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Surgery Review 8

SR 8: Urology, Gyn, Neurosurgery, Ortho, Pediatric, Statistics

Describe the anatomy of the renal vasculature Anterior to posterior – reval vein, renal artery, renal pelvis; right renal artery crosses posterior to IVC
What are the most common type of kidney stones? oxalate - especially after small bowel resection
What type of kidney stones are associated with proteus infection? struvite stones, "staghorn" - proteus produces urease
What are markers for non-seminomatous testicular cancer? AFP and B-HCG
What tumor markers are elevated in a seminoma? Often none (10% have B-HCG elevation, should not have AFP elevation)
What is the surgical approach to biopsy a testicular mass? Orchiectomy via inguinal incision. Never trans-scrotal
What stage seminomas get RT? Chemotherapy? All stages - very radiosensitive, Node+ get platinum-based chemo
What are the long term effects of cryptorchidism? increased testicular cancer, orchiopexy can increase fertility but not decrease cancer risk
What is the treatment of nonseminotamous testicular cancer? Stage I – orchiectomy and prophylactic retroperitoneal lymph node dissection, Stage II+ also get XRT, chemo, and resection of residual masses
How is PSA level affected after prostatectomy? Should go to 0 within 3 weeks post surgery
What is the classic triad of renal cell carcinoma? abd pain (capsule stretching), mass, hematuria
Where is erythropoetin made? What stimulates its production? 95% made in kidney, stimulated by hypoxia, (decreased production in ESRD)
What causes fever and hypertension in a renal cell carcinoma patient? Increased erythropoetin - erythrocytosis
What is the treatment of renal cell carcinoma with extension into the IVC? Can still perform radical nephrectomy and pull tumor thrombus out of IVC
What is the most common tumor of the kidney? Metastasis from the breast
What paraneoplastic syndromes are associated with renal cell carcinoma? erythropoietin, PTHrp, ACTH, insulin
How does prostate surgery affect clotting? Can release urokinase -> activates plasminogen -> thrombolysis
What is Von Hippel-Lindau syndrome? Multifocal and recurrent renal cell carcinomas, renal cysts, CNS tumors, and pheochromocytomas
What is the treatment for transitional cell cancer of the renal pelvis? radical nephroureterectomy
How is a urethral injury diagnosed? retrograde urethrogram (RUG), do not place foley - needs suprapubic catheter
What is the treatment for a traumatic bladder injury? Extraperitonal - a/w pelvic fx, foley only for drainage Intraperitoneal - no pelvic fx, usually dome rupture - laparotomy with multi-layer closure and foley
What is the treatment of bladder cancer? intravesical BCG or transurethral resection if musle not involved (T1), if T2+ then cystectomy with ileal conduit, chemo, and XRT
What is the treatment of testicular torsion? Bilateral orchiopexy
What is post-TURP syndrome? hyponatremia secondary to irrigation with water; can precipitate seizures from cerebral edema
What is the treatment of stress incontinence? Kegel exercises, alpha-adrenergic agents, surgery for urethral suspension or pubovaginal sling
What is the treatment of urge incontinence? anticholinergics, behavior modification, cystoplasty, or urinary diversion as last resort
What is the treatment of overflow incontinence? TURP (caused by BPH leading to distention and leakage)
What is a varicocele associated with? Renal cell carcinoma (left gonadal vein drains into left renal vein, obstruction by renal tumor causes varicocele), or other retroperitoneal malignancy
What contains the uterine vessels? Broad ligament
What contains the ovarian artery, vein, and nerve? Infundibular ligament
What hormone do sertoli cells produce and secrete? anti-mullerian hormone causing ipsilateral regression of mullerian ducts (eventual fallopian tubes, therefore not produced by females)
Which embryonic structure forms the epididymis, vas deferens, and seminal vesicles under the influence of local testosterone? mesonephric ducts
What type of abortion is characterized by a 1st trimester bleeding, closed os, and absent heartbeat? Missed abortion
What type of abortion is characterized by a 1st trimester bleeding and a positive heartbeat? Threatened abortion
Rectal bleeding, irregular menses, pelvic pain, and bluish mass on proctoscopy in a female - what is the diagnosis? Endometriosis involving the rectum
What is the treatment of endometriosis? hormonal therapy / OCPs
What are the long-term effects of PID? Increased risk of infertility and ectopic pregnancy
What is the staging of ovarian cancer? I - limited to ovary (including bilateral involvement), II - in pelvis, III - throughout abdomen, IV - distant mets
What type of ovarian cancer has the worst prognosis? Clear cell type
What is a Krukenberg tumor? colon or stomach CA met to ovary - see signet ring cells on path
What is Meig's syndrome? pelvic tumor causing ascites and hydrothorax
What are the indications for oophorectomy for an ovarian cyst? Septated, increased vascular flow on Doppler, solid components, or papillary projections
What is the treatment for an ovarian mass found incidentally at time of laparotomy? Oophorectomy with frozen section initially, if postmenopausal and cancer then TAH and BSO; if premenopausal and cancer, simply remove tube and ovary
What are contraindications to estrogen therapy? Endometrial or breast cancer, active thromboembolic disease, undiagnosed vaginal bleeding
What is the difference between these types of peripheral nerve injuries: neuropraxis, axonotmesis, neurotmesis? Neuropraxis - focal demyelination, improves Axonotmesis - loss of axon continuity (nerve and sheath intact). Regen 1mm/day Neurotmesis - loss of nerve continuity, surgery required for nerve recovery
What triggers ADH release? Produced when high osmolarity is sensed at supraoptic nucleus of hypothalamus
What is Diabetes Insipidus? Alcohol and head injury inhibit ADH release - high UOP, low urine SG, high serum osmolarity/Na
What is SIADH? Increased ADH release most often by head trauma/tumors or SCLC. Oliguria, high urine osmolarity, low serum osmolarity/Na
What is the effect of ADH? Causes increased free water absorption at the distal tubules and collecting ducts and increases peripheral vascular resistance
What is cerebral perfusion pressure? Mean Arterial Pressure (MAP) - Intracranial Pressure (ICP) Keep ~70
When does maximal brain swelling occur after traumatic brain injury? 48-72 hours after injury
What is Cushing's triad? Hypertension, bradycardia, and Kussmaul respirations (slow, irregular) associated with increased ICP
Describe the Glasgow Coma Scale ratings Motor: 6 commands, 5 localizes, 4 withdraw pain, 3 flexion, 2 extension, 1 none Verbal: 5 oriented, 4 confused, 3 inappropriate, 2 incomprehensible, 1 none Eyes: 4 spont, 3 command, 2 pain, 1 none
What are the signs of spinal shock? Hypotension with bradycardia, warm perfused extremities (vasodilation) Cord injury above T5
What are the deficits in anterior spinal artery syndrome? Lose bilateral motor, pain, and temperature. Keep position sense, light touch
What is Brown-Sequard syndrome? Spinal cord hemi-transection Lose ipsilateral motor, contralateral pain and temperature
What is Central Cord Syndrome? Acute cervical spinal cord injury characterized by bilateral loss of upper extremity motor, pain, and temperature; legs relatively spared. Often due to hyperextension
What are the indications to operate on a skull fracture? If open or depressed
What test are useful for a paraganglioma? urine metanephrines, MIBG for extramedullary chromatin tissue
What type of intracranial hemorrhage is seen in premature infants? Treatment? Intraventricular (subependymal) hemorrhage, secondary to rupture of fragile vessels in germinal matrix after ECMO or in congenital heart disease. Tx – ventricular catheter for drainage and prevention of hydrocephalus
What is the treatment of a patient who presents in shock after XRT for a pituitary adenoma? Steroids (cause is pituitary apoplexy)
What cells act as brain macrophages? Microglial cells
What is a Salter-Harris fracture? Which types need open procedures? fracture that involves the epiphyseal plate or growth plate of a bone Types III, IV, V are intra-articular and thus need open repair
What fractures are associated with non-union? clavicle, 5th metatarsal fracture
What three fractures are prone to compartment syndrome? Calcaneous, tibia, supracondyle of humerus
What three fractures are prone to AVN? Femoral neck, talus, and scaphoid
What are the effects of L3-L4 disc herniation? L4 root compresson - quadriceps, weak knee jerk
What are the effects of L4-L5 disc herniation? L5 root compression - foot drop, possible big toe hyperesthesia
What are the effects of L5-S1 disc herniation? S1 root compression - weakness in plantar flexion (pushing off toes), weak ankle jerk, hyperesthesia lateral foot/calf
What does the median nerve do? thumb apposition, sensation to most of palm, 1st 2 1/2 fingers (carpal tunnel)
What does the ulnar nerve do? intrinsic musculature of hand, finger abduction, wrist flexion, sensation to 2 1/2 fingers/back of hand
What does the radial nerve do? Wrist/finger extension, sensation to back of lateral hand; no motor in hand
What is commonly injured in shoulder dislocation? axillary nerve in anterior dislocation (90% of dislocations), axillary artery in posterior dislocation
What is a Monteggia fracture? What is the treatment? proximal ulnar fracture with radial head dislocation Treat with ORIF
Which nerve injury results in foot drop? Which nerve injury results in decreased foot eversion? Foot drop = deep peroneal nerve Foot eversion = superficial peroneal nerve
What is the terrible triad of O'Donaghue? lateral blow to knee - injury to ACL, MCL, medial meniscus
What are the benefits of early ORIF in femur fracture? early mobilization decreased fat embolization
What are the signs of hip dislocation? Posterior (90%) - internal rotation, flexed, abducted thigh Anterior - frog leg (external rotation, abduction)
What is treatment of knee dislocation? Most texts say arteriogram all posterior, but at least some vascular assessment (ABI/CT angio/duplex US) is necessary to evaluate popliteal injury even in the presence of normal vascular assessment
What is a Volkmann's contracture? What is the treatment? Permanent flexion contracture of the hand at the wrist. Caused by supracondylar humerus fx -> compromised anterior interosseous artery -> deep forearm flexor compartment syndrome Needs fasciotomy
What does a tender snuffbox indicate? Navicular/scaphoid fracture - even with negative XR, requires cast up to elbow
What is most commonly injured after lower extremity fasciotomy? Superficial peroneal nerve
What is a Dupuytren's contracture? What is the treatment? Progressive proliferative of palmar fascia causing flexion contracture of fingers of hand, unknown exact cause (trauma, DM, EtOH, epilepsy) Treatment with steroids, physical therapy, but may need fasciotomy
What is a sunburst pattern on x-ray suggest? Osteogenic sarcoma
What does "onion layering" on x-ray suggest? Ewing sarcoma
What do pseudorosettes on path suggest? Ewing sarcoma
What is the last sign in compartment syndrome? Loss of pulses
What is compartment syndrome most likely to occur? Anterior compartment of the lower extremity
What is AVN in a child under 2 years old? Legg-Calve-Perthes disease, caused by hypercoagulable state resulting in a painful gait limp
What is tibial tuberosity apophysitis caused by traction injury from quadriceps in adolscents aged 13-15? Osgood-Schlatter disease
What is pulmonary sequestration? Treatment? mass of non-functioning primitive tissue in the lung Extralobar - systemic artery and vein - resection not necessary Intralobar (75%) - aorta in and pulmonary vein out - lobectomy for recurrent infections
What is the most common presentation of pulmonary sequestration? recurrent pulmonary infections
What is the cause of respiratory distress at birth, and massive hyperinflation of a single lobe of the lung? What is the treatment? Congenital lobar emphysema Rx: lobectomy, excellent prognosis
What is the treatment for a choledochal cyst? Must excise, leaving cyst increases cancer, pancreatitis, and cholangitis risks Transplant if type IV or V
What are the types of choledochal cysts? I - (>90% of cysts) dilatation of CBD (part or whole) II - diverticulum III - choledochocele involving sphincter IV - intra and extrahepatic cysts (Caroli's disease) V - intrahepatic cysts
Lateral neck mass in infancy with rotation of the head? Treatment? congenital torticollis Treatment = physical therapy, rarely surgical resection of muscle
What is a cystic hygroma? What is the most common location? lymphangioma - left posterior triangle of neck
What is the #1 complication of cystic hygroma? infection
What is the most common branchial cleft cyst of childhood? 2nd, on anterior border of SCM muscle (goes through carotid bifurcation into tonsillar pillar)
What is the treatment for a thyroglossal duct cyst? Sistrunk procedure - en bloc excision of cyst (midline) with hyoid bone (there is a risk of malignant degeneration of thyroid tissue in cyst)
What is the treatment for a strawberry hemangioma observation - most involute by age 7
What gene is neuroblastoma associated with? N-myc
What is elevated in neuroblastoma? VMA - Vanillyl mandelic acid HVA - homovanillic acid, metanephrines, and catecholamines; NSE (neuron-specific enolase) elevated in all patients with metastases
What is the treatment for a Wilm's tumor? nephrectomy (80% cure), all patients except stage I weighing less than 500g get vincristine and actinomycin
What is the #1 pediatric malignancy overall? Leukemia
What is the #1 cause of painless GIB in children? Meckel's diverticulum
What is the embryologic origin of a Meckel's diverticulum? Persistent omphalomesenteric/vitelline duct
What are the two types of tissue in a Meckel’s diverticulum? Pancreatic (most common) and gastric (most likely to be symptomatic)
What metabolic disorder is present in pyloric stenosis? hypochloremic, hypokalemic metabolic acidosis
What is the treatment of intussusception in children? air/contrast enema (max 120mm Hg) IV glucagon can help (relaxes smooth muscle) OR if free air/peritonitis
What is the cause of intestinal atresia? Intra-uterine vascular events Mother may have polyhydramnios
What is the most common type of tracheo-esophageal fistula? Type C - blind esophagus, distal TE fistula. Spit up feeds, NGT won't pass
What other abnormalities can a patient with a tracheoesophageal fistula have? VACTERL - vertebral, anal atresia, cardiovascular, TEF, esophageal atresia, renal, limb defects - structures derived from embryonic mesoderm
What is the surgical treatment for malrotation? Ladd's procedure - appendectomy, take down bands, counterclockwise rotation
What is the treatment for a meconium ileus? Gastrograffin enema - diagnostic and therapeutic, can also use N-acetylcysteine enema
What test should be performed after diagnosis of meconium ileus? sweat chloride test or PCR for Cl channel defect
How does necrotizing enterocolitis in a newborn present? After initiating feeds in a neonate (premie) in the 2nd or 3rd week of life with blood in the stool OR free air/peritonitis/acidosis Classic triad: abd dist, bloody stools, pneumatosis
What is the treatment for imperforate anus? If low (below levators) - anoplasty If high (meconium in urine, fistula to bladder, vagina, or urethra) - need colostomy
What are the characteristics of gastroschisis? Congenital abd wall defect, intrauterine rupture of umbilical cord, no associated defects (except maybe malrotation), lateral (right) defect, edematous inflamed bowel, no sac
What are the characteristics of omphalocele? midline defect, may contain liver or other non-bowel contents, frequent anomalies, has peritoneal sac
What anomalies are associated with omphalocele? Cantrell pentology: Cardiac, Pericardium, Sternal, Diaphragmatic, and Omphalocele
What is the first sign of CHF in children? hepatomegaly
What is the #1 cause of a colon obstruction in a newborn? Hirschsprung disease - no BM in first 24 hrs, diagnose with rectal bx
What is caused by absence of ganglion cells in myenteric plexus? Hirschsprung’s disease
What is the treatment for biliary atresia? Kasi procedure - hepatoportoenterostomy - before age 3 months. 1/3 get better, 1/3 go on to liver transplant, 1/3 die
What is characterized by hypoplasia of abdominal wall, urinary tract abnormalities with dilated urinary system, and bilateral cryptorchidism? Prune-belly syndrome
Describe a type I error rejects null hypothesis incorrectly – falsely assumed there was a difference when no difference exists
Describe a type II error accepts null hypothesis incorrectly because of small sample size
What type of bias does a randomized controlled trial avoid? Treatment bias
What type of bias does a double-blind controlled trial avoid? Observational bias
How do you calculate relative risk? incidence in exposed / incidence in unexposed
How do you calculate power of a test? 1 – probability of type II error
How do you calculate sensitivity? true positives / (true positives + false negatives)
How do you calculate specificity? true negatives / (true negatives + false positives)
How do you calculate positive predictive value? true positives / (true positives + false positives)
How do you calculate negative predictive value? true negatives / (true negatives + false negatives)
What values depend on disease prevalence? Predictive value, whereas sensitivity and specificity are independent of prevalence
Created by: jclanton82
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