Surgery-Algorithms by hedongchenchen


									Thyroid Nodule:
         a. Low: thyrotoxicosis
         b. High: T4 assay → hypothyroidism or pituitary tumor
         c. Normal:
                      1. cystic: fluid cytology → if malignant go to 2
                      2. solid
                              a. benign: T4 suppression and repeat FNA (possible hashimoto’s with low T3/T4)
                              b. Suspicous:
                                       i. follicular neoplasm: scintigraphy 131I scan
                                              1. cold: thyrodectomy
                                              2. warm: do nothing
                                      ii. atypical: calcitonin test → go to medu CA
                                     iii. papillary: thyrodectomy
                              c. Malignant
                                       i. Papillary & Follicular:
                                              1. near total thyrodectomy, central node dissection
                                              2. 131I remnant ablation, T4 suppression
                                              3. Thyroglobin levels, 131I scan F/U for metastasis
                                      ii. Medullary
                                              1. total thyroidectomy, central node dissection, lateral node biopsy
                                              2. positive lateral node in i and ii → modified neck dissection
                                              3. T4 replacement
                                              4. Calcitonin, CEA check for metastasis
                                     iii. Anaplastic
                                              1. excision or radiation followed by excision
                                     iv. lymphoma
                                              1. extrathyroid → biopsy → radiation
                                              2. intrathyroid → excision → radiation
Hypercalcemia and Hyperparathyroidism
      I.    Serum Ca Phosphate
      II.   BUN, creatinine
      III.  Sestamibi scintiscan
      IV.   Cervical US
      V.    Neck exploration
            a. 1 or two adenomas: excise adenoma, biopsy one normal one
            b. missing inferior gland:
                    i. thymectomy,
                   ii. explore carotid sheath,
                  iii. excise lower pole of ipsilateral thyroid
                  iv. if still hypercalcemic:
                           1. sestamibi scintiscan, CT/MRI of mediastinum, selective venous PTH
                           2. mediastinal exploration
            c. multiple ones enlarged
                    i. sporadic
                           1. leave 60 mg behind in forearm
                           2. cervical thymectomy
                   ii. familial
                           1. MENI: same as i , f/u prl, ACTH – pituitary CT, pancreatic GI hormone screen
                           2. MEN II: excise glands, total thyrodectomy
                                   a. F/U calcitonin, catecholamines, 131I-MBG scan

ZE syndrome
Severe refractory ulcer disease
       I.     MEN
              a. PPI
              b. Parathyroidectomy (1/2 in forearm)
              c. Laparotomy →
                       i. Gastrinoma: excision followed by annual gastrin levels
                      ii. No gastrinoma: vagotomy, pyloroplasty or highly selective vagotomy and duodenotomy
                     iii. If surgery fails: total gastrectomy
       II.    Sporadic:
              a. PPI, octreotide and CT scan
              b. No liver mets → same as MEN gastrinoma
              c. If liver mets → chemotherapy
HTN, headache, sweating, flushing
   I.    CT, MRI, MIBG / Urinary catecholamines, VMA, metanephrine
         a. Preoperative alpha AND beta blockade → adrenelectomy
                 i. Intraoperative HTN: nitroprusside
                ii. Intraoperative hypotension: fluids, inotropes

Truncal obesity, HTN, glucose intolerance, menstrual and sexual dysfunction
      I.     low dose dexamethasone suppression fails → establishes diagnoses
      II.    high dose dexamethasone suppression
             a. ACTH low (cortisol not suppressed) → Adrenal tumor
                     i. CT scan, venous sampling, androgen measurement
                           1. Benign: unilateral adrenelectomy
                           2. Malignant
                                  a. Local: radical nephrectomy
                                  b. Metastatic: tumor debulking
             b. ACTH high (not suppressed) → ectopic ACTH from tumor → lung CT, aminoglutethimide (↓cortisol secretion)
             c. ACTH normal (partly suppressed) → pituitary tumor → transsphenoidal hypophysectomy → give exogenous steroids post-op

  I.    excisional or incisional biopsy
  II.   microstaging:
        a. <1mm: wide local excision (1cm)
        b. 1-4mm: sentinel biopsy
                i. nodes - : wide local excision as above
               ii. nodes +: regional lymph node dissection → chemotherapy, polyvalen autologous vaccines, interferon therapy
  III.  Clinical staging:
        a. Localized: wide local
        b. Palpable regional nodes: FNA of nodes
                i. Negative: wide local
               ii. Positive: regional node dissection: chemo, vaccine, interferon
        c. Metastatic disease: 100% mortality
                i. Local: excision, radiation and as above
               ii. Systemic: chemotherapy as above
Retroperitoneal mass
Incidental finding on CT
   I.      Renal (see later)
   II.     Primary retroperitoneal tumor
           a. Laparotomy → En Bloc resection
   III.    Adrenal
           a. Biochemically active: en bloc resection
           b. Biochemically inactive:
                   i. Solid
                          1. large: laparotomy and resection
                          2. small: laparoscopic
                          3. tiny: serial imaging
                  ii. cystic: FNA:
                          1. Clear: serial imaging
                          2. non clear: en bloc resection
                 iii. Mets: work up primary tumor
   IV.     Secondary retroperitoneal tumor
           a. CT guided biopsy → fails → laparoscopic biopsy
                   i. Lymphoma → chemo
                  ii. Mets → chemo
                 iii. Germ cell tumor: testicular exam and Ultrasound
                          1. negative: chem +/- radiation
                          2. positive: radical inguinal orchiectomy
                 iv. vascular: AAA (See later)

   I.     Hct, electrolytes, acid base
   II.    IV access, O2 admin, urinary catheter, EKG, CVP
   III.   CVP
          a. Flat neck veins: Fluid challenge: swan ganz catheter
                   i. low filling pressure:
                          1. high SVR, low CO, low CVP → volume repletion, correct acidosis → R/O continuing hemorrhage
                          2. low SVR, normal CO, low CVP → fluids, support renal perfusion, TREAT CAUSE (sepsis etc)
                  ii. high filling pressures, low CO → (cardiogenic, tamponade, pericarditis) → diuresis with furesamide → ↑HR, ↓ SVR
                      (nitrosoprusside, nitroglycerine)
                 iii. equalization of pressures: tamponade suspected → Ultra sound → pericardiocentesis
          b. Distended neck veins: arrhythmia?
                   i. No arrhythmia and shock → then same as with fluid challenge
                  ii. Arrhythmia: correct it, pacemaker, stabilize electrolytes
Nipple Discharge
       I.    Bilateral
             a. Milky or clear: Prolactin
                      i. Normal: observe
                     ii. Elevated: pituitary imaging
             b. Colored: observe
       II.   Unilateral: hemoccult
             a. Blood positive → ductography
                      i. Abnormal: excision or microdochectomy
                     ii. Normal: f/u by repeat hemoccult or ductography
             b. Blood negative: observe or do ductography

Breast mass
   I.    Palpable (dominant) → needle aspiration
         a. Cystic
                 i. Clear fluid + mass disappears → f/u in 6 weeks
                ii. Bloody fluid → cytologic exam as with solid lesions
               iii. Clear fluid with mass remnants as with solid lesions
         b. Solid
                 i. FNA cytology not good
                ii. Excisional biopsy is gold standard
               iii. Core needle biopsy is used for larger masses
                       1. Benign:
                                a. Fibroadenoma:
                                       i. Excised: D/C
                                      ii. In situ: observed
                                b. Fibrocystic changes:
                                       i. No atypical hyperplasia: D/C
                                      ii. Atypical: F/U closely
                                c. Malignant
   II.   Non-palpable (occult – mamographic)
         a. Intederminate or moderately suspicious: Stereotactic, U/S guided core needle biopsy
         b. Highly suspicious lesion: needle localization biopsy
Early breast carcinoma
   I.     Non-Invasive:
          a. DCIS:
                  i. Diffuse → total mastectomy → chemotherapy
                 ii. Local:
                         1. high grade (comedo): wide local excision → radiation
                         2. low grade: wide local excision
          b. LCIS: Annual exam and mammogram
   II.    Invasive:
          a. Conservation candidate (stage II and IIA) → Wide local excision (+ axillary dissection if >5cm) + radiation
          b. Not a candidate (>5cm, multifocal/multicentric, previous radiation, pregnancy) → modified radical mastectomy +/- radiation

Advanced breast carcinoma: Staging
  I.     IIB and IIIA (N1 or T3 and less) → biopsy
         a. Neoadjuvant, chemotherapy
                 i. Response: lumpectomy and axillary dissection, radiation, systemic adjuvant
                ii. No response: mastectomy, systemic adjuvant therapy
  II.    IIIA and IIIB (N2 or T4)
         a. Neoadujvant → radiation:
                 i. Respectable: mastectomy → further systemic therapy
                ii. Non-resectable → radiation and further systemic therapy
  III.   IV ( metastatic)
         a. Estrogen + receptor
                 i. Premenopausal: ovarian ablation
                        1. response: Tamoxifen
                        2. no response: chemotherapy
                ii. Postmenopausal: Tamoxifen
                        1. response: second hormonal agent
                        2. no response: chemotherapy
         b. Negative estrogen receptor: chemotherapy
  IV.    Recurrent
         a. Chest wall and nodes other than axilla: radiation then chemotherapy
         b. Axilla: axillary dissection
Pre-Op diagnosis

Everybody gets a → CBC
Kidney dz → lytes and BUN/Cr
DM → lytes + ECG
>70yo → lytes, ECG, CXR
peripheral vascular dz → lytes, ECG, CXR
loss of >10% of body weight → transferring, peralbumin, creatinine-height index, triceps skin fold, absolute lymphocyte count

Pre-Op Cardiac evaluation
    CAD, Valvular Dz, CHF, arrhythmia, CVD, PVD
    (>4 mets means carrying a bag of groceries up one flight of stairs)
    Always do an ECG, Beta-blockers reduce mortality in all of them if given pre/post-operatively

   I.      Major risk factors → stabilize CHF, angina, valve disease prior to surgery
   II.     Intermediate risks
           a. >4 mets
                   i. high risk procedure: noninvasive test (excersize stress, echocardiography, thallium/sestaMIBI radionucleotide tests
                          1. low risk → operate
                          2. high risk → coronary angiography → revascularization prior to operation
                  ii. low risk procedure → operate
           b. less than 4 mets → always do non-invasive testing and proceed as before
   III.    Low risk or NO RISK
           a. >4 mets → operate
           b. less than 4 mets
                   i. low risk procedure → operate
                  ii. high risk procedure → non-invasive testing as above
Peri-operative arrhythmia
ECG, CXR, lytes, ABG
   I.     Supraventricular
          a. Hypotensive (V-fib, V-tach) → DC countershock
          b. Stable
                   i. Premature atrial contraction: treat underlying dz
                  ii. Paroxysmal atrial tach: digitalis, beta blockers
                 iii. Multifocal atrial tachycardia: tx dz
                 iv. Atrial flutter/ atrial fibrillation: diltiazem/digitalis
                  v. Junctional tachycardia: vagal stimulation
   II.    Ventricular
          a. Hypotension: as above
          b. Stable: treat PVCs with lidocaine (may deteriorate into v-tach)
   III.   AV conduction disturbance:
          a. 1st degree: observe
          b. 2nd degree: morbitz I: observe
          c. 2nd degree: morbitz II: temporary pacing
          d. 3rd degree: temporary pacing (may deteriorate to asystole – see below)
   IV.    Asystole
          a. Resuscitation + epi, calcium, bicarb, atropine
                   i. Still asystolic: temporary pacing
                  ii. V-fib: DC countershock

Cardiopulmonary resuscitation
       I.   Yes pulse: check breathing
            a. breathing: coma
            b. not breathing: intubate and determine rhythm
                    i. sinus
                   ii. VT: synch cardioversion
                           1. not converted: lidocaine → countershock
                           2. converted: lidocaine
       II.  No pulse:
            a. VF or pulseless VT: 3X counter shock
                    i. Converted → intubate, lidocaine
                   ii. Not converted → compressions, intubate → epinephrine → counter shock → lidocaine
            b. Other rhythm: assisted ventilation → compressions, intubate
                    i. Pulseless electrical activity: epinephrine
                   ii. Asystole: if VF: defibrillate → epinephrine and atropine
Bleeding disorders
H&P: brusing, medications, chronic liver/kidney dz, Collagen vascular disease, FHx
   I.     Massive transfusions → give FFP and platelet transfusion, transfuse with blood warmer
   II.    Platelet disorder
          a. Thrombocytopenia: platelet count, bone marrow → transfuse platelets
          b. Functional defect: platelet function tests, tx dz
   III.   Anticoagulants:
          a. Heparine: in-vitro protamine neutralization (PTT)
          b. Coumadin: vitamin K + FFP
   IV.    Liver dz: FFP, cryoprecipitate
   V.     Consumption coagulapathy → Treat precipitating agent: FFP, cryoprecipitate, platelets
   VI.    Hyperfibrinolysis: (high levels of fibrin split products) due to clot busters: give EACA then FFP, CP, Plt
   VII. Hemophilia: give factor VIII concentrates, CP
   VIII. vWF: DDAVP then CP

Post-Op Fever
CBC, urinanalysis, urine Cx, CXR
   I.     Early fever (less than 48hrs)
          a. >39 → necrotizing clostridial infection of the wound → debride
          b. less than 39 → pulmonary toilet
   II.    Late fever (>48hrs)
          a. Respiratory: CXR
                   i. Infiltrate → Gm stain, sputum Cx, ABx
          b. Wound:
                   i. Cellulites: ABx
                 ii. Drainage: open wound, Cx, ABx (indication of dehiscence) → evisceration and secondary closure in OR
          c. Genitourinary → UA, Cx, Abx and change catheter
          d. Vascular access site → cellulites or pus → remove catheter and culture tip → ABx
          e. Abdomen: CT scan → drain abscess
          f. Cardiopulmonary: ECG, CXR → MI or PE
          g. Swollen extremity: duplex → DVT
          h. Critically ill patient: CBC, UA, CXR, LFTs, Blood Cx → if still in doubt do U/S, CT abd, sinuses
                   i. Consider drug fever, subacute bacterial endocarditis → change lines, culture tips
Closed head injury
ABG, O2 sat
   I.     Conscious:
          a. Fully alert → observe (if coma score less than 8 then monitor ICP
          b. Lethargic, confused, focal signs → emergency CT scan
                  i. Normal: observe and repeat neuro exam
                 ii. Focal signs not explained by CT → carotid artery visualization
                iii. Abnormal
                         1. focal mass:
                                a. shift: craniotomy
                                b. no shift: monitor ICP, medical management
                         2. Diffuse swelling: monitor ICP, medical management
   II.    General anesthesia: monitor ICP
   III.   Unconscious: intubate, ventilate, diuresis → emergency CT and as above

Unequal Pupils
   I.    Anisocoria greater in light (large pupil is abnormal)
         a. Orbital trauma
                i. If theirs is globe laceration → emergent repair
               ii. Fractures or iris damage → observe
         b. No orbital trauma → pilocarpine test
                i. Constriction: Adie’s pupil → (R/O syphilis) observe
               ii. No rxn → concentrated pilocarpine test
                        1. constriction: oculomotor nerve abnormality: emergent neurosurgical consult
                        2. no rxn: pharmacologic blockade: observe
   II.   Anisocoria equal in darkness → simple anisocoria → observe
   III.  Anisocoria greater in darkness (small pupil’s got issues) → cocaine test
         a. Both pupils dilate equally → simple anisocoria
         b. Small pupil fails to dilate → horner’s syndrome → hydroxyamphetamine test (releases NE from preganglion cells)
                i. Dilation → preganglionic lesion
               ii. No rxn post ganglionic lesion
Otorrhea (drainage from ear)
   I.     TM intact, mobile
          a. Bacterial otitis externa → Topical antibiotics, possible canaloplasty
          b. Otomycosis: topical antifungals, possible canaloplasty
          c. Eczematous otitis externa: topical steroids
          d. Abnormal tissue in canal: biopsy, Cx → debridement, topical gentamycine, control diabetes → debride skull base
   II.    Unable to see TM → clean and visualize then proceed as in I or III
   III.   TM perforated
          a. Acute otitis media: oral antibiotics
          b. Chronic otitis media: topical Abx, steroids, local clearning
                 i. Dry ear: tympanoplasty
                ii. Wet ear: CT scan → tympanomastoidectomy
          c. Cholesteatoma → CT scan → tympanomastoidectomy (this is a form of chronic otitis media)
          d. Abnormal middle ear tissue/mass → biopsy/Cx → granulomatous dz → specific therapy → tympanoplasty
          e. CSF otorrhea → CT scan, glucose → elevate head, pack ear, spinal catheter, ABx → transmastoid or cranial repair of dura

Parotid tumor
Operative exploration
   I.      Benign:
           a. Superficial lobectomy
   II.     Malignant
           a. Low grade → conservative parotidectomy → re-resect recurrences, do neck dissection and radiotherapy
           b. High grade → total parotidectomy, neck dissection with adjuvant chemo and same tx for recurrences as above

Neck Mass
CT-scan of neck
   I.     Midline mass: thyroglossal duct cyst → excision with segment of hyoid
   II.    Lateral mass: infected node or branchial cleft cyst → excision
   III.   Supraclavicular → CXR, bronchosocpy, mammogram, upper GI series → FNA, excisional biopsy → radiation chemo if met
   IV.    Suspicious primary site: panendoscopy with biopsy → excision of primary, neck dissection → rad chemo
   V.     No suspicious primary site → FNA
          a. Malignant: same as IV
          b. Benign → excisional biopsy → if malignant then same as IV – if not then you “know something”
   VI.    Submandibular glands
          a. FNA → excise gland if malignant or persistent
   VII. HIV + → FNA or excisional biopsy → lymphoma or Kaposi sarcoma → rad/chemo
   VIII. Tender → culture, Abx, if persistent → excisional biopsy
Laryngeal carcinoma
CXR, CT neck, LFTs
EUA, laryngoscopy, bronchoscopy, biopsy
   I.     Supraglottic –
          a. Microexcision or radiation if insitu or superficial T1
          b. Resection or radiation for stage I,II
          c. Stage III,IV → multimodality
   II.    Glottic → Same as above
   III.   Subglottic → total laryngectomy, neck dissection

Chest injury
Hct, ABG, type and match, CXR
Intubate, large bore peripheral IV, ABx, O- transfusion, foley, tube thoracostomy
    I.      Stable → CXR, echo
            a. Cardiac injury
                     i. Tamponade: emergent median sternotomy
                    ii. Valvular or septal defect
                            1. CHF → emergent repair
                            2. no CHF → elective repair
                   iii. coronary injury → emergent repair with cardiopulmonary bypass
            b. pneumothorax or hemothorax
                     i. small volume: observe
                    ii. large volume: emergent thoracotomy
            c. Missile below nipple line: emergent laparotomy
            d. Mediastinal emphysema → esophagoscopy, bronchoscopy (esophagus or bronchial injury) → emergent thoracotomy
            e. Subcutaneous emphysema in neck → brnochoscopy → emergent neck exploration
    II.     Unstable → emergent thoracotomy

Chest pain, dyspnea, hemoptysis, altered mental status
   I.      Stable → VP scan
           a. Low probability → PE excluded
           b. Low probability but high suspicion. Or moderate probability → pulmonary arteriogram → if positive → anticoagulation
           c. High probability → anticoagulation, leg elevation → recurrence → vena cava filter
   II.     Unstable → mechanical ventilation, vasopressors, ionotrpics, swan-ganz monitoring empiric anticoagulation → if still not stable →
           thrombolytic therapy or embolectomy (surgical)
Pleural Effusion and Empyema
CXR → THoracentesis, or tube thoracostomy
   I.     All drained → repeate CXR
          a. Recurrent:
                   i. First time → thoracentesis or thoracostomy
                  ii. Second time → VATS, pleurodesis (video assisted thoracic surgery)
   II.    Loculations, not drained
          a. Infected: evaluate for decortification
                   i. Early: VATS, decortification
                  ii. High risk: rib resection and empyema tube placemtent
                 iii. Late diagnosis: thoracotomy and open decertification
          b. Sterile: second drainage procedure
   III.   Bronchopleural fistula → thoracentesis → if unresolved then open thoracotomy

Lung Cancer
  I.    Effusion → thoracentesis/cytology → if malignant → chemotherapy and or radiation
  II.   No effusion → bronchoscopy, sputum cytology + tranbronchial/transthoracic needle aspiration
        a. Small cell → chemotherapy
        b. Non small cell
                i. CT, MRI, mediastinoscopy
                      1. stage I-IIIA (upto N2) → labs and PFTS
                             a. bad PFT and comorbidities → chemo and radiation
                             b. marginal PFTs and comorbidities → VATS wedge or open wedge → chemoradiation
                             c. good PFTs and comorbs → pneumonectomy or lobectomy
                      2. Stage IIIB and IV → chemoradiation
Coronary Artery Disease
ECG, lipids, CXR
   I.     Asymptomatic → EST
          a. Negative → yearly medical f/u
          b. positive → stress thallium
                  i. no ischemia → yearly medical f/u
                 ii. ischemia → cardiac angio
                         1. left main or three vessel dz → CABG
                         2. two vessels 50% or one vessel 90-100% dz → CABG/MIDCAB/PTCA
                         3. single vessel → or just do a MIDCAB
                                 a. distal: medical therapy and f/u
                                 b. proximal: PTCA → if recurrence → CABG
   II.    Symptomatic
          a. Stable → EST and as above
          b. Unstable
                  i. Crashing → cardiac angio and as above
                 ii. Not crashing → stress thallium
   III.   Acute MI
          a. Thrombolysis, PTCA or CABG

Blunt Abdominal Trauma
IVF, NG, foley, xray, trauma US
Remember that DPL misses retroperitoneal injury – CT is best option for that
   I.     Diffuse Peritoneal irritation → laparotomy
   II.    Hemodynamically unstable:
          a. U/S shows hemoperitoneum → laparotomy
          b. U/S equivocal→ Diagnostic Peritoneal Lavage → laparotomy
          c. If DPL is negative → observe
   III.   Stable → secondary survery
          a. U/S negative
                   i. Altered mental status, gross hematuria, low Hct, local abd tenderness → abd CT → if positive → laparotomy
                  ii. None of above → observe
          b. U/S positive → DPL (to determine that free fluid is actually blood)
Penetrating Abdominal Injury
   I.     Hypotension → resuscitation → damage control laparomotomy
   II.    Normal BP with symptoms (peritonitis, evisceration) → resuscitation → laparotomy
   III.   Normal BP asymptomatic
          a. Thoracoabdominal (between nipples and costal margin)
                 i. Right side:
                        1. stab: tube thoracostomy → serial exams and CXR
                        2. gunshot: abd CT
                                a. grade I-III → observe
                                b. grade IV → thoracotomy/laparotomy
                ii. Left side → CXR, US, AbdXR
                        1. positive → laparotomy
                        2. abnormal diaphragm → thoracoscopy, laparoscopy
          b. Anterior stab wound → US
                 i. Positive → serial exams or DPL
                        1. positive → laparotomy
                        2. negative → stop
                ii. negative → local wound exploration
                                a. positive → laparotomy
                                b. positive → stop
          c. Anterior or flank gunshot wound → same as “b” except that if US is positive you go straight to laparotomy and if negative you go to
             DPL (generally more aggressive)
          d. Flank or back → serial exams or double, triple CT contrast
                 i. Negative → observe
                ii. Positive → laparotomy

Duodenal injury (abdominal trauma)
AbdXR and contrast studies → laparotomy
   I.    Simple laceration → suture closure or pyloric exclusion
   II.   Tissue loss
         a. lateral injury → pyloric exclusion or Roux-en-Y duodenojeunostomy
         b. medial injury or transaction
                 i. proximal to ampulla: antrectomy, gastrojeunostomy and stump closure
                ii. distal to ampulla: Roux-en-Y to proximal end and stump closure
   III.  Hematoma
         a. Detected at laparotomy → evacuation of hematoma
         b. Detected non-operatively → NG suction, TPN, observation
   IV.   Associated destruction of pancreatic head → pancreaticoduodenectomy
Pancreatic Injury
   I.     laceration, no ductal damage, or devitalized tissue → suture large laceration and drainage
   II.    ductal damage or devitalized tissue
          a. head
                   i. associated duodenal or bile duct injury → pancreaticoduodenectomy or pyloric exclusion
                  ii. isolated pancreatic injury → division, connection to distal gland, ligate duct, oversew stump
          b. Body
                   i. division, connection to distal gland, ligate duct, oversew stump
                  ii. AND distal pancreatectomy with or without splenic salvage
          c. tail: distal pancreatectomy +/- splenic salvage

Esphageal cancer
Endoscopic US, CXR, CT chest/abd, blood chemistries, bone scan
   I.     Stage I (T1) → curative radiation
   II.    Stage II (T2-3) → curative radiation or operation
   III.   Stage III (T4 OR N1) – T4 means adjacent structures → curative operation or palliation with radiation
   IV.    Stage IV → palliation

   The operation
         A) Upper third → laryngo-pharyngo-esophagectomy with gastric pullup
         B) Middle/Lower third → near total esophagectomy with high intrathoracic or cervical anastomosis to stomach or colon
         C) Cardia → abdominal/right thoracic or transhiatal approach

IF medical therapy does not control symptoms
EGD +/- biopsy
       I.      normal → 24 hr pH prove: IF abnormal → fundoplication with pre-op manometry to determine need for partial wrap
       II.     abnormal
               a. esophagitis grade II/III → fundoplication and preop manometry
               b. large hiatal hernia → barium swallow
                       i. hiatal hernia → fundoplication
                      ii. paraesophageal hernia → repair
               c. stricture → biopsy
                       i. malignant → see cancer
                      ii. benign → dilation +/- surgical repair
Gastric Ulcer
   I.     Perforation → excision of ulcer – consider also doing truncal vagotomy and pyloroplasty
   II.    Endoscopy with biopsy → test for H. pylori
          a. Positive → treat for pylori: if FAILS to heal → surgery
          b. Negative → stop NSAIDS, medical treatments (PG, sucralfate and antacids): IF FAILS → surgery
                   i. Type I: distal gastrectomy
                  ii. Type II,III: truncal vagotomy and antrectomy’
                iii. type IV: excision of ulcer w/ or w/o roux-en Y esophagogastrojejunostomy
                 iv. Type V (carcinoma) radical subtotal gastrectomy (Billroth II)

Duodenal Ulcer
Serologic or breath H pylori test
   I.      Uncomplicated → medical management fails → endoscopy → if intractable after repeat medical management → highly selective
           vagotomy or vagotomy and antrectomy
   II.     Atypical (massive diarrhea, prominent rugae or multiple ulcers) → serum gastrin
           a. Normal → proceed as above
           b. Elevated → see ZE syndrome
   III.    Complicated
           a. Bleeding → transfusion, lavage, antisecretory drugs → therapeutic endoscopy
                    i. Bleeding stops → medical mangagement
                   ii. Bleeding continues → angiographic embolization → IF still continues → ligation of bleeder, vagotomy and pyloroplasty
           b. Obstruction → NG suction, antisecretory drugs → diagnostic endoscopy
                    i. Obstruction clears → medical management
                   ii. Obstruction continues → vagostomy and antrectomy/gastroenterostomy
           c. Perforation
                    i. No ulcer history → graham patch followed by intense medical management
                   ii. Ulcer history → highly selective vagotomy or vagotomy and antrectomy
Upper GI bleeding
CBC, LFT, PT/PTT, Platelets
Gastric irrigation, intubation
Hematemesis → acute upper GI bleeding (most common cause is peptic ulceration)
Melena → usually means moderate UGI bleeding – though it could also be just slow lower GI bleeding
1st Test: Endoscopy
        I.      esophageal varices → endoscopic ligation or sclerotherapy
                a. bleeding controlled
                          i. moderate child A,B cirrhosis
                                 1. endoscopic ligation or sclerotherapy
                                         a. two or more rebleeds → TIPS shunt operation or transplant
                                         b. controlled: endoscopic surveillance
                                 2. elective portosystemic shunt
                         ii. advanced cirrhosis (child C) → liver transplant
                b. Bleeding not controlled → octreotide or vasopressin
                          i. If controlled see above
                         ii. If not controlled → emergency porto-systemic shunt, GE devascularization or TIPS
        II.     Gastroduodenal source → endoscopic hemostasis
                a. Controlled → medical therapy
                b. Not controlled
                          i. Gastric ulcer → excision or gastrectomy
                         ii. Esophagogastric ulcer → ligate vessel, vagotomy and pyloroplasty
                        iii. Duodenal ulcer → vagotomy and antrectomy
        III.    No bleeding source → selective angiography + arterial embolization
LFTs, hemolysis screen, CXR, AbdXR, pregnancy test
First Step: U/S and CT
    I.      dilated ducts, gallstones → ERCP
            a. no CBD stone → cholelithiasis
            b. CBD stone
                     i. Acute → IVF, ABx → IF no response → emergent open CBD exploration
                    ii. Chronic → sphincterotomy
                            1. stones extracted → lap chole
                            2. stricture → biopsy stent
                            3. stones not extracted → open CBD exploration → IF persistent → duodenotomy/sphincterotomy,
                                choledochoduodenostomy, roux Y choledochojejunostomy
    II.     dilated ducts, no gallstones →ERCP → CBD stricture → brushings biopsy
                     i. Benign → diversion
                    ii. Malignant → resection
    III.    dilated ducts, pancreatic mass → CT guided FNA or ERCP
            a. benign → chronic pancreatitis
            b. suspisicous or malignant → pancreatic cancer
    IV.     normal ducts → viral serologies → liver biopsy

Indications for open chole
   I.     emergent: peritonitis, gas in gallbladder
   II.    conversion from lap: when Calot’s triangle is not well visualized
   III.   counterindications to laparoscopic surgery: surgical scars, something to do with CO2 ???

Acute pancreatitis
Amylase, lipase, Hct, WBC, ABG, Ca, BUN, Glu, LDH, SGOT, Abd US
First Step: NPO, NG tube, IVF, pain relief – once acute event resolves:
    I.      Mild
            a. Gallstones: cholecystectomy with cholangiography
            b. No stones: avoid alcohol, drugs, consider metabolic or anatomic cause
    II.     Severe → CT scan, ventilation, hemodynamic support, nutritional support
            IF not improved:
                     i. Pancreatic necrosis → CT guided aspiration → IF infection → debridement
                    ii. No necrosis → peritoneal lavage → IF not improved → debridement
                       KEY: if infected percutaneous drainage is NO GOOD → necrosectomy is way to go
Chronic Pancreatitis
Cancer vs chronic pancreatitis
        1) absence of alcoholic history
        2) onset of symptoms in 60s or 70s
        3) Ca-19
        4) Helical CT scan
   I.      Pseudocyst
           a. Unresolved acute peripancreatic fluid collection → acute pseudocyst
                   i. Uncomplicated → percutaneous drainage only if increasing in size
                  ii. Complicated (2* infection, rupture, hemorrhage, obstruction) → embolization, surgery and other invasive things
           b. Chronic pseudocyst → drain uncomplicated only if greater than 6cm
           c. No hx of pancreatitis → intracystic fluid analysis (biopsy) → cystic neoplasm → resection
   II.     Pancreatic ascites, pleural fistula → TPN, somatostatin → if no results in 2 weeks → pancreaticojejunostomy
   III.    Pseudoaneurysm → angiographic embolization → pancreatectomy
   IV.     Pain(you don’t wanna get them addicted to narcotics) → no alcohol, enzymes, H2 blockers, insulin → pancreaticojejunostomy
   V.      Common duct obstruction
           a. No pain → choledochojejunostomy
           b. Pain
                   i. Dilated duct → Beger or Frey procedure
                  ii. Non-dilated duct → pancreaticoduodenectomy
   VI.     Duodenal obstruction
           a. Pain → pancreaticoduodenectomy
           b. No pain → gastrojejunostomy
   VII. Splenic vein thrombosis → splenic vein thrombosis (left sided portal HTN and bleeding gastric varices) → splenectomy

Periampullary carcinoma
Spiral CT scan
   I.      No invasion of major visceral vessels, no metastasis
           a. Jaundice → cholangiography by ERCP or PTC + stenting
                   i. CA of ampulla duodenum or distal bile duct → exploration
                         1. pancreaticoduodenectomy if resectable
                         2. palliative procedure
                  ii. CA of pancreas → exploration for resection – if metastasis then same as invasive disease
           b. No jaundice → carcinoma of pancreas
   II.     Invasion of major vessels → percutaneous biopsy → chemosurgery palliation
   III.    Metastasis → percutaneous biopsy → chemosurgery palliation ]
Small Bowel Obstruction
NPO, NG, IVF, UOP monitoring
  I.     Partial
                  i. Transiet → do nothing
                 ii. Persistent → laparotomy see below
  II.    Complete → laparotomy
         a. Ileus
                  i. Peritonitis → treat underlying disease
                 ii. Retroperitoneal disease → biopsy
         b. Tumor → Eneterectomy with primary anastomosis
         c. Ischemia → enterectomy with primary anastomosis
         d. Foreign body → enterotomy
         e. Adhesions → lysis of adhesions
         f. Intussusection
                  i. Tumor → reduction and resection
                 ii. Adhesions → lysis of adhesions and reduction
  III.   Hernia → reduce → herniorrhaphy

Acute Mesenteric Vascular Occlusion
ECGG, Echo, ABG to exclude non-vascular causes
Mesenteric angiogram → laparotomy
   I.     non-occlusive → intra-arterial papaverin → bowel resection
   II.    venous occlusion → anticoagulation → bowel resection
   III.   embolic → embolectomy → bowel resection
   IV.    thrombotic → vascular bypass → bowel resection

Crohn’s Disease

              I.     Non-acute → medical treatment: IF unsuccessful:
                      i. Gastroduodenal → vagotomy, gastroenterostomy, strictureplasty
                     ii. Obstruction → resection of diseased intestine → primary anastomosis or diverting colostomy
                    iii. Fistula → resection of diseased intestine → primary anastomosis or diverting colostomy
                    iv. Intractability → resection of diseased intestine → primary anastomosis or diverting colostomy
              II.    Emergent surgery
                      i. Perforation → resection of diseased intestine → primary anastomosis or diverting colostomy
                     ii. Abscess → drainage with or without resection
                    iii. Ileitis → biopsy mesenteric node, appendectomy
Acute Right Lower Quadrant Pain
Laparotomy or laparoscopy if signs of peritonitis or hemodynamic instability
   I.    leaking AAA
   II.   Acute mesenteric occlusion
   III.  Ectopic pregnancy
   IV.   Acute appendicitis
   V.    Meckel diverticulitis
   VI.   PID
   VII. Crohn’s
   VIII. Diverticulitis

Abdominal XR, barium enema
   I.    small bowel → urgent laparotomy → resection and anastamosis
   II.   Sigmoid → proctoscopy or colonoscopy
         a. Decompression → good risk → elective sigmoid colectomy
         b. No decompression → urgent colostomy or resection
   III.  Cecum
         a. Poor risk → emergency detorsion cecostomy
         b. Good risk → emergency right colectomy

   I.      obstruction → hartmann’s
   II.     generalized peritonitis → hartman’s
   III.    localized peritonitis → IVF, ABx
           a. improved → recurrence → one stage resection
           b. not improved → hartman’s
   IV.     Abscess CT guided drainage → IF fails → Hartman’s | if successful → one stage resection

Carboxyhemoglobin (if high give 100% O2), urine myoglobine (if high vigorous diuresis and bicarbonate therapy)
IVF: %burn x 4 x body weight in Kg – half of which is given 8hrs after
Intubation, NG tube, tetanus toxoid, immediate enteral feeding + resuscitation
First step: wound debridement and evaluation including bronchoscopy with evidence of airway/pulmonary injury
    I.      constricting eschar → monitor compartment pressures → escharotomy
    II.     superficial partial thickness → total antimicrobial or biologic dressing
    III.    deep partial thickness → topical antimicrobials(Ag-sulfadiazine/mafenide acetate) → consider surgical excision
    IV.     full thickness → topical antimicrobials → surgical excision → autograft/biological dressing
Lower GI bleeding
NG aspiration
  I.       No blood, no bile → upper GI endoscopy or redo NG aspiration (sample error suspected)
  II.      No blood, bile → sigmoidoscopy
           a. Anorectal pathology → hemorrhoids
           b. No anorectal pathology → RBC scan
                  i. Positive → angiography
                          1. site localized → vasopressin infusion → IF still bleeding → emergent segmental resection
                          2. site not localized → emergent segmental resection
                 ii. negative → colonoscopy
                          1. lesion identified → elective or emergent segmental resection
                          2. lesion not identified → total abdominal colectomy
  III.     Blood → upper GI bleed

Ulcerative Colitis
   I.     severe acute
          a. hemorrhage → colectomy
          b. perforation
                    i. abscess → turnbull blowhole procedure (multiple colostomies)
                   ii. no abscess → abdominal colectomy and brooke ileostomy
          c. toxic colitis → NG suction, steroids, ABx, TPN, cyclosporine
                    i. not improved → abdominal colectomy
                   ii. improved → follow for 7 years with colonoscopy and multiple biopsies yearly
   II.    mild acute → bedrest, diet, steroids enema
          a. improved: monitor for 7 years
          b. not improved: medical Tx 6 months → IF not improved → total protocolectomy with ileoanal anastomosis
   III.   chronic
          a. medical Tx 6 months → IF not improved → total protocolectomy with ileoanal anastomosis
          b. extracolonic diseases → → total protocolectomy with ileoanal anastomosis

  I.    Extrenal → only excise if thrombosed
  II.   Internal
        a. 1st degree (bleeding only) & 2nd degree (bleeding and spontaneously reducing prolapse)
                 i. medical treatment → IF it fails → rubber band ligation/sclerosis/IR coagulation
        b. 3rd degree (prolapse requiring manual reduction) 4th degree (irreducible) and strangulations → hemorrhoidectomy
  III.  Special circumstance: pregnancy, IBD, HIV → avoid surgery
Carcinoma of the colon
   I.   Polyps
        a. Polypectomy
        b. Partial colectomy
        c. Total colectomy with ileal pouch
        d. If its carcinoma go to II
   II.  Staging (CXR, LFT, CEA, ERUS) → bowel prep → colon resection
        a. Locally confined → segmental resection
        b. Liver mets → wedge resection of mets
        c. Spread to adjacent organ → en bloc resection
        d. Diffuse disease → diverting colostomy/colonic anastomosis
        e. Follow ALL with chemo radiation unless locally confined

Liver Tumor
LFTs, AFP, CEA, abd CT, CXR, chest CT, radionucleotide scan
Biopsy (FNA, core needle)
   I.     Primary benign
          a. Hemangioma (most common benign tumors) – distinguish by technetium scan or dynamic CT
                  i. Resect if symptomatic
                 ii. Asymptomatic → hepatic artery embolization, radiotherapy, corticosteroids
          b. Adenoma (OCP associated 90% of cases) – 50% present with bleeding, others with mass or pain
                  i. Symptomatic → resection
                 ii. Asymptomatic → D/C OCPs
          c. Focal nodular hyperplasia
                  i. symptomatic → control bleeding
                 ii. asymptomatic → resection
   II.    Primary malignant
          a. Cholangiocarcinoma → resection
          b. HCC
                  i. Stage I, II (if not a resection candidate → cryosurgery and microwave coagulation)
                        1. no cirrhosis → resect
                        2. cirrhosis → consider transplant
                 ii. Stage III, IV → palliation with systemic chemo, arterial ligation, chemoembolization, alcohol injection, radiation etc
          c. Hepatoblastoma in children(resect), angiosarcomas (inoperable)
   III.   Metastatic
          a. Neuroendocrine
          b. Colorectal → resect if respectable otherwise try chemo
          c. Other
TSH test
   I.     High: evaluate pituitary tumor
   II.    Normal: euthyroid
   III.   Low:
          a. High T4 → Radioactive Iodine Uptake
                  i. Low: subacute thyroiditis, postpartum thyroiditis, facitious thyrotoxicosis, stroma ovarii, functioning mets
                 ii. High: hyperthyroidism
          b. Normal T4 → subclinical hyperthyroidism, nonthyroid illness, thyroid hormone therapy, dopamine, glucocorticoids, T3 toxicosis

Intermittent Claudication
ABI, doppler US and other non-invasive tests
First step: smoking cessation, graded exercise, weight reduction, antiplatelet therapy
Monitor non-invasively every 3-6 months
    I.       improves → monitor non-invasively annually
    II.      functional deterioration or disability → arteriography
             a. aortoilliac lesion → PTLA/stent or surgical revascularization
             b. infrainguinal lesion → surgical revascularization

Peripheral arterial embolism
Distinguishers between thrombosis and embolism: hx of arrythmias, recent MI, AAA
   I.      severe ischemia → heparin → pulses
           a. femoral(s) absent bilateral → bilateral groin exploration → balloon catheter thrombolectomy → complete angiography
                    i. no clot → anticoagulation
                   ii. distal clot → repeat balloon catheter embolectomy → intraoperative angioscopy or urokinase
           b. femoral present, popliteal absent unilateral → same as above
           c. femoral present, popliteal present, pedal absent unilateral → explore popliteal below knee → then same as above
   II.     irreversible ischemia → amputation
   III.    moderate ischemia → heparin → angiography
           a. isolated femoral embolus
                    i. no distal propagation → embolectomy → anticoagulation
                   ii. distal propagation → thrombolytic therapy → anticoagulation
           b. popliteal embolus → thrombolysis → anticoagulation (consider embolectomy)
Triple A
Sx: sudden epigastric/back pain and hypotension
U/S best screening test – CT best pre-operative test
    I.     Symptomatic
           a. Ruptured
                   i. Moribund (profound hypotension, cardiac arrest): analgesia, comfort measures
                  ii. Responsive/unstable → resuscitate → emergent open aortic replacement with graft
           b. Intact, stable → semiurgent open aortic replacement with graft/possible endovascular graft placement
    II.    Asymptomatic
           a. Small(less than 5cm): U/S q6months → enlarging → open graft replacement/endovascular graft replacement
           b. Large (>5cm) → comorbid assessment → anatomic assessment → open graft replacement/endovascular graft replacement

Extracranial Cerebrovascular Disease
Detected as TIAs, prior stroke, carotid bruit, Arm BP gradient
ESR, Echo, ECG, Duplex scan, CT scan, MRI/MRA
   I.      Inconclusive → contrast angiogram → if serious lesion proceed as below
   II.     Arch vessel or vertebrobasilar lesion → contrast angiogram → if serious lesion proceed as below
   III.    Carotid bifurcation disease
           a. Critical disease
                   i. Stenosis ulceration → carotid endarterectomy
                  ii. Fibromuscular dysplasia → dilatation
                 iii. Kink → surgical angioplasty
                 iv. Internal carotid artery occlusion → external carotid endarterectomy, stump removal with angioplasty
           b. Non-critical lesion → antiplatelet anticoagulation therapy

Renovascular Hypertension
Suspect it in severe diastolics (>105) or poorly controlled hypertension
Captopril venography, captopril rennin assay, peripheral plasma rennin, spiral CT, MRI/MRA
   I.       highly suspicious or positive → angiography, aortography → medical therapy
            a. bilaterally disease: transaortic or transrenal thromboendarterectomy
            b. redundant vessel → reimplantation of renal artery
            c. high risk patient → extraanatomic bypass/PTA
            d. 1st choice → aortorenal bypass
            e. branch vessel → ex-vivo repair
            f. unreconstructable → nephrectomy
            g. nonostial lesion → PTA
            h. AFTER SURGERY → renal duplex US
   II.      negative → medical therapy
Varicose Veins
Venous duplex US, VRT( venous recovery time compared to contralateral leg)
   I.     Primary (85%)
          a. No saphenofemoral incompetence → stab avulsion or sclerotherapy
          b. Isolated saphenofemoral incompetence(60%) → saphenous stripping or stab avulsion +/- sclerotherapy
          c. Saphenofemoral and lesser saphenous/perforator incompetence → saphenous stripping or stab avulsion +/- sclerotherapy
   II.    Secondary
          a. Deep venous reflux (90%) → elastic compression, hose orthosis, intermittent elevation
          b. Anomaly or AV fistula → palliative embolotherapy, surgery not a good idea

Venous Stasis Ulcer
H&P previous DVT, varicose veins, skin changes, edema, ABI – do a complete coag profile
Continuous wave Doppler and plethysmography
   I.     arterial (ischemic ulcer) → arterial evaluation (see above)
   II.    venous stasis ulcer → duplex scanning → compression therapy
          a. successful → compression stockings
          b. unsuccessful
                   i. incompetence of superficial veins, perforator veins or deep veins
                          1. high ligation and stripping of saphenous vein with varicose vein avulsion
                                 a. successful
                                 b. unsuccessful (deep vein incompentence)
                                         i. valvuloplasty, valve segment transfer
                  ii. deep vein obstruction → phlebography → venous bypass → skin graft
Neonatal Bowel Obstruction
Suggested by polyhydramnios, bilious emesis in newborn
NPO, IVF, NG, ABx, Abd XR, contrast imaging

  I. congenital antral obstruction → gastrotomy, membrane excision
 II. hypertrophic pyloric stenosis
III. Air in dilated stomach and duodenum (double bubble) → duodenal atresia/obstruction/prepyloric portal vein/annular pancreas or malrotation →
IV. Duodenal web → web excision
 V. Several dilated loops → proximal intestinal obstruction (jejunoileal atresia) → upper GI series
VI. Multiple dilated loops → distal intestinal obstruction → lower GI series
           a. Colonic atresia → resection with colostomy
           b. Malrotation
                    i. No volvulus → Ladd’s procedure
                   ii. Volvulus → if viable then Ladd’s procedure, resection with end ostomies, close abdomen
           c. Necrotizing enterocolitis
                    i. Complicated → resection, ostomies, peritoneal drainage
                   ii. Uncomplicated → Contrast enema
           d. Meconium ileus
                    i. Complicated → enterotomy, irrigation, resection, irrigating ostomy
                   ii. Uncomplicated → hyperosmolar enema
           e. Meconium plug/small left colon syndrome → hyperosmolar enema, suction rectal biopsy
           f. Hirschsprung’s (delayed passage of meconium) → barium enema → if microcolon, if irregular mucosa, if 24hr retention → rectal
               biopsy → if aganglionic → colostomy
           g. Imperforate anus

Surgical Jaundice in Infancy
Alpha1-Antitrypsin, Hepatobilliary scintigraphy using iminodiacetic acid (IDA) scan, US, liver biopsy
    I. Hypoplasia → just close
   II. Billiary atresia → consider liver transplant
  III. Choledocal cyst → excision Roux-en-Y
  IV. Spontaneous perforation of bile duct → drainage cholecystectomy
Traumatic Hematuria
   I.    Retrograde Urethrography
         a. Urethral extravasation
                 i. Vesical opacification → suprapubic cystostomy
                ii. No vesical opacification → bridging catheter → urethral repair
         b. Bladder extravasation
                 i. Extraperitoneal → urethral catheter
                ii. Intraperitoneal → operative repair
   II.   IVP or CT scan
         a. Renal function present
                 i. Extravasation → repeat IVP in 72 hours → IF unimproved → operative repair
                ii. No extravasation/ renal laceration → IF bleeding persists or recurs → arteriography → therapeutic embolization/renal repair or
         b. No renal function
                 i. Arterial thrombosis or avulsion → observe
                ii. Renal fragmentation
                        1. stable hematoma → observe
                        2. expanding hematoma → renal repair or nephrectomy

Renal Calculi
   I.     Ureteral stone → >1cm, febrile patient, intractable pain, vomiting and inability to hydrate → use following means to kill it:
          a. Radiolucent (uric acid) → alkalinization of urine (oral sodium bicarbonate, potassium citrate) → dissolution
          b. Mid or distal ureter → ureteroscopic or operative removal
          c. Proximal ureter → extracorporeal shock wave lithotripsy (ESWL)
          d. Febrile → blood and urine cultures, ABx, percutaneous nephrostomy or ureteral stent
                  i. Afebrile → treat like afebrile ureteral stone
                 ii. Perinephric fluid collection → drain
                iii. Febrile → correct position of stent or nephrostomy
   II.    Nonstaghorn renal stone
          a. Lower pole, less than 1cm, pelvic, mid or upper pole and less than 2cm → ESWL
          b. Lower pole > 1cm, pelvic mid or upper pole > 2cm → percutaneous removal
   III.   Staghorn renal stone
          a. Normal renal anatomy → ESWL and/or percutaneous removal
          b. Abnormal anatomy or very large stone → open surgical removal
          c. Poor function in affected kidney → nephrectomy
Renal Mass
IVP (do US if pt has impaired renal function – contrast counterindicated)
   I.     probably cystic → renal US
          a. complex cyst or abcess → cyst puncture
                    i. clear fluid/negative cytology → observe
                   ii. pus → drain
                  iii. abnormal cytology → radical nephrectomy
          b. simple cyst → observe
   II.    probably solid → CT
          a. simple cyst → observe
          b. solid
                    i. suspicious for RCC → MRI, venocavagraphy, arteriography, renal biopsy (avoid bx unless absolutely necessary due to risk of
                       bleeding and tumor spillage) → radical nephrectomy
                   ii. angiomyolipoma → observe if less than 4cm and asymptomatic
                  iii. suspiscious for TCC(transitional cell CA) → retrograde pyelography, brush biopsy, ureteroscopy +/- biopsy → radical

Bladder Tumor
Gross painless hematuria, bladder irritability Sx, do digital rectal exam
UA, UCx, and cytology + IVP
Cystoscopy with random bladder biopsy and transurethral resection of all tumor mass → staging
   I.      superficial disease → transurethral resection or partial cystectomy → Intravesical chemo → f/u cystoscopy, IVP, urine cytology
   II.     Invasive disease (T2-4) → CXR, CT, LFT, Bone scan
           a. Locally invasive
                    i. Radical cystectomy with urinary diversion → adjuvant chemo
                   ii. Radiation
                  iii. Bladder sparing combination chemotherapy
                  iv. Radical transurethral tumore resection
           b. Metastatic disease
                    i. Combination chemotherapy
                   ii. Palliation → urinary diversion, radiation, intravesical formalin, sliver nitrate
Prostatism (BPH Sx)
Rectal exam is always followed by cystoscopy
PSA NOT for screening, >4 are SUSPICIOUS for CA, >50 indicate metastatic disease
   I.     indurated nodule → indurated nodule → transrectal guided US needle biopsy → IF cancer:
          a. T1a → observe
          b. T1B-T3 → radical prostatectomy → monitor PSA
          c. N1 → hormonal therapy
          d. M1 → delayed hormonal therapy
   II.    benign hypertrophy
          a. benign hypertrophy → transurethral incision of prostate, prostatic stent, alpha blockers, ballon dilation
          b. median bar → transurethral incision of bladder neck or prostatectomy
   III.   congestive obstructive prostatitis → massage, ABx → persist or recur → prostatectomy
   IV.    normal
          a. no obstruction → urodynamic (cystometrography, EMG, Flowmetry) → neurogenic or myopathic bladder → medical tx →
              prostatectomy if unresponsive
          b. urethral stricture
                   i. urethrotomy
                  ii. urethroplasty or urethral stent

Scrotal Mass
   I.     painless
          a. transilluminates – just observe and take out if you have to
                   i. spermatocele
                  ii. hydrocele
          b. doesn’t transilluminate
                   i. tunica albugina cyst/plaque
                  ii. varicocele → observe/possible varicocelectomy
                 iii. mass in vas
                 iv. testis mass → orchidectomy
                  v. inguinal hernia → herniorrhaphy
   II.    painful
          a. traumatic → scrotal exploration with testicular reconstruction or orchidectomy
          b. non traumatic
                   i. torsion → rotation and bilateral orchidopexy
                  ii. appendage torsion → observe with possible excision
                 iii. epididymis → observe
                 iv. epididdymoorchitis → observe with possible excision
Testis Tumor
Inguinal orchiectomy
   I.      Child
           a. Teratoma → no further tx
           b. Yolk sac tumor(most common) → surveillance CXR, Abd CT, serum markers → IF mets → chemo with radiation
   II.     Adults
           a. Spermatocytic seminoma → observe
           b. Seminoma
                    i. Minimal or no retroperitoneal mets, neg markers → retroperitoneal radiotherapy
                   ii. Bulky mets, positive markers, extraabdominal tissue → chemotherapy → monitor markers
           c. Non-seminomatous germ cell tumor
                    i. Bulky mets, positive markers and extraabdominal tissue → chemotherapy → monitor markers
                   ii. Minimal mets → retroperitoneal lymph node dissection → observe
                  iii. No mets and negative markers → node dissection and surveillance

Back pain
   I.     radicular (dermatomal signs) → IF nerve root compression (disc prolapse or lateral stenosis) → medical tx (6wks of NSAIDS, muscle
          relaxants, physio/rehab, epidural steroids
          a. pain relieved → observe
          b. pain not relieved → prolapse excision
   II.    non-radicular → medical treatment
   III.   Claudication
          a. Nerve root ischemia and compression
                  i. No neurologic deficit → medical treatment
                 ii. Neurologic deficit → surgery (decompression, reduction, stabilization, reconstruction, fusion)
          b. No nerve root ischemia and compression → re-evaluate
Cervical Spine Fracture
   I.     awake/cooperative
          a. no neurologic deficit
                  i. no neck pain → C-spine XR
                         1. no fx → observe → repeat XR if pain
                         2. possible fx → flex – ex XR → IF unstable → CT scan
                                a. minimal bony abnormality → MRI or CT myelography
                                        i. no compression lesion
                                               1. no neurologic deficit → MRI when stable
                                               2. neurologic deficit → external orthosis
                                       ii. compression lesion → surgical decompression and stabilization
                                b. bony disruption, good alignment → keep in collar nothing further
                                c. marked subluxation → traction
                                        i. reduction → external orthosis or surgical fusion
                                       ii. no reduction → MRI → surgical reduction
                         3. fx → CT scan → (see above)
                 ii. neck pain → cross table lateral XR
                         1. no fx → C-spine
                         2. fx → CT scan → (see above)
          b. neurologic deficit → cross table exam (see below)
   II.    Uncooperative → cross table lateral XR
          a. No fx or subluxation → C-spine
                  i. No fx
                         1. no neurologic deficit → observe
                         2. neurologic deficit → MRI or CT myelography
                 ii. fx → CT scan → (see above)
          b. fracture → CT scan
          c. Marked subluxation → traction (as above)

Hip fracture
UA, Cr
   I.     Extracapsular femoral fracture →Impacted, unimpacted, subtrochanteric → reduction and internal fixation (good blood supply here)
   II.    Intracapsular (immediately distal to femur head) fracture
          a. Impacted → multiple pins → rehab → observe for nonunion/aseptic necrosis
          b. Unimpacted → screws, hemiarthroplasty, total hip replacement(oldies) or multiple pins (young ones) → rehab → observe for
              nonunion/aseptic necrosis
Pelvic Fracture
Serial Hct, UA
    I.      pelvic ring disruption
            a. hemodynamically stable
                     i. closed
                            1. anatomically stable → mobilize, modified weight bearing
                            2. anatomically unstable → open reduction, internal fixation
                    ii. open → laparotomy, external fixation
            b. hemodynamically unstable
                     i. DPL (-) – diagnostic peritoneal lavage → external fixation → angiographic embolization
                    ii. DPL(+) → laparotomy → closed reduction, internal or external fixation
    II.     Acetabular
            a. Displaced → skeletal traction
                     i. Incongruent joint surface
                            1. hemodynamically stable → open reduction with internal fixation
                            2. hemodynamically unstable → delayed open reduction with internal fixation (possible total hip arthroplasty)
                    ii. congruent joint surface → traction
            b. non-displaced → mobilize, toe touch weight bearing

Knee Injury
  I.     vascular insufficiency → reduction → IF pulse not restored → angiography and arterial repair
  II.    fracture
         a. patella or tibia
                  i. undisplaced → immobilize → rehab
                 ii. displaced → open reduction and internal fixation
         b. femur
                  i. supracondular or condylar or intercondylar → open reduction, internal fixation
                 ii. osteochondral defect → arthroscopy
                         1. small fragment → excision
                         2. large fragment → replacement and fixation
  III.   no fracture
         a. cruciate ligament/meniscus/collateral ligaments → MRI → immobilize → rehab → possible operative repair/resection
         b. patellar dislocation → reduction → immobilization → rehab

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