SURGERY VIVA QUESTIONS

A. SUTURES
1. What is the purpose of sutures? Ligation of blood vessels and approximation of tissue
2. how are sutures sized? By diameter, larger the number in front of the 0 the smaller the diameter ie 2-0 has a
larger than a 3-0. The thickness is the opposite, A 1-0 is thicker than a 2-0
3. what are the 3 properties of sutures?
a. absorbable or non-absorbable. What does each mean? Non-absorbable means permanent suture. Absorbable
means that it gets broken down by the body.
b. Whether its braided or mono-filamentous. What’s the advantages and disadvantages of each. With a braided you
have a larger surface area (higher friction co-efficient) per X sectional area, this makes the knot stronger and
more secure. But on the flipside, it also can damage the tissue if some dumb fuck keeps pulling on it. Also, the
higher the surface area will result in more space for bacteria to enter thus possible infection. Mono-filamentous,
harbor less bacteria because there’s less space for the fuckers to enter. Also, when monomers start to breakdown,
they lower the pH of the tissue, making the environment shitty for the bacteria.
c. Whether the suture is natural or synthetic
d. Memory. Monofilaments tend to have more memory/stiffness . Braided sutures have less memory
What’s the problem with natural sutures-(subject to inflammation)

4. How long does a suture need to be in place? Until the wound has adequately healed.
5. how do you know the wound has adequately healed? Its adequately healed when it has enough strength to stand
without a suture. This factor is dependent on where on the body the wound is. Also, some area’s never regain the
same strength they once had ie blood vessels) as a guide :
Suture removal timing :
 Scalp: 6-8 days
 Face, Eyelid, Eyebrow, Nose, Lip: 3-5 days
 Chest and abdomen: 8-10 days
 Back: 12-14 days
 Extremities: 12-14 days
 Hand: 10-14 days
 Condition delaying wound healing: 14 to 21 days eg Corticosteroid use and Diabetes Mellitus

LIDOCAINE
why have adrenaline in it? Reduces the bleeding, it’s a vasoconstrictor
1. whats the deal with lidocaine without epi? This is the lidocaine you use when your anaesthesizing end organs,
digits, and the cock, where the blood supply is via terminal branches. You don’t want to shoot a guys cock up
with lidocaine with epi because the thing will become necrotic and fall off. Not used in ears, nose, fingers, toes,
penis
2. what are the %’s and their breakdown? 2% and 1% EPI and 3% breakdown’s the following

CHEST TUBES AND PNEUMOTHORAX

How do you treat pneumothorax?
Pneumothorax-tube thoracostomy (chest tube insertion)
How do you put in a chest tube?
1. get informed consent
2. administer local anaesthetic
3. its an aseptic technique so clean patient and
4. make an incision in the 4th or 5th intercostals space between the mid and anterior axillary line.
5. dissect with a Kelly clamp
6. explore with finger to confirm your in the intrapleural space
7. place tube within the triangle of safety (above the rib below and below the rib above. Extend it upwards behind
the ascending ribs (posteriorly and superiorly) remember that below each rib is the neurovascular bundle.
8. clamp the tube
9. suture with prolene (purse string) 2 sutures are used
10. connect to water seal
11. unclamp
 how do you know the chest tube is working? –check for oscillations in the water seal
what is the next thing you should do-post insertion CXR to see if has been placed correctly. Look for the break in the
radioopaque line (sentinel eye).

What are the complications of chest tube insertion-damage to the long thoracic nerve which supplies the serratus
anterior (winged scapula) or to the thoracodorsal which supplies the lat dorsi(cant do pull ups)

What is the position of the patient when you insert the chest tube? Depends on whether their conscious or not. If
the patients conscious, they can be sitting upright with their arm fully abducted away from their chest wall. If they
are unconscious then elevate bed, abduct and rotate arm away.

When would you not treat a pneumothorax- if its small less than 25% and the patient is well with no other
concominant conditions

What are indications for a chest tube insertion

1. drainage of pneumothorax greater than 25%
2. drain a hemothorax or large pleural effusion
3. prophylactic treatment for a patient with suspected chest trauma before transport to a specialized trauma center or
+ pressure ventilation
4. empyema
5. chylothorax

what are contraindications

1. Coagulopathy or platelet dysfunction warrants caution.
2. Known or suspected mesothelioma: can extend through the chest wall at
thoracostomy site.
3. Tuberculous effusion: May convert to mixed pyogenic
infection.
4. Known diaphragmatic hernia – caution
5. Severe skin infection

PERFORATED PEPTIC ULCERS

What are complications from a Peptic ulcer?-perforation, bleeding, and obstruction
How does the patient with a perforation present?
What is the diff Dx
What is the initial Mx?
If you could only take one blood sample which one would it be?
What do you do after patient has stabilized?
What treatment modalities are available with endoscopy? If endoscopy doesn’t yield shit what do you do?-if that
is unequivacable what do you do?
What side of the duodenal bulb does the ulcer bleed? Why whats there? What site does it perforate?
What’s a kissing ulcer?
What are operative options for a perfed PU?
What are complications of a perfed PU? Abscess, (subhepatic) infection, and death
What is the diff Dx of an upper GI bleed?
What are the indications for surgery? For an upper GI bleed?
What imaging would you do?
Causes of pneumoperitoneum are? Perfed viscus, and pos laparatomy/laprascopy, intestinal obstruction,
penetrating trauma
 COLOSTOMY
Inidcations;
1. removal of the distal colon and rectum colon
2. to divert faeces to allow healing of an anastomosis or fistula
3. to decompress a dilated colon as a prelude to resection of the obstructing lesion
types of colostomy
1. loop colostomy
2. end colostomy
3. double barreled colostomy

complications of colostomy formation

1. retraction
2. stenosis
3. paracolostomy hernia
4. prolapse
5. lateral space small bowel obstruction

BILIARY
Describe the anatomy and physiology of the biliary tree?
- bile is produced in the liver @ a rate of 500-1500 mL/day by the hepatocytes and the cells of the intrahepatic
ducts. Bile is then stored and concentrated in the gallbladder.
- After bile is produced it is then secreted into the canaliculi which run between the hepatocytes.
- From there bile flows though the canals of hering (interlobular ductules), and then into large collecting bile ducts
which merge to form the Rt. And left intrahepatic ducts.
- Then it flows into the respective R and left hepatic ducts which meet to form the common hepatic duct in the
hilum. The origin of the common hepatic duct is always close to the liver, but never inside its substance.
- It runs approx 4 cm before it is joined on its right side by the cytic duct to form the common bile duct.

Is there a mechanism which allows for bile to directly drain into the gallbladder from the liver?  yes, the ducts of
luschka!

Describe the course of the common bile duct?

- it begins in the hepatoduadenal ligament

what other structures are contained in this ligament?

1. hepatic portal vein
2. hepatic artery
3. common bile duct
- all 3 make up the portal triad

after originating in the hepatoduadenal ligament the CBD runs behind the 1st portion of the duodenum. It then runs in a
groove on the posterior surface of the pancreas before entering the duodenum (in the 2nd part). Its terminal 1 cm is
intimately adherent to the duodenal wall.

What is the length of the CBD?  9cm

- in 80-90% of individuals the main pancreatic duct joins the CBD to form a common channel about 1 cm long.

What are the variations in anatomy of this area and what are they based on?  variation are based on where and how the
cystic duct joins the common hepatic duct to form the CBD. The variations are;
1. low union merger
2. high union merger
3. adherent cystic duct
4. absent of short cystic duct
5. whether the cystic duct spirals around anteriorly to join the common hepatic duct on the left side or
whether it
 6. spirals posteriorly

THE GALL BLADDER

- It is a pear shaped organ which is adherent to the undersurface of the liver in a groove which separates the Rt.
And left lobes. It can hold about 50 mL of bile when fully distended
- This organ has an infundibulum, which is near the cytic duct. It also has a fundus which is at the end of the gall
bladder.
- At the end of the infundibulum is the neck of the gall bladder which tapers into the cystic duct and eventually
merges with the common hepatic duct to form the CBD.
- Internally in the neck, it spirals into a fold called the spiral valve of heister which keeps the cystic duct open so
that bile can easily diver into the gall bladder

BLOOD SUPPLY

to the CBD
7. proximal part of the CBD cystic artery/ and the veins enter the liver directly
8. the middle part of the CBD  the Rt. Hepatic artery
9. the retroduadenal artery  the posterior superior pacreaticoduadenal artery and gastroduadenal artery

- the distal part of the CBD is drained by the posterior superior pacreaticoduadenal vein which drains right into the
portal vein.

To the gall bladderthe cystic artery/ venous drainage is via the cystic vein.

PHYSIOLOGY

OVERVIEW OF THE BILIARY SYSTEM

1. the hepatocytes of the liver synthesize and secrete bile to the common hepatic duct which transfers bile to the gall
bladder.
2. the gallbladder than concentrates the bile by absorbing water and ions
3. when chyme reaches the small intesting CCK is screted and the following occur;
a. contraction of the gallbladder and
b. relaxation of the sphincter of oddi

- this causes stored bile to flow from the gallbladder to the lumen of the duodenum, where bile emulsifies fats.

4. when lipid absorption is complete the bile acids from bile are absorbed through the terminal ileum and
recirculated to the liver by the portal circulation (enterohepatic circulation)

ROLE OF BILIRUBIN
- it is a product of Hb degradation. It is carried in the blood bound to albumin.
- The liver extracts bilirubin from blood and conjugates it with glucoronic acid to form bilirubin glucoronide,
which is secreted into bile.

PATHOGENESIS OF GALLSTONES
- mention smalls triangle and origin of triangle and its meaning.
Mention contents of pigment stones
Most gall stones are cholesterol gallstones (75%). The remaining 25% is pigmented stones.

What is murphy’s sign?

What are complications of acute chole?
1. Empyema
 2. perforation

perforation can take 3 forms;

a. localized perforation with pericholecystic abscess
b. free perforation with generalized peritonitis
c. perforation into an adjacent hollow viscus with the formation of a fistula.

Exam question-why do you place a T-tube in after after CBD exploration?

To allow for decompression of the CBD and encourage healing, it also will allow you to do a post op cholangiogram,
and remove any retained stones 4-6 weeks post op.

What are other indications of a cholangiogram?

UROLOGY

URETHRAL CATHETER

how you will be questioned on the osce with the Uro table is as follows:

they will give you a catheter and ask “what is this”. Your response should be “this is either a two way or three way
foleys self retaining or balloon catheter.”

Another way they could ask this is as follows: they will paint a clinical scenario where the patient comes in MVA or
some other sort of trauma scenario and they will ask how do you establish how much fluid the patient needs?
1. pulse
2. BP and
3. look at urine output (.5 cc/kg/per hour, this is your minimal obligatory urine output per hour)

or they can give you the clinical scenario of an 70 year old who has been unable to pass urine for the last 16 hours. How
do you Mx this patient first ask the examiner if the patient is in pain!! This will tell the examiner whether or not you
have the ability to distinguish between acute and chronic urinary retention. Chronic is painless and acute is painful. Also
one of the ways to confirm if this is chronic retention is to do a U & E’s with creatin and BUN. Why is it important to
establish if the retention is chronic or acute? Because if its chronic Urinary retention and you suddenly decompress the
bladder the patient can go into shock. Plus you develop shering forces in the kidney urothelium which tears and then
bleedshematuria. (everything is dilated like the ureters and bladder and all then all of a sudden it just collapses by
sudden decompression). If its acute you can decompress the bladder right away.

1. complete Hx and P/E including palpation of a bladder which is a dull mass arising from the pelvis (how do you
know its coming from the pelvis you can get below it) and DRE
2. decompress the bladder with catheterization
- if its chronic urinary retention you need to decompress the bladder via controlled release of urine. Declamp every
two hours and allow 300-400 mls to flow, or attach the IV giving set the wrong way and control the knob by
allowing a certain amount of fluid to pass out.

Why would you use a 3 way and what are the different ports for? remember the port that comes out to you is the output
port where you hook up the bag too.

What are the indications of passing a urinary catheter?

1. urinary retention
2. to monitor I/O (in patients who are in shock or in patients who are post-op because they are not ambulating)
what are the indications to pass a 3 way catheter?
1. to irrigate the bladder with saline who are post-turp
- why is it important to wash out blood from a post turp you can get clot retention
2. to wash out patients who have pyuria
you pass a catheter in a patient in clinic and he presents 6 hours later with a pulse of 170 and a bp of 90/50, what do you
suspect?  gram – septicemia
1. admit patients
2. IV fluids
3. antibiotics

What would you do in an elderly male in who is in pain and you cant pass a catheter?
1. call a urologist who’s options are
a. passing a catheter via an introducer (complications of using an introducer is causing a false passage,
which is why this is not in vogue)
b. dilate the urethra via a dilator using a urethral sound (or boggie)
- done under local or general anesthesia

c. you can attempt to dilate endoscopically (using cystoscope, you may be able to pass a guide wire)
d. suprapubic decompression (can be done via general or local anesthetics)
- catheter is introduced into the bladder above the symphisis pubis.

They can even see a big bottle of sorbitol

When is foley catherization contraindicated?  when there is urethral injury

How can you tell if there is urethral injury?
1. presence of a high riding ballotable prostate
2. blood @ the urethral meatus
3. scrotal or perineal ecchymosis

Resectascope?
Complications of TURP? What fluid do you use for irrigation?  sorbitol (know what TURP syndrome is) cant use
water water intoxication, hyponatremia

Common pics, testicular torsion

How do you catheterize? Know what a urine bad looks like.

What are the indications for catheterization-urinary retention and to monitor I/O
What r causes of urinary retention-BPH, stones, urethral stricture
Contraindications-blood at the urethral meatus, high riding prostate, scrotal oedema
What is the difference between 2 and 3 way catheters?
Why would you irrigate?
What are causes of painless haematuria? Its workup?
Which part hooks up to drainage bag?
Which part gets irrigated?
Which French is it?
How do you Dx bladder cancer?
What is urethral sound looks like? Why is it called that?
When do you use it?
Know about urethral strictures?
How can u treat strictures
What is complication of using a urethral sound
Tru-cut->discussion into breast or prostate cancer
How can u stage advanced prostate cancer. Bone scan and x-ray (lumbo-spinal or pelvic) showing osteosclerotic lesions
What are some causes of high PSA?
What are complications of BPH?

THE OESOPHAGUS

What is it?  it is a muscular conduit for the passage of food and liquids from the pharynx to the stomach.

Where does it arise from?  from the level of C6 posterior to the cricoid cartilage

Describe the course of the oesophagus.  it runs posterior to the arch of aorta and left bronchus, enters the abdomen
through the oesophageal hiatus of the diaphragm, and terminates in the cardia of the stomach.

What are the 3 areas of anatomical narrowing? 

4. @ the level of the cricoid cartilage pharyngeoesophageal sphincter
5. the mid thorax as it gets compressed by the arch of aorta and the left bronchus
6. @ the level of the esophageal hiatus of the diaphragm aka the gastroesophageal sphincter

What is the blood supply to the esophagus?

A. the upper end
1. inferior thyroid arteries

B. the thoracic portion receives elements from

1. the bronchial arteries
2. esophageal branches originating directly from the aorta
3. the intercostals arteries may also contribute

C. the diaphragmatic and abdominal segments

1. the left inferior phrenic artery
2. esophageal branches of the left gastric artery

what is the venous drainage of the esophagus?  the only important thing you need to know is that the venous drainage
of the lower end of the esophagus drains into tributaries of the portal system (gastric veins?). Thus, portal hypertension,
or when the portal system is obstructed such as in liver cirrhosis, this can cause a back flow of pressure reaching all the
way back to the lower end of the esophagus leading to esophageal varices and thus upper GI bleeding.

What is the nerve supply of the esophagus?  the vagus nerve as it runs with it.

What are the functions of the UES and the LES?

UES swallowing
LES prevention of reflux from the stomach

What is the length of the esophagus?  approx. 25 cm in the adult

What is the muscle type in this organ?

1. upper third skeletal muscle
2. middle third  smooth muscle > skeletal muscle
 3. lower third smooth muscle

why is the esophagus notorious for leaks?  because it has no serosa like the rectum

OESOPHAGEAL MOTILITY DISORDERS

What are the oesphageal motility disorders?

e. achalasia
f. nutcracker esophagus
g. diffuse esophageal spasm
h. hypertensive lower esophageal sphincter
i. nonspecific esophageal motor disorder

DIFFUSE ESOPHAGEAL SPASM

What is it?  strong non-peristaltic contractions of the esophagus

How does it present?  intermittent chest pain that mimics angina pectoris. The pain may radiate to the back, ears, neck,
jaw, or arms. Many patients complain of dysphagia also.

How is it diagnosed? 
a. manometry is the key to Dx. In the patient who swallows it shows simultaneous non-peristaltic
contractions instead of normal peristaltic waves. LES function may or may not be normal in response to
the swallowing. In nutcracker esophagus the abnormality is high amplitude peristalisis.
b. An upper GI (esophagram) may show a “corkscrew esophagus” (segmented esophageal spasms).

What is the differential Dx?

1. angina pectoris
2. nutcracker esophagus
3. achalasia
4. hypertensive LES
5. nonspecific esophageal motor disorder
6. GERD

Tx
- is medical and in patients who are refractory to medical Tx long esophagomyotomy

medical Tx
1. antireflux measures
- change in diet (soft diet, taken as 5-6 small meals daily)

2. Calcium channel blockers, nitrates (long acting like hydralazine), anticholinergics

ACHALASIA

What is it? 
a. failure of the LES to relax during swallowing and
b. a loss of esophageal peristalisis

why does it happen? ganglionic degeneration of Auerbach’s myenteric plexuses, the degeneration may be due to an
infectious agent (virus, herpes zoster). This infectious theory is supported by the fact that similar findings occur in
Chagas’s disease in South America.

What is chagas’s disease?  a condition in where an infectious organism destroys parasympathetic ganglion cells
throughout the body, including the heart, GI, Urinary, and resp. tract.
How does the patient present?
j. dysphagia for both solids and liquids. In achalasia dysphagia for liquids starts first.
k. followed by regurgitation
- regurgitation of retained esophageal contents occurs @ night while the the patient sleeps in a recumbent
position.

l. aspiration
- can lead to repeated bouts of pneumonia

how is Dx made?
A. A barium swallow shows a characteristic “birds beak appearance”. This demonstrates
1. narrowing @ the cardia with a filling defect
2. proximal dilatation and a tortuous esophagus.

5. Manometry
- shows and increase of pressure in the LES (almost twice of normal) and
- failure or incomplete relaxation of the LES during swallowing.

6. esophagoscopy
- should be done to R/O other intraluminal lesions and to take an actual biopsy specimen, because
remember prolonged exposure to carcinogens in food retained in the dilated portion of the esophagus is
thought to cause inflammation and metaplasia with later development of dysplasia and cancer. The type
of cancer that develops is squamous cell carcinoma.
- During esophagoscopy the scope can be advanced through the narrowed sphincter without increased
force, this feature distinguishes achalasia from carcinoma of the esophagus.

What are the features of achalasia on plain X-ray?

a. widening of the mediastinum
b. absence of the gastric bubble (because no air is getting down to the stomach to produce a bubble you
dipshit!)
c. fluid level in the chest (the esophagus has the fluid level instead of the chest)
d. may see evidence of aspiration pneumonia.

Tx.

i. fogerty balloon tip dilatation of the LES

- usually 2-4 dilations with balloons are needed to obtain desired results based on symptoms and
manometric pressure results.
- a successful dilatation is associated with an immediate 60% decrease in LES pressure. Thus after
dilatation most patients experience immediate relief. But long term results are good in only 50% of
patients. The remaing suffer from persistent dysphagia or reflux esophagitis.
- Esophageal perforation, complicates 7 % of cases. Thus its important to keep the patient overnight in the
hospital for observation. Also these patients should be scheduled for endoscopy afterwards
- Dilatation is contraindicated in patients with advanced achalasia with megaesophagus, because of the
higher risk of perforation.

ii. extramucosal cariomyotomy aka Heller cardiomyotomy

- can be performed via a thoractomy, open lap, and laparoscopically.
- The lower end of the esophagus is exposed by one of these aforementioned methods and the muscle is cut
longitudinally so that the ring of tight muscle that causes the increased pressure @ the LES is broken.

What does myotomy mean? Its when a you cut into a muscle to gain access to an underlying structure or to relieve
constriction in a sphincter.

iii. botulium toxin

 - inhibits cholinergic excitation activity @ the LES and stops spasm & relaxes muscle thus allowing free
flow.

What is the long term implication from achalasia?

1. carcinoma of the esophagus and
2. Barrett’s esophagus

OESOPHAGEAL PERFORATION

What are the causes of esophageal perforation?

1. iatrogenic
a. balloon dilatation
b. endoscopy

2. severe vomiting
3. external trauma

what determines the clinical manifestations?  site of the perforation (ie cervical or thoracic), and in the case of thoracic
perforations, whether or not the mediastinal pleura has been ruptured.

What are the most common sites of perforation?  instrumental perforations are most likely to occur in the cervical
esophagus as the esophagoscope presses the posterior wall against the osteoarthritic spurs of the cervical vertebrae,
causing contusions and lacerations. The cricopharyngeal area is the most common site of injury.
If injury occurs in the thoracic region, the most common sites of perforation are in the sites of anatomical narrowing.
Ie the diaphragmatic hiatus, the level of the aorta and left bronchus.

What is Boerhaave’s syndrome?  it is spontaneous perforation of the esophagus

- it occurs mostly in the absence of pre-existing esophageal disease
- but 10% of patients have reflux esophagitis, esophageal diverticulum, or carcinoma
- most cases follow a bout of heavy eating and drinking. Excessive retching and vomiting increases
intraluminal pressure and causes a tear in the lumen.
- The tear usually involves all layers of the esophageal wall and most requently occurs in the left
posterolateral aspect just above the gastroesophageal sphincter.
- The overlying pleura is also involved resulting in a mediastinitis from contamination with esophageal
contents.

How does the patient present? as stated earlier, the clinical manifestations are dependent on the site of perforation. The
Hx although will reveal one of recent instrumentation of the esophagus, or severe vomiting and of course pain. The site
of pain is dependent again on the site of perforation.

Cervical perforations:
- early manifestation is pain which is felt in the neck.
- This is followed by dysphagia, crepitus in the neck, subcutaneous emphysema, and gradually developing
signs of infection

Thoracic perforations
- pain in the chest or upper abdomen. The pain may radiate to the back.
- If the thoracic perforation communicates with the pleural cavity (which occurs in about 75% of cases).
The following occur
a. tachypnea
b. hyperpnea
c. dyspnea
d. and the early development of hypotension
this can also result in a pneumothorax, followed by a hydrothorax and if not promptly treated an empyema.

What are the features of perforation on X-ray?

Cervical perforation
1. air in the soft tissues (especially along the cervical spine)
2. anterior displacement of the trachea by air and fluid
3. widening of the superior mediastinum

thoracic perforations
1. mediastinal widening
2. pleural effusions with or without pneumothorax
3. mediastinal emphysema

what investigation should every patient suspected of having an esophageal perforation have?  an esophagram/ studied
in both the decubitus and erect position. If a leak is not seen the examination should be done with barium.

How can you tell how much time as passed since the perforation has occurred?  thoracocentesis will show either a
cloudy or purulent fluid depending on the time frame.

Tx of perforation depends on the size of the perforation.

A. small perforations that have been diagnosed early (ie perforations occurring during endoscopy), Tx can be
conservative
1. NPO
2. antibiotics
3. IV fluids and nutrition

B. if the perforation is large then  open thoracotomy and repair (closure of the perforation and external drainage)

-Primary repair has a high failure rate if the perforation is older than 24 hours! And the survival rate drops from 90% (if
repair occurs before 24 hours) to 50% when Tx is delayed beyond 24 hours.
1. patients with achalasia in whom perforation has resulted from balloon dilation of the lower esophageal
sphincter should have the tear in the esophagus repaired and a Heller myotomy performed on the opposite side.
Also definitive therapy should be performed in patients with other surgical conditions ie carcinoma.
2. for patients who have a perforation that is older than 24hours there are two options.
a.
- isolate the perforation by performing a temporary cervical esophagostomy which would minimize contamination
- ligate the cardia
- construct a feeding jejunostomy

or you can

c. resect the site of the perforation bringing the proximal end of the esophagus out through the neck and close the
distal end.
- the mediastinum is then drained and a feeding jejunostomy is created.
- Later the esophagostomy is taken down and the colon interposed to bridge the gap at the site of resection.

OESOPHAGEAL CARCINOMA

What are the two types of esophageal carcinoma?

1. squamous cell carcinoma
2. adenocarcinoma

what is the most common site of esophageal carcinoma?

1. the lower third of the esophagus (50% of cancers arise there)
- the next two are
- the middle third (30%)
- the upper third (20%)
what are predisposing factors to esophageal cancer?
1. tobacco
2. alchohol
3. GE reflux
4. Barrett’s esophagus (metaplasia of normal squamous epithelium to columnar epithelium as a result of chronic
irritation from reflux.

What are the common sites of spread of esophageal cancer?

1. lungs
2. liver
3. adrenal
4. bone

how does it spread?

1. direct extension to adjacent structures
2. lymphatic spread
3. hematogenous spread

how does the patient present?

A. There are symptoms related to the esophagus

1. dysphagia
2. pain whether its constant or odonophagia
3. regurgitation and aspiration, especially @ night when patients is recumbent
4. coughing related to swallowing is indicative of either a high lesion or a tracheoesophageal fistula
5. hoarseness (spread to the recurrent laryngeal nerve)

B. systemic symptoms
1. anemia
2. loss of apetite
3. weight loss
4. chest pain
5. back pain
6. inanintion (an exhausted state resulting from starvation)

what is the work up to a patient?

1. esophagoscopy with biopsy
- provides an accurate tissue Dx in 95% of cases
- however in many instances the mucosa proximal to a very stenosed lesion may not be visible because of
the level of edema and inflammation. In this case esophageal washings or brushings should be taken for
cytology.

2. Bronchoscopy
- to check for adjacent spread
3. Barium swallow
- can show two common types of cancer (fungating or annular)
- a Barium swallow narrowing of the esophageal lumen at the site of the lesion and dilation proximally
(although not to the degree as would be seen in achalasia)
- remember the characteristic “shelf” sign

4. transesophageal ultrasound
- shows the depth of penetration and mediastinal invasion

5. CT scan of chest and abdomen

- to check for metastasis to the lung, mediastinal lymph nodes, and liver.
 6. CXR
- can show a pleural effusion, lung abscess
- a column of air in the esophageal lumen, absent in a normal esophagus may be visible on plain films
- an air fluid level may also be present.

7. bone scan

Thus the workup overall will be

1. barium swallow to localize the lesion
2. ESG to obtain a biopsy and assess respectability
3. full metastatic workup
a. LFT’s
b. CXR
c. CT scan of chest and abdomen
d. Bone scan

What is the differential Dx?

1. achalasia
2. metastatic tumor
3. benign stricture
4. GORD

What are the complications of esophageal cancer?

- the most common complications result from invasion of important mediastinal structures such as
a. the tracheatracheal obstruction or traceoesophageal fistula
b. major bronchiaspiration, purulent bronchitis, or a pulmonary abscess
c. pericardium  cardiac dysrhythmias

Tx.

Tx for esophageal cancer is surgery, radiotherapy, and chemotherapy, or a combination of these methods. As long as the
patient is a suitable candidate for major surgery and distant organ metastases are absent, the primary tumor should be
resected if possible. If life expectancy is longer than a few months, resection is usually recommended regardless of the
chance for cure, because it provides the best palliation.

What determines whether or not a lesion is respectable or not?  non-resectability is suggested by

a. direct spread to the tracheobronchial tree or aorta as seen on bronchoscopy or CT scan, or
b. by noting the angulation of the esophageal axis.
c. The presence of a tracheoesophageal fistula and vocal cord paralysis

For patients in whom resectability is possible:

A. In patients where there is no involvement of the trachea, bronchi, and aorta

- esophagectomy can be performed without a thoracotomy through simultaneous abdominal and cervical
incisions. The esophagus is resected, and the stomach is brought up to the cervical esophagus through the
posterior mediastinum.

B. for tumors of the lower third of the esophagus

- most surgeons prefer to perform the resection through a laparotomy followed by a right thoracotomy.
- The resection should include
a. the celiac lymph nodes
b. left gastric vessels
c. the stomach proximal to the left gastric artery
d. the lower esophagus to a point above the azygous vein.
 - a pyloroplasty is performed and the site of gastric transection is closed.
- The stomach is pulled up into the chest and an esophagogastrostomy is performed at a convenient spot on
the anterior surface of the gastric remnant.
- The spleen in preserved in patients squamous cell carcinoma, but should probably be removed in those
with adenocarcinoma.

C. for tumors of the middle and upper thirds of the esophagus

- the esophagectomy should extend to the cervical esophagus, and the anastomosis should be performed
through a separate (third) incision in the neck.
- Whenever possible, at least 10cm of grossly uninvolved esophagus should be resected proximal to an
esophageal cancer. This is to prevent the incidence of reoccurance.

NON-RESECTABLE CANCERS
- if the patient can withstand a major surgery, then patients are best treated with a preliminary substernal
gastric bypass with a cervical esophagogastrostomy.
- Post-operatively the patient can be treated with radiotherapy and chemotherapy.

ESOPHAGEAL HIATAL HERNIAS

What are the types?

1. type 1 aka sliding esophageal hiatal hernia (90% of cases)
2. type II aka paraesophageal hiatal hernia ( less than 5% of cases)

A. Type I aka sliding esophageal hiatal hernia

What is it?  results from herniation of the fundus of the stomach and GE junction through the esophageal hiatus into the
lower thorax.

- normally the competency of the LES is a function of the high intra-abdominal pressures. When the GE
junction and fundus herniates into the thorax, the LES will no longer be exposed to the high external
pressures found in the abdomen but will be exposed to a different set of pressures found in the thorax,
thus resulting in incompetence of the LES and reflux.

How does the patient present? Many of them are asymptomatic and require no treatement, but for those that do present
with symptoms, the patient can present with:

1. retrosternal or epigastric pain (heartburn) that is burning in nature

- the pain is occurs while eating and while sleeping or lying in a recumbent position.
- The distress is partially or completely relieved by drinking water or other liquids, antacids, or in many
instances, by standing or sitting.
- Patients may complain that the relux reaches all the way to the throat or mouth when supine. (taste of
bitter or sour tasting fluid)

2. dysphagia
- results from inflammatory edema (stricture formation) in the lower esophagus.

3. pulmonary symptoms as a result of aspiration

- wheezing and dyspnea

what is the differential Dx?

1. angina pectoris
2. GERD
3. peptic ulcer disease
4. achalasia
INVESTIGATIONS:

1. UPPER GI SERIES
- to demonstrate reflux

2. esophagoscopy
- can visualize the actual herniation and the presence and degree of esophagitis.
- A biopsy can also be taken

What are the complications associated with a sliding esophageal hiatal hernia?  refluxesophagitisbarrett’s
esophaguscancer and stricture formation. It can also result in Upper GI bleeding from esophageal ulcerations, and of
course aspiration pneumonia

Tx: is either medical or surgical

A. medical Tx
1. diet and lifestyle changes
a. diet (meals low in fat and high in protein increase LES tone and decrease reflux.)
b. frequent small meals keep gastric contents neutralized and avoid gastric distention.
c. Every effort should be made to enlist the aid of gravity in preventing reflux at night. The patient should
not lie down after meals and should not eat a late meal before bedtime. Also, the patients head should be
propped up by pillows to keep it elevated.

2. H2 receptor blockers/PPI’s
- omeprazole is substantially better than cimetidine or ranitidine, achieving complete remission of
symptoms and healing of esophagitis in 80-85% of patients. The problem with these drugs is that
reoccurance occurs because they do nothing to improve LES pressure of esophageal peristalisis.

B. surgical Tx
1. Nissen’s fundoplication (involves wrapping the fundus around the LES and suturing it in place)
- can be done laparoscopically
- provides relief in the majority of patients. (up to 90%)

PARAOESAPHAGEAL HIATAL HERNIA

What is it?  aka type II esophageal hiatal hernia. Results from herniation of all or part of the stomach into the thorax
(adjacent and left to the non-displaced GE junction) through the esophageal hiatus. The GE junction is intact and non-
displaced.
How does the patient present?
- heartburn is uncommon. Mostly the symptoms result from pressure phenomena caused by enlargement
of the herniated gastric pouch by food displacing the fundic air bubble. These symptoms include a sense
of pressure in the lower chest after eating, and occasionally palpitations due to cardiac dysarrythmias.
- These hernias can also be asymptomatic

What are the complications associated with type II hernias?

1. hemorrhage
2. incarceration
3. obstruction
4. strangulation

Tx.
- anterior gastropexy (returning the herniated stomach to the abdomen and fixing it there by sutures to the
posterior rectus sheath. The enlarged hiatus is closed snugly around the GE junction with interrupted
sutures.)
 ESOPHAGEAL ATRESIA WITHOUT TOF

How does the patient present?

1. excessive salivation (swallows saliva but it goes right into a blind pouch)
2. cant put down any food thus they are regurgitating what they put down

these symptoms appear shortly after birth.

How does the infant with a TOF present differently to the without a TOF?
- these fuckers will have signs of respiratory compromise and maybe aspiration pneumonia!
- But before even this you should know something fishy is up because they will cough or choke when they
eat food or take in liquids.

What are the signs of CXR of esophageal atresia without TOF?

3. coiled up NG tube
4. absence of a gastric air bubble

What is the initial Tx of esophageal atresia without TOF?

1. IV fluids since the patient can’t put any food substances down.
2. sump suction catheter should be placed in the upper esophageal pouch and the head of the bed should be elevated.
3. gastrostomy to drain stomach if prolonged pre-operative esophageal stretching is planned
4. Tx any aspiration pneumonia before embarking on surgery
5. place baby in a humidified incubator turning the infant from side to side every hour
6. stimulate baby to cry and cough.

PANCREATIC PSEUDOCYST

What is it?  it is an encapsulated collection of pancreatic fluid. It is not a true cyst as it has no epithelial cell lining but
it’s wall is formed by inflammatory fibrosis.

Why do they occur?  in response to chronic alcoholic pancreatitis mostly. Other causes are:
1. severe acute pancreatitis (pseudocysts occur in 2 % of cases as complications)
2. trauma to the abdomen

where do the cysts occur?  when they do occur they occur mostly as single pseudocysts (85%), and the remaining occur
as X pseudocysts. They are mostly found in or around the pancreas in the lesser sac, but they have also been known to
pop up in
1. the neck
2. mediastinum
3. pelvis

how does a patient with a pseudocyst present?

The Hx will show a patient who with acute pancreatitis fails to recover after a week of Tx or when, after improving for a
time, symptoms reappear. The patient will complain of the following:
1. epigastric pain
2. fever
3. weight loss
4. vomiting
5. a few patients may have jaundice which is a manifestation of the intrapancreatic segment of the bile duct
O/E
The patient will be febrile and in pain. He/she may also be dehydrated if the vomiting is severe (if the cyst becomes
infected  high fever and marked vomiting). The patient may also present with symptoms of shock if there is
hemorrhage into the pseudocyst.

- MM may be pale and dry (from the dehydration and anemia of infection and hemorrhage respectively).
- A palpable mass in the epigastrium which is tender may be found.

Investigations:
1. CBC with differential
2. LFT’s
3. U &E’s
4. group and X match
5. serum amylase
6. abdominal U/S (will show a pseudocysts but wont give much info on it)
- It is a better study to monitor the size of the pseudocyst after its been already imaged by CT scan so that
the amount of X-ray exposure is kept to a minimum.
- Can show the presence of a gallstone (biliary cause for the acute pancreatitis which lead to the pseudocyst
formation)

7. CT scan
- it is the Dx test of choice
- shows a fluid filled cavity
- shows the size and shape of a cyst
- can tell you if it’s an acute or chronic pseudocyst by the shape  acute are irregular while chronic are
regular
- can also demonstrate the relationship of the cyst to adjacent viscera

8. ERCP
- if the U/S shows the presence of gallstones in the gallbladder and the U/S and CT scan both show a
dilated CBD ERCP with sphincterotomy to remove the stone
- if there is marked obstruction and the scope is ineffective  MRCP can also be used

what is the differential Dx?

1. pancreatic abscess (these patients have higher swinging fevers)
2. neoplastic cyst cystadenoma or cystadenocarcinoma
- account for 5% of all cystic pancreatic masses and may be indistinguishable preoperatively from the
pseudocyst.

What are the complications of a pseudocyst

1. infection (very rare)
- can be drained externally by a catheter placed percutaneously via ultrasound guidance

2. hemorrhage
- bleeding can occur into the cyst or an adjacent viscus in which the cyst has eroded into.
- If its intracystic the abdominal mass will grow in size, and if the cyst eroded into the stomach, there may
be hematemesis, melena, and blood in the NG aspirate.
- If patient stable  arteriography and embolization of the bleeding vessel
- If patient unstable emergency laparotomy, open the cyst and suture ligate the bleeding vessel in the
cyst wall. Then external and internal drainage of the cyst. If possible excise the cyst also as this avoids
the risk of recurrent hemorrhage.
 3. perforation
- very rare as it occurs in less than 5% of cases, but even with prompt treatment it can be very fatal.
- Sudden perforation into the peritoneal cavity results in a severe chemical peritonitis with board like
abdominal rigidity and severe pain.
- Tx is emergency surgery with irrigation of the peritoneal cavity and a drainage procedure for the
pseudocyst.

Tx
- Tx can be either expectant Tx or surgical intervention.

When is expectant Tx warranted?  most pseudocysts that occur because of acute pancreatitis tend to spontaneously
resolve. If after 6 weeks the cyst persists and its size is greater than 5 cm in DMsurgery is needed (internal drainage)

Internal drainage is the preferred method where the cyst is anastomosed to either
a. a roux-en-Y limb of the jejunum (cystjejunostomy)
b. the posterior wall of the stomach (cystgastrostomy)if cyst adherent to stomach
c. to the duodenum (cystduodenostomy) if cyst adherent to duodenum

- the interior of the cyst should be inspected for evidence of a tumor and a biopsy should be taken to R/O a malignant
cyst.

External drainage
- is best suited for critically ill patients
- has a high cyst reoccurance rate
- a large tube is sewn into the cyst lumen and its end is brought out through the abdominal wall.
- External drainage is often complicated by a pancreatic fistula that sometimes requires surgical drainage

Nonsurgical drainage
- is done by a percutaneous catheter placed into the cyst under radiographic or U/S guidance.
- Preferred method in cases of an infected cyst
- Can also be used to shrink a massive cyst

PANCREATIC ABSCESS

- It is an infected perpancreatic purulent fluid collection.

- It develops as a complication of acute pancreatitis, and as post-op complication to surgical treatment of
acute pancreatitis
- The organisms isolated mostly are gram –‘s ie E.Coli, klebsiella, pseudomonas, and gram +’s like staph
aures
How does the patient present?

- an abscess should be suspected when a patient with severe acute pancreatitis fails to improve and
develops a rising fever or when symptoms return after a period of recovery. The patient will present with
a. epigastric pain and tenderness
b. fever
c. and a palpable mass that may be tender.

Dx is made via
1. Leukocytosis on CBC
2. CT scan is Dx as it shows a fluid collection in the area of the pancreas.
- percutaneous aspiration via CT guidance can be used to obtain a specimen for gram stain and culture.

Tx
- percutaneous catheter drainage as a first step in order to decrease toxicity and then surgical debridement
of necrotic debris within the retroperitoneal space.
 ADENOCARCINOMA OF THE PANCREAS

- pancreatic cancer is adenocarcinoma of the pancreas

where do the adenocarcinomas arise from?

1. ductal cells (80-90%) and the rest are
2. cystadenocarcinomas and
3. islet cell tumors
4. acinar cell

where are the cancers located?

1. 2/3 of cases are in the head of the pancreas and the rest are
2. in the body and tail

Risk factors include

1. smoking
2. high fat, high protein diet (fried foods)
3. heavy alcohol use
4. chronic pancreatitis

males tend to get it more 3:2

in western culture blacks tend to get it more 2:1

- the peak incidence is in the 5th and 6th decade of life.

How does the patient present?  presentation is dependent on the location of the tumor!

Cancer of the head of the pancreas

The Hx will reveal a patient who is suffering from relentless jaundice (in contrast to CBD stones), in addition to other
signs and symptoms of obstructive jaundice. There is also abdominal pain that is deep seated. One characteristic feature
of the pain is the tendency for the patient to seek relief of pain by assuming a sitting position with the spine flexed.
Recunbency, on the other hand, aggravates the discomfort and sometimes sleeping becomes impossible. Back pain can
also occur in 25% of patients and is an indicator of a worse prognosis (unresectability). The patient will also complain of
significant weight loss. There may be a sudden onset of DM in 25% of patients.

On PE
Inspection
- the patient is jaundiced and cachetic looking

palpation

- supraclavicular nodes
- a palpable non-tender mass may be felt in the RUQ. (couvoisier’s sign a palpable non-tender gall
bladder in a jaundiced patient is not due to a stone but can suggest neoplastic obstruction)
- hepatomegaly
- sister mary joseph nodule
- ascites may be present

how does this differ from cancer of the body and tail?
- since the body and tail are away in anatomic location to the bile duct jaundice doesn’t really occur with
this type of cancer.
 - Thus the chief complaints are abdominal pain which can be vague and weight loss.
- Some patients may have migratory thrombophebitis but this occurs in about 10% of patients.
- Supraclavicular nodes are present also here
- Sister mary joseph nodule
- Ascites may be present

Differential Dx?
- any periampullary tumor

1. pancreatic cancer
2. CBD cancer
3. duodenal carcinoma
4. cancer of the ampulla of vater

investigations:

1. CBC- check WBC if there is evidence of infection

2. LFT’s (elevated total bilirubin and Alk phosp)
3. CA 19-9, and CEA
4. PT/APTT (coagulopathies if the CBD is obstructed)
5. CT scan
- CT scan show you a shit load. It can show you
a. a pancreatic mass with a central zone of diminished attenuation
b. extension beyond the boundaries of the pancreas
c. dilation of the upstream portion of the pancreatic duct
d. dilation of the bile duct
- the presence of both c and d strongly suggests evidence for pancreatic cancer even in the absence of a
mass
e. findings suggesting unresectability

which findings on CT scan show unresectability?

1. local tumor extension ie behind the pancreas into the liver hilum
2. contiguous organ invasion ie stomach or duodenum
3. distant met
4. involvement of the superior mesenteric or portal vessels
5. ascites

If CT doesn’t show a mass or ductal dilation ERCP

- ERCP should also include a pancreatogram.
- In pancreatic cancer pacreatogram findings consist of stenosis or obstruction of the pancreatic duct.
- Adjacent elsions of the bile duct and pancreatic duct (double duct sign) are highly suggestive of a
neoplastic disease.

UPPER GI series is indicated not to detect pancreatic cancer but to assess the patency of the duodenum that may be
useful in deciding whether a gastrojejunostomy can be performed.

Aspiration biopsy- done as percutaneous aspiration biopsy of the pancreatic mass

- it is contraindicated in patients who are suitable for surgical resection
- this procedure should only be done on patients in whom CT scan indicates unresectability

surgical Tx

A. for resectable head of the pancreas tumors whipple procedure

what is a whipple procedure?  pancreaticoduodenotomy

it entails
1. cholecystectomy
 2. truncal vagotomy
3. anterectomy
4. the pancreaticoduodenotomy (remove the head of the pancreas and the duodenum)
- why do you take out the duodenum?  because the head of the pancreas shares the same blood supply
with it
5. choledojejunostomy- connect/anastomosis the CBD to the jejunum
6. pancreaticojejunostomy- connect/anastomosis the distal pancreas to the jejunum
7. gasrojejunostomy-connect the stomach remanant to the jejunum

B. for resectable tumors of the body or tail?  distal resection

C. for non-resectable tumors

- need to provide relief from jaundice and pruitis, thus
1. cholecystojejunostomy
2. choledocholejejunostomy
- both with a gastojejunostomy

a preop cholangiogram should be done beforehand to assess the patency of the cystic and CBD. If they are not patent a
percutaneous or endoscopic placement of a biliary stent can solve the problem.

CHRON’S DISEASE

How does the patient with CD present?

1. vomiting
2. recurrent abdominal pain

DIVERTICULAR DISEASE OF THE COLON

Make sure you look at a double contrast BE for diverticular disease cause that shit’s coming up on the surgery osce!

Encompases two disease entities:

1. diverticulosis
2. diverticulitis

DIVERTICULOSIS:

what is diverticulosis?  the presence of X false diverticula in the colon.

What is a diverticula?  it is an outpouching of mucosa and submucosa which herniates through the bowel wall.
Herniations occur at pts. Of structural weakness where nutrient blood vessels penetrate the circular muscle layer.
Increased intraluminal pressure causes the outpouching.

What is the most common site of diverticulosis?  the sigmoid colon

Risk factors include:

1. low fiber diet
2. + family Hx
3. the elderly (50-60 % of individuals develop diverticula by age 60)
4. person’s who suffer from chronic constipation

how does the patient with diverticulosis present?  most (80%) are asymptomatic and those who do present, do so
because of complications.

What are the complications?

1. diverticulitis
 2. bleeding

so, how does the patient present?

1. the patient can be bleeding per rectum (the bleeding can be massive in some cases)
2. the patient can have diverticulitis.

What is the Dx approach to these patients?  depends on how they present?

1. bleeding patients without signs of inflammation colonoscopy!

2. bleeding patients with signs of inflammation stop the bleeding first, then abdominal or pelvic CT scan. BE or
colonoscopy can be done 6-8 weeks later when the inflammation has subsided.

Tx of asymptomatic diverticula high fiber diet

When do you operate in a patient with diverticulosis? when it becomes diverticulitis and results in any of the
complications of diverticulitis.

DIVERTICULITIS

What is it?  infection or perforation of a diverticulum. With either mechanism only 1 diverticulum is involved @ a
time.

When do symptoms occur?  not with infection of 1 diverticulum, but when the infection spreads to the peridivertiucular
tissues.

When and how does perforation occur?  perforations can be either

1. microperforation  a fecalith obstructs and divertiuculaleads to
inflammationmicroperforation
2. macroperforationleads to either
a. generalized peritonitis or
b. abscess formation which can form a fistula or itself burst leading to generalized peritonitis.

What are the fates of an abscess resulting from a diverticulum that undergoes macroperforation?
1. regress with antibiotic therapy
2. be contained by adjacent structures
3. enlarge and drain spontaneously into adjacent viscous to form a fistula, or into the lumen of the bowel
4. rupture and caused generalized peritonitis
5. become a chronic abscess

how does the patient with diverticulitis present? It is important to realize that an acute attack of diverticulitis may be
asymptomatic and that it’s the complications that can cause a patient to go seek help.

PC- abdominal pain

Hx of PC-
- the abdominal pain is located most frequently to the LLQ (resembles acute appendicitis only that its in
the opposite LQ)
- pain is mild to severe and can be either steady to cramping
- farting relieves the pain
- the patient also complains of associated constipation or an increase in defecation
- nausea and vomiting may be present dependent on the degree of inflammation
- if the inflammation is adjacent to the bladder than dysuria is present.
- The patient complains of a fever
Sometimes these fuckers can present in a worser scenario ie  generalized peritonitis due to perforation. Or swinging
pyrexia due to an abscess.

Investigations
 1. CBC looking at the WBC’s
2. AXR can show free abdominal air if perforation has occurred. It can also show if there is any evidence of
obstruction.
3. Contrast CT scan- initial imaging study of choice. The contrast can be either IV or oral

What can a contrast CT scan show?

1. effacement of pericolic fat
2. abscess or fistula
- the advantage with an abscess is that the CT can also show you if it is accessible for percutaneous
drainage.
- Disadvantage of the contrast CT is its findings are non-specific in cases of perforation and that a BE and
or colonoscopy needs to be done (when the inflammation has subsided)
- If your doin a BE, barium is contraindicated in cases of acute infection, because if the barium leaks into
the peritoneum peritonitis. But, water soluable contrast is safe and can be used.

How long should you wait to do the BE and what are its associated findings?  BE should be done when the
inflammation has resolved, after 1 week or more. Its associated findings are:
1. fistulas
2. intramural sinuses
3. an abscess cavity or sinus tract outside the colonic wall communicating with the lumen
4. intramural abscess producing an indentation of the barium column
5. extrinsic compression by a paracolic mass

colonoscopy can also be used if the BE findings are non-specific and of course with colonoscopy a tissue sample can be
taken for a biopsy.

What is the differential Dx?

1. acute appendicitis
2. crohn’s disease
3. perfed PU
4. perfed colonic carcinoma

complications:
1. perforation
2. obstruction
3. bleeding
4. abscess formation
5. fistula
6. strictures

Tx is medical or surgical

Initial medical Tx
1. admit to ward
2. NPO
3. NG suction
4. IV fluids
5. broad spectrum antibiotics
6. Contrast CT –scan

BE once inflammation has subsided by 1 week or more

When do you perform surgery if any of the complications are present ie peritonitis
COLORECTAL CARCINOMA

You will be given a barium enema showing the characteristic apple core lesion or the photo of colorectal carcinoma.

What is this? BE
What contrast is it and how do you know?
What are the risk factors for colorectal cancer?
Screening?
How can this patient present? And what is the distribution of the cancers within the colon?
How would you Mx this patient?
Where else is CEA elevated?
How do you stage colorectal carcinoma?
What are the sites of metastasis?
Are there any investigations specific for rectal cancer?
How would you prepare the patient for surgery?
What does bowel prep involve in pre-op prep involve?
What is the definitive Tx for this patient?
Explain the surgery?
What if there is liver met? How would that affect your operative technique?
What is the post-op Mx?