNANT TUMOURS + usally erymptomatic until advanced stage w225 30% ansoclted with distant metastases atime of diagnosis — * most common peimery tamu of smal intestine + oly 50-70 years old, male predoninanee + nally in pronimal smal bowel incidence decreases distally = 8 facto: Gln dese: FAP rly metasais to lymph nodes _ 60% metastatic at ime of operation * Investigations CT sbdolpevi Endoscopy + bestnent— sone mocction chemotherapy = Syearenreval 5%Toronto Notes 2011 Differential Diagnoses of Common Presentations + carcinoids = acreared incidence 50-60 yeas old * riginate from enterochrodaafin cell in crypts ‘= moet commonly 60 em fram the Heocecl(1C) valve feappendix 46%, distal eum 28% rectum 17% = ote * calied by embslgeaoriin (oat with morphology bop bebe ‘epsom adem, peas EE "rr eeing ng sy eum ply nuptial hg ‘abstraction bleeding, crampy abdamina! pan, latusroserption carina eyadrame (<1OK) hot fates, hypotension, darrhes,bronchoconsticion (wheezing) tricuspid! pimonic a inmaicency. igh ear he _ EXCEPTION: crena tmours arising inthe broncht can cause clnld syndrome cethout ver involvement Because of acest spstemiccrcation . ‘© most found at sumgery for obstruction or Eivated sHIAA (bretkdown product of serotonin) arneorinzeaed 5-H in Blood + weston ‘tumour and metastases: surgical maectlan = chemotherapy + carina spndreme: tered, exmine, ocmenlde * prgnodic " metastatic rik 2 fine > indiret inguinal > direct inguinal inteone pain flowed by tendernese {intestinal obstruction, gangrenous bowel, sepsis ual emeprcy -DONOT stem to manually reduce hernia septi orf contents of ermal ec ungrenoce ‘Trestment + Ral men erioph) nye nd econ ‘cosmens or symptoms if ‘epalr may be dane open or ¢ and may ve mesh fr tenon re ous most repars are now done with a pug in the ermal defect and a patch ove it or patch elon ‘ cberoston ir acceptable fr mall rmpramacic inguinal horns Postoperative + recurrence (15-20) * risk factors: recurrent hernia, age >50, smoking, BMI >25, poor pre-op functional satus (ASAD3 see Anzesthesia, Ad), associated medial conditions type It DM, hyperlipidemia, | mmaiiemuppermson. any como eandiions increasing intr abil pre + Tess common with mesh? Tension free’ repair + scr hematomas Dalnful scrotal swelling from compromised venous return of testesToronto Notes 2011 Groln Hernlas Differential Diagnoses of Common Presentations General Surgery GSS ‘Tolle 5 role Herein Sn lever stay Diet ig Te | Fenenl feito iin ipienideny a9 ean Nos cobnen toma nrmard weet Ala eae seers cena mae See Mcs>tehaes | th eid wares f gr pesmcs Pepys aS reacts me oredr bd ase ‘Nooenzenatrl oman — asony Tray beating ga ‘frm ao gt Metlonete pent Led oat te cer ety andy del dened dca oa me abd oteend enw sole rice nae) female Toament Susie Sayalo Suara ogi 3 skefece cthrsefeamece ‘ Des gab Rg Operng nts face pepe RBHGTOVE pam | Toner al te i me Spey ata bode ena cb gud snberusatonhs marke a Definition + partial ete Blockage ofthe bowel resulting in fllureof intestinal contents to passthrough Pathogeneste + disruption ofthe normal lw of intestinal contents“ prexdmal lation + dstl decompreseion + may take 12-24 hrs to decompres, therefore passage of feces and fatus may occur ater the oeet of traction «Bowel schema may occur if blood supply is strangulted or bowel wal inflammation leads to « Dowel wall lems and disruption of normal bowel absorptive function ~>increaed inrabania ‘ald -> tranmadatve fad lm ata perineal cary, ecg deters Diforontal Diegrasis + small bowel obstruction (SBO), large bowel obstruction (LBO}, pseudo-obstructir Clinical Features mus diferentiate between obstruction and ileus, and characterize obstruction as acute vs chronic, paral vs. complete (constipation vs ostipation), small vs. large Bowel, stangulating ‘ecnon-srangulating, and with vs, without perforation ‘Tete 7. Deal Oberaction Pert a we Tae ag en ea Fa (tenia Pee a chy Cocky (Mame ofebsent ut tates Som ehes) Coin : : + ou pein pr Seon et emma ete et Sorimwon ie testtecm oarnins ei sat erat “ommiice § Fankesees Stain Seri cae "oe Harald ater = CombaGS General Surgery Ihre Rak Pecan wh Sean Jem Pranaladeno bn g 93 Canoe 580 (a 7 bat i) EL Goerreina) Differential Diagnoses of Common Presentations “oronto Notes 2011 Compleatons (of total obstraccon! SSrangatngobtructon (03 crbowal btruction) msl emerge: + Gamma cate a etn rn + petal ps, xy 1 Keanna hoa, S27 rete secondary to chemi end il tention {yore (ue od pein) Investigations + radiological * speight CXR oc left ate} decubitus (LL.D) to rule out free wr, usually seem onder the right lbdominal xray (3 views) to determine SBO vs. LBO vs. ileus (ee Table 7) if schemic bowel look for: te at, peumatosis, thickened bowel wall, al in portal vein, lated small and large bowels, thickened or hosaike haustra (normally fingerike projections) other ‘= CT provides information on leva of abstraction, severity, conse ‘upper GT seties/small bowel series for SBO (ifn cause apparent, Le. no hernias, 0 previons mrgees) + HTsuspect THO, consider a rectal water soluble (Gastograin® Sax PO/PR: Hipage far 1¥)enec nather than becium enema (can thicken end cause complete obstruction) + may consider ultrasound or MRI in pregnant patients ‘ony be normal eatly in disnne comrae BUN, creatinine, hematocrit (nemoconcentraton) to assess degree of dehydration ‘ald electalye shaoemalticn * metabolic ekaloae ve to frequent emesis 'ifstangulation: leukocytosis with lef shif lactic acidosis, elevated LDH (late signs) Treatment «stabilize vitals, Suid and electrolyte resuscitation (with normal saline/Ringer’ fist, then with ‘ded potatoe fer fd efits ae corrected) 4 NG tube to relieve vomiting, prevent aspration and decompres small bows! by prevention of Surter daca by emalowed et + Boley oueter to mantior in/out Small Bowel Obstruction (SBO) Etiology “able Coen Coens of 200 inward or Erman asscpin ats ‘aed oo face ara a denccmhene| Fee orforain Treatment «consider whether complete or partial obstruction, ongoing or impending strangulation, Tocutn and couse SHO wht bory fsbdo/pelvic surgery > conscrvatve mansgermcat (tly t resale) + surgery io resolution in 48-72 hrs or complications ‘cumple $0, cangubtion > urge aargry afer iablising patient + tel often maoxjenent may bended in Gaby etme SBO, casinos * special case: erly postoperative SO (within 30 day of abdominal surgery) prolonged ‘ial of enacrvanve therapy appropriate, eager reserved fr complications ich a strangulation Prognosis + mortality: non stranguating <1%,stranguating 8% (25% if>36 yrs), ischemic _yp t0 50%Toronto Notes 2011 Differential Diagnoses of Common Presentations Large Bowel Obstruction (LBO) Etiology ‘alle 9. Commen Come ofL30 inva Treat van a Orta Dawn Sees ‘Clinical Features {unique to LEO) + open loop (10-20%) (ole): ‘incompetent leacedl valve allows relief of colonic pressure as contents reflux into ileum, therefore clinical presentation emilar to SBO + doncd lop (80-90%) (dangerene): = competent Neoceca valve eeultiag In proxtmal and distal occusons ' mnave colonic ditentioa ~ lnceseed presure ia cecuro “> bowel wall schema -> necrosis perforation | ‘Treatment + surgical earection af obtraction (usually eqalns resection + aloe) 1 volvulus requires sigmoidoseapic or endoscopic decompression followed by operative reduction SCumceesefal if eacenaful, consider cgmoid reecton on usm adenition Prognosis + overall 10% + cecal perforation + feculent peritonitis: 20% morality cir Sal) Definition + condition with symptoms of intestinal blockage without any physical signs ofblockage Diflerertia! > seme: tate nemologie dees, retroperttonel disease megacolon, tum, postopeatie, 1 chronte: neuralogic dlseare (enter, central peripheral neous eye), scleroderma Toxic Megacolon Pathogonasle + extension of inflammation into smooth muscle layer causing paralysis 1 darnage lo myenteric plenaswnd cecruyte sbnomnabiies are not comisten(y fond Etiology + indlammatory bowel disease (ulcerative colitis > Cros Disease) 1 feces bacterial (C df Saonella, Shigella, Campsfobacter, veal (cyeamegalovion), parse (B histlyics) + volvo, diverticulitis, ischemic colt, obstructing colon cancer are rare canes Clinical Features + infectious colitis usually present for >1 weck before colonic dilstation * diaches blood (but inprovenent uf deze may ported onset of 1 sbdominal distention, tenderness, + loel general peitonedl signs (suggest perforation) Diagnostic Criteria _must ve both clits and systemic manifestations fic dagnosis evidence of dated cola ‘daee of fever, >120, WBC >10.5, anemia + ene oh fad and electrolyte distances, hypotension, altered LOC General Surgery GSS op cn 18 fr tf ebitanleGS General Surgery Uses hen hi ers ‘spo wn aaron Differential Diagnoses of Common Presentations “oronto Notes 2011 Investigations + CBC (leukocytosis with eft shift anemia fom bioady diarthes), electrolytes, elevated CRP, ESR > mntnboic ellalons (volume carmction end hyppolalen) end hypoolbuminersin relate ndings + AXR diated colon > cm (eight > transverse» le), lose of haustra + Tv mefal to anes undeiying dione Treatment + NPO, NG tube, stop constipating agents, correct fui and electrolyte abnormalities, transfusion + sci AR {broad spectrum amibitis (reduce sepea, anticipate perforation) + aggressive treatment of underlying disease (eg, steroids in ISD, metronidazole for € dite) + indications for surgery (50% improve on medical management): * worsening or persisting toxicity or dilation ater 48-72 hrs + progedure: subtotal colectomy + end ileostomy with 2nd operation for re-anastomoss| Prognosis * yerige 25-30% mortally Paralytic leus Puthogonests + temporary persis ofthe opener perms Assostotions + pontapertis intra-abdominal pis medications (opiates, methtic,pechotsopc), ‘Besooiyedturbaness (Ne Ks Cal, Clif noely Treatment + NG decompression, NPO, uid resuscitation, correct causative abnormalities (eg Sepsis, medications eletzelytes), consider TPN for prolonged ileus + post-op gasric and small bowel motility returns by 24-48 hrs, eolonic motility by 3-5 + current interest in novel therapies such as gum chewing and pharmacologic therapy (opioid ‘uti, neorigine) Oglivie’s Syndrome 4 arises in bedridden pat fous extraintestind illness or trauma + exact mechanism unknows, likely autonomic motor dysregulation -» pow epcraton to colon, parasympathetic tone, and intecroption of socal ‘etuympatede tne to deel bowel « first presents ith abdominal distention (290%) + tenderness 4 aes spamptomae minke true ebetution Aazoclations ‘most common: tums, infetion,cacdiac (MI, CHF) + sh ng tr aon ee nm ed Send dog pt perepleg), drugs (ascot wee, lamattvecboee, polppharmeey}, othe (eveat orthopaedic of ‘Beuromurgsy, poo partum, hypokalemia, retroperieneal hematows, difose carinoroataie) Investigations + AXR: cecal dilatation _ if diameter 12cm, increased risk of perforation ‘Treatment + trea endearing cause + NPOLNG tube + decompression: cect] tbe, clonoscopy. neostigmine (ehellnergie drug) uggical ‘decompression (cstomy/netection) uncommon + rergery (eauemely ur) M pefuraion bela or Eure of commervalve managessent Prognosts + most reolve with conservative managementToronto Notes 2011 Differential Diagnoses of Common Presentations ssc “cre hub entol exsindecpceson (eg stangultng el) ‘non-acclisive: mesenteric vasoconstriction 2° to apsteme bypoperfasio ‘ppl oval organs) ‘¢tumn/desetion + venous thrombosis (prevents venous outflow}: consider hypercongulable state, deep ‘thremboais (VT) + chunicr ually dae to etheroeclerotc disease look fot CVD rk foctors Cancel Features ‘neater oi etn ou of proportion to phe Snug, vomilg, bloody dros, ‘Sango ete me byte soc ps {Common ste superior mesenteric artery (SMA) spied ero, "watershed ‘plate ocae, at calm geen cnion + abe leukocytosis (non-specific) lactic acide (ite finding) * amyiase, LDH, CK, ALP cat be used to observe progress * hypercoagulabilty workup if suspect venous thrombosis + AXR: portal venous gas, intestinal peumaloss, fee ae if perforatos + contrast CT: thickened bovel wall, luminal dilatation, SMA or SMV thrombus, mesenteric ‘portal venogs gas, peematosis + Grrangiograpiy the gold standard for acute arterial ocemia Treatment uid resuscitation, NPO, prophylectic broad-spectrum anibios 1 angiogram, embolecomy/thromectomy, bypas/graf, mesenteric endarterectomy, ‘sxticongalation therapy = tegmental macrton of neerotleinestne: Passes extent of viability if extent of bowel viability is uncertain, «second look laparotomy 2 2hmktaemmodetry PN) Tal he Appendicitis, Epldemiology + Gal popubtion, ME + pore between 5-35 pear of age Pathogunects + heat cbstructin > hactatal evergrenth -+inflsnanattan/eweling + increased preane localized iachemin gangrene/perfortion “localized absces (walled off y omentum) oF peritonitis ‘log: 7 le or young pera foe le ed yen + adult sboststtcure, felt obstructing neoplasm * other cases: peracten. oreyn body Cnet Festuree 1 owt ile tee progrenion ofsigne nd apctams Timed ever O60), re perio * shtimninl pln en sone cme ed eating 238Nepurr: pan ital perma constant Gul, pool localize, then wel icalined TE ete proprio boc fom veer ett (ouig mired ps frm sacs ‘te Cate mids incacng te appends) otras of pert rcs, + Madunmey gn General Surgery GSS oy fa ee ‘rng hoot ot oe nace +GSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 + signs * infeior appendisy McBucney' sign (ee sbove), Rovsing’ sign (palpation pressure toe abdomen causes MeBurneys point tendernes) ‘+ rerocecal eppendtr: paras sign (pain on flexion ofp again recstrice or pastre Inypererterin ofp) + perc append: ober sgn (lexan then exermal ar itera ataton cout right hp + couplierinon * peefrtion epectlly f>24 hrs duration) + abecrs phlegnon Iewentigations lahe * tli leokocyoss with ef sit (ony have normal WBC counts) 1 higherlekooye count with peoraion 1 bets ROG tole out ectopic regmescy + oat ‘apr CXR, AXR- usally nonspecific _e seperated (rare), cal eal loss ofpea dow + clrasounds may visualize appendix, but also hep rule out ayneclogial exuses_ overall sccuncy 90.54% + CT scant thick wall ppendicolh, inlamma ‘ptinal imeigrion ‘Troamont hpi, cornctelectoiteshaaemalien 1 surgery + atta + ifloclized absces (palpable mass or large plegmon on imaging and often pain >45 days), consider radiologic drainage + antibiotics x 14 + interval appendectomy in 6 weeks sppsadecioare: *aparoecapic ve open (se sidebar) + complications spliage of bowel contens, pelvic abscess, enteracutancous fistula ‘ampiclin = gentamicin + metronidazole (anblotes x24 only ifnon-perfrated) + other choices 2nd/3ed generation cephalosporin for aerobic gut onganisns rages _ overall necuracy 94-1008, Prognosis + morbidityimortality 0.6% if uncomplicated, 5% if prforsted Tumours of the Appendix CARCINOID TUMOURS (most common type) + vee Timoers of Small Itstines: Gren GSB ADENOCARCINOMA ‘= SON present mo acate appendicitis {spreads mpi ro lpmpl nodes, ovaries and peritoneal surfaces 1 restment right bemicoleesamy + ser Gastroemertogy. G18 Painelples of Surpleal Managemant 1 eam llevate spins adem camplicaons prow aly afc 1 conserve bow. resect as lifes possible to avoid short put syndrome * PE mie medic status may require TPN especially i>7 days NPO) and bowel rest ld smamuncmapprenive therapy pte prowid pre-op stem dot fcc ‘patient ad scent sero Deep ~ Sep rea thrombonls (OVD peoples hepaa (IED peiens et ncened rk of aamboembalic eran)“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Crohn‘s Disease eo Treatment uy NOT curative bur over iftme 70% of Cr pte ave surgery “inden rsp menage failure of medica) management ai 150 {deste ammsion:indaton in 5% of supe aes OF * sac esa eres wan ep xno ice), niyo pein, | eMart ‘Soorhagy dni daly as he (chdnen) posal noe less) + surgi proces + See 208 sity ‘resection and anestomosis/stoma if active or subacute inflammation, perforation, Sst ‘sreat tum ‘resection margin only has tobe fre of grow econ (alroncopk seve lelevant wm | * Dl nid oobi! yy etapa Cm Complications of Treatment Siete! enmuceal ice hort gut syndrome (Alora, searches, malnctttina) thet toned ln sens + 'Siptbre minal mca ‘Satalae «+ gallstones (i termina ewan resected, decreaed bile ail resorption + increased cholesterol > Etsy ston Qo of ein in darchen + incensed late ceorpton alpen > stones) Prognosls + recurrence ate at 10 years leocolie (25 50%), smal bowel (505), colonic (40-508) + re-operation at 5 years primary esection (208), bypass (50%), strituroplasty (10% at 1 year) + 80-85% of patients who need surgery lead normal ives = moriaiy: 1596 30 years Ulcerative Colitis 6 Trostmant lea sal eacagemet tae of eal manager ncking aby apr ec) pte ees) ‘ne 1 reduce caer risk (1-2% risk per year after 10 years of disease) ‘= proctocolectomy end ileal pouch-anal anastomosis (PAA) + rectal mucosectomy (operation of choice) - + proctocolectomy with permanent end costomy (ifnot a candidate for Leoanal procedures) * colectomy and [PAA + rsctl mucosectomy * im emergency: total eSlectomy and ileostomy wit eertion Compliestions of Trestment + carly: bowel obstruction, trensient urinary dysfunction, dehydration (high stoma output) ssumocnoticlouk « late sricture, anal fistulaebscess, pouchitis, poor anorectal function, reduced fertty jartmann closure ofthe rectum, rete, Progansi + morta 596 over 10 years + total proctocolectomy Will completely eliminate risk of cancer + perforin of toe econ the ening cee of death from ulcerative clitsGS General Surgery Differential Diagnoses of Common Presentations “oronto Notes 2011 oo EEE Definitions + diverticulum _ abnormal sc or pouch protruding from the wall af hollow organ + right sided (rue) divertcul contains ll layers (congenital) (se Figure 14) Te ded (fle) diverticot = contains only macanal ond suborsconl yer equi) "ause onvexncuuna Epidemiology + 35-50% of general popabtion, Mo? + jncreaeed incidence in Sth 10th decades of ie £9586 involve sigmoid colon (site of highest pressure) {higher incidence in Western countries, relate to low re diet Pathogenesis "ok face: = Tow-fibre de (increases gue transit time and intraluminal pressure) + muscle wall weakness from aging and fliness (eg, Fhler-Danls, Marfan) * pone gente enmponent + high intraluminal presires cause outpouching to occur at arex of greatest weakness most ‘commonly atthe ae of penetrating vemel at antimesenterc tenis, therefore increased rk of Temorthage Clinical Features + uncomplicated diverticuosis: symptomatic (70-80%) += episodic L1Q sbelominal pain, Hosting, flatulence, constpatian, diarthen tevefleubocytods ied LQ tenderness * initly work up and treat as any lower GI bess * trhemorthage does not stop, resect haired regan (“left Diverticul: Definition + fection om perforation of tverticskam jed appen + erosion of the wall by increased intraluminal pressute (or inspissated food particles) ‘ilcopeterslon/tacoperiestion ~ tafatasnaticn snd Seal wecresia sual mild inflammation with perforation walled of by pericolic fat ‘ignoid eslon most often invebred“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Cindeat Peetree ranges fram mild inflammation to feolent peritonitis 1 11Q painitenderness, present for several days before admisso «+ alerting constipation and diarshea, mninary symptoms (dpenria iftnflanmation adjacent ta palpable massif plegmon or sbeces, nauses, vorting + acca or goes blood in too ess common, + generalized tenderness suggests macroperforation and peritonitis ‘recurrent attacks RARELY lead to peritonitis, atic = ATR, upright CR: ™ localized diverticulitis (les, thickened wall, SBO, arta colonic obstruction) + fre alr may be see in 30% with perforation and generalized peritonitis + C1 scam (optima method of tvestigation) = = 37% serve, very useful for assesment of severity and prognosis *= very bef ln oellsng an abscess HHypoque® (water soluble) enema SAFE (under low pressure}: ‘sae-toath pater (colonic pam) 1 ine show ate of pedoation bcos cvtcs snus tractus + Sarin enema: contraindicated dortogan are aac: rink of chemical peitonls (bcos of pecartion) sgmoidonpylelonoscopy: ‘not during an acute attack, only done on an elective bans * take bipeier to rule out other agnaces(pebype malignancy) ‘Treatment + admit, NPO, fluid resuscitation, NG-+ suction, IV antibiotics covering fags (64 dprefcancin. metronidazole) + iniatone or srry * unstable patient with peritonitis + Hinchey sage 2-4 (oc Table 10) * afier 1 attack i€ (a) imamanosupprcteed,(t) sbecrs needing perertancous dainage * conser after 2 oF more attacks, reeent trend is toward conservative management of ‘ecarrent mildmoderste attack + complications generalized peritonitis fre ai abscess stu obstruction, hemorshage inability ‘orale axt colon cancer on endoscopy oF fthte of medical management + mpl recedes ‘Harcmasn procedure: resection ~ enloeremy and rectal nurp -*colosromy reversal fn 3-6smanth (ce Figare 15) resection + primary anastomosis (+ pre-op bowel prep or on-table lage): controversial (erastomons of slaved taausaw iteneaned rik of enantomotic leakage) Prognosts + 13-308 recurrence aftr Ist attack, 30-50% after 2nd attack Tale 10 Hinchey Staging and Treatment for Diverticulitis Hnchey Saye Descpion ‘ate ene Pheynan/ sha perc cass —Mesdb 1 7 2 Lage atscas/tana esas ange esetn pry asses 1 no 2 eve ptont ane beets) rman pee, ny antrn no 4 Fesvent a Aernan pcedueGSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 Colorectal Neoplasms Colorectal Screening G SBivinmttares patron er Tyan tet ny Me he er Colorectal Polyps Deftnition Epidemiology Clinical Features + polyp: mall mucosal outgrowth into the lumen ofthe colon or rectum + sesile (lat) or pedunculated (ona stalk) (see Figure 17) Table oristios of Tabu Teta ince Cane (2 90H Se Sra (<2 tachment Peenebtes Mera Prem ova Dita wn 5086 in the rectosigmoid region, 30% are multiple (ea en + 3085 of population have polyps by age 50, 40% by ag 60, 50% by age 70 Tas anc (OR Loge tau y>2on Let sel pace H usually asymptomatic, but may have rectal Dleding, change in bowel habit, mucous per rectum + unually detected during routine endoscopy ofan ial/high risk screening Pathology moet commen 1 preusopolyps inflammatory serocsted with I8D, no malignant potential“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS + neoplastic ‘hamartomas juvenile polyps (rg bowel), Peuts-egersyedrove (aml bowe) * malignant risk det ateoclted adenomas large bowel) “Tow malignant potential “> ment spontancosly regres stoaorptae + adeno - pemaigent fin crcl in ot some may conta ivasvecarctnura elignat polyp” _3-9%):ivasion into a + malignant potenti: villous >tubulvillous> tabular (ee Tele 11) Investigations + flexible sigmoidoscope can reach 60% of polyps in men and 35% of polyps in womens if polyps detected, proceed to colonoscopy fr examination of eatie bowel and biopsy + colonoscopy sl the god erandecd Trantment * Sndicatane symptoms, mllgnancy or kof malignancy (Le. edenomstous polyps) + eaoecopic removal af exis 1 sergio rescesion So those invading into mascslsle high ak of malignancy) and those oo tp rernore + follow-up endoscopy Iyer later, very 3-5 years Familial Colon Cancer Syndromes FAMILIAL ADENOMATOUS POLYPOS'S (FAP ote finan (AD) ihertanc, mutation in adenomatous polpossol (APC) gee on ronson Clinical Features y by age 20 (by 408 in atenusted FAP) * carcinoma of duodenum, bile duct, pancreas, stomach thyroid, adrenal, small bowel + congenital hyperteaphy of retinal pigment epithliam presents early in lien 23 of + virally 100% lifetime rik of colon cancer (Deeause of number of polyps) "Gardner syndrome: FAP + extraintestinal lesions (sebaceous css, osteomas, desmold tumours} \ * Turcots syndrome: FAP + CNS tumours (glioblastoma multiforme) ents Feel etn Gora erin tr APE Tretia eco {apache aan teri oar AP et ‘ego ther woe ye Investigations + genetic testing (80-95% sensitive, 99-100% specifi) (see sidebar) 1 fo polypadis found: animal exe sigmnidnscopy from puberty to age 80, then roatine sceening. + fpmlypasi ond: anne enlonosanpy and cones sargery (eee Pigare 16) ‘Treatment, 7 ‘sug indicated by age 17-20 + Temi fe cops tons total proctocolectomy with ileostomy OR total colectomy with leorecal anastomosis [at inanions win cloned damrubicin based chemotaergy ened ‘+ NSAIDS for imra-abdominal dermolds HEREDITARY NON-POLYPOSIS COLORECTAL CANCER (HNPCC) ‘AD inheritance, mutation ina DNA mismatch repair gene resulting in genomic instability and ‘wbeequent mutations nical Features + early age of onset, right > left colon, synchronous and metachronous lesions + etn ge fcc presen is yeu tine rk 70-08 (DT) 1 fae Padre cancer Rey odes “hgh ne of execu (endometeia, ovarian, hepatobiliary, small bowel) Diagnosis, + diagnosis is clinical_ based on Amsterdam Crter ‘least 3 relative’ with colorectal cancer or HINPCC related CA, + 2or more generations involved, and I mist be Ist degre relative ofthe other 2 1 cave mur be dlagnosed before 50 year od TAP encasedGSE General Surgery imped con ea Differential Diagnoses of Common Presentations Toronto Notes 2011 Investigations + genetic testing (89% sensitive) _ colonoscopy mandatory even if negative * refer for genetic screening individuals who fll EITHER the Amsterdarn Criteria (as + total colectomy and ieorectal anastomosis with yearly proctoscopy Colorectal Carcinoma (CRC) ccs) Epidemiology + 3ed mast cotton cancer (ater lng, prostatebreas), 2nd most common cause of cancer death lek Factors > most patiots ve no specter fctoee + HAR LINPCC, family hisory of CRC + adenomatous polyps (especially f>1 cm, villous, multiple) + age 350 (dominant risk factor in sporadic cases), mean age is 70 {HIRD (especially UC rise -2%Iyr€ UC >10 yr) + prvi cot ener (lo god or be) + Gia (creased ft, rod ment, deceased fhe) and smoking 1 diabetes melius (nsulin isa growth factor for colonic mcosal cell) and acromegaly Screening Tools * dig reaal eram (DRE): most common exam, but not recommended sa screening tool * fecal acelt boad teat (FOBT): * proper tes requires 3 samples of soo calloced wt 3 diferent mes ss ecommended annually bythe World Health Orgenization (WHO) * results in 16-33% reduction in mortalityin RCTS * Minnesota Colon Cancer Study: RCT shoved that annual FOBT can decrease mortality rate by 1/3 panier 50-90 years ld sigmoidoscopy: nly 60 ofa Sgmosninys PORT mes 24 ofl neopans * can ee or pry Inka dg prooiane om le tooth sts if I one d + Ghadventager expense not alvay salle, por complance, requires sedation, ko ‘ecmon (a0) « vinta colonoscopy (CX eslonogrepy: 91% sensitive 17% ae pov te 1 contrast baru enema (ACRE) 50% senaive forage (1c) adenomas, 39% for polyps Pathogenesis + adenoma-cardnoma sequence, rary arise de 0% (Clinical Features (se Tale 12) often + hematocheriamelena, abdominal pan, change in bowel habits 1 others: weakness, anemia, weightloss, palpable mass, obstruction + 3-58 have syuctronous lesions Tee Cet Pre beep ecm tn tect arene merrsetereesne ‘Table 12: Chace Presestaton vf CHE Tecan Fregmney 2 Prchoay Gupte exes theccstbetday Arua, maeibesenss 1 Ls Ueseagd 1 ov Symptons Wek, wa ny Cmepsin's to rag Chet, ere, eS Itt doe any Heo (aoe kc ei og Sams Feddcenysnema LOmssT05) GR. BO 144 Papterass on, PA“Toronto Notes 2011 Differential Diagnoses of Common Presentations Investigations ‘+ calonoacapy (het), look for synchronous lesions; shertive: ar contract hark enc (Copple cae lesion) + sigma ncopy General Surgery GSS $——— Stain eR + ifapatentis FOBT +, has micoeytic anemia or has change in bowel habits, do colonoscopy | F-tznee ‘netasttic workup: CXR, abdominal CT/ultrasound 1 new ‘bane scan, CT hood only iflxons ee abs CBC, urinalysis, liver function tess, CEA (before surgery fr baseline) ‘suing (ore Tie 13 ond bes) 1 rectal eancer: pelvic MRI or endorectal ultrasound to determine T and N stage ay Tole 13.TNM Classification System for Staging of Colorectal Cre Pom ta Pinay aoe aga yep odes Tino oases See breil 70 Weir een a a Te Chere nat 1 Mensa petals Oram Tih 1) bi trmas (2 Races nA atc ne te Te bent ear Nami ae ding enn Ms 1 hetntragh nantes teas Toran nats 1+ tanto cn encore ‘Trestment Bet oe * AEB Quad a penal emnbiocermpamat cu — net emay i ong) Melocasen curative: wide resection oflesion (5 em margins) with nodes and mesentery te i 1 palit fat spd, he eal cant for menage or trot Bos of recurrences oveur within 2 years of resection “= improved survival metastasis consists of solitary hepatic mass tha is resected colectomy: ‘Smost patients get primary anstomosis [eg hemicolectomy, low anterior resection (ARO (eve Pgue 18 + ifeancer is low in rectum, patient may requite an abdominal perineal resection (APR) a permanent end colostomy, especialy iflesion involves the sphincter complex + compllotione anartomode leak or etreture, recurrent Aieate, pave abscess, ‘euterocatancoue Sta + radiotherapy and chemotherapy: * chemotherapy (5-FU based regimens): fr patients with node-positive disease + radiation or patients with node-positive o trensmural rectal cancer (pre + post-op), nt ‘ecve sa 1° estment of colon camer ‘+ scjurant therapy chemotherapy (colon) and radiation (rectum) * palliative chemotherapy/radiation therapy for improvement in symptoms and survival * neoadjuvant chemoradiation for T3 of NI rectal cancer Case Finding for Colorectal Cancer (symptomatic or history of UC, polyps, of CRC) + survellance (when polyps are found): colonoscopy within 3 years eter inital finding tients with port CRC: colonoscopy every 3-5 yearn of more frequent’y 1 Ip: some recommend colonoscopy every 1-2 years after 8 years af disease (especially UC) Follow-Up + Intensive follow up improves overall survival in low risk patients + curently there ate no deta suggesting optimal follow-up. ‘ombination of periodic CT chestabdolpdvis, CEA and colonoscopy s recommended + carcinogenic embryonic antigen (CEA): to monitor for initial response to eatment, and to ‘ome fr rcrence 3 onthe (not soreeniog et} Py gGSE General Surgery sox Sette Sic St eter bow on uso ot Sid Wis RE lt eae 2 pons d, Dem ean orate hs Fraley sme rater ley get Differential Diagnoses of Common Presentations Toronto Notes 2011 Other Cond Angiodysplasiz Deftettion += vascular snontaly: focal eubnucotl nenous dilatation ond torwoaity Peet Clinical Features + most frequently in right colon of patients >60 years od Investigations 1 eodooeopy (Cherry zed pote branching pater from centr rome) ography (low iingieaty emptying mente vin, aula a) 3RNC technetham 9 scan 1 fecum ene coniindicted(cbcares other my gio) a + cautery right bemicolectomy, embolization, vasopressin infusion, sclerotherapy, band ligation, Taser dctaolle, a0 realy ogunental moectian ioe treatin fail Volvulus Definition rotation of segment of hovel about its mesenteric axis + sigmoid (70%), cecum (30%) Filsk Factors ge (50% of patients >70 yrs stetching/clongstion of bowel with age i predisposing factor) {high fibre diet (can cause elongsted/redundent colon, chronic constipation, laxative abuse, pregnancy, bedridden, institutionalize (ies frequent evacuation of bowls) + camgensally kyperinelie cecum, Clinical Features symptoms due to bowel obstruction (S23) oF intestinal ischemia (S27) Investigations XR “omega "bent inner tube “coffe bean” signs (ee sidebar) 1 batiu/gasteografin enemas “ace of spades” (or “birds beak”) appearance due to funnel: ike nina lapering of lower segment towards velvulus ital supportive management wit fd, electrolyte resuscitation * mesg ray after calmonce dtaon ad decmpentin Hight cokctomy + seotransverc colonic anastomoals dectnpresion by Hele slgmcidencapy snd insertion of rca tbe past abtration + subsequent elective surgery recommended (30-70% recurrence)Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Definition + abnormal communication between two epithlialized surfaces (eg enterocutaneous, ‘coloreseal sortoeszrt, entero emtele) nr se Sy Oper 0900 Fey Etiology + femign object erosion (eg galbtone, graf) + infection, IBD (espedlly Grok), dverticuer disease = a — petaea cee Tre tater Soren Semen ee 1S ent dng fr “site tn ma crys 1 drain any sbacmenfcntol eps ‘auton ~ elementaViow resis, TPN Aecreate secretion _octreatdelsamatostatin/omeprazole + shin care (fr enterocutancos fala) * mea nterenton = dependent pon eso enn Sau); mer of Definition + an opening ofthe GI tract onto the surface of the abdomen wall at + type (ce igure 19): cclostury va feotoany, temporary v. permanent, cetinent wt, ‘ncantinent, end vs laop, flecandt leupteesny * end (Brooke) Neostony: fr incontinent, continacus dranoge in poles regalrng total +» Koch ieoftomy: for continent, manual drainage _rarely used Complications [10%] + obstruction: herniation, stenosis (skin and abdominal wall), adhesive bands, volvulus ‘peci-leostoany abscess and fatale skin ication *Comactenel ox rt son (cans anon el Camactncl at bat ota Nest tema Neestomy Colstamy xd ColstomyGSE General Surgery Differential Diagnoses of Common Presentations Toronto Notes 2011 ¥v Hemorrhoids (otek esaame | Esology Fonte cs and + vascular nd connective lose compares form a plexus of dated vein (cusblon} ‘Interna: supesar hemorsholdal veins, above dentate ne, portal ctcwtian «+ external: interior hemorthoidal veins, below dentate line systemic circulation Fisk Factors + tnceseedintr-ebdominal preesure: chronic comtipatioa, preguancy,cbesty, portal Ihyperteaian, henry fing | (Canical Features ond Treatment + Internal hemorshetds (eo Figae engorged vascular cisions Usually at 3,7, 11 oelock postions (patien a ithotomy position) = panes rectal blending, anemia, prolapse, mucus discharge, pratt buring pan, rectal ‘Tet deme Heed bt da not prolapse rough the ame “reste ig ibre/bulk diet, sit baths steroid ctear, parmoxine (Anusol”), rubber band ligation, scertherapy,photncaagniation (+ aad degree prolapee with aiming, spontaneous eduction treatment: rubber band ligation, photoconguleion + Sed degree: prolapse equlring manual redaction treatment: santas 2nd degree, but may require closed hemorchoidectny degree: permanently prolapsed, cannot be manually reduced = treatment dase henonhoidectonry + extemal hemorphaids (tee Figare 20) * dined venules pai er Dorel nerenetc steed with poor hype + peta rs dey elt van es an) perie + ttnient bene wry at Sree nth? wes may eves sn perl skin g cae ne ice Anal Fissures Definition + tear of ana canal below dentate ine (very sensitive squamous epithelium) + 90% posterior midline, 10% anterior micline + fof mnlline consider ID, STi, T2, leukemia or anal earcinama, + patie inary opel iat ea cars Som healing and leads to Farther Etiology + larg bard tools and ita dlacheal tools tightening of anal canal secondary to nervousness/pain 1 ether: ata! ue af ethtien ult, Clnkeal Fearures cule Garam very painful bright red besding especially after bowel movement + treatments conservative sol sofleners,sitz baths + ehronic fire: * trad: fasure, senting akin tgs, hypertrophied papillae * teem ‘ stood sotenen, bulking agent, ts bathe + topical nitroglycerin oF nlledipine _ increases local blood flow, promoting h — ‘+ rurgery (nod effective) ~ lateral internal aphincteretomy; objective ia to reieve sphincter ‘spasm = increases blood low and promotes healing but 3% chance of fecal incontinence therefore not common dase * seraatie reanaent ‘botulinum toxin _ inhibits release of acetylcholine (ACh), reducing sphincter spasm ngand“Toronto Notes 2011 Differential Diagnoses of Common Presentations General Surgery GSS Anorectal Abscess Deflnition ction in ane or more ofthe anal spaces see Figure 21) ‘usually bacterial infection flocked aml gend tthe dentate ine "coli Proteus, Streptococl, Staphylocec, Bacteroides, samen Primal sbscose lofammed Figure 21 Different Types of Peonal Abscesses ical Features robbing pain that may worsen with straining and ambulation + abscess can spread vertically downward (perianal), vertically upward (supralevator) oF ‘pertzmtaly (echlorecta) «ter perineal mason exam ‘Trastmant + Saeilon and * carattve a 50% of cases 1 50% develop ancretal aulas + muy roqlteentbloties if diabetic, heart murmur or collie Fistula-In-Ano ton between two epithelialized surfaces, ane must be the rectum or anus {an inilammatory tract with internal os at dentate line, external os on skin Edology oe Pande, 0337 ame perirecal process as anal abscess therefore usually associated with abscess = otter carer: poop, tana, al rare elyponcy, dion pct Clinical Features «+ tnermittent ar const puralet iacharge fea perianal opening, pata 1 pabpele cond ie tet += Mestiention: > Goo alee Pig 2) “Sf with a eternal opening anterior othe transverse ana ine wil eves internal opening rately the ume positon (eg extemal operat oct ineral opening at 2 dock woerets dl external pening poteriot to teline tend to have ther terml opening in he ina + fatal probing faalogphy der enedGS General Surgery ert ere Differential Diagnoses of Common Presentations “oronto Notes 2011 + surgery: * fstulotomy; unroof tact from external to internal opening, allow dexinage * low ying istala (doesnot involve external sphincter) pay fstadeeamy = high fying ical (salves exeznalsphinces) - ssged fstulotomy wits Seton suture placed shuoagh ace ‘+ promotes drsinage ‘+ promotes fibrosis and decreas incHdener of incantinense delineates enetomry ‘© uruly dane to spare musee eutting Postoperative + siz baths, iergation and packing to ensure healing proceeds from inside to outside Complications. 1 rely fal Incontinence Definition + scale sbeome or onde datning slau n scrococcygeal rea Epidemiology + occurs most requently in young men age 40 yr Etiology + chsttuctlon ofthe heir lees in this een > formation of cysts, sinuses ar abscesses Clinical Features + asymptomatic until acutely infected, then pain/tenderess, purulent discharge ‘Trostmont ete abso ‘incidom and drainage * wound packed Me develop chicos macs + chine denne * plonial ‘* excision of sinus tract and cyst + mersupializtion (cyst edge sewn to surrounding issue to Jervesimas tactopen) Rectal Prolapse Definition «protrusion of fal thickness of rectum throogh ams Epldemiology ‘extremes of ages _ <5 yeas old and >5th decade + 03% women Etiology + lenglhened stiachment ef recham secondary to cnatant ening cayper 1 false/mucosel: redundant rectal mucosa, radial furrows Ti incomplete: rectal intussusception without siding hernia TF truelcomplete (most common) (ee Figure 23) 5 protrusion of entire rectal wal through anal orfce with herniation of pelvic peritoncusm! eldeae cecal furows Flsk Factors * epnecclogial gery 1 SStonic neurologie!poychiatic disorders affecting motility Clinical Features «extrusion of mars wit increased inta-sbdominal pressure: iyextruded rectum nd constent soiling + may be essocated with urinary incontinence or uterine prolapseToronto Notes 2011 ‘Anorectam/Liver ‘General Surgery GSA Treament ‘Mppes ed imam) omc center meet tn + Kemeny ei cionl aan a ot eet nye "Peete spn + Say comin pena emma pea Anal Neoplasms ANAL CANAL ‘Squamous Cell Carcinoma (SCC) of Anal Canal (above dentate tine} + most eammon tumour of anal canal (73%). + anus prone to human paplloaravinus (HPV) infection, therefore st rsk for anal equamoas ‘ntrcplthella eons (ASIL) "high grade squamous intraepithelial lesion (HSIL) and low grade squamous intraepithelial + ctinelfetares: anal pein, mse, alcration + trestment chemotherapy i radision 3: gery 1 prognonis 8095-yeareureival Malignant Melanoma (MM) of Anal Canal + 3rd most common site for primary MM after kin, eyes ANAL MARGIN + clinical features and treatment as for skin tumours elsewhere + squamous and basal cell carcinoma, Bowers disease (SCC in stu) and Paget disease * moet cootmon typeof Ever cyst, uy have msltpe simple ets + clinical features usually asymptomatic, i large may present with pain or mass ‘+ treatment generally nt required Sr simple cyst unless very large 1 complications: intraystic hemorrhage (may be confused with complex cysts) POLYCYSTIC LIVER DISEASE + progressive condition where cysts replace mach ofthe liver 0% associated with plyeystic kidney discase + teetment if symptomatic treat by parti Iver reaction or by covatlog dabuage for cyte(CHOLEDOCHAL CYSTS. » congeni jn of poncreaticobliary tee J Atypes most extreme form clled Carol disease (multiple cystic dilations in intehepatic ducts) * clinical Seeme:recarrentehdomfne] pals mecraninen aon ale, HUQ mass 1 Giagnosie U's, trenshepatie cholangiography, LET » teoiment hgh tak of malignancr. caren testment i complete excision of cys extent of reveeton depends on ype of cyt * leer transplant indicated cyt inloes intrahepatic be duct (Carat aca) HYDATID LIVER CYSTS (CYSTIC ECHINOCOCCOSIS) * ion with pants Shiner 2 Sndene to Seinen Europe Mil ast sla, South America + Srotted with eaposure todos sheep and cate + dnt feos = aemmpromatic moss {moet often) or chronic prin, heprtomegnly 1 ruprore can ons bilary colt, rondhce or anapiyeie racer ‘detection of entiEchinococcus Ab (IgG) using ELISA or RIA, = UIS.CT: presence of mass often clctied + DO NOT perform needle biopsy as can cause seeding * medical: albendazole (ant-helminthie) _ cure upto 30% \dominal cavity or anaphylaxis (CYSTADENOMA (PREMALIGNANT)/CYSTADENOCARCINOMA, + ele eae = gm ecco egg nkre myo ein jan ese ig . sheomple, ied eye (Cxoet echinocoeea be excieed because of malignancy Liver Abscesses ‘por yogente (bacterta): moet often Grnm-oegatves — col, Kael, Proteus : (arochic): Entamoeba histelyion > sources: dict spcad frm tilary toc infection, portal eprad from Gl infection, eyteaic ‘infection (eg-endocanditia) Clinical Features fever, melas, chills, anorexia, weight loss, abdominal pain, nausea + RUQ ndernes,bepuinmrgply jenn, dullest perrnion Investigations + leukocytosis anemia, elevated iver enzymes, hemagglutination ites for Betamax antibod 1 US, CXR (right basilar eeletaisefusion), Treatrverrt ‘eat underlying case 1 mug or perertancons deiaage end IV antbitice Prognosis + overall mortality 15% _ higher rate if delay in diagnosis, multiple cbsceses, malnutrition Neoplasms BENIGN LIVER NEOPLASMS Herangiares fxvorous) "Eigen ome bens hep tency hematin ang + risk factors: PM 1 Ante feeare= + ual eral end eymptomat are zou ny procs pan comorem ach aiacires 1 chock fruptned (rry see) 1, steroid therapy, estrogen (exogenous, pregnancy)* Hemant (wel demarcated hypodente mass wih peripheral enhancement and delayed ‘enous emptying), UIS (homogenous hyperechoic mass), arteriography (rarely used ‘cotton ‘woat” appearance) RAC scan + Dopey may rel fu hemorrhage + treatment usually aone unless tunpour bleeds or emptomati then ecion by hbectomy er enucleation benign glandular epthaie mmoar 1 Ho factor: feral age 30-50, estrogen (OCE, pregnancy) * clinical features: asymptomatic 25% present with RUQ pain or mass + Investigations: CT (well-demarcated masses, often heterogenous, sodense on non-contrast CCI, peripheral enhancement /sodense/aypodense on contrast C1), UIS (va ‘amally hyperecheic),biapey - omen tap anabolic etecos or OCP ‘cise especialy i large (>5 em), due to risk of malignancy and spontancous rupture! aershage Focal Nodular Hyperplasia + Pathogmenis thoaght to be de to local ischemia end taeue regemeretion Fuk actors female, mele age inal features asjrplomate, racely grows or bleeds, no malignant potential ‘investigations: cena sate sar n CT sez, tehmetim-99 scam hepa * treatment maybe dificult to distiagaich from adenoma (liguast poteatial) -> often resected MALIGNANT LIVER NEOPLASMS Primary usualy hepatocellular carcinoma (CCV hepatoma ‘othertincdeanglosarcoms hepetckiasome, hemmgloendotbeiome 1 pidemiology: uncommon in North America, but represents 20-25% ofall carcinomas in Asia ‘zl Afca = gk factors * chranic ivr inflammalion: chronic hepatitis B Gnhereily oncogente) aed C cross {penal macroodalr epost ans pea : Crincresed sal), teaide ing alcobal « chemical cateinogens (llatoxin, vinyl chloride _assocated with angiosarcoma) + lial features: Tg dics “enti tp eg Dita Roo aati LIEReP ane Cod Gen ina abdominal hemorshage) a etna lng bow bn fetinealncdng ier, tro, eae sneexigtlons: 7 dewied ALP, rain, and c-Leoprotein (8% of plies) UB poony-detnedsargins with internal ees) tpese CT (enbanceent on arterial ‘hase and wathovt on portal venous phase), MR Cor MRI angiography = biopey “T Gnthosa ina reatvcontraindction to tumour rection dvcto deceased hepatic etree Surge rsecton(10%o" patients ave resectable tumours) iver transplant (ifetrhont pls salary nodule c5 cm, or ls than 3 nodules each <3 cm {Sin enter) general not wih extrahepatic dss vascular invasion) = no sgl sletion, pescetmenne ethanol injection, temacetheterertetal Ghemoertbozation (INCE), chemotherapy (imted eticsy) PP eve meat nodes and ang, * survival without traiment 3 moat * Syenr survival: al pauents 59% patients undergoing complete resection _ 11-40% Secondary * tur eaminan beptmalignancy Gl Gort common) ng, bare paces. rary. irs, ry, publ rostte “Tien necion icon of a0 ce "ig secon feof pin cata eiony «prognosis 30-40% 5 yen suv! wih curative” esetion; prognosis same if metastases are Trltlobar compared wits confined oon lobeGSi4_ General Surgery Liver/Biliary Tract Toronto Notes 2011 Liver Transplantation Tob 14 Conditions Leading to Transplantation Precip ase Cheese i Tab rr Their Vegans (Cantcal inition SUEiy orl or ansplant should be considered fr al patents with progres ver disease ‘oc upon wo meiieal ear expecially decompenaied drshousuaceecie pesary ecraticemehd Gminan hepa re « end-stageliverdisave with i expectancy <1 yes and if no other therapy is sppropiate + Ege in cry as pomp ec np «eet wlan hemathage. nnplopat ee eign cera for Modal or end Sage Liver Disease (MELD): considers probaly of exh within 3 months if Patient doesnot receive transplant; based on creatinine, bilirubin, INR + Child-Torcotte-Pagh Scare: patient must have 7 points (Class 8) Contalndleations epee EV pote ae Sinhepetmtetss 1 nant cardlopelmonary dlecase Post-op Completions ney aon facto (gn Gr) — pete tegen sinned 1 Kei bd come spect ces Sey 5 selar- hep ay orp ts Gembons VC aberaon {Uiky completions ever tnresongbilbinand ALP + recuenceot bear mee therapy my cen prevent ‘oarenes i pls Celt securene tangy ike ee at ounce sabe ‘Sura ely Prognosis poet minal 1 yee — 859% + graft survival at | year _ 60-70%, at5 years _ 40-50% Choleli: ok etaition Senay of tir at Contos | + the formation of gallstones (see Figute 25) ater ri + imbalance of cholesterol ands solubilizing agents (bile salts and lecithin) ame + Clas hopate heatr ection > cas ond “ode? => vce ‘spent chlersa can pecans wn a coe = NUipkmarcs chose! toes B09), pigment senes 00) tot fon Tate | Rak Factera Se | ee, = mee] TEES, matpat ocr # Sdhneiy iret Nations heritage > Caucasian > Blake ' terminal lal resection or disease (eg Crobri see) Q + impaired gallladder emptying starvation, TPN, DM type L * rapid weight lors repid cholesterol mobilization and bry stasis maw erchoenual cones + pigment anes (gata acts Wie}: “Pe feo ert Fran ehods + Giron hemolysis = bry sais (ictus, ation, bikary infection)‘Toronto Notes 2011 ‘Biliary Tract General Surgery GS45 * consider cholecystectomy i porcelain (calcified) gallbladder (25% risk of malignancy), sickle cl isons, pediatric patent, having bariatric anger, diabetes, immonosuppresion ‘any enlie (10-258). (215%) ieee acral oe Ande Pets SS) Investigations US gaa proce cht “image for signs of inllammation, obstruction, localization of stones = | ENGF (endoscopic remograde cholanglopencreen grap? USiesepone pce fees * visualization of upper Gl tract araplarycepio,bilary and pancreatic ducts ts _nethed for treatment of CBD stones n periampalary region = Complictions: raumaic pancreas (128), panctestc or Diary sepsls + MRCP {magnetic resonance eholanglopancreatography) * ame information gained as ERC? but nco-ioace 1 Ghote wed be hepatic pres PE in a cinerea ‘etl fr proximal bile duct estos o when ERCP favor not sealable 1 pins people tactics * contcaincictions coagulopathy, ascites, perfintraheptic sepa, discos of right lower lung HDR ea Gepacbty ne dace ane + HIDA sean (eepatobilary imino dactie ah eam * vee lest. commanly 1 Fadloleotope tnchnen-99 injected nto a ven i excreted in high concentratian nt ie, ‘lowing eauaaion ofthe = does not visualize stones diagnos by seeing occluded cystic duct or CBD Biliary Colic Petrogenesis + gallstone trnstenily impacted im cyte duct infection (ileal Features ¢ et an een or RUQor intr mend dco pate 1 audit trig sar or scale, 1 peta fen ens 1 Fe pean inding 0 psec ignInvestigations + normal blood work: CBC, electrolytes, LFTs bliubin, amylase 1 UiS shows cholelithiasis, may show stone in eystie duct ‘complications: CBD injury (03-0.5%), hollow viscus injury, bile peritonitis, vessel injury "= laparoscopic cholecystectomy is the standard of care + sk cfopen colecpmectmy higher in anergy tions Acuta Cholecystiti= Peahecensets| + Snflanmation of gallbladder resulting from sustained gelbtane impaction ln cyte ductor “Hartmanes pooch + no chabdlihass in 5 10% (108 Acacalous Chelecptti, GSAT) Clinical Feeturoe * often have hietory of lary cole + severe constant (hours to des) epigastric or RUQ pain anarexta, nauses, vomiting, low grade ever (3850) + focal peritoneal findings: Murphy’ sign, palpable, tender gallbladder (in 33%) + Bo jg: right ebecypolar pa Investigation + BloodWork:clevated WIC end left shit, mildly clevated bilirubin, AST, ALT, ALP tus 1 98% sensitiv, consider HIDA scan f UIS negative * fegruret on UIS (5 eign): ‘sonographte Murphys Sign maximum tenderness on inspiration when probe over ‘Comptlestions » ur mcd fp lng pt dct steno nanos $comulstion in gallladder (clear + pps pertinence formation cr pets 1 Sinema palace = suppurative choLeyatin pin ladder ick patent 1 dobbs tne tei epee acs of eye can eed pone es + emphysematous cholecystitis _ bacterial gas present in gallbladder lamen, wall or ericholerytc space (risk i abetic pati!) + Mirrzas eyndrome _exira-himinal compression of CED/CHD due ta large stone in etic duct Treatment «admit, hydrate, NPO, NG tube (it persistent vomiting from associated ileus), analgesics once Bio ee eit wn snes eaioecne coum i272 hrs) vs, delayed (after 6 weeks) ‘equal morbid and moctlty + early cholecystectomy prefered: shorter hospitalization and recovery ime emergent OR indicated if high rd, diabetic patent = laparascopic i seandard of care (convert © open foe compliction cr dificult case) ‘laparoscopic reduced risk of wound in sorter hospital stay, reduced postop smal stones in gallbladder with a wide cystic duet (>15 mm), single faceted stone in + pester kept tel egret tneAcalculous Cholecyst Definition, + scum or chronic cholecyttis in the absence of ranes Pethogenests > pally dive to gallbladder cuss ->dudge fren in gallbladder Fisk Factors + DM, immunosuppression, ICU admission, trauma patient, TPN, sepsis (Clnteal Features = 20 Acs css 1 ocere in 20% of cases of acute cholecystitis Investigations + UIS: shows sludge in gllbladder, other US features of coleeysits (see Acute Chalet, 46) ‘creeiiDA sewn Tenure {itp cne-+ chelepetony Choledocholithiasis: Definition «+ aones in camman bile duct (CBD) arympenmatic ‘aan have latary of Mary colle * pray armed ie decides dct pthclogy (eg benign iia scr ‘sora loch Tada. brmelingtadder 2 of csesin US) F MRCP (90% sensitive, almost 100% specifi, not therapeutic) ekg pcre ry secured bry ce Treatment 1 Htnocdence of cholangitis: tet with ERCP for CRD stone extraction possibly flowed by dsctve chlecectmyin 23% of patiets Acute Cholangitis + obstruction of CBD leading t biliary ssi, bacterial overgrowth, suppuration and biliary sepsis Etiology + choledocholithisis (0%), stricture, neoplasm (pancreatic or billary), extrinsic compression (pancreatic or instrumentation ef ile duct (PTC ERCP), bar etext «Sorat Pd RUE Rendortmen Enrrocecas Bags Pots 1 can ee pn nde ee epee See eae es ee — Se ee cun ete - Se enc an Cee Ser a + amylosfipose: rule out pancrestiis 1 Unk Sota/entes hepate dur eatinnoes monroe Ea Etat Posen oon oes rao ea gnera froth toeysnossrc Troatment + inti: NPO, uid and electrolyte resuscitation, + NG tube, IV antibotis "ERE? + sphncteotonny - dagnartic and PTC with catheter drainage _1TERCP not avaiable or unsuecessfl * lapacotory with CBD exploration and T tube placement ifabove fs > al patente shoud abe lve a cholecpmcionng:unkem nvemsiedicated Prognosis + suppuritive cholangitis _ mortality rate S08 Gallstone Ileus Pathogenesis * owthegrandimpaatorner leo at ehong eed oben (cote: anion nlc in ths contest) vane (Clinical Foatures + cxampy abdominal! pei, neue, venting (sce Bowel Obstruction, GS22) Investigations © AXR'isted small intestin 30%) + Cie bay trac ai obstruction, gallstone in intestine ‘Troster, + fie resasctation, NG + surgery: enterotomy and removal of stone, inspect small and large bowel for addtional proximal — += fila veal loses epontancousty + eecaivecholecytectony afer recovery If patient experiences pallbladdersyrmpeoms vir lad levels, may ree Carcinoma of the Gallbladder Rsk Factors + chronic symptomatic gallstones (70% of cases), old age, female, gallbladder polyps, porcelain eller Cneot Festuree 1 srk om denotes, Ina be eldntal finding om eletve cholecystectomy (-1% of elective cholcptctomles) + may pees ae eymponticmail ac “ocal wea UO pa pebble RU seas 1 ft aundice S00) dno invson of CBD or compresion of CBD by peicoledcha oda weight an ales, morn + Emel exteralon tives my eed to stomach, dvodenam 1 Sty meus common ave lng bone Investigations + US: ural thickening, calcification, loss of interface between gallbladder and liver, fixed mass + endoscopic US (EUS): good for distinguishing carcinomas from other diagnoses such as polyps, good fr staging, allows sampling of bile for cytology + abdominal CY: polypotd masa mural tckening. Iver iwarion.nodol tnvnlvement int mete Traetmont + ifearesnams ofthe glblacer ie mupected preoperatively, an open ebolecytectmy should be dane to avoid tumour seding of trocar aa + confined to mocons (rare) “beyond mucosa ~ choleystectomyen bloe wedge resection of 3-5 em underlying liver, Aieetion of hpatodaedena Imps nodes Prognosis + poor 5-year survival (108) as gallbladder cateinoma is often detected ateCholangiocarcinoma Definition ‘malignancy of extra intrahepatic le ducts Risk Factors + age 50-70, gallstones, ulcerative colitis, primary sclerosing cholangitis, choledochal est, (Choewchis ines inectic (live ike) tea Features poe$——_ + majority are nfenocarnoms ns joes s emt + andl igs of liary obstruction: janice, provi dak rin, posto Speen roc 1 norexa, weight loss, RUQ pai, Courvosirs sign (Hf CED abstrcted), hepatomegaly + early metastases ae uncommon, but commonly tumour grows into portal vein or hepatic artery + Klaskin tumour cholangiocarcinoma located at bifurcation of common hepatic duct vy Investigations couvoisers San "LFTs show obaructvepleare ‘ope ston dae £'UIS, CT ile ducts usually lated, but nat necessarily ice 0 teen ‘ERCP or PTC: to determine retetablt, or biogas Dasreiceacnors, hese 1 Coun. bone sean for mensestie workup ‘Trestment ‘odds on 1 ssi: lary drainage and wide excision marin * ape hid leona dict eseton + Rexx hepacojeunaeromy, Heer reseton * dl hind lesions (uncouunoa): duc esecton ~ Roux-en-Y hepotco}juDoeionny * Tower third Ioan: Whipple proved + wnresectable lesions state cheladachojfunoetny (urge pes) Prognosis + aor ienal aio, cemetery my beh + overall 5-year eurelal— 15% Ss Acute Pancroatitis Pathogensels + obstruction of pancreatic duct by lange or eral gallstones ad biliary dadge "backup of pancreatic enzymes can eauseautodigestion ofthe pancreas nica Festures (pancresitis of any etiology) 1 ae eplau pale radtating back) nso vomiting, Neus pecan] slgns junds Sever 1 Ike sig pain wore when supine beter when sting Or (+ taredy may have cocxistrat cholangrtls or pancreatic necrosis 1 Hantck cater ne deeming opandsof cte penctat (ee debs) Investigations igh emylese (higher than alcoholic pancreatitis), lipase, high liver enzymes, leukocytosis + UNS may show multiple stones (may have passed spontaneously), edemetous pancreas 1 CRR'AXR, CI Gf severe to evaluate for complications) Treatrmont 1 NTO, hydration, analgesia and antibiotics for severe cases of necrotizing pancreatitis o signs of sep + stone often passes spontaneously (-90%); usually no surglel management in uncomplicated + cholecystectomy during same admission after acute attack has subsided (25.60% recurtence if ‘po eupesy)+ my need wigeat ERCP + sphinctortomy if flue of conservative mansgemcat (oo beni hat ‘een shown for ealy ERCP + sphinc 1 obstructive jaundice is present) + surge indications in sce pancreas (are: ' dcbridement and drain placement fr necrotizing pancreatitis ifrefratoryto medical ‘management, if septic oF in ICU without other sources of sepsis Complications + pretidocyst (collection of pancreatic screions >4 weeks old surrounded by a defined wall of ‘gaulaton tasue) + Shscen/infoction, mecrois 1 Splenie!mesenteril portal vessel thrombosis or eupture 1 pancreatic escits/pencreaicpsural laid effusion + sumtoiniealabuoraalty casdng recurrent pancretii + pre-op CT’ andlor ERCP are mandatory to 1 aurea option: ‘drainage procedares- ly fective f dct) eyte i ited da ‘+ Puestow procedure longitudinal panerestojejunostomy) _ proves pain in 60% of atin = pancresteciony beet option Ia absence af ated duct proximal disease Whipple procedure (pancrestaduodenectomy): pin relief in 809% "clit plexus block _ lasting benefit in 30% patients, much ess invasive + pseudocyst (most resolve spontaneously with pancreatic rest) weeks) = internal drinage (pecfered): Rows-en-Y cyt jjunostamy or crt-guatro tomy * external drainage may require second operation to test pancreatic tala onsider biopsy of cyst wal (orl out eystadenocareinamna Pancreatic Cancer Epidemiology + fourth most common caute of cancer-related morality in both men and women in Cansda 1m2007 (Canadian Gancer Society) + madera = 71, evesge og 60-70 Fisk Factors = Aocaeatedage 1 smoking 5x increased risk, most clearly established risk factor 1 chemicals betanaphthylamine, benzidine Afton desesatClinical Fontures \ ead ofthe pancreas (708). weight los, obstructive unde, vague constant mid-eplgastrie pan often worse at night, | iguana pn wih nah es say radiate tack) funder napeten ove SO a + painless jaundice (occurs more often with periampullary), Courvuiser’ sgn (ge sidebar | SE Pewee anc rome cs) sass * palpable tumour mass ocunsble «+ body ar tall of panczeas ‘ends to present Inter and usally inoperable = weight los, vogue mich300 uml + UIS,conteast CT fals evaluates metastasis and rsectblliy), FRCP Pathology + ductal adenocarcinoma _most common type (75-80%) exocrine pancreas + intraductal pally eicinows neoplasm (IPMN) ! + other: maicinous cystic neoplasm (MCN) acinar ell eareinoma, iset-cel (insulinoma, + _gstrinams, VIPame, Gucapmnoma, somatstnoma) Wetec Trostment, [mont + reeetable (20% of pancreete cxnces) Se ony ‘=o involvement of liver, peritoneum or vasculature (hepatic artery, SMA, SMV, portal ein, | Bootweeam 1G, aera no distant metctaaie Dat stn, Steeles + Whipple procedure (pancreatoduodenectomy) for cure _ 59% mortality (Figure 26) * dial pancreatectomy 4 splenectonry,Ipmphadenectomy if earcinoane of mdbody and tai of + aadeaer cae (lati -+ ree ‘ most body/tall tumours are not resectable (duct late presentation) + relieve billaryiduodenal obstruction with endoscope stenting or double bypass procedure Prognosis + most important prognostic indicators ate Iymph node statu, size >3 cm, perineual invasion (avasion of amour into microscope nerves of pancreas) + overall 5 year survival a 2% 1 average survival. 6 months if unresected, 12-18 months with curative resection epost Spent met Fowenngtomy (erect eel Sven Une tcc ie - . ahs roe Cate tit nu ata Dieu Figure 25. Schomatc of Whipple Resection, Showing the Resocted ComponentsSplenic Trauma + typically from bun trauma (especially in people with splenomegaly) ‘owt cosmo inre-ebdombnal tablet tana {in have Kehr’ sign left shoulder pain due to diaphragmatic ieritation fom splenic rupture Treatment + inslable patients _exlended bedrest with serial hematocrit levels, lose monitoring 1 hemomte contd 1 eplenic erery embellzation : runt of pees) ~ If patent hemodynamic sale, patent he stopped ‘Weetng end cron doce notin bien ‘BalopLaccty pen masts or high gd tary Splenectomy ‘pete tsee (os common reson for weno heretry mmo imery Brecon chrse imme trembochopens poe TH), opens Yon robe ravce opal es lout lacbocyiope purpucs CTF. non-t primary splenic tumour (rare) . onal all thrombocytopenic sixes (e.g, infection, most malignancies involving the + probbity of curso 1 Pby splenectomy i 60-70% maybe predicted by response to IVIg Completion clectsis of ef Jower lung, bleding, infection ry to surrounding structures (eg, gastric wal tll of pancreas) moray * pre-op prophylaxis with vaccinations (pneumococcal, Hflueane and meeningococcus) * Tera ase of pencilin especially im children <6 years old sion jteg | yea eeeBenign Breast Lesions NON-PROLIFERATIVE LESIONS: + aka locale change, chronic epee macs 1 benign breast condition characterized by fibrous and cystic changes inthe breast ‘= no increased rik ofreas cancer 1 oge30m manopanse (nd afer EHIET wad) 1 Ginical feature, breast pat, foal ree of nodalarity o eyes often inthe upper outer bilateral, mobile, vaties with menstrual cele, nippe discharge (trav lke, brown of green) + weatment evaluation of beet mess tad romeurance + if 540 years olds mammography every 3 years of randrine-canteining product (coffe, tea, chocolate, PROLIFERATIVE LESIONS - No Atypla Fibroadenoma + syst cannon Benga breast tumour in women underage 30 1 kof abaequent reac cance Screed nly if Shroadenoen te cone, there adjcent ora frees cancet 1 spinor cng Sy iy orotate ete, wel-cueumseibed nn tender, mail hormone depend + ‘unl yy, needle eptatin yde no ld ‘com or eacklonal blpey required ‘ ullasound and FNA alone exnao differentiate fbroadenoma from phyllodes tumour + trotment, ‘generally conservative: eri bervation ‘consider excision if sie 2-3 em and rapidly growing on sera ult patient preference sound if symptomatic or Intraductal Papilloma etary intraductal benign polyp - ‘+ yreerl asnipele ischarge (most common coum af spontaneous, unilateral bloody nipple ‘breast mass, nodule on WIS + can burbour areas of eypia ot DCIS 1 restment excision of volved dict to enmure no stypin Ductal Hyperplasia Without Atypia + ineressed numberof celle within the ductal space «cll reiain benign cytology ‘bo treatment 1 align cancer rik moderate or rid hyperplasia PROLIFERATIVE LESIONS - With Atypia Atypical + can involve ducts (ductal hyperplasia with atypia) or lobules (lobular hy + cell lose spa baal orentation 1 ncxeared sak of beast cancer 1 diagnose core or excell treatment complete resection, risk modification (eve exogenous hormones), close follow-up sn with atypia) OTHER LESIONS Fat Necrosis + uncommon, eslt of trauma (may be minor, positive history in only 50%), aftr breast surgery «em illdefined mase with skin o nipple retraction, + tenderness ‘rapa apontaneouay, but emmplte imaging 2 biog to rab on ceretnorne fa Bont Mass Seer 1 rete dtarmes {Feta ‘fete | Reon enomss Gee Oarecars Deseo hype + Somsoguenes 1 negeacona * Gonloremisrasistea Wiser sess ieee + Seo rtsMammary Duct Ectasia + obstruction of« eubarvler duct leading to Gnct dilation. inflammation, and basi + may presesnt with nippe discharge, bluish mass under nipple, local pan + kof wrcandecy infection (obeces, mastitis) _eslves epantanerusly Montgomery Tubercio + Montgomery tubercles aka Morgagni tubercles are papular projections at the edge ofthe areola + stn he decom naan ores to Monger : > Hage eet certo ‘ermaate Abscess + lactational (see Obstetrics, OBS) vs. periductl/subarcolar + unatera localized pain tenderness, erythema, subareolar mass, nipple discharge ple ae + mle ont nfenenstory carcinoma, a indicated + traument inisally broed-specrrum antibiotics and I&D, if penitent wal duct excision +i mass does not resolve: ine needle aspiration (FNA) 10 exelude cancer, IS to asses for Presence of sbscess Breast Cancer Epidemiology + nd leading ex Gide tenet geen ne — | 21/9 women in germtontoriebertere | 719: e of cancer mortality in women (Isis lung cancer) da willbe diagnosed with breast cancer in their lifetime 1127 women in Canada will ie fom breast cancer Fisk Factors > gender JOM female) 1 ge (60% >40 years cd) 1 most importa risk factors are prior history of breast cancer n/a prior bresst biopsy ef pathology) + Ist degree relative with breast cancer (greater sk if relative was premenopausal) + inezeated risk with high breast density, muliprity, fist pregeancy >30 years old, menarche <<13 years ol menopause >55 year cl «+ decressed risk with lactation, etry menopause, esly childbirth 1 radiation exposure (eg. Mantle radiation for Hodglin’s disease) t3syemnmr : Investigations oot ‘Stuer Ao lal i a me tndlestonst ete ‘ seroning (see Table 15: ee ~ every {-2 year foe weanen age 50 69 ji ute iy history gre: every 1-2 ear ating 10 ea before ox, , theron ag of remtion ap inate enlist fellow up aes bers canes sugery een "tong diane anpnso Sihleweacsbuets se Mundas ‘architecaral dortion ‘¢imerval mammographic changes ‘¢ nonnal mammogram does not rule out suspicion of cancer based on cakes findings + other radiograph tudier: ultrsound -diferentiateberween cystic and solid Sant ~ high denser. Sow + galactogram/dctogram (Tor nipple discharge) _ identifies lesions in duets + netastatie wore a8 indicated (usually after sigery or If cinia suspicion of metastatic Aiseas) bone sean, bdo U'S, CXR, head CTTab 15 Seroning fr Broast Can in Women of Avorage Fisk Tettinson ses Tia fies toner Mewes einned— Geroenal akerenmogety nh Cl Car ce heap ie enetn Sant ee oene remote ree ‘acuang nnmnaty ost ea ieee a Grek mae entice Smeets sectors co fend nee esc mara yt Cad " = = ‘eer pemas mcrae ‘et bl aaa = Eee acne Saeco ele Tettavbmesimiain tread mtetnnne in farotncafeobet dat tne Eeenean tanautonre one ieee) tem tear perenne Chae) bet Be tp Steen erie SSeemtcusas Ketones oot) beet l ine ee tara Tea aaa a etme GD rep mtr] alent Taner TTT 6 8 Diagnostic Procedures + needle septation: for palpable eytc lesions gend fll for eytology ifbLond or ext doesnot ‘ampetely resolve ™ + UiSor mammography guided core needle biopsy (most common) + fine needle aspiration (ENA): for palpable solid masses; need experienced precttionr for ‘semi semping + Cacnnal bop. oly peared a seund chalet cre necae bpsy: shold nr be dave ‘Grdignostsif posible ‘Genetic Screening * cooler tstg for BECAL/2 I patient Gegooved wit breast AND ovarian cancer Etong fami history of bresstfovaran cancer (og Ashkenazi Jewish) ‘seat hisoy of mae bear cancer ‘young patent (35 you ld) (eee 16) Stzaog i or amose dey ppaton ener 1 Sabrent byppeton # nctasanby pyle! exam, CXR and abdo US (or CT chestvabdo/plis), bone san {esuly done pot op f ode poate dacs) ‘pethologiat * tumour ie 1 Bisbcefarfryania pane Er aaigaay ou ca eke mace cma : rk ary oi pave frag Ampito SSeerioere mere 1 trogen reeptnr (ER) + progesterone reeptar (FR) tenting + HieeiNen receptar © angio: negate, cen wm ae Meccan? 9+ anfrdudsaron + actly | Mogan dir Meme? * miinyne tmecioyS chsh en rn BS aod doen + ractgy hes meepolrm Mey + myc ev percpnd erg mea ER mi ‘Showy edo Ley masctiny + a syne secon Mey yl aie earn ‘rabahey ‘Serle ed nro ers dae ‘Sademagy nays eS ‘formaoryLeymaseahy + ax aryoieB seston eta ‘wath v Suey acaperatee ca cece | Fray tert ses thay b canbe atime are Sa SS scenes re Bis eo acy aba mmm yn eeriePrimary Surgical Treetrmeet + breast conserving surgery (BCS) _ lumpectomy with wide local excision * for treatment of senge 1 end 1 Zisease + must be combined with radiation for survival equivalent to mastectomy * contraindication: * high risk of local recurrence ~ extensive malignant-type calcicalions on marmmogram, -mutkifca peimary tumours, or falfure to obtain tumour fee margins afer z-excsian * egtendenton mdi hear (prepancy previous rdition calla Yscler ‘lenge temour eae selrtoe to beeast lad aster (rey done amma) abreast tise, skin, pectrais " anymore) - remo smunce arilary nodes ‘+ modifed radical mastectomy (MRM) _removesall breast issue, skin, and axillary nodes 1 simple mastectomy ~ removes all brea tinue and akin se Pasic Surgery. PTI for hrean reconstruction + axilacyYngh node daection (ALND) * performed if SINE is postive or nodes are clinically concerning + tak of arm lymphedema (10-15%), decreased arm sensation, shoulder pain + centine Imaph node! yma (SLNB) * decrease risk of local recurrence; almost lays used after BCS, sometimes afer ‘mastectomy (is>4 nodes postive or tumour >S cm} + inoperable localy sdranced cancer + ery nodal redltion maybe aided if nodal tapalvement + hormonal * fadleatons: “+ ER pode put node postive or high-tsk ande-pegative + palloton fr metastses foxifen if premenopausal or aromatsse inhibitors (eg, anastrozole) * ovarian ablation (eg. goserelinjGaRH agonist, oophorectomy), progestin (eg. megestol cera), androgens (eg, @uarymestrone) ace other options hemabexpy indications ERsextrlosnode grt rghit nde eps “+ ER poste aod yours, 3 sage deena high kof recarence (high grad Ipmphomascalar Iron) * palin for mctaatic diane PostTrestment Follow-10 + wibls q3-6 months x2 years and annually thereafer (frequency is controversial) + samuel mammography no otber imaging nls cic indicated 1 peycbococil support tnd comeing Local/Regional Recurrence += recurrence in tested breast or ipliera ila 715 per year upto maximum of 15% risk of developing contralaterel malignancy 1 stnemeaed sof developing metotaene : a po ——— fastest woman wih a Tenet eet eager aS re Ines wei onect ico eo esSurgical Endocrinology Thyroid and Parathyroid «se Endocrinology £28 and Otolaryngology O32, 0134 Adrenal Gland ‘ee Endacrinnlagy, 135 ‘Ta min it ce hecho + tad cscs (eptnpbrng morpnephrae) « types fimcinal (og Ching yr, Cart acme) or net-functonal INCIDENTALOMA + edzenal aus dscored by lavetigalon of uneted ypmptoms Epidemiology + benign adenoma (38%) > metastases to adrenal (2%) >> cyt carcinoma, pheochromocytoma + metastasis to adrenal gland from: ung > breast, colon, lymphoma, melanoma, kidney + peak incidence of carcinoma: females ages 80-60, isk decreases with increasing age and male spender Investigations IMI, CT size >6 om i best predictor of primary adrenal carcinoma (92% are >6 cm) + functional sedien + pheochromacytoms: 24 hour urine epinephrine, norepinephrine, metanephrine, hormetanephrine, VMA (vanllylmandelc acid) + Cushing 24 hour urine cortisol or I mg overnight dexamethasone suppression te eldoatenmnorna elertrlyter. kdostone: ravn level caine rapprestn teat feppropriate sdrenal androgens: 17-OH progesterone, DHEAS « FNA biopsy: if suspect metastasis to adrenal (must excade pheochtomocytoma fist) indicated ifhistnry of cancer ar patient is masher + jodochelasteral scintigraphy ay distinguish benign vs malignant isons Trostment fimetional rumour esect 1 non functioning tanton: Sem: resect 3-6 cm: MRI (T2 density sh old 163 em: fllow with repeat CT in 12-18 months + sce Dermatology D6, Emergency, ERI7; Basie Surgery PLIA J, margins), more likely to eset in females andi <0 yeas bes Antiemetics (Gravat) 25-50 mg PO/IVIIM 42-ch pen oalegperoe(Semc) 310g POV + Denageete fee 10mg mg VM 42-95 pn 0-15 mg PO qi (30min before mes += Salas aan) + gomecron OI) 1 mg PO bid (or nausea rom chemotherspyradaton)Analgesics «+ sextemioophen + cndeine (Yylenal”#37pls) 1-2 tabs at-sh FOMPR pra 75-10 mg IM/SCq4-6h pn (-2 mg lV qlh pen for breakthcough + ketalac (Tara) 1 Pompei (acctominophen/oxycadone, 25/5 mg) 1-2 tabs PO gt-sh pen DVT Prophylaxis + heparin S00 nits SC bd tcancer pret then heparin S00 mite Sd Antidiarrheals «= legersnide motes") 4 mg PO initially, shen 2 mg PO after each loose stool up ta 16 mg/d + diphennsplete + atopine (Lomott") 2 tabs/10 mL BO ai Laxatives + sennotides(Senokut"] 1.2 taba gs * docusate soda (Colace") 100:mg PO bid, + ghyverine supp I tb PR pra 1 Tectuloge 15-30 ml PO gid pm. silk of magnesia (MOM) 30-60 ml PO gid prn ‘iaacody) (Dalcalaa®)10-15 mg PO pen Sedatives += zopiclone Cmovane?) 5-752mg FO af pen. 1 Toranepam (Atiran®) O5-2.mg POISE his pes Antibiotics + cefeasta (Anee®) |g V/IM on callto OR or qBh _ GP except Bnteocneews GN only B eo, ‘Klee and Proteus + exalt (Reflex) 250-500 mg RO ald ~Letrt, GP except Fterococens, GN only FE. cl, ‘Fidsala sod Proteus + cefltaxone 2g TMIIV q24h _ broad coverage including Rewdomomas «+ ampiclin 1-2 g1V gf sh — Literie, GP (Bteroceas) except Srepocoerus end Ecol orl ‘soaercber except Bacterider + gentamicin 3-Simg/kg/day IM/IV divided gSh; monitor creatinine, gentamicin levels_ GN Pecadornonas sncing rollorcin 400 mgV @12, 500mg PO bid_ GN including Pandomomas * iptrnsacle (agp) 500 sng POMLY bi, (60.ng PO Ud oe Cafe) ~ anverobea + clindamycin 600-900 mg IV qh, 150-400 mg PO qid _ GP except Brerocacens, snaerabes Over-the-Counter Medications epto-DiumoF (bismuth subsliylate) 2 tabs or 30-ml PO q30min-Ihr up to 8 doses/day ide effete black stole, ree of Reps eyndcome in children + All Seltar"(ASA « ctate + bicarbanete} 2 tabs in4or water PO qth prn, max 8 tabs + Maalox® (aluminum hydroxide + magnesium hydroxide) 10-20 ml or I-¢ tabs PO pen {Tams (caletum carbaeate) 1-3 gPO qah pen 1 Rand (calicur carbonate and magresium hydroxide) 2-4 tabs PO qih pra, ‘max 12 rbdEcpateate lichen 0 yeMOwe%SioelRehce eta pan deen | Sister tn perf Sere ot 2 Eenieiaacreeto let oe Coos sore UA EOI BON “ta Fe cep Ct were 8 hoa Sanecss tcvesnaondon ne noe eeepc es es dy J AA na Sembids Neiemayavaccohvatedatacesie stan snd xinial Oa MET TY Sep ese Oners et es Mo 2 ‘ Sinan syed HO 08 1 ‘emia iene op Srachke gh dt Cone a eb PoC Jo, enn Ma Santino sien esvhams a aconttcnncatosiageks ogee TRC IER " ican Bein aeeys Sarees Somaiin we Reape ear termi ofyetcriey ste oderte CO MENT yA eine tea Bm rs eo a A fear Sta Apa palm idee SMe! HVA WH V1 Jrerts cman sc 970960 ‘me jr apa BS itert veep atte Aono ee vets ee. oes Ao ema , iat hraraneste re ome tT tctzher tone pte ohh, S99) 1 8 1 rue credgremo he wai tstetispyessMe Ri 397 24 bao ‘Ghesoensrh upeemnnesvo pes corer cacevtar merry te "|| : sihacinayieebeecshded og Neeser HAR ec ecru ingrid MN ee 9 too es nha ea) Rl, anaes tons sory ny: tmnen teense Sn WEA Bt Seas san ona es rion nna oer on esto rat new nsh 11 1 SEAR cat des Tete Bed rong Sn hh tae edna age creo pent bty MM Eh. ms a i ea mS ri Ly io hie oe A . Sei ten sn Sg ab TY * napa Gel Geer Soars Get 1 Way 4.861 8 1 doa hota eps ar EM SNOT ns rams tema ye ED 5 ON a 4 08 1 mt Simian ay fnongarey wba rr Vers opr spo memo ee ma Mi UUs ay rene TL ESSE ett oeareatpeende Te 2a Chem + hoe