General Surgery Syllabus 2
General Surgery Syllabus 2
General Surgery Syllabus 2
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Anatomy
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Hyperthyroidism
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Hepatic failure
• Patient preference
When????
• RAI most utilized modality
• Pregnancy planning
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Hyperthyroidism Hyperthyroidism
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Thyroiditis Thyroiditis
§ High dose steroids, tamoxifen may help § Large, hypoechoic, taller than wide, rapidly growing
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§ Surgery for debulking often needed with airway § FNA standard for tissue diagnosis with Bethesda classification
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When to
FNA???
• Metastasis
§ AMES-age, mets, extent of disease and size
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§ +Margins
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Surgery Review Course The Osler Institute
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Genetics
§ Risks factors same as for well diff thyroid cancers § Most are rapidly lethal and surgery is not an
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option
§ Follicular and papillary variants
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Goals of Surgery
Goals of Surgery
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§ U/S??
§ Permanent (1-2%)
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§ Represents contusion or temporary alteration of the § Only treated if symptomatic because you want
blood supply to PT with low or absent PTH secretion parathyroid glands to be stimulated
§ PTH – single most important regulator of Calcium § PO Calcium – 1 to 2 g QID (Calcium carbonate – 40%
§ Stimulate Ca resorption Kidneys/Bone elemental calcium – 1 g CaCO3=400mg Ca)
§ Indirectly stimulate GI absortion through hydroxylation of Vit. D
in kidneys § IV Calcium – prefered Calcium gluconate – 1g/10cc
§ Calcium – 50% ionized / 40% protein bound / 10% organic § Rocatrol – Active form Vit. D – 0.25 mcg BID
ion bound
QUESTIONS? QUESTIONS ?
QUESTIONS? QUESTIONS?
Recurrent laryngeal nerve damage (permanent) Recurrent laryngeal nerve damage (permanent)
during thyroidectomy should be approx: during thyroidectomy should be approx:
2. 10% 2. 10%
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3. 20-25% 3. 20-25%
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4. 50% 4. 50%
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QUESTIONS? QUESTIONS?
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Fine needle aspiration biopsy (FNAB) is Fine needle aspiration biopsy (FNAB) is
characteristically inconclusive for: characteristically inconclusive for:
1. Thyroid lymphoma
1. Thyroid lymphoma
2. Papillary Ca
2. Papillary Ca
3. Medullary Thyroid Ca
3. Medullary Thyroid Ca
4. Follicular thyroid Ca (correct)
4. Follicular thyroid Ca
Follicular thyroid cancer is characteristically non-
diagnostic, due to the lack of demonstration of
capsular or lymphovascular invasion.
QUESTIONS? QUESTIONS?
The Bethesda Diagnostic Category for thyroid The Bethesda Diagnostic Category for thyroid cancer uses
cancer uses a scoring system to: a scoring system to:
QUESTIONS? References
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Surgery Review Course The Osler Institute
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1852- Sir Richard Owen performed an autopsy on a rhinoceros and first described
the parathyroid gland
1880- Swedish medical student, Ivar Sanstrom first identifies and names the human
parathyroid gland
Anatomy Physiology
Etiology of Hypercalcemia
Physiology
• Hyperparathyroidism
• Malignancy
• Vitamin A or D intoxication
• Thiazide diuretics
• Hyperthyroidism
• Milk–alkali syndrome
• Sarcoidosis and other granulomatous diseases
• Familial hypocalciuric hypercalcemia
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• Immobilization
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• Paget disease
• Lithium therapy
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• Addisonian crisis
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Familial Hypercalcemic
Hyperparathyroidism Etiology
Diseases
o Unknown cause
Familial Hyper PTH o 75-85% adenoma, 10-15% hyperplasia
Familial Hypocalciuric Hypercalcemia o 1% carcinoma
MEN I (Menin)àP.P.P. (all 3 p’s)
o XRT exposure associated
MEN IIA (Ret-proto oncogene)àMTC, Pheo, Hyper PTH
o Post-menopausal women 2-3x’s
o Familial MEN I/IIa
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Diagnosis
Systemic Effects
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o Sestamibi Scan
o Personal and family historyà young patients need
attention o 4D CT scan
o Serum calcium, ionized calcium, intact PTH, 25-OH vitamin o High resolution ultrasound
D, 24hr urinary calcium, volume status, creatinine levels o CT imaging MRI +Angiography
o Malignancy? o Venous Sampling
o MEN??
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Surveillance
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Absolute indications: MEN syndrome, Failure of PTH to drop, failure o Traditional 4-gland exploration
to find diseased gland, more than one enlarged gland, negative
o Sestamibi guided unilateral exploration
imaging, multiple suspected diseased sites, thyroid disease that
requires a total thyroidectomy o Scan guided surgery with ‘quick’ PTH
o Under local anesthesia
o Scan directed parathyroidectomy with
Advisable indications: lithium induced disease, familial non-MEN intraoperative gamma probe
disease (physiologic approach)
Options for
Parathyroidectomy Parathyroidectomy
Technique
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Baseline PTH
Limited incision ~2cm If glands are missing or not found-> perform secondary
Subplatsymal flaps parathyroid survey
Open midline raphe TE groove (below main trunk of inf thyroid artery)
o Recurrent/Persistent hyperparathyroidism
Intraoperative monitoring of PTH:
o Usually gland in neck/mediastinum
o Inferior glands from styloid to aortic arch
Miami protocol-> 4mL whole blood pre-incision, pre-excision
o Superior glands usually in TE groove
after dissection, 5 and 10 min after removal and 20 minute if
not dropping at 10 minutes o Repeat preop localization!!!
o Angiographic/Percutaneous ablation? 66% @ 4yrs
o Hypercalcemic crisis – Lasix and saline
Need decrease of 50%
o Emergent parathyroidectomy may ne needed
o Pregnancy - Rare
Accuracy of 98% normocalcemia post-op
o High morbidity and mortality
o Newborns at risk for neonatal tetany
o Parathyroidectomy in 2nd trimester
Secondary/Tertiary
Hyperparathyroidism Treatment Calciphylaxis
o Usually consequence of chronic renal disease
o Control hyperphosphatemia – dietary restrictions,
phosphate binding, gels
o Calcium supplementation
o Dec. aluminum intake
Surgery - Persistent symptoms not controlled medically
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or transplant in secondary
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radioguided parathyroidectomy)
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Parathyroid Carcinoma
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“Endoscopic”
Parathyroidectomy
o Video-assisted
o “Endoscopic”
o “Skin Lifting”
o Trans-axillary
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o NOTES Parathyroidectomy???
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Parathyroidectomy Has Become So Easy,
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o Relaxed Indications
o Improved Imaging
o Gamma Guidance/Videoscopic Assistance
o NIM
o Intra-operative PTH
o Low Morbidity
o Success in excess of 96%, in abundance of published studies
Question #1 Question #1
Question #2 Question #2
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Question #3 Question #3
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Question #4 Question #4
Questions References
Uptodate.com
What are the embryological origins of the parathyroid glands ?
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Background Embryology
Medulla
Elevate blood glucose
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Dark gray
Contain chromaffin cells that secrete sympathetic hormones Adrenal sex steroids à reticularis à male and female sex
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hormones
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Blood flow from cortex to medulla then exit via central medullary
venous system Release regulated by ACTH
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Adrenal Cortex
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Aldosterone Secretion
Hormone Production
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Regulated by ->
Decreased afferent arteriolar pressure in renal cortex
Decrease Na, increase K content in renal tubule
ACTH secretion much lesser degree but some effect
Renin converts angiotensinogen to Angiotensin I in kidney
Angiotensin converting enzyme (ACE) converts AT I to AT II in the
lung
AT II simulates aldosterone production
Aldosterone stimulates Na-K exchange, dumps H+ as well
Immune depression
Circadian rhythms
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Steroid Physiology
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Hyperaldosteronism Hyperaldosteronism
Secondary
Increase renin production secondary to RAS,
cirrhosis, CHF, etc
Paraneoplastic tumors secreting renin
Hyperaldosteronism
Atrial Fibrillation
Refractory HTN
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Hyperaldosteronism Hyperaldosteronism
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Screening
1. Plasma aldosterone AND renin levels upright position
2. A:R ratio >20-25 mg/dL with aldosterone >15mg/dL and
Hyperaldosteronism
Hypercortisolism Hypercortisolism
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Hypercortisolism
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Subclinicial Cushing’s
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microadenoma)
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Diagnosis
Age bimodal, 5 and 60 yrs old
Suspected with rapid onset Cushing’s syndrome
Most commonly presents with stage III, IV disease (75%)
> 6 cm ion diameter, heterogenous, lymphadenopathy, local
Present with Mets in 40% and 85% recur locally or distant
invasion
40-60% are hormonally active
T2 MRI with higher signal intensity and T1 heterogenous
R>L enhancement
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Pheochromocytoma Pheochromocytoma
Bilat 10%, NE and Epi production primarily affect alpha receptors for
vasoconstriction
Extra-adrenal 10%
+ Screen but no mass, consider venous sampling, then
Familial 10%, unilateral adrenalectomy
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Multicentric 10% 10% bilateral, unless associated with MEN II where 70%
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Children 10%
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MEN II 10%
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Pheochromocytoma Pheochromocytoma
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Treatment of Treatment of
Pheochromocytoma Pheochromocytoma
Pheochromocytoma Overview
Adrenal Incidentaloma
0.35 - 5% of abdominal CT
10% Functional
5% pheo (10% of pheos are incidentalomas)
7% aldosterone
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0.06 carcinoma
All patients with incidentaloma should BE SCREENED
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Incidentaloma
Biochemical workup
Patient history ?
2. Asymptomatic
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3. Non-functional
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4. Functional
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Adrenal Incidentalomas are: The usual arterial supply to the adrenal gland include all
but the following?
1. Never functional
1. Superior suprarenal (inferior phrenic)
2. Always functional
3. Variably functional (correct)
2. Middle suprarenal (aorta)
4. Unnecessary to evaluate functionality
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4. Gastroduodenal
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References
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4. Gastroduodenal (correct)
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§ C. Pheochromocytoma § C. Pheochromocytoma
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Adrenocortical lesions 20-50% Leiomyomas 10% endocrine neoplasia type 1 (MEN1). J Clin Endocrinol Metab 2012;97:2990-
3011.
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MEN – 1: MEN – 1:
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§ Most frequent and earliest onset § Disease course similar to sporadic primary hyperparathyroidism
§ Penetrance 90-99% § Osteopenia by age 35
§ Discovered on routine labs, renal stones, or vague § Surgical indications similar to sporadic primary hyperparathyroidism
abdominal pain
§ Localization studies or imaging rarely helpful and often misleading
§ Asymmetric 4 gland hyperplasia
§ largest gland usually 10x bigger than the smallest gland
MEN – 1: MEN – 1:
PRIMARY HYPERPARATHYROIDISM ENTEROPANCREATIC LESIONS
§ Subtotal parathyroidectomy or total parathyroidectomy with § Penetrance 30-80%
autotransplant in forearm § Age of onset 30-40
§ Utilize cryopreservation when possible
§ Usually multiple small lesions
§ Transcervical thymectomy
§ Frequently malignant – most common cause of death and
§ Supernumerary glands 6%
morbidity in MEN-1
§ 50% of missing glands are in thymus
§ Thymic carcinoid 8% § Functional and non-functional
family history does not rule out the diagnosis of § A consensus for optimum radiological screening has not been established.
gastrinoma. A suggested minimum imaging protocol includes annual pancreatic and
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§ 10-33% malignant Thakker RV, Newey PJ, Walls GV, et al. Clinical practice guidelines for multiple endocrine
§ Often multiple neoplasia type 1 (MEN1). J Clin Endocrinol Metab 2012;97:2990-3011.
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Thakker RV, Newey PJ, Walls GV, et al. Clinical practice guidelines for multiple endocrine Thakker RV, Newey PJ, Walls GV, et al. Clinical practice guidelines for multiple endocrine
neoplasia type 1 (MEN1). J Clin Endocrinol Metab 2012;97:2990-3011. neoplasia type 1 (MEN1). J Clin Endocrinol Metab 2012;97:2990-3011.
MEN – 1:
ANTERIOR PITUITARY TUMORS
§ Age of onset 30-40
§ Usually macroadenomas (85%)
§ Prolactinoma - galactorrhea
§ GH - Acromegaly
§ Non-functional
§ ACTH – Cushing’s Disease
§ Mass effect
§ Optic nerve compression
§ Headache
§ Hypopituitarism
MEN – 1: MEN – 1:
ANTERIOR PITUITARY TUMORS ADRENAL LESIONS
§ Treatment Surgery vs Pharmacologic
§ Prolactinoma: Cabergoline
§ Penetrance 15-20%
§ Acromegaly: Somatostatin analogs
§ Non-functional: Surgery
§ Bilateral
§ Cushing’s: Surgery § Often non-functional, usually Indolent
§ Failure to pharmacologically inhibit
§ Transsphenoidal hypophysectomy § Hypercortisolism, hyperaldo - rare
§ Surgical failure § Pheochromocytoma – very rare
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§ Radiation therapy
§ ACC – very rare
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MEN – 1:
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MALIGNANT LESIONS
Th
Thakker RV, Newey PJ, Walls GV, et al. Clinical practice guidelines for
multiple endocrine neoplasia type 1 (MEN1). J Clin Endocrinol Metab
2012;97:2990-3011.
MEN-2A
FAMILIAL MTC (FMTC)
§ Medullary Thyroid Cancer: 90-100%
§ MTC is the first endocrinopathy to develop
§ Multigenerational transmission of MTC in which no family member
§ Multifocal and bilateral
has PHEO or PHPT.
§ Usually the cause of death
§ The typical age of onset of this condition is later in life than MEN 2A
§ Primary Hyperparathyroidism: 15-30%
§ Asymmetric hyperplasia § The penetrance of MTC is lower
MEN-2B MEN-2B
§ Medullary Thyroid Cancer: 100%
§ Gastrointestinal abnormalities: 90%
§ Early age of onset – infancy <1 year
§ Vomiting
§ Highly aggressive – nodal metastases <3 years § Dehydration
§ Pheochromocytoma: 50% § Constipation: 60-100%*
§ Unilateral or bilateral § Megacolon: 67-100%
§ No Hirschsprung's
§ Mucosal Neuromas: 100%
§ Proliferative lesions of nerves and Schwann cells § Inability to cry tears: >85%*
§ Lips, tongue, and conjunctivae most common § Markedly enlarged peripheral nerves
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§ Marfanoid Habitus
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§ Skeletal abnormalities
§ Slipped capital femoral epiphyses, and club foot
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ONCOGENE.
§ RET gene first identified in 1985
§ MEN2A, FMTC, and MEN2B linked to germline RET mutations in 1993 1
and 1994
§ Somatic RET mutations have been found in 40-50% of sporadic MTC.
§ Genotype-phenotype relationships
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§ Pheochromocytoma (MEN2a and MEN 2b) § Pheochromocytoma (MEN2a and MEN 2b)
§ 40-50% of MEN 2 patients develop
§ Hyperparathyroidism (MEN2a) pheochromocytoma
§ Medullary thyroid cancer (MEN 2a, FMTC, § Present at a younger age (30-40 years)
MEN2b) § Classic symptoms in only 50%
§ Commonly bilateral (>50%)
§ Screening begins if suspected or proven mutation
Interventions are based on the results of § Positive or borderline results lead to imaging
screening studies, biochemical tests and codon
mutation
§ C-cells can be found anywhere in the gland but are concentrated in TUMOR MARKERS
the posterior upper poles of the thyroid lobes.
§ Primary tumor markers
§ Calcitonin Doubling time
§ flushing, diarrhea
§ CEA
§ Somatostatin
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SURVIVAL
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AGE AND LNM
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YEAR AND LNM
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100%
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100%
90%
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90%
80%
80%
70%
Percent of Patients
70%
Percent of Patients
60%
no LMN 60%
50% LNM no LMN
60%
50%
40% LNM
43.8% 40%
30% 41.5%
32.5% 30%
20% 29.7%
20% 26.2%
10%
12.5% 10%
0%
0%
0 to 6 7 to 12 13 to 18
(n=16) (n=40) (n=89) 1985-1990 1991-1994 1995-1997 1990-2001
1998-2001
Age Categories in years (n=25) (n=41) (n=37) (n=42)
(P = 0.045)
Year Categories
(P=0.03)
Raval MV, Sturgeon C, Bentrem DJ, et al. Influence of lymph node metastases on
survival in pediatric medullary thyroid cancer. Journal of pediatric surgery
2010;45:1947-54.
1.0- 98.4%
99.4%
0.9- 0.9-
91.7%
SYSTEMIC THERAPY
Normal RET Mutation
FDA APPROVED MULTIKINASE INHIBITORS FOR
PROGRESSIVE METASTATIC AND UNRESECTABLE
MTC
•Vandetanib (Caprelsa) April 2011
•EBRT or IMRT
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§ Annual biochemical screening and imaging begins at age 5 § MTC is the usual cause of death
§ UPTODATE.com
§ Genetic consult before testing
§ False negative rates are higher in MEN1
gene testing
§ RET testing guides potentially curative
interventions
ANY QUESTIONS? rg e
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Mediastinum &
Chest Wall Disorders
Ahmed Mahmoud, MD
Associate professor of clinical surgery
[email protected]
Incidence
• 60% of Mediastinal masses in adults are: • In children the most common are (80%) are:
– Thymoma – Neurogenic tumors
– Neurogenic tumors – Germ cell tumors
– Benign cysts – Foregut cysts
– lymphadenopathy
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• Optimize medically prior to operation (i.e. • The most common anterior mediastinal mass
plasmapheresis or large steroids doses)
in adults
• Anti choline esterase: neostigmine is medical treatment
• Intraoperatively avoid neuromuscular blocking agents • 50% of thymoma are malignant
– Volatile inhalational agents and short acting narcotics are the • Patients are often asymptomatic but may
best anesthetic choice
present with chest pain, cough, or dyspnea
• Complete thymectomy should be done through a
median sternotomy • Often indolent but can be locally invasive and
• Clinical improvements after thymectomy are not recur at local or distal sites
immediate • Surgical resection is the mainstay of treatment,
including stage III and IV a thymomas
Thymomas Thymomas
• Histologic evidence of malignancy is • Treatment is complete thymectomy through a median
difficult to obtain sternotomy
– Stage I – surgery alone
• Benign and malignant lesions can have
– Stage II and III – post op radiation after complete
similar histologic and cytologic features resection
• Surgical evidence of invasion at the time of – Stage IV – optimal treatment unknown
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benign Thymomas
• Post op follow up for 10 years
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• Median sternotomy
• Complete resection entails removal of all
structures attached
• Phrenic nerve is controversial
Lymphoma
• Anterior mediastinal
• Large Mass ++
• Dx: Surgical incisional Bx
• Treatment: non surgical
• T cell = Chemotherapy
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• Classification; benign teratoma – Seminoma • Tumor markers, HCG increase in 10% AFP is
– nonseminoma not elevated
• Non seminoma are: teratocarcinoma-yolk • Treatment is non surgical
sac tumor-choriocarcinoma-endodermal • Radiation + Cisplatinum chemo = up to 100%
sinus and embryonal cell cure
• Benign teratoma is entirely benign: • Residual tumor = Salvage chemo
treatment is surgical excision only • Residual tumor may be teratoma especially if
tumors markers normalize after chemo
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Trachea
Mediastinal Compartments
• Anterior- prevascular compartment
– thymoma, lymphoma, germ cell
– thyroid, parathyroid
• Visceral- central or Middle compartment
– foregut cysts: bronchogenic, esophageal
– lymphoma, pericardial cyst
• Paravertebral- posterior compartment
– neurogenic: neurilemoma, neurofibroma,
ganglioneuroma, neuroblastoma
– Thoracic duct
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Pathology
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Neurogenic Tumors
• Posterior mediastinum
• 90% benign
• Commonly asymptomatic
• May extend into vertebral foramina
• Complete surgical excision
• Malignancy needs post op XRT
– Vena cava
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– Posterior heart
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– Arch vessels
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Classification Classification
Benign Malignant
• From Soft Tissue • From bone (ribs, sternum) • Soft tissue • Bone
– Hemangioma (common) – Fibrous dysplasia – Rhabdomyosarcoma – Myeloma
– Lymphangioma – Aneurysmal bone cyst – Ewing Sarcoma – Chondrosarcoma
(Common) – Giant cell tumor – Malignant fibrous – Osteosarcoma
histiocytoma – Ewing sarcoma
– Schwannoma – osteochondroma – Malignant peripheral
– Neurofibroma nerve sheath tumor
– Ganglioneuroma – Dermatofibrosarcoma
– paraganglioma protuberans
• Chondrosarcoma
– General
• most common primary malignant tumor of the chest
wall
• still uncommon (60 per year dx in the US)
• most commonly occurs in the anterior chest wall
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• age = 20-40
• ? After trauma, occ malignant transformation of
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Chondrosarcoma
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• Chondrosarcoma
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– Diagnosis
• X-ray
– lobulated mass arising in the medulla of the bone
– ill defined margin of tumor with extensive
destruction of the bony cortex
– CT important to evaluate extent of invasion
• Pathology
– low grade - hyaline matrix with a few cells
– higher grades have more cellularity
– may combine with other histologic groups
Chondrosarcoma
Malignant Bony Tumors
• Chondrosarcoma
– Treatment
• wide resection
– 5 year survival based on ability to
completely resect the tumor = 67 - 89%
– without complete resection, 50% 5 year
survival
– local recurrence significantly decreases
Clinical Features/Diagnosis
• Metastatic tumors to chest wall are the most • Pain and presence of mass
common of all • Pain more common in malignant tumors
• Breast tumors local recurrences to chest • Asymptomatic in 20-25%
wall • Any age (older more malignant)
• Resection with reconstruction provide the
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• Surgical anatomy
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• Anatomic
– Potential sites of neurovascular compression • Traumatic: rare
• Interscalene triangle – Fractured clavicle
• Costoclavicular space
– Dislocation of head of humerus
• Subcoracoid area
• Congenital – Crushing injury to upper thorax
– Cervical rib and its fascial remnants – Sudden effort of shoulder girdle muscles
– Rudimentary first thoracic rib – Cervical spondylosis; c-spine injuries
– Scalene muscle
• Anterior, middle, minimus
– Other, i.e. enlarged transverse process of C7
• Venous obstruction
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Velocities
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Therapy Therapy
• Subclavian vein thrombosis (Urschel, • Arterial compression
Stoney) – Prompt attention to avoid irreversible ischemia
– Catheter guided thrombolysis and tissue loss
– followed by first rib resection /scalenotomy – Principles of surgical management
promptly in the same hospital admission • Complete removal of anatomic abnormality
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CME Question 1
• Mediastinal masses: Which of the following
best represent surgeon role?
A. radical curative resection
B. Palliative resection
C. only to make tissue diagnosis
D. standby for radiological tissue sampling
E. resection after chemo
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Lung Cancer:
Pathological Types
• Adenocarcinoma • Squamous cell carcinoma
– More common in females – Central part of the lung
– Peripheral location – More to obstruct bronchus with distal
– Spread mainly by blood (Brain) atelectasis, cavitation and abscess
– Incidence is increasing (the most common) – Spread more by lymphatics
– Bronchoalveolar is a variant of adeno with the
best prognosis of all when localized
Clinical Presentation
• Small cell (oat cell) • Nonspecific presentation
– Worse prognosis – cough, hemoptysis, loss of weight,
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• Pleural effusion
• Hoarseness of voice in left side tumors
(left recurrent laryngeal nerve)
• Superior vena cava syndrome:
– face edema
• Pancoast tumor: thoracic outlet
syndrome with ulnar nerve symptoms,
Horner syndrome
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Diagnosis
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– Bronchoscopy: sputum, Bronchus, carina • PET scan, depends on glucose uptake by active
• Percutaneous needle biopsy: peripheral lesion cells. Very sensitive (not specific). small cell has
the highest uptake. Renal cell cancer is false –
ve. Sarcoidosis is a cause of false+ve
Determination of Irresectability
• If all above fail ,Tissue DX is obtained during • ANATOMICAL (Extra or Intra thoracic)
thoracotomy – Extrathoracic mets, (bones, liver, adrenal?)
• >20 % of thoracotomy/thoracoscopy – N.B exceptions are:
are done on –VE Tissue DX (the best • solitary brain met in adeno-
chance of survival) • Hormones production is not a contraindication
• 50% of patients are inoperable when first • Clubbing, osteoarthropathy
seen because of Anatomical (extra or
Intrathoracic invasions) or Physiological Causes
Causes of Inoperability
• ANATOMICAL (Intrathoracic): • Physiological
– SVC Syndrome, Contralateral LN, Recurrent – Post operative FEV1 > 800 CC at least for
Laryngeal N, Malignant effusion, heart, vessels
resection of lung to be successful
• The following are not contraindication,
– MVV(maximum voluntary ventilation) = MBC
– Chest wall, Diaphragm, pericardium
> 50% of predicted
– Ipsilateral mediastinal LN(resect after chemo xrt)
– CO diffusion capacity DCo (best measure for
– Pancoast tumor(resect after chemoradiation)
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T3 >5-7 cm
T4 >7cm
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STAGE IIIA
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STAGE IV Treatment
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cisplatinum)
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Pneumothorax
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• Aspergilloma • Empyema:
• Fungus ball – In early stages: thoracic drainage by
thoracocentesis or chest tube placement
• H/O TB, HIV … previous scar
– In late fibrotic stage: lung entrapment,
• Hemoptysis decortication is the procedure of choice
– Pleural thrombolysis is a mid alternative with
some mixed results
D. tumor in pericardium
E. tumor in diaphragm
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Cardiac Surgery
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n Tumors
n Metastatic malignant tumors 20 times more
Osler General Surgery common than primary
n Primary tumors à 75% benign, 25%
Ahmed Mahmoud malig
n Myxoma is the most common (40%)
n 75% in left atrium near fossa ovalis
n familial in young females, sporadic in old
Myxoma
n Mitral valve obstruction n Rhabdomyoma: most common in infants
n Embolization in 50% with acute ischemia in and children – occurs in ventricles, usually
peripheral circulation multiple – bad prognosis
n Histology of the surgically removed
embolus is diagnostic
n Echo is test of choice
n Treatment is excision
Cardiac Trauma
n 10% of penetrating chest trauma involves
the heart
n Right ventricle is the most commonly
injured in stab wounds
n Diagnosis: Suspect in any injury near the
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(Myocardial Contusion)
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n Left anterolateral thoracotomy down to the n Incidence: unknown . Most are asymptomatic
table n May range from benign arrhythmia to fatal
ventricular fibrillation. Myocardial rupture and
n Control obvious source of bleeding e.g. left
death
hilum
n ST, T changes and sinus tachycardia are the most
n Open pericardium, watch phrenic nerve common EKG changes
n If no injury is seen, extend to the right chest n Tests of DX:
n Open cardiac massage. Clamp the Aorta n Stable à EKG monitor for 12-24 h
injuries
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hypertension
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t 2) 2 or 3 vessel disease
Mechanical Complications of MI
n 1)Ventricular septic defect: n 2) Mitral regurgitation: Worse prognosis
pansystolic murmur. 1 % of MI. than other causes of Mitral regurg- try
u Differentiate from mitral regurgitation: by medical support before surgery
measuring the O2 sat step up at the Right n 3) Ventricular Aneurysm
ventricle: if more than 10 à VSD
u If small (2-3) cm and asymptomatic = no
u Treatment is initial medical support (if
ttt
possible) until scar matures then surgical
closure. Sometimes Emergency closure u Large/symptomatic or false needs surgery
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Valve Diseases
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Congenital Cardiac
n Aortic valve stenosis is significant and n The fetal pulmonary vascular resistance is
requires surgery if high in utero, causing blood to shunt from
right to left through the patent foramen
u The valve area is less than 1 cm (N 2-3)
ovale and also from the pulmonary artery
u The pressure gradient is > 50 mm Hg (N into the descending aorta by the Patent
none) ductus arteriosus
u Aortic stenosis is the most serious of all
and should be always corrected before n After birth, the PVR starts to fall with the
any surgery beginning of ventilation
Coarctation syndrome
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HYPETROPHY
u Cyanotic spells, relieved by squatting, no
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n Obstruction at the aorta 2 cm distal to left n Most common congenital heart anomaly is
subclavian u A- ASD primuim
n 2 types: infantile (usually severe CHF) and u B- ASD secundum
childhood u C- VSD
n Repair by a subclavian artery flap or
u D- PDA
extended resection and anastomosis
u E- TOF
n Recurrence is repaired by Angioplasty
u B – left ventricle
u C- right atrium
u D- right ventricle
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• The secretion of monokines and other • Half life time is 12 hours in the circulation
mediators of inflammation (platelet and 24 hours in the tissues. Because of
activating factor and leukotrienes), quickness of release of PMNL from the
complement activation (classic by IgM and bone marrow, some are still premature and
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differentiated
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• 3) intracellular killing
SPECIFIC FUNCTION
• PMNL have receptors for IgGs, C3B. • HUMORAL (B CELL)
• CELLULAR (T CELL)
EFFERENT
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B Lymphocytes
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early maturation
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T lymphocytes
Th
• T lymphocytes originates in the bone • The TCR is antigen specific and has alpha, beta
marrow but mature in the Thymus. sub dimer and an essential part is CD3
• Acquire a specific receptor T cell receptor =
TCR. • All TCR have CD3
• T cells can not recognize antigens without a
TCR. The antigen has also to be associated • The TCR also has either CD4 or CD8
with MHC II (HLA II) to be recognized by
the T cell receptor
• Resting (non activated) T cells do not express IL2 • T helper cells (Th1, Th2) have CD4
receptors. • T cytotoxic cells(Tc1,Tc2) have CD8
For CD8 to act on targets, an MHC I has to
• Only when stimulated by a specific antigen with be present
MHC II at the T cell receptor, they then express IL2
receptors and bind the IL2 to become active in
inducing more T-cells to express IL2 receptors. • Interferon Gamma increases the
expression of MHC I (HLA I) on the cells
• This is why IL2 inhibitors e.g. Cyclosporin(mainly to be attacked.
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Immune Response(Afferent &efferent)
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– Type I; A,B,C.
• Present on all nucleated cells, including T cells,
B cells and platelets and are targets for cytotoxic
CD 8 T cells = efferent limb of the immune
response
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Graft survival ; HLA matched
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Complication of transplantation
• Infection • Malignancy
– First month = usual post op infection – Skin tumors SCC > BCC (cardiac transplant)
– 2 to 6 month = opportunistic infection e.g. – B cell Lymphoma (EB virus infection)=
CMV – Pneumocystis- Aspergillosis – Post Transplant Lymphoproliferative Disorders =
– After 6 months = low incidence of infection PTLD - discontinue IL II inhibitors
– give Ganciclovir for EB virus infection
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• Cardiovascular disease
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Renal TX
Th
• The most common cause of mortality within • EARLY ( 1st YEAR) • LATE (2-17 YEARS)
the first year after renal Tx is – Sepsis 45% – CVS 35 %
– CVS 35% – Malignancy 20%
• A. Malignant tumors
– Sepsis 19%
• B. Cardiovascular disease
• C. Sepsis
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• Liver Transplantation
– The recipients are arranged according to the degree of
illness (coma, encephalopathy, coagulopathy,
pulmonary hypertension)
– MELD: Model for End Stage Liver disease (0-40);
less than 17 = no transplant yet
– Creatinine, bilirubin, INR
– Fulminating liver failure = immediate transplant
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• INDICATIONS OF Liver Tx: Liver failure from: • It could be done with incompatible Blood
• 1) Hepatitis C is common groups (results are mixed) and even in the
e
Th
• 2) Non Alcoholic hepatic steatosis (NAHS) will be the most presence of preformed antibodies.
common
• 3) Alcoholic Cirrhosis
• 4) Sclerosing Cholangitis
• Hyper acute rejection is rare with Liver TX
• 5)Biliary atresia in pediatric patients
• 6)Tumors ? Fibrolamellar carcinoma (Best prognosis) and • Acute rejection occurs in 50%
some Hepatocellular carcinoma Stage I or II A in cirrhosis.
Milan criteria; if resection is not feasible for HCC à liver
transplant is good option for tumors less than 5 cm or 2
• Chronic rejection (vanishing bile duct
tumors 3 cm each. Patient is given a MELD of 22 syndrome) is also common
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• Lung transplantation:
• Most common cause of technical failure in
– Bronchiolitis obliterans is the most common
complication pancreas transplant is
– Most lung transplants are unilateral. • A- Pancreatitis
– In cystic fibrosis Bilateral lung transplant is
needed to avoid infection in the new lung
• B- Arterial thrombosis
• Heart transplantation: Atherosclerosis of the new heart • C- venous thrombosis
coronary arteries is the limiting long term
complication • D- pancreatic duct stricture
• E- acute rejection
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• Pancreatic divisum
Pancreas • Failure of the 2 pancreatic ducts to combine during embryological
development
Benign & Malignant Disorders • Common, but typically asymptomatic
• Most of the pancreas (tail, body and neck) will be drained by accessory small
Ahmed Mahmoud, MD duct
Benign Pancreatitis
• Annular pancreas • Biliary
• May present later in life • Most common. CBD stones.
• Majority resolve (90%) within 5 days
• Duodenal obstruction: double bubble sign • Timing of laparoscopic cholecystectomy
• Treated (by pass) • IOC
• Duodenoduodenostomy • MRCP prior to ERCP
• Impacted stone in 2%
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Pancreatitis
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• Biliary
• 5% develop complications
• Timing of lap cholecystectomy is not related to complications
• Alcoholic, more likely to develop complications
• Metabolic hyperlipidemia, viral, trauma, post op, post ERCP
Pseudo Cysts
• More in alcoholic than biliary
• At least 6 weeks after attack to use the term pseudo cyst
• Acute fluid collection is the term used prior to 6 weeks
pain
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• Complications • Surgical
• Hemorrhage, infection, rupture • >90% success rate
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Puestow Procedure
(Pancreato Jejunostomy) Pancreatic Cysts
• Pancreatic pseudocysts
• Serous cystadenomas
• Mucinous cystic
neoplasms
• Solid pseudopapillary
tumors
• Intraductal papillary
mucinous neoplasms
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• Main duct
• Branch duct
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• Mixed type
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Cystic Neoplasms
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Th
Mucinous cystadenoma Multilocular, well encapsulated smooth margin, body tail of pancreas,
Sixth decade, all female internal septations, (calification (16%) = malignancy)
• Including metastasectomy
Well-encapsulated lesion w/ mixed appearance
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• Premalignant
• Patients: 60-70yo (M=F)
• Non functioning adenoma is the most common
• Imaging (MRCP)
• Main: duct dilation • Insulinoma is the most common of endocrine producing tumors
• Panductal (diffuse) • Insulinoma is mostly benign (90%)
• Segmental • Insulinoma is equally distributed through the glands
• Branched: cluster of
grapes • It is more vascular than all others
• Mixed • In children it is more diffuse and more difficult to treat
• Duct communication • Presents typically with hypoglycemia symptoms; sweating, confusion,
• Fluid Analysis tachycardia
• Mucin • CT scan, no role for OCTERIOTIDE SCAN
• Amylase ↑
• CEA ↑
• Part of MEN I
• Diffuse, more likely metastatic
• Secretin test,
• Localization
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• Individuals with two or more blood relatives, and at least one first-
degree relative, with pancreatic cancer
• Carriers of p16, PALB2, or BRCA2 mutations with a first-degree
relative with pancreatic cancer
• All individuals with Peutz-Jeghers syndrome
• Individuals with Lynch syndrome and a first-degree relative with
pancreatic cancer
• If no mass is evident in the pancreas on CT protocol imaging, EUS is • Tumor abutment to the SMA < 180° of the circumference of the
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intrapancreatic SMV
dissection by removing
specimen from SMV and
SMA
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• Types
• Primary anastomosis
• Vein patch
• Interposition graft
• Saphenous
• Internal jugular
• Right gonadal vein
• Tension free
• Mobilize liver, hilum
• Cattel-Braasch
• Ligate splenic vein
• Impact
• No impact on survival
• 23.4 mo vs 26.5 mo (standard) Tyler DS, Evans DB. Ann Surg. 1994 Feb;219(2):211-21
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Answer 2 References
•C • William Fisher, Schwartz’s Principles of Surgery 11th edition 2019;
• Gastro jejunostomy is not a good option because of the pylorus Pages 1429:1477
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anomalies
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Congenital anomalies
n Polycystic kidney
n Failure of communication between
mesonephros and metanephros
n So the kidney is producing urine that is not well
drained = multiple cysts not draining into the
ureter
obstruction
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Wilm’s tumor
(nephroblastoma)
n Variable histology: Renal tubular adeno myo n Lungs are the most common sites for mets
sarcoma
n Clinically, abdominal mass which does not
n Most common abdominal tumor in children. 80% cross the midline (rarely haematuria)
occur in children < 4 years
n Associated anomalies: Aniridia – Undescended n Treatment:
testis n Surgery (radical nephrectomy)
n Hematuria is rare and late n Post op Radiation if tumor is outside capsule or
n Most important prognostic sign is Histological spillage during surgery
gradingà n Chemotherapy is effective
Renal trauma
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Bladder tumors
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Bladder trauma
n Blunt: 80% extraperitoneal, 20% n Penetrating, always explore, may repair the
intraperitoneal bladder from inside.
n Extraperitoneal à conservative treatmentà
foley catheter
n Intraperitoneal à repaired immediately
n Diagnosis: cystogram (300 cc, AP, Lateral
and post voiding films
Prostate cancer
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Testicular tumors
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Tumor markers
n Most arise from Germ cells, n Alpha feto protein: Elevated in 70% of
n Seminoma or NSGC, when elevated you can rule out
n Nonseminoma germ cell tumor (NSGC) seminoma
n Teratocarcinoma- embryonal-teratoma or n Beta HCG: In choriocarcinoma
choriocarcinoma n LDH
n All spread by lymph, rarely by blood except
choriocarcinoma
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Testicular torsion
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(proliferative) Malignant
Th
n Most occur in women above age of 60 n Cystic ovarian enlargement in young females,< 5 cm
and suspected to be physiological e.g. corpus luteum
n If malignant. the classic is Total abdominal
cyst and follicular cyst are treated by close
hysterectomy + BSO + Omentectomy + observation and US
subdiaphragmatic Scrapping. ? Second look n Premenopausal, benign tumors (benign cystic
laparotomy teratoma, most dysgerminoma) can be treated by
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n In advanced cases, debulking is effective cystectomy = simple excision of the cyst and preserve
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especially if tumors left is less than 3 cm the ovary as long as they are cystic less than 5 cm.
Patient requires children. If postoperative pathology
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masses
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n Perform the original operation.. Splenectomy in n Postmenopausal, solid and more than 5 cm then
ITP unilateral salpingo-oophorectomy
n If Open Cholecystectomy; examine both ovaries, n Endometriosis; chocolate ovarian cyst, painful
look for peritoneal nodules, omentum mets or menstrual cycles
subdiaphragmatic mets n Most respond to hormonal suppression cycles e.g.
n Never TAH +BSO androgens or contraceptive pills
n Premenopausal: nothing else now and return to n Rarely: surgery if there is colon obstruction or
OR later(3-4days). You may also remove the solid intraabdominal bleeding
tumor if less than 5 cm or the cyst , but preserve
the tube and ovary
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n Acute cholecystitis. Try to wait to 2nd trimester n Ruptured is a life threatening emergency
n Recurrence is common with medical treatment n Treatment:
n Lap chole. is safe in 2nd trimester n Salpingostomy if possible
n If not à resection of the tube
n Fetal monitoring during lap chole.
n Tocolytic: Mg, B agonist, Ca blockers
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Q1 CME Answer q1
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n Three years after radical nephrectomy for n C. Resection of lung mets has 40% 5 years
renal cell tumor, patient has 2 lung survival rate
metastatic lesion on right and left lung.
n Best management is:
n A- chemotherapy
n B- radiation therapy
n D- immunotherapy
CME q 2 Answer q2
n C- splenic artery
n D- renal artery
References
Howard Jones and Michael Coburn. Sabiston textbook of
surgery, 20th edition. 2017;2013:2040
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Objectives
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Abdominal Hernias
n GROIN n ANTERIOR WALL
n Inguinal n Umbilical
n Direct n Ventral / Incisional
n Indirect
n Epigastric
n Pantaloon
n Spigelian
n Femoral
n Parastomal
n PELVIC
n POSTERIOR /LUMBAR
n Obturator
n Superior (Grynfeltt’s)
n Sciatic
n Inferior (Petit’s)
n Perineal
n
Inguinal direct and n Slower descent of R testicle
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n Sac contains visceral
peritoneum indirect n Barrier of Sigmoid Colon on L side
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n
n Inguinal n Skin
n Indirect (2/3 – most common) n Subcutaneous Fat
n Direct
n Camper’s Fascia
n Pantaloon
n Scarpa’s Fascia
n Treatment is the same for all of the above n Superficial Vasculature
n Mesh repair n Superior Circumflex Iliac
n Primary repair n Superficial Epigastric
n External Pudendal
Inguinal Anatomy
n Ilioinguinal and Iliohypogastric
n Sensation to groin, base of penis, upper medial thigh
n Pierce internal oblique and run along spermatic cord
scrotum/labia laterally
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Inguinal Anatomy
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Lichtenstein Repair
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n Indications n Advantages
n Bilateral hernias n TAPP vs. TEP
n Recurrent
n Primary?
n Disadvantages
n Complications
n Contraindications
n Learning curve
n Not tolerating GETA
n Extensive PSH(x)
n Radical Prostatectomy
n Triangle of Doom
n Vas deferens, Spermatic vessels, Peritoneum
n Femoral vessels and nerve
n Triangle of Pain / Electrical Zone
n Spermatic vessels, Iliopubic tract, Peritoneum
n Cutaneous nerves in iliac fossa
n Corona Mortis
n b/w obturator and inferior epigastric vessels
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Nam & Brody - Management and Therapy for Sports Hernia Nam & Brody - Management and Therapy for Sports Hernia
J Am Coll Surg: Vol. 206, No. 1, January 2008 J Am Coll Surg: Vol. 206, No. 1, January 2008
R.M. Kirk
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Anterior Hernias
n Umbilical
n Ventral
n Incisional
n Epigastric
n Spigelian
n Parastomal
n Emergent procedures
n CT scan
n COPD
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n Technical issues
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Principles of repair
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No tension
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n Open repair
n Various techniques
n Primary
n Mesh (Stoppa)
n Laparoscopic repair
n Advantages? – Does not violate overlying skin
n Technical concepts
n Overlap
n Tacking
n Fixations
Separation of Components
n Used to decrease tension
on abdominal wall repairs
n Contaminated environment
n Loss of domain
n Can be used along with
mesh
n Biologic
n Technique
n Incision of external oblique
aponeurosis
n Incision of posterior sheath
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n F>M
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n Inferior Lumbar Triangle (Petit’s) n Localized pain with bulge (hernia is behind anterior
fascia)
n Iliac crest, latissimus dorsi, external oblique
n High risk of incarceration – REQUIRES REPAIR
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Congenital Abnormalities
Clinical Scenarios
pediatric
n Gastroschisis n Omphalocele n Patient with infected mesh
n R abd wall defect n 1 in 5000 births
n Enterotomy during repair
n No peritoneal sac n Umbilical ring defect
n Thickened bowel due to n Peritoneal cover n Strangulation and bowel resection
amniotic irritation n 50% have anomalies n Dehiscence with contamination
n Anomalies infrequent n Chromosomal abn.
n Nonrotation (always)
n Loss of abdominal domain
n Liver / GI tract within.
n Post delivery problems n Surgical management
n Fluid loss n Silastic silo
n Surgical management n Closure if < 2cm
Anatomy Anatomy
n Placement of tacks between the vas deferens n Placement of tacks between the vas deferens
and the gonadal vessels during laparoscopic and the gonadal vessels during laparoscopic
hernia repair may lead to: hernia repair may lead to:
n A. testicular atrophy n A. testicular atrophy
n B. hemorrhage n B. hemorrhage (triangle of doom)
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Questions Questions
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During exploratory surgery of the abdomen, an incidental finding During exploratory surgery of the abdomen, an incidental finding
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was a herniation of bowel between the lateral edge of the rectus was a herniation of bowel between the lateral edge of the rectus
abdominis muscle, the inguinal ligament and the inferior epigastric abdominis muscle, the inguinal ligament and the inferior epigastric
vessels. These boundaries defined the hernia as a(n): vessels. These boundaries defined the hernia as a(n):
Questions Questions
The superficial inguinal ring is an opening in which structure?
The superficial inguinal ring is an opening in which structure?
a. External abdominal oblique aponeurosis
a. External abdominal oblique aponeurosis
b. Falx inguinalis
b. Falx inguinalis
c. Internal abdominal oblique muscle
c. Internal abdominal oblique muscle
d. Scarpa's fascia
d. Scarpa's fascia
e. Transversalis fascia
e. Transversalis fascia
References
Kristine Makiewicz. Rush University review of surgery, sixth
edition. 2019;226:235
Thank You
Scott Kizy. Schwatrz textbook of surgery 11th edition.
2019:1549-1570
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GS-W202107ROR Bibliographic Sources
Selected references are listed below. Additional bibliographic sources are provided in the recorded presentations.
Pediatric Tumors
● Ashcraft’s Pediatric Surgery, 6th Ed. Holcomb, Murphy & Ostlie Eds., Elsevier Pub. 2014, Section VII (neoplasms).
● Sabiston Textbook of Pediatric Surgery, 20th Ed., Townsend Ed. Elsevier Pub. 2017, Chapter 66 on Pediatric
Surgery, pp. 1858-1899.
Congenital GI Disorders
● Ashcraft’s Pediatric Surgery, 6th Ed. Holcomb, Murphy & Ostlie Eds., Elsevier Pub. 2014.
● Sabiston Textbook of Pediatric Surgery, 20th Ed., Townsend Ed. Elsevier Pub. 2017, Chapter 66 on Pediatric
Surgery, pp. 1858-1899.
Thyroid Surgery
● NCCN guidelines 2019
● Current Surgical Therapy 12th Ed. 2017 (JL Cameron and AM Cameron, eds) Endocrine Gland Section. pp 767-786.
● Textbook of Complex General Surgical Oncology 2017 (S Morita and C Balch, eds) Endocrine Section. pp 333-386.
Parathyroid Surgery
● Lowney JK, Weber B, Johnson S, et al. Minimal incision parathyroidectomy: cure, cosmesis, and cost. World J
Surg. 2000;24:1442-1445.
● Bilezikian JP, Brandi ML, Eastell R, et al. Guidelines for the management of asymptomatic primary
hyperparathyroidism: summary statement from the Fourth International Workshop. J Clin Endocrinol
Metab. 2014 Oct;99(10):3561-9.
● NCCN guidelines 2019
● Current Surgical Therapy 12th Ed. 2017 (JL Cameron and AM Cameron, eds) Endocrine Gland Section. pp
787-801.
● Textbook of Complex General Surgical Oncology 2017 (S Morita and C Balch, eds) Endocrine Section. pp
333-386.pp 409-416.
Adrenal Surgery
● Fergany AF. Adrenal masses: A urological perspective. Arab J Urol. 2016 Dec; 14(4): 248–255.2016
● NCCN guidelines 2019
● Current Surgical Therapy 12th Ed. 2017 (JL Cameron and AM Cameron, eds) Endocrine Gland Section. pp
749-759.
● Textbook of Complex General Surgical Oncology 2017 (S Morita and C Balch, eds) Endocrine Section. pp 421-454.
Multiple Endocrine Neoplasia
● Wells SA et al. Revised American Thyroid Association Guidelines for the Management of Medullary Thyroid
Carcinoma: The American Thyroid Association Guidelines Task Force on Medullary Thyroid Carcinoma Thyroid Vol
25, No 6, 2015. p567.
● Raval MV, Sturgeon C, Bentrem DJ, et al. Influence of lymph node metastases on survival in pediatric medullary
thyroid cancer. Journal of pediatric surgery 2010;45:1947-54.
● NCCN guidelines 2019
● Current Surgical Therapy 12th Ed. 2017 (JL Cameron and AM Cameron, eds) Endocrine Gland Section. pp
749-759.
● Textbook of Complex General Surgical Oncology 2017 (S Morita and C Balch, eds) Endocrine Section. pp 416-420.
● UpToDate
Sarcoma
● Sabiston Textbook of Surgery, 20th ed. Ch. 33: Soft Tissue Sarcomas
● Pinchus LB and Fox LP. The Stewart–Treves Syndrome. N Eng J Med 2008; 359:950
● Robbins and Cotran Pathologic Basis of Disease. 9th Ed. 2014 (V. Kumar et al., eds) Chapter 26 Bones, Joints and
Soft Tissue Tumors
Thoracic Trauma
● Mattox KL, Moore EE, Feliciano DV. Trauma. 7th Edition. McGraw-Hill. New York. 2013.
● Cameron JL, Cameron AM. Current Surgical Therapy. 10th Edition. Elsevier Saunders. Philadelphia. 2011
Abdominal Trauma
● Mattox KL, Moore EE, Feliciano DV. Trauma. 7th Edition. McGraw-Hill. New York. 2013.
● Cameron JL, Cameron AM. Current Surgical Therapy. 10th Edition. Elsevier Saunders. Philadelphia. 2011
Pelvic Trauma
● Mattox KL, Moore EE, Feliciano DV. Trauma. 7th Edition. McGraw-Hill. New York. 2013.
● Cameron JL, Cameron AM. Current Surgical Therapy. 10th Edition. Elsevier Saunders. Philadelphia. 2011
Gastrointestinal Bleeding
● Rush University Medical Center Review of Surgery, 5th ed, 2011; Chapters 19, 20 and 22.
● Current Surgical Therapy 12th Ed. 2017 (JL Cameron and AM Cameron, eds) Section: The Liver pp. 335- 386
and Section: Portal Hypertension pp.387-426.
● Sabiston textbook of surgery: the biological basis of modern surgical practice. 20th ed., 2017. Chapters 53 and
54 – The Liver and Biliary Systems.