Surgery :-

⁃ Acute cholangitis is due to an acute, ascending bacterial infection of

the biliary tree caused by an obstruction. The most common pathogen is Escherichia
coli and than Klebsiella.
⁃ Risk factors for adenocarcinoma in gallbladder polyps include size over
10 mm, growth of lesion during follow-up, presence of stones and age over 60. In
these cases, a cholecystectomy is indicated, even in asymptomatic patients.
( Asymptomatic lesions that are smaller than 10 mm, with no risk factors and no
suspicious features in the US, sonographic follow-up is sufficient).
⁃ The definitive treatment for acute cholangitis is
⁃ ERCP, that allows an endoscopic removal of the obstructing stone; also,
drainage of the ducts by inserting a stent and performing a papilla sphincterotomy
(papillotomy). … in the case of question the patient presents with Charcot triad,
that includes RUQ abdominal pain, high fever and jaundice, and is the classic
presentation of acute cholangitis. When this condition begins to be manifested with
shock, the two additional findings of mental status changes and hypotension join
Charcot triad to become Reynolds pentad.
⁃ Patients with bile duct injury that is identified after cholecystectomy
present with jaundice, elevated alkaline phosphatase level, or leakage from the
injured duct. Leakage may be evident in the drain that was placed at the time of
operation or from a surgical incision. Treatment includes intravenous antibiotics,
drainage of periportal fluid collections, and cholangiography followed by stenting,
dilations or surgical reconstruction of the biliary tree.
⁃

⁃

⁃ • The current treatment options for acute variceal hemorrhage include
medications (vasopressin, somatostatin, and their analogs) and endoscopy as first
treatment. • Transjugular intrahepatic portosystemic shunt (TIPS) placement, and
surgery are options for recurrent bleedings despite pharmacologic and endoscopic
treatments.
⁃ The patient described has an Emphysematous Cholecystitis, based on the
US finding of air in the gallbladder wall, which is a life-threatening condition.
According to the clinical parameters, the patient is in a state of septic shock,
therefore is in high operative risk, and should be managed by PTC and conservative
treatment.
⁃ Liver cell adenoma could be life threatening when it presents with free
intraperitoneal rupture and bleeding.
⁃ Splenic abscesses with septa or multiple abscesses usually require
splenectomy, upper left abdominal drainage and antibiotics.
⁃ Focal Nodular Hyperplasia is the second most common benign tumor in the
liver. benign In asymptomatic patients the approach is conservative
⁃ Asplenic patients are at increased risk from encapsulated bacteria,
such as Haemophilus influenzae type B and Neisseria meningitides.
⁃ The MELD index reflects the likelihood of mortality within 3 months,
reflects the severity of liver disease and is based on a formula that includes
bilirubin, creatinine levels, IN and sodium levels.
⁃ The primary treatment for an echinococcal cyst is surgical. There are
two main approaches: resection or drainage. During the operation; a review of the
abdomen, liver mobilization and cyst exposure are performed. Tearing the cyst
during surgery can cause anaphylaxis and seeding of the parasite in other places.
For this reason, when preparing for surgery, anesthesiologists should have
Epinephrine at hand
⁃ The clinical course of hemangioma is benign and if the diagnosis is
certain, the management will only require follow-up.
⁃ The treatment of choice for patients that are able to endure the stress
of the surgery is a cholecystectomy. Most patients, who are incapable of undergoing
surgery, will be treated with percutaneous drainage. A cholecystectomy is not
necessary in patients that were treated with percutaneous drainage, in case there
were no stones in the follow-up US.
⁃ Pyelophlebitis is a type of thrombophlebitis of the portal venous
system acquired usually through an ascending infectious disorder of the
gastrointestinal tract. The most common causes of pyelophlebitis are
diverticulitis, appendicitis, pancreatitis, inflammatory bowel disease, pelvic
inflammatory disease, perforated viscus, and omphalitis in newborns.
⁃ The hörmone cholecystokinin (CCK), which is secreted by the intestinal
mucosa, causes gallbladder wall contraction and induces biliary tree secretion.
⁃ Asymptomatic cholelithiasis should not be treated as a fraction of
patients develop complications before symptoms.
⁃ The treatment of amebic abscess is usually non-surgical - with
antibiotics, metronidazole (=Flagyl), for 10 days
⁃ Acalculous cholecystitis may occur in patients who are critically ill,
elder, diabetic, or immunosuppressed. Patients may not have RUQ pain, so any
evidence of cholecystitis on US, especially in absence of gallstones, should raise
suspicion. Initial treatment is with IV antibiotics, fluids, and imaging-guided
percutaneous cholecystostomy.
⁃ Acute acalculous cholecystitis is an acute inflammation of the
gallbladder in the absence of stones. Risk factors include: advanced age, sepsis,
patients after severe trauma or burns, prolonged TPN, unbalanced diabetes, and
immunocompromised patients. The treatment of choice for patients who are able to
withstand the stress of surgery is an open cholecystectomy.
Patients who are unable to undergo surgery will be treated with percutaneous
drainage (cholecystostomy).
⁃ Cholangiocarcinoma that occurs in the bifurcation region of the biliary
tree is called
⁃ Klatskin tumor. Due to the localization of Klatskin, it is common that
the intrahepatic bile ducts are severely dilated, while the extrahepatic ducts are
normal.
⁃ In symptomatic hemangiomas with no other explanation, significant
growth, Kasselbach-Mirrett syndrome, rupture and bleeding or in rare cases where
the nature of the finding is not certain - resection should be performed. The
preferred therapeutic approach to resection is enucleation with arterial flow
control. A biopsy is not recommended for suspected hemangioma as it can be
dangerous!
⁃ Hydatid cysts often have daughter cysts or septae, and calcifications
of the cyst wall are highly,suggestive of echinococcal disease.
⁃ Cholangiocarcinoma is a tumor of the bile ducts which is classified by
its location in the biliary tree: proximal and in the bifurcation between the ducts
(Klatskin tumor or Bifurcation) and distal. The treatment depends on the extent of
the disease and the location of the primary tumor.
⁃ Acute cholangitis is suggested by the Charcot triad - fever, jaundice,
and RUQ pain, frequently accompanied by leukocytosis and elevated transaminases and
ALP. US shows a dilated biliary tree. Initial treatment is with IV antibiotics and
fluids, and emergent ERCP or PTBD for decompression.
⁃ Bile duct injury is a complication of cholecystectomy presenting with
fever, abdominal pain, and jaundice. Treatment is divided into three goals:
antibiotics and percutaneous drainage to control the infection, PTC (and/or ERCP)
to delineate biliary anatomy, and surgical reconstruction.
⁃ The most common organism that causes infection after splenectomy is
Streptococcus pneumonia which is responsible for 50-90% of cases.
⁃ In case a bile duct injury is detected during a cholecystectomy
surgery, the laparoscopic surgery should become an open surgery (laparotomy).
Cholangiography may help in the management of the case.
⁃ Gallstone ileus presents similarly to any small bowel obstruction with
abdominal pain and constipation. It may be diagnosed based on the appearance of a
stone or pneumobilia on abdominal X-ray, or diagnosis may require CT.
Enterotomy with retrograde stone extraction is the mainstay of treatment, with
cholecystectomy being considered for young, healthy patients.
⁃ Treatment for liver amebiasis includes antimicrobial agents to clear
the infection such as metronidazole followed by luminal agents to treat the carrier
state.
⁃ The only chance for remission of gallbladder cancer is with surgery.
⁃ Asymptomatic polyps that are smaller than 1 cm, without risk factors or
sonographic signs for malignancy, should be managed with US surveillance.
⁃ Surgery for hemangioma is performed only in cases of symptoms
attributed to hemangioma and only after other causes of the symptoms have been
ruled out. Other indications for surgery include blasting, significant enlargement,
and Kasabach-Merritt syndrome.
⁃ Cirrhotic patients undergoing surgery should be assessed for the Child-
Pugh scoring system and decision on whether or not to proceed with surgery depends
on patient's classification. Generally, in Child's A and B
class, ascites and coagulopathy should be treated accordingly and the patient can
proceed to surgery.
⁃ • Treatment of splenic abscesses depends on whether the abscess is
unilocular or multilocular. •
Unilocular abscesses are often amenable to percutaneous drainage.
• Multilocular abscesses are treated with splenectomy, drainage of the left upper
quadrant, and antibiotics.
⁃ A simple asymptomatic cyst in the spleen requires only follow up. In
any case, prior to puncturing a cystic spleen finding one should rule out a
parasitic etiology, for example, by serology.
⁃ • Liver abscess if formed through bacteria exposure from different
routes including the biliary tree, portal vein, hepatic artery, direct extension of
nearby infection sites, and trauma.
• The most common etiology of liver abscess is infections from the biliary tree.
⁃ The three most common objective measures of surgical risk in cirrhotic
patients are the Child-Turcotte-Pugh (CTP) score, the MELD score, and residual
liver volume.
⁃ The most common malignant tumors of the liver are metastatic lesions.
The most common primary malignant neoplasm of the liver is hepatocellular carcinoma
followed by intrahepatic cholangiocarcinoma.
⁃ Splenectomy as a treatment for ITP is a second line option after
steroid therapy failure. It is worth noting that the current treatments available
today such as Rituximab are often a second alternative to those who do not want
surgery.


⁃

⁃ Transgastric and transduodenal drainages are safe and efficient
procedures for patients with pancreatic pseudocysts located close to the stomach\
duodenum (<1 cm).
⁃ The most common bacteria isolated in the case of the perforated
appendix are Escherichia coli and Pseudomonas Aeruginosa. Infections associated
with appendicitis are considered to be polymicrobial, and antibiotic coverage
should include agents for both gram-negative bacteria and anaerobes.
⁃ Common causes of small bowel obstruction include adhesions following
abdominal or pelvic surgeries (60% of cases), followed by neoplasms (20%), hernias
(10%), Crohn's disease (5%) and miscellaneous causes (<5%). Symptoms include
colicky abdominal pain, nausea, vomiting, obstipation and abdominal distension.
Abdominal × RAY demonstrates air fluid levels.

⁃

⁃ ANENs of less than 1 cm should be observed and no operation is
necessary cause they almost act as benign

⁃ The most common cause for acute lower Gl hemorrhage in adults is
diverticulosis. The most common causes for significant lower GIB in children
and adolescents, are inflammatory bowel disease and juvenile polyps. Hemorrhoids
and anal fissures may cause a minor bleeding and inconvenience but severe bleeding
as described is less likely.
⁃ Vascular compression of the duodenum, also known as superior mesenteric
artery syndrome or Wilkie syndrome, is a rare condition characterized by
compression of the third portion of the duodenum by the superior mesenteric artery
as it passes over this portion of the duodenum. Symptoms include profound nausea
and vomiting, abdominal distention, weight loss, and postprandial epigastric pain,
which varies from intermittent to constant, depending on the severity of the
duodenal obstruction.Weight loss usually occurs before the onset of symptoms and
contributes to the syndrome (Option 4).
⁃ Persistent vomiting ultimately leads to hypochloremic metabolic
alkalosis and hypokalemia.
⁃ All of the following imaging findings support the diagnosis of
gallstone ileus:- • 1. Calcified mass at the right lower quadrant • 2. Air in the
bile system • 3. Distended loops of small bowel with air-fluid levels• 4.
Cholelithiasis on ultrasound
⁃

⁃ CT is the imaging modality of choice for the evaluation of suspected
pancreatic cancer.
⁃ Symptoms of an insulinoma tumor include sweating, dizziness, confusion,
and syncope supported by lab results of fasting hypoglycemia (<50 mg/dl).
Insulinomas present with a constellation of symptoms known as the "Whipple triad"
including fasting glucose levels less than 50 mg/dL, symptoms of hypoglycemia, and
resolution of symptoms upon administration of glucose. The diagnosis was made
during a monitored 48-hour supervised fast where plasma glucose, insulin, and C-
peptide levels are measured at 6-hour intervals. An elevated i low glucose level is
diagnostic. The use of oral hypoglycemic agents should be excluded during the
duration of the supervised fast. Other parameters that are measured include plasma
glucose, insulin, C peptide, proinsulin, and beta-hydroxybutyrate levels Tumor
localization is made with a CT or an MRI. Treatment is surgical
resection. Since over 90% of insulinomas are benign, enucleation is usually
preferred, when possible, in order to preserve functional pancreatic mass. Anatomic
resection (distal pancreatectomy, central pancreatectomy, or
pancreaticoduodenectomy) is indicated for tumors bordering the main pancreatic duct
or for large tumors.
⁃ procedures of bariatric pt. carries the lowest mortality risk is
Laparoscopic adjustable gastric band (LAGB)0.0% and the highest one is Duodenal
switch (DS) 1.9%.
⁃ Courvoisier sign is a characteristic sign of pancreatic adenocarcinoma,
and it includes the presence of jaundice and a painless, distended gallbladder.
⁃ The first steps in differentiating UGIB from LGIB (Lower GI bleeding)
is aided by a nasogastric tube lavage.

⁃

⁃

⁃ To conclude, for clinical suspicion of appendicitis of symptoms
duration of less than 48 hours: male patients with equivocal presentation and
nonpregnant females should get a CT scan prior to surgery. On the other hand, male
patients with classic presentation or localized peritonitis should be treated with
laparoscopic appendectomy.
⁃ The most malabsorptive bariatric procedure is laparoscopic
biliopancreatic diversion (LBPD).

⁃ The confirmatory test for acute mesenteric ischemia is CT angiography,
which may demonstrate disrupted arterial flow or arterial stenosis, thickened bowel
wall, edema, hemorrhage and a demarcation between normal and abnormal mucosa.
⁃ Cherry red stool = diverticulosis
⁃

⁃ Which of the following is the most common location of the base of the
appendix in acute appendicitis? - Where the three taeniae coli merge ( most
commonly in the retrocecal area, followed by pelvic and retroperitoneal positions )
⁃ BRCA2 is a tumor suppressor gene located on chromosome 13 which is
involved in hereditary breast and ovarian cancers, as well as hereditary cancers of
the colon, prostate, gallbladder and biliary tree, pancreas, stomach, and melanoma.
Since this patient with pancreatic adenocarcinoma has a sister with early-onset
breast cancer, a mutation in the BRCA2 gene is suspected. A BRCA2 mutation carries
a 10-fold increase in risk of pancreatic adenocarcinoma when compared to the
general population.

⁃ The next step in a patient with GIB whose gastroscopies and colonoscopy
are normal is a small bowel evaluation with a video capsule.*
⁃ Pancreaticoduodenectomy, known as the Whipple's procedure, includes
removal of the pancreatic head, duodenum, gallbladder and the bile duct; and
reconstruction and reattachment of the remaining organs by pancreaticojejunostomy
and hepaticojejunostomy.
⁃ Whenever possible, enteral nutrition
⁃ (Nasojejunal feeding tube placement is currently favored) should be
used rather than TPN in Acute pancreatitis.
⁃ Patients with massive UGIB who are stable enough should undergo urgent
therapeutic endoscopy.
⁃

⁃

⁃ The most common complication of chronic pancreatitis is pancreatic
pseudocysts, which dévelop also in acute pancreatitis but less frequently.
⁃ TIPS has replaced operative shunts for managing acute variceal bleeding
when pharmacotherapy and endoscopic treatment fail to control bleeding
⁃ • Meckel's diverticulum is the most common congenital anomaly of the
small intestine. • The most accurate non-invasive diagnostic test is sodium
99mTc-pertechnetate scintigraphy. • When surgery is indicated a segmental
resection of small bowel is performed.
⁃ Patients with gallstone ileus are treated with an enterotomy performed
proximally to the obstructing stone so that the stone can be moved backwards (in a
milking pattern) and removed through the enterotomy.
⁃

⁃ Treatment of sigmoid volvulus begins with proper fluid resuscitation
and nonoperative endoscopic decompression of the bowel (placement of a rectal
tube). If nonoperative decompression fails, or the patient is presenting with
peritoneal signs or colonic necrosis, Hartmann operation is required.

⁃ • The basic concept of ATLS is to rapidly identify and address life-
threatening conditions during the initial assessment of the patient. Injuries
should be treated according to severity. •
Confirmed diagnosis and full patient history are NOT essential for treatment and
should not delay it.
⁃ • Esophageal cancer is typically seen in the form of squamous cell
carcinoma (SCC) or adenocarcinoma. Adenocarcinoma is more common than SCC.
• SCC (upper 2/3 of gastroesophageal junction) risk factors are mainly tobacco and
alcohol use, while adenocarcinoma(lower 1/3 of gastroesophageal junction) risk
factors are related to Barrett's esophagus in the context of GERD.
⁃ In cases of hemothorax, chest tube insertion in hemodynamically stable
patients with no active bleeding will yield fresh blood at a constant rate of no
more than 150-200 mL\hr over 2-4 hours. On the other hand, tube
thoracotomies that drain large amounts of blood on initial placement or demonstrate
ongoing output indicate active intrathoracic bleeding, and therefore patients tend
to be hypotensive.
⁃ For colon cancers without metastasis, surgical resection is curative
and sufficient, and no neoadjuvant chemotherapy or radiation is needed.
⁃ Transanal endoscopic microsurgery (TEM) is a method for the local
excision of favorable rectal tumors (T1 cancers and sessile polyps) through a
device intended to provide access to the mid and proximal rectum.

⁃ In Adrenal incidentaloma :- Imaging characteristics suggestive of a
benign incidentaloma include homogenous appearance, well-defined borders, high
lipid content, rapid washout of contrast material and low degree of vascularity.
Imaging characteristics that are concerning for malignancy include ill-defined
borders, necrosis, internal calcifications, hemorrhage and high vascularity.
⁃ The clinical manifestations of carcinoid syndrome include flushing
(80%), diarrhea (76%), hepatomegaly (71%), cardiac lesions (40-70%) and asthma
(25%). The diagnosis of NETs and carcinoid syndrome consists of the evaluation of
humoral factors such as 24-h urinary 5-HIAA, CgA ( chronogranin A) or their
combination.
⁃ In patients with anterior abdominal stab wounds, the presence of
hemodynamic instability, peritonitis, or evisceration require immediate exploratory
laparotomy. In the absence of these signs, the reminder of patients should undergo
local wound exploration to determine whether the anterior or posterior abdominal
fascia is violated.
⁃ Then most common causes of primary hyperaldosteronism are unilateral
aldosterone-producing adenomas and bilateral adrenal hyperplasia.
⁃ • The lethal triad (sometimes referred to as the "trauma triad of
death") is a term used to describe the combination of acidosis, hypothermia, and
coagulopathy. • This triad is common in cases of severe blood
loss.
⁃

⁃ It is important to note that the IMV continues beyond the IMA along the
base of the mesentery to the left of the ligament of Treitz and into the portal
vein.

⁃ The order of actions in trauma is according to the following principle:
we should treat whatever is life-threatening first. Hence, blunt trauma patients
who are hemodynamically unstable and have a positive FAST examination
(intraabdominal fluid is identified) are in need of an urgent laparotomy to control
the bleeding. It is very rare that an intracranial hemorrhage will cause
hemodynamic instability.
⁃ The Cecum is the most common location for perforation in closed-loop
obstruction.
⁃


⁃ The earliest compensatory mechanism in hypovolemic shock is an increase

in sympathet activity.

⁃ Colonic volvulus which occurs most commonly in the sigmoid colon can
present as bowel obstruction with constipation, abdominal pain and a distended
abdomen. Diagnosis is made with abdominal XRAY and in the absence of colonic wall
necrosis is treated with endoscopic decompression.
⁃ Signs of sigmoid volvulus on imaging include the "bird's beak" sign on
contrast enema, and the "coffee bean" sign on abdominal radiographs. Sigmoid
volvulus is treated with non-surgical decompression. Elective sigmoidectomy is
recommended as volvulus tends to recur.

⁃ Indications for adrenal excision include hormonally active tumors and
high-risk for malignancy. The chance of malignancy increases with the size of the
finding. The recommendation is to remove all adrenal tumors that are 3-4 cm or
larger.
⁃ The algorithm for the treatment of acute-onset severe, generalized
abdominal pain is as followed: In the absence of peritoneal signs and in the
setting of acidosis and increased lactate levels, CT should be done. However, if
peritoneal signs are present, an abdominal X-RAY is done. If pneumoperitoneum is
demonstrated, indicated by free air under the diaphragm, then patients should be
transferred to the operating room without delay. If no pneumoperitoneum is detected
by abdominal X-RAY, water-soluble contrast swallow studies should be done.
Stage Il or higher rectal cancers should be treated with neoadjuvant
chemoradiation. Possible surgical options include either low anterior resection or
abdominal perineal resection. This patient's tumor is classified as T3, N1b or N2
(exact number of lymph nodes involved is not mentioned) MO, i.e., stage IIIB or
IIIC rectal cancer. Current guidelines recommend that stage Il or higher rectal
cancers should be treated with preoperative (neoadjuvant) chemoradiation. Surgery
(either low anterior resection or abdominal perineal resection, laparoscopically or
open) is usually done 6 to 10 weeks after completion of the radiation therapy.
⁃ The approach to Barrett's Esophagus with high-grade dysplasia is to
treat with ablation or mucosal resection. Current approach to
high grade dysplasia is ablation by cryotherapy (RFA) or endo-mucosal resection (in
the past, treatment was with esophagectomy for everyone).Chemotherapy, radiotherapy
and resection are reasonable for people with advanced disease.The approach to low-
grade dysplasia is follow-up by repeat endoscopies first every six months and then
yearly) and taking biopsies to rule out progression to high grade.
⁃ The Nissen fundoplication is the standard antireflux surgery.
⁃ Patients who suffer from secondary adrenal insufficiency can develop
adrenal crisis due to lack of perioperative glucocorticosteroids administration.
Treatment includes large-volume IV fluids, and glucocorticoid administration.
⁃ The most common symptom combination in
⁃ GERD is reflux, aspiration, epigastric pain (heartburn) and cough.
⁃ It is recommended that patients suffering from uncomplicated
diverticulitis undergo a colonoscopy after 4 to 8 weeks to exclude malignancy
⁃ Pilonidal disease is associated with obesity, sedentary occupation and
local irritation or trauma.
⁃ Indications for severe blunt cerebrovascular injury (BCVI), are an
expanding neck hematoma, arterial hemorrhage, focal neurological deficit, a
cervical bruit in patients younger than 50 years old (over 50 a bruit may be better
explained by atherosclerosis), imaging supporting a stroke or neurological deficit
not explained by CT findings.
⁃ Ulcer perforation is characterized clinically as sudden, sharp and
acute epigastric abdominal pain, and is generally accompanied with free air on
plain films and often with local peritonitis as well. Surgical intervention is
indicated in nearly all cases.
⁃ The perineal approach for surgically correcting rectal prolapse named
the Altemeier procedure is the preferred procedure for patients with the highest
operative risk (older patients with multiple comorbidities) because it results in
fewer patient morbidities.
⁃ Cardiogenic shock occurs due to significantly decreased cardiac output.
Extrinsic causes are unrelated to the heart pump itself and include tension
pneumothorax, hemothorax, or cardiac tamponade. Intrinsic causes refer to pump
failure and include infarct, cardiac failure, contusion, or cardiac laceration.
 ⁃ A hemodynamically stable patient who suffers from a left-sided large
bowel obstruction probably secondary to malignancy should undergo surgery and
segmental resection.

⁃ auma, the lack of a definitive diagnosis uld not delay the application
of an indicated ent treatment according to ATLS guidelines.
⁃ Full caloric administration after a period of starvation results in
Refeeding syndrome. It could lead to hypokalemia, hypophosphatemia, and
hypomagnesemia
⁃ Abdominal Perineal Resection (APR), also termed the Miles procedure, is
composed of complete excision of the rectum and anus through the abdomen and
perineum, with suture closure of the perineum and creation of a permanent
colostomy. It is indicated for tumors involving the anal sphincters or those which
are too close to the sphincters for adequate margins to be obtained.
⁃ The initial treatment of anal fissures consists of topical therapy with
nitroglycerin or calcium channel blockers, in addition to dietary modifications.
(Topical application of nitrates and calcium channel blockers are often used as an
adjunct in the nonoperative management of an anal fissure). Lateral internal
sphincterotomy should be offered after the failure of conservative treatment as it
may pose a risk for fecal incontinence. ‫ باختصار‬- Treatment of anal fissure begins
with topical drugs, dietary changes, painkillers, followed by Botox injections and
possibly surgery (sphincterotomy) if other options failed. During a sphincterotomy,
incision of the internal anal sphincter muscle is done which can lead to
incontinence.
⁃ Recent findings show that the combination of a mechanical and an oral
antibiotic bowel preparation is associated with a very low rate of postoperative
infectious complications in patients undergoing colorectal surgery.
⁃ Hypotension and presence of cancer are the most significant risk
factors for morbidity and mortality in esophagus perforation.
⁃ Patients who are hemodynamically stable in the setting of blunt and
penetrating liver trauma should be considered primarily for nonoperative
management. Mild injuries may be observed in the ICU.
⁃ Damage control resuscitation focuses on rapid control of bleeding,
allowing permissive hypotension until definitive surgical control, initial use of
5% hypertonic saline and early use of blood products to reduce the total volume of
crystalloid solution necessary, and considering drugs to treat coagulopathy.
⁃ Intestinal obstruction can be mechanical (tumor block, volvulus,
external pressure) or non-dynamic (pseudo-obstruction) resulting from poor
peristaltic contractions of the colon.
Treatment of non-dynamic obstruction includes :- NGT, fluids, electrolyte repair,
and discontinuation of drugs that can cause or exacerbate the disease. If the
treatment does not help, neostigmine, epidural or decompression colonoscopy can be
performed.
Ogilvie syndrome

⁃ In a patient with a history of corticosteroid use, an infection may
cause decompensation of adrenal function, exacerbated by weaning off
corticosteroids. This condition is called critical illness-related corticosteroid
insufficiency or acute adrenal insufficiency.
⁃ After decompression of sigmoid volvulus, the patient should undergo a
colonoscopy to rule out malignancy. Then, the patient should be referred to
elective sigmoidectomy.
⁃ Cardiac tamponade is the accumulation of pericardial fluid which leads
to increased pericardial pressure and compression of all 4 heart chambers. Physical
findings include hypotension and tachycardia, elevated jugular venous pressure.
⁃ Thrombosis of external hemorrhoids cause severe anal pain. Treatment
includes both surgical and non surgical approaches.

⁃ The main intracellular electrolytes are the cations potassium and
magnesium. The principal intracellular anions are phosphates and proteins.
The main extracellular electrolytes are the cation sodium (predominant), and the
predominant anions are chloride and bicarbonate.
⁃ When concerned about hollow viscus perforation, an upright plain film
taken at the level of the diaphragm will reveal free air under the diaphragm which
is diagnostic and should prompt surgical exploration.
⁃ Large bowel obstruction caused by left colon cancer is treated by
resection of the involved segment. In emergency surgery, it is usually acceptable
to create a diverting stoma, and consider anastomosis at a later date. Important
👉🏻 ( treatment is guided by the location of the obstruction. Cancer in the distal
or mid rectum is treated by loop sigmoid colostomy and then neoadjuvant
chemotherapy, followed by tumour resection at a later time. Obstruction at the left
colon or sigmoid colon is treated by either a Hartmann operation (left
hemicolectomy/sigmoidectomy with descending colostomy and closure of the rectal
stump or mucous fistula) or left hemicolectomy/ sigmoidectomy with a primary
anastomosis (depending on the patient's condition). Right sided obstruction is
treated by resection and primary anastomosis of the ileum and transverse colon if
the patient is stable. In emergency surgery, it is usually
acceptable to create a diverting stoma, and consider anastomosis at a later date.
⁃ The Glasgow coma scale consists of the best motor, verbal and eye-
opening responses.
⁃ Blunt abdominal trauma assessment starts with abdominal examination. In
the absence of peritonitis or hemodynamic instability with positive FAST, abdominal
and pelvic CT scans are ordered.
⁃ In cases of a pelvic fracture identified on abdominal \pelvic
radiographs and hemodynamic instability, pelvic sheet wrapping should be done
quickly followed by free fluid on focused assessment with sonography (FAST)
examination. If negative, immediate transfer to the operating room for an
exploratory laparotomy is not needed.
⁃ In a suspected gastric tumor, gastroduodenoscopy with biopsies to type
the tumor, and endoscopic ultrasound to stage it should be done. Gastric cancer is
aggressive and affects mainly elderly men. Treatment varies, depending on grading
and staging of the tumor. There are two types of gastric adenocarcinoma,
intestinal and diffuse. Intestinal type is associated with the factors mentioned
above( include nutritional (high nitrate and complex carbohydrate consumption,
salted meats or fish and low fat or protein consumption), environmental (smoking,
poor drinking water), social (low socioeconomic status) and medical (H. pylori
infection, gastric atrophy and gastritis, adenomatous polyps and prior gastric
surgeries). while the diffuse type is
usually familial, affects younger patients and women more than men.
Staging is done mainly by using the TNM classification and modalities used are
endoscopy, endoscopic ultrasound, CT, MRI, PET scan and diagnostic laparotomy.
Treatment varies, depending on grading and staging of the tumor and includes three
main treatment paths: resection (with or without subsequent adjuvant therapy),
neoadjuvant therapy followed by resection or palliative systemic therapy for
patients with unresectable or metastatic disease.
⁃ When diagnosing gastric cancer it is important to search for local and
distant signs of metastases. Gastric cancer is aggressive, and does not respond
well to chemotherapy. Treatment is mostly surgical and based on staging.
examination should include signs of advanced disease. These signs include Sister
Mary Joseph's node at the umbilicus, Virchow's nodes above the clavicle, and signs
of abdominal metastases-hepatomegaly, jaundice, or ascites. Pelvic examination may
reveal signs of metastases to the ovaries or peritoneum.
⁃ Symptomatic seromas should be aspirated under sterile conditions and
have a pressure dressing applied. Many asymptomatic seromas will resolve
spontaneously because the fluid can be resorbed by the surrounding tissues
⁃ Crohn's disease is a chronic inflammatory bowel disease of unknown
etiology that can involve any part of the gastrointestinal tract but it most
commonly affects the small intestine and colon.
Clinical presentation includes abdominal pain, diarrhea, and weight loss.
Upon gross inspection, macroscopic teatures include asymmetrical involvement of the
bowel referred to as skip lesions, thick bowel loops, and the characteristic
cobblestone appearance and wrapping fat; while microscopic histologic lesions
include transmural inflammation and noncaseating granulomas with Langerhans giant
cells. Diagnosis is made by barium contrast studies and endoscopy. CT demonstrates
transmural wall thickening and is a good method of choice in acute settings of
complications, such as perforations or abscesses. Follow-up and disease activity
and bowel damage assessment can be done with either MRI or CT, however MRI seems to
be superior due to lack of radiation exposure.

⁃ In the first 2 days post-wounding, the inflammatory phase( 4-6 days) is
ongoing, and in this phase the predominant constituents are neutrophils and
macrophages. Neutrophils are present in peak concentrations at day 2, and
macrophages at day 3. Neutrophils are present in peak concentrations at
day 2, and macrophages at day 3.
T lymphocytes appear in large numbers by day 5 after injury and peak on day 7.
Fibroblasts are the predominant cells during the proliferative phase( 4/24 days).
Last phase is maturation ( lasts for 21 days to 2 years ).
⁃ This disorder is characterized by increased PTH secretion,
inappropriately relative to the serum calcium levels, leading to hypercalcemia.
Approximately 85% of cases are due to parathyroid adenoma, which is a single
parathyroid gland enlargement. The rest of the cases are due to multiple adenomas
or hyperplasia, with parathyroid carcinoma being a rare cause. Some familial cases
with multi-gland involvement are due to MEN1 and MEN2A.Symptoms include muscle and
bone pain, frequent urination, abdominal pain, constipation, nausea, vomiting, and
neurocognitive dysfunction such as fatigue, mood changes, poor concentration and
insomnia. Additional signs of primary hyperparathyroidism include nephrolithiasis
and nephrocalcinosis, osteopenia and osteoporosis, osteitis fibrosa cystica, brown
cysts and as a consequence, pathologic fractures.Known Mnemonic is: "stones, bones,
abdominal groans, and psychiatric overtones".
⁃ A Spigelian hernia is created by a defect in the Spigelian fascia,
which is located between the rectus muscle medially, and the semilunar line
laterally. The treatment is a surgical repair.
⁃ Anal disease occurring in patients with colitis suggests a diagnosis of
Crohn's disease.

⁃ Paget disease accounts for 1% or less of breast malignancies. It is
characterized clinically by nipple erythema and irritation with associated pruritus
and may progress to crusting and ulceration. The condition may spread outward from
the nipple and onto the areola and surrounding skin of the breast The differential
diagnosis of scaling skin and erythema of the nippleareola complex includes eczema,
contact dermatitis, postradiation dermatitis, and Paget disease. A biopsy of the
skin of the nipple should be performed; a specimen containing Paget cells confirms
the diagnosis. Treatment of Paget disease
includes mastectomy with axillary staging or wide local excision of the nipple and
areola to achieve clear margins, axillary staging, and radiation therapy. More than
95% of patients with Paget disease have an underlying breast carcinoma.
⁃ After the placement of a drug-eluting stent (DES), non-cardiac elective
surgery should be postponed by 12 months due to the risks of discontinuing dual
antiplatelet therapy. In patients with STEMI or non-STEMI who have undergone
interventions, the guidelines are:
• Postpone elective surgery by 14 days after balloon angioplasty.
• Postpone elective non-cardiac surgery by 30 days after placing a bare metal stent
(BMS). • Postpone
non-cardiac elective surgery by 12 months after placing a drug-eluting stent (DES)
due to the risks of discontinuing dual antiplatelet therapy.
⁃ Increasing age seems to adversely affect the outcome of surgery. In
geriatric patients, preoperative careful assessment of cognitive, comorbid,
functional, and psychosocial factors is needed. ( Mini-Cog evaluation).
⁃ The risk of postoperative VTE depends on procedure-related factors
(e.g. anatomy, invasiveness, type and duration of anesthesia, postoperative
immobilization) and patient-related factors (e.g. age, prior VTE, malignancy).The
risk of postoperative VTE depends on procedure-related factors (e.g. anatomy,
invasiveness, type and duration of anesthesia, postoperative immobilization) and
patient-related factors (e.g. age, prior VTE, malignancy).The Caprini risk
assessment score is used to classify surgical patients into very low risk (0-1
point), low risk (2 points), moderate risk (3-4 points), and high risk (25 points).
Very low risk patients usually only require early ambulation for prevention of VTE.
Low risk patients may be managed with mechanical methods such as compression
stockings and intermittent pneumatic compression.
Moderate to high risk patients are managed with pharmacologic prophylaxis and
additional mechanical methods if necessary.
The 35-year-old man undergoing resection of the rectum due to malignancy- is
assessed with the highest risk for VTE among the patients in the options. The
assessment includes at least 2 points for cancer and 2 points for major surgery-
bringing his Caprini score to at least 4.
⁃ Two complications of parathyroidectomy that must be taken into
consideration following the surgery are neck hematoma and hypocalcemia.
⁃ LCIS(Lobular carcinoma in situ) is not an indication for surgery,
although it predisposes to subsequent carcinoma.Noninvasive neoplasms of the breast
were previously broadly divided into two major types, LCIS and DCIS. LCIS is no
longer regarded as a neoplasm of the breast but is regarded as a risk factor for
the development of breast cancer.
⁃ LCIS is not an indication for surgery, although it predisposes to
subsequent carcinoma. The three
options that can be discussed with the patient are close observation;
chemoprevention with tamoxifen, raloxifene, or arimidex; or bilateral mastectomy. A
5-year course of tamoxifen provides a 56% reduction in breast cancer risk. For
patients who elect surgery rather than observation, bilateral total nipple skin-
sparing mastectomy is the procedure of choice.
⁃ Primary hyperparathyroidism is the most common type of
hyperparathyroidism and is normally caused by a single gland adenoma which is
treated with surgery. Secondary hyperparathyroidism is less common and is usually
caused by vitamin D deficiency and chronic renal failure leading to hyperplasia of
all four glands which is treated medically.
⁃ Early-stage breast cancer is treated surgically by either breast
conserving therapy- lumpectomy + radiation, or mastectomy. When there is no
clinical evidence of lymph node involvement, sentinel lymph node biopsy is
performed to complete surgical staging and determine whether axillary lymph node
dissection is necessary. Like in Excision of invasive breast cancer (IDC).
Patients with locally advanced or inflammatory breast cancer should receive
systemic therapy prior to surgery. Patients with positive receptors are candidates
for receptor targeted therapies. Option 1 - Treatment of phyllodes
tumors depends on their classification as benign, borderline, or malignant, and
includes local resection, wide excision with margins of at least 1 cm, or tumor
resection with margins of healthy tissue, respectively. They are not treated by
lumpectomy. Option 2 - LCIS is considered a noninvasive
neoplasm of the breast. For most patients, a conservative approach is preferred and
includes close observation or chemoprevention with tamoxifen or raloxifene, or
bilateral mastectomy. Option 4 - ADH, proliferative changes with atypia, is a
histological risk factor for breast cancer. The risk for breast cancer development
in women with ADH is roughly 4-5 times the risk in the general population and the
annual risk is 0.5-1% per year. It is not considered as breast cancer and therefore
lumpectomy is not indicated.
⁃ Laparoscopic inguinal hernia repair is superior to open hernia repair
in patients with recurrent or bilateral hernias, however is not the preferred
approach in patients who have had extensive lower abdominal surgery, such as
radical retropubic prostatectomy.
⁃ Surgeons in favor of the laparoscopic approach for inguinal hernia
repair note a quicker recovery, less pain, usefulness in all inguinal hernias and
better anatomy visualization. It is commonly agreed by most surgeons that
laparoscopy is a better approach in patients with recurrent or bilateral hernias.
general anesthesia is the only absolute contraindication for this procedure.
⁃ The estimated lifetime incidence of all hernias are 5% of the world
population, with 75% of them being inguinal hernias.
⁃ The treatment of choice in case of toxic megacolon is subtotal
colectomy and ileostomy and Hartmann procedure. The patient with IBD is
presenting with signs and symptoms of fulminant colitis that developed into a toxic
megacolon (tachycardia, leukocytosis and fever), indicating imminent colonic
perforation. Since this is a life-threatening situation, urgent surgery is
required. The operation of choice in this case would be subtotal colectomy and
ileostomy and Hartmann procedure.

⁃ common factors that may inhibit wound healing nclude infection,
ischemia, diabetes, ionizing adiation, advanced age, malnutrition and itamin
deficiencies (vitamins A and C), and drugs like chemotherapeutics (e.g.
doxorubicin) and steroids.
⁃ Factors that raise the suspicion of a nodule for a thyroid cancer are
divided into clinical findings, sonographic findings and Bethesda score.
Clinical findings with increased risk for malignancy include: age<20 or older than
70, male sex, local compressive or infiltrative symptoms (e.g, hoarsness,
dysphagia), firm and/or immobile nodule, nodules larger than 3-4 cm, cervical
lymphadenopathy, history of neck irradiation and history of thyroid cancer in
first-degree family members.


⁃ Gastrointestinal Stromal Tumors (GIST) are differentiated on the basis

of the markers CD34, CD117 (which codes for the tyrosine kinase transmembrane
receptor C-kit), and DOG1 expression and the lack of smooth muscle staining.
Cajal cells and GIST share common markers for CD117 and DOG1. DOG1 is a calcium-
activated chloride channel, while CD117 is another name for the KIT gene, which
codes for a tyrosine kinase transmembrane receptor called C-kit. GISTs are
differentiated on the basis of CD34, CD117, and DOG1 expression and the lack of
smooth muscle staining. Gastroscopy usually shows a round lesion associated
with the submucosa, and sometimes a central ulcer. Diagnosis is usually made by
EUS-FNA, due to the difficulty obtaining reliable samples using gastroscopy.
Abdominopelvic CT is performed in order to detect distant metastases.
Treatment usually includes resection of the tumor. GISTs larger than 2 cm should
undergo complete resection, whereas tumors with a diameter of less than 2 cm are
treated based on their appearance. If the tumor has irregular borders, an ulcer is
present, or looks heterogenous, the tumor should be resected completely. When the
above characteristics are not present, observation every 6-12 months is
appropriate. Depending on the tumor size, the resection may be a wedge resection
(Wide Local Excision), enucleation, a sleeve gastrectomy or total gastrectomy. When
the tumor is unresectable, or metastases are detected, Gleevec (Imatinib) should be
administered and the patient's response monitored.
⁃ There are many etiologies causing ascites that can be divided into 4
main groups- ascites due to portal hypertension (cirrhosis, portal venous
obstruction, multiple hepatic metastases, Budd-Chiari syndrome, etc.), ascites due
to cardiac conditions ( CHF, chronic tamponade and constrictive pericarditis),
ascites due to malignancy (peritoneal carcinomatosis, lymphoma. Gl carcinoid
tumors, etc.) and miscellaneous reasons (bile ascites, pancreatic ascites, chylous
ascites, and peritoneal infections). In the US,
the most common cause of ascites is cirrhosis, which accounts for 85% of cases. In
uncontrolled heart failure, the increase in the hydrostatic pressure in the
splanchnic system results in the extravasation and accumulation of peritoneal
fluid. The Identification of whether the ascites are due to portal hypertension or
not is best done by calculating the serum-ascites albumin gradient (SAAG).

⁃ The most common cause of spontaneous unilateral nipple discharge is a
solitary intraductal papilloma. The diagnosis and
treatment are based on surgical resection. When it comes to peripheral polyps, the
differential diagnosis includes breast carcinoma, but breast papilloma is not a
risk factor for breast cancer.
⁃ The recommended treatment for a symptomatic hernia is surgery. Presence
of continuous or severe pain may indicate incarceration or strangulation, which
require an emergency surgery.
⁃ Patients that have been taken more than 5mg prednisone (or equivalent)
per day for at least 3 weeks within the past year are considered to be at risk at
major surgeries. Patients that take lower doses of steroids or those undergoing
minor operations under local anesthesia are not at risk for adrenal suppression. So
There is no need for any treatment prior to surgery
⁃ Most umbilical hernias close spontaneously by 2 years of age. Those
that persist after the age of 5 years require surgery.
⁃ • In infants, umbilical hernias are common and congenital. They require
repair if they do not close by the age of 5. • In adults,
umbilical hernias are acquired, more common in women, and most of the time do not
need to be repaired. Only adults who have symptoms, a large hernia, incarceration,
thinning of the overlying skin, or uncontrollable ascites should have a hernia
repair.
⁃ Surgery using a nonabsorbable mesh substantially reduces the risk of
inguinal hernia recurrence.
⁃

⁃ Coumadin should be stopped 5 days prior to surgery. Bridging
anticoagulation should be considered for patients at very high risk for
thromboembolism: recent ischemic stroke, acute arterial embolism, a mechanical
heart valve, or VTE.
⁃ The most significant risk factor for postoperative delirium is dementia
and existing cognitive impairment. It is important to recognise patients at risk
for developing delirium and use appropriate prevention strategies.
⁃ • In patients with DCIS lumpectomy is preferred (with or without SLNB)
unless there is an indication for mastectomy such as diffuse calcifications in
mammography. • SLNB is always indicated for mastectomy and in some cases of
lumpectomy.

⁃ Patients with uncontrolled hyperthyroidism should postpone any
nonthyroid elective operations until hyperthyroidism is addressed.
⁃ Postoperative pulmonary complications include patient- and procedure-
associated factors. While emergency surgery is considered a risk, mild to moderate
asthma and obesity are not.

⁃

⁃ Extraintestinal FAP manifestations can be a desmoid tumor involving the
mesentery and abdominal wall. In these patients, cancer can develop in other places
such as the biliary tract, pancreas, gallbladder, thyroid, adrenals and liver.
‫ 🏻👉 ملخص‬Another tumor that can develop (usually after surgical treatment) is
desmoid tumor in the mesentery and abdominal wall. The tumor does not spread but is
locally aggressive and can penetrate the central blood vessels, ureter or small
intestine, and can even cause death. The abdominal wall desmoid is usually excised
during surgery. The treatment of mesenteric desmoid is difficult and dangerous. The
initial treatment is usually with sulindac or tamoxifen.
Hamartomas polyps are characteristic of Peutz-Jeghers' syndrome not FAP.
⁃ In older male patients with asymptomatic or minimally symptomatic
inguinal hernias, a strategy of watchful waiting is safe.
⁃ Apixaban (Eliquis) is a highly selective oral direct factor Xa
inhibitor that blocks the conversion of prothrombin to thrombin. In patients at
low-bleed risk, it should be discontinued ≥24 hours prior to surgery; and in
patients at high-bleed risk, it should be discontinued >48 hours prior to surgery.
⁃ Healthy patients without comorbidities do NOT require preoperative
testing for low-risk surgeries.
⁃ A patient with hypercalcemia and abdominal pain most probably has
primary hyperparathyroidism.
⁃ Breast cysts are fluid-filled epithelial lined cavities that are
influenced by ovarian hormones which explains their variation with the menstrual
cycle. Most cysts occur in women older than 35 years. Intracystic carcinoma is rare
and cyst presence is unrelated to an increased risk of malignancy. Therefore, if
the cyst resolves after aspiration and its contents are not grossly bloody, the
fluid does not need to be sent for cytological analysis.
⁃ Older patients with asymptomatic or minimally symptomatic inguinal
hernias can be observed rather than electively operated in the near-future.
⁃ The diagnosis of an inguinal hernia is done clinically. imaging is kept
for cases where the diagnosis is unclear. When urgent surgery is indicated, we have
no time to complete a full evaluation. According to the text, it is important to
evaluate risk factors that are likely to influence intra-operative strategies,
monitoring and perioperative management.
⁃ The amount of maintenance fluid given per day to surgical patients is
calculated using the following formula: 4 x the first 10 kgs, 2 x the next 10 kgs,
and 1 x the remaining weight.
⁃ The most important risk factors for malignancy of GISTs are tumor size
> 10cm and more than 5 mitoses per high-power field (HPF).
⁃ Treatment usually includes surgical resection of the tumor The most
important risk factors for malignancy of GISTs are tumor size> 10cm, and more than
5 mitoses per HPF Patients with a moderate-high risk of recurrence or metastases
(>3cm, >5 mitoses per HPF) should receive adjuvant therapy using Gleevec.
⁃ A lumpectomy is an option in pregnant patients, with radiation therapy
completed after delivery. There is no
advantage in survival rates for mastectomy over breast-conserving therapy in
appropriate patients in clinical trials.
⁃ he repair of a suspected strangulated hernia is lone in a preperitoneal
approach. In this nanner, the herniated sac contents are easily risualized, their
viability can be assessed using a single incision, and bowel resection can be
performed using the same incision.
⁃ The most common incarcerated hernia is inguinal. ‫🏻👉 مهم تفريق بينهم‬Most
strangulated hernias are indirect inguinal hernias. However, femoral hernias have
the highest rate of strangulation (15%-20%) of all hernias, and it is therefore
recommended that all femoral hernias be repaired at the time of discovery.
⁃

⁃ A patient presenting in POD 5 with serosanguinous fluid excreted from
the surgical wound is probably suffering from wound dehiscence.
⁃ The 30-day postoperative mortality rates in patients with a
preoperative albumin level lower than 2 is 30%.

⁃ Breast cancer in men is rare and usually presents with a breast mass.
Risk factors include advanced age, radiation exposure and conditions associated
with estrogen and androgen imbalance. The most common type is invasive ductal
carcinoma and most are ER+ and PR+. Diagnosis is done via breast imaging studies
and core needle biopsy and treatment options depend on stage and local extent of
the tumor, similarly to women.
⁃ Anemia is the most common metabolic disturbance following gastrectomy.
Its main ethology is iron deficiency related to decrease in iron intake, impaired
iron absorption, and chronic blood loss.
 ⁃ Anemia is the most common metabolically related disorder following
gastrectomy. Megaloblastic anemia due to vitamin B12 deficiency occurs due to lack
of intrinsic factor, which leads to poor absorption of the vitamin.
⁃ Diastasis recti is an acquired thinning in the linea alba in the upper
abdomen, presented as a protrusion of the anterior abdominal wall. The protrusion
occurs in the midline of the abdomen, and is smooth when palpated. Diastasis recti
is not defined as a hernia, as a hernia is defined by a defect in the transversalis
fascia, which does not occur in this case. Margins of fascia are not visible, and
therefore strangulation is not a risk. The defect is usually visible while
straining, or lifting one's head when supine. No treatment is necessary, and
patients should be reassured that the condition is benign and not worrisome.
There is no defect in the transversalis fascia in diastasis recti and therefore it
is not considered a hernia Diastasis recti is an acquired defect and doesn't
require treatment.
⁃ Benzodiazepines are categorically contraindicated and stopped before
surgery as they have been demonstrated to increase the risk of cognitive
impairment, delirium, falls, and other adverse outcomes in older adults.
⁃ The borders of the femoral canal include the Iliopubic tract
superiorly, the Cooper ligament inferiorly, the Femoral vein laterally and the
Lacunar ligament medially.
⁃ Atelectasis is the most common cause of postoperative fever in the
early postoperative period, usually presenting on postoperative day 1.
Option 3 - Nosocomial pneumonia is the second leading cause of nosocomial infection
and is more common in surgical patients. The diagnosis of postoperative pneumonia
requires the absence of infiltrates before admission or before surgery. It usually
develops more than 48 hours after admission and is less likely to be the situation
in this patient. Option 4 - UTIs usually present around
postoperative day 3.
⁃ Succinylcholine, a depolarizing neuromuscular blocking agent, is
associated with hyperkalemia in patients with burns, paraplegia, quadriplegia, and
massive trauma.
⁃ Enteral feeding should be considered in low output enterocutaneous
fistulas.
⁃ erioperative evaluation of a diabetic patient hould include hemoglobin
A1C levels.
⁃ New findings that indicate malignant / pre-malignant findings require a
biopsy. The method of choice to sample breast lesions is core needle biopsy which
can be performed under mammographic (stereotactic), ultrasound, or magnetic
resonance imaging (MRI) guidance.
⁃ Neoadjuvant treatment of breast cancer improves disease free survival
and the rates of breast conservative surgery. Patients with a full pathologic
response after neoadjuvant treatment still need surgical removal of the tumor and a
formal removal of axillary lymph nodes on the affected side.
⁃ There is a very strong association between mucosa-associated lymphoid
tissue (MALT) lymphoma and H. pylori infection. These lymphomas tend to regress
after eradication of H. pylori.
⁃ Inflammatory breast cancer is the most aggressive subtype of breast
cancer. The pathologic hallmark is the presence of tumor cells within dermal
lymphatic channels and overlying skin. Manifestations range from solely skin
thickening, breast erythema, edema and overt peau d'orange appearance, frequently
without an underlying or palpable mass.
⁃ Factors which increase the risk of surgical site infections include
age, diabetes, obesity, hypothermia, hypoxemia, hypercholesterolemia, chronic
inflammation, corticosteroids therapy and more.
⁃

⁃ Surgical ICU patients tend to have SIADH resulting in hyponatremia,
which is usually managed with fluid restriction.
⁃

⁃ A patient with breast cancer who cannot undergo radiation therapy has
an indication for total mastectomy.
⁃ DCIS is a precursor for invasive carcinoma Mastectomy is preferred in
patients with diffuse calcifications on mammogram
⁃ US and mammography can be negative in cases of Paget disease but this
does not preclude extensive surgery.
⁃ The indications for a genetic work-up for the BRCA gene include: breast
cancer diagnosed before the age of 50, bilateral breast cancer, concurrent breast
and ovarian cancer in the same woman, and breast cancer in men.
⁃ The recommended therapeutic agent used in pregnancy for the prevention
and treatment of venous thromboembolism is low-molecular-weight heparin.
⁃

⁃ • Venous thromboembolism (VTE) is a possible postoperative complication
and it includes deep venous thrombosis (DVT) and pulmonary embolism (PE).
• The diagnosis is confirmed with imaging tests. For DVT the test of choice is
venous duplex US, and for PE the test of choice is chest angiography CT.
⁃ An open hernia repair should be offered to a patient who already had a
recurrence after laparoscopic repair.
⁃ One of the important complications of thyroidectomy is hematoma which
can endanger the airway. The relevant treatment options are intubation and opening
of the wound for drainage of the hematoma. The order of actions depends on the
clinical condition of the patient. (Reopen neck incision).
⁃ Urea breath test and stool antigen are the two tests of choice for non-
invasive testing with relatively high sensitivity and specificity and to assess
response to therapy.
⁃ Sarcoma is a neoplasm that originates from mesenchyme( epithelial
tissue).Tissue types include skeletal muscle, adipose cells, blood and lymphatic
vessels, and connective tissue or those cells with a common mesoderm origin.
⁃ Postoperative urinary retention presents with inability to urinate
within 6 to 8 hours following surgery, lower abdominal fullness, suprapubic pain
and discomfort, and a palpable bladder. Treatment
includes urinary catheterization.
⁃

⁃ Chronic renal failure causes secondary hyperparathyroidism (SHPTH) by
multiple mechanisms that may result in low calcium, high phosphate and low active
vitamin D balance. SHPT occurs as a physiologic response of parathyroid glands to
hypocalcemia.
⁃ Patients with unilateral compressing (symptomatic) masses and benign
biopsy results are treated with total thyroidectomy or lobectomy. Patients with
bilateral goiter are treated with total thyroidectomy.
⁃ Rivaroxaban (Xarelto) is a highly selective direct factor Xa inhibitor
(prevents the conversion of prothrombin to thrombin). It should be discontinued at
least 24 hours before a procedure.
⁃ The Child-Pugh scoring system is used to assess the surgical risk of
cirrhotic patients.
⁃ The cremaster muscle arises from the lowermost fibers of the internal
oblique muscle.
⁃ Dabigatran is associated with an increased risk for perioperative
bleeding and is withheld for 48 hours before surgery.
⁃ The earliest sign of hypermagnesemia is the loss of deep tendon
reflexes.
⁃ Ketamine, which produces a dissociative state of anesthesia, is the
only IV induction agent that increases blood pressure and heart rate and decreases
bronchomotor tone
⁃ Generally, patients that have been taking more than 5mg prednisone (or
equivalent) per day for at least 3 weeks within the past year are considered to be
at risk at major surgeries. Patients that take lower doses of steroids or those
undergoing minor operations under local anesthesia are not at risk for adrenal
suppression. The patient described is undergoing a major procedure
and should be given supplemental glucocorticosteroids of 100 mg bolus and 150
mg/day of hydrocortisone equivalent for 2 to 3 days. If supplementation is not
given, adrenal insufficiency presents as perioperative hypotension.
⁃ A palpable tender inguinal mass in which pain is exacerbated on
exertion is highly suggestive of an incarcerated inguinal hernia.
⁃ Patients with lactational infections may benefit from an ultrasound-
guided needle aspiration if a breast abscess is diagnosed.


⁃ The initial evaluation of gastric ulcers requires endoscopy with

multiple biopsies. If no cancer is detected, patients receive PPIs with H. Pylori
eradication, if needed. If ulcers do not heal on repeat endoscopy, they are
biopsied and, in the absence of cancer, ulcers are surgically excised.
⁃ Asliding hernia is defined as a hernia in which part of the hernial sac
is composed of visceral peritoneum of an internal organ. Usually, sliding hernias
are indirect inguinal hernias and the organs most commonly involved are the urinary
bladder and the colon. The repair of a sliding hernia may be difficult and even
dangerous if the surgeon does not recognize the visceral peritoneum composing the
hernial sac.
⁃ MEN2 syndrome includes medullary thyroid carcinomas, pheochromocytomas,
and parathyroid tumors.
⁃ Glucocorticosteroids impair fibroblast proliferation and collagen
synthesis and therefore delay wound healing.
⁃ When high-grade dysplasia is found on a biopsy of a patient with
Ulcerative Colitis, the recommendation is to perform a total proctocolectomy since
the presence of an invasive carcinoma already existing in the colon is likely.
⁃ Thyrotoxicosis must be managed medically before thyroidectomy! If the
patient is not properly treated preoperatively, a thyroid storm can develop in the
postoperative period and can be life-threatening. We give steroids
⁃ The initial imaging methods used in acute abdomen may be abdominal US,
radiograph, CT or none. All depends on the medical findings, availability and the
physician's considerations.
⁃ The most frequent retroperitoneal sarcoma subtypes are liposarcoma,
leiomyosarcoma, and malignant fibrous histiocytoma (MFH).
⁃ The appropriate time for preoperative administration of antibiotics
prophylaxis is 60 minutes prior to surgery.
⁃ • Albumin and prealbumin levels reflect nutritional status.
• Albumin has a long half-life (20 days) and is an indicator of chronic nutritional
status. • Prealbumin has a shorter half life (2 days) and therefore reflects
more recent nutritional status.
⁃ Acute rejection is considered to be the only rejection type which is
fully reversible. This can be achieved by changing or increasing the dosage of the
immunosuppressive therapy.