Professional Documents
Culture Documents
Table of Contents
Topic
Pages
Breast
Orthopedics
Renal, Adrenal, Pituitary
Spleen
Thoracic/Mediastinum/CV
Head and Neck
Skin/Melanoma/Sarcoma
Transplant
Pancreas
Hand
Burns
Vascular
Esophagus
Stomach
Small+Large Bowel/Rectum
GU/OB/Gyn-Onc/Neurosurg.
Coagulation
Infections/Critical Care/Trauma/ICU/FEN
Parathyroid/Thyroid
Hepatobiliary
Pediatric Surgery
Anesthesia
Miscellaneous
4-7
7-8
8-9
9
9-12
12-13
13-14
15
15-16
17
18
18-20
20-22
22-23
23-25
25-26
27
27-30
30-31
31-32
32-33
33-34
34-36
BREAST
In a patient who has undergone neoadjuvant chemo., even though the tumor may
disappear, you should realize that there is a 90% chance of residual tumo r there
which must be treated with surgery
Stewart -Treves: lymphangiosarcoma in a pt. who previously underwent a MRM
about 10-15 years ago. Pt. develops a purple mass on the arm
Angiosarcoma of the breast: pts. usually 10-15 years younger than typical IDC;
lymph node spread is rare, spreads hematogenously, tx. with simple mastectomy
without LND; ? benefit of XRT, chemo. no benefit
DCIS: age 54-58, 2% incidence, can have pain, a mass or nipple discharge,
microcalcifications are present in vast majority, 1/3 premenopausal, 18%
incidence of synchronous invasive carcinoma, 40-80% mutlicentric, 10-20%
bilateral, 2% axillary mets., 25-70% incidence of a subsequent cancer (ipsilateral)
with an interval of 5-10 years; if it comes back, it will most likely be an
infiltrating ductal carcinoma; the greatest risk for recurrence is size > 2.5cm and
comedo necrosis; Treat with salvage mastectomy.
DCIS: 4 subtypes: papillary (best prognosis), cribriform, solid, and comedo
(worst prognosis); Comedo assoc. with poor prognostic indicators: overexpression
of HER-2/neu, ER/PR (-) receptor, high thimidine index, p21 ras oncogene
expression, aneuploidy and high S-phase fraction
DCIS: local recurrence following a lumpectomy alone is 17%; if you give XRT
to the breast after lumpectomy, this decreases the local recurrence rate to 7%.
There is absolutely no difference in overall survival. XRT only helps decrease
local recurrence rate.
Comedo DCIS represents a high grade, aggressive, poor prognosis type of DCIS;
It is only for this form of DCIS would you probably perform a SLNB with
lumpectomy and XRT
The most common genetic abnormality in breast cancer is a mutation in the tumor
suppressor gene p53 (seen in 30-40% of all breast cancers)
Locally advanced cancer seen in patients with primary tumors > 5cm (T3
lesion), fixed or matted axillary nodes (N2 disease), primary tumor fixed to the
chest wall (T4 lesion) and inflammatory breast cancer. For any of the above, give
neoadjuvant chemo. prior to any surgery. Remember, even if the patient has a
great response to neoadjuvant chemo., you must assume there will be residual
microscopic disease at the primary site (in over 90% of cases), therefore, you
need to operate after neoadjuvant chemo, most likely with MRM.
In a pt. with a low risk of tumor recurrence (T1N0MX) and ER+, the addition
of chemo. (CMF) adds no improvement in survival compared to tamoxifen alone
Trials with adjuvant chemo. do not demonstrate any comparable reduction in
cancer in the opposite breast (as tamoxifen does)
LCIS: It is not a premalignant condition; it is a marker for the development of a
subsequent cancer; there are no clinical signs, seen on pathology specimen for
some other breast surgery, there are no microcalcifications, 1% incidence of
axillary mets., 70-80% bilaterality, incidence of a subsequent infiltrating ductal
cancer developing is 20-35%, in either breast at a 15-20 year interval from the
time of diagnosis; There are only 3 treatment options for all patients: bilateral
simple mastectomies, close follow-up with yearly MMGs, and tamoxifen. There
is no confusion on this.
Inflammatory breast cancer: Patient presents with an inflamed, tender breast,
often near and/or involving the nipple areolar complex with enlargement of the
entire breast; they will have been previously treated with ABX. for a suspected
breast abscess or mastitis which doesnt get better. Do a punch biopsy for
diagnosis; cancer cells penetrate and involve the dermal lymphatics; treat with
neoadjuvant
chemo.>>>>mastectomy>>>>XRT>>>>consolidation
chemo.
Associated with a 50% 5-yr survival
Tamoxifen: It is a SERM (selective estrogen receptor modifier); It binds to the
estrogen receptor on cancer cells and prevents any estrogen from binding to it.
Remember, it is an anti-estrogen for breast tissue, but acts as an estrogen for other
tissues like endometrium, bone and liver. Thus, this is why tamoxifen causes a
slight increase in the risk of developing endometrial cancer (and DVTs and
PEs). It is effective in ER/PR + pre- and post- menopausal women as an adjuvant
endocrine therapy at 20 mg/day; 5 years duration (no improvement if given for 10
years). NSABP P1/24: high risk women (GAIL>1.66%, >60y/o, LCIS) have a
49% reduction in risk for the development of invasive breast cancer in the
ipsilateral and contralateral breast; increased survival in stage I,II pts. NSABP-24:
DCIS>>>lumpectomy and XRT>>>randomized to placebo vs. tamoxifen;
tamoxifen associated with a decrease in all breast cancer events (invasive ipsi.
cancer 3.4% in placebo vs. 2% in tamofien group, with similar decrease in noninvasive cancer)
CIs to SLNB are: multifocal disease, palpable axillary adenopathy, primary
tumor >5 cm, locally advanced cancer, pt. who received neoadjuvant chemo.
In patients with negative LNs, tumor size is the most important prognostic factor
for relapse; <1cm>>>>90% 10- yr. Survival; >1cm>>>25-44% of stage I,II
patients will develop recurrent disease, therefore, adjuvant chemo. is indicated in
these patients with either AC (adria/cycloph) or CMF (cyclo/methotr/FU)
BRCA 1, BRCA 2: About a 60-80% lifetime risk of developing breast cancer if
mutation is present (general population is 12%); BRCA1 (chrom.#17) is also
associated with ovarian cancer and prostate cancer; higher occurrence of
medullary cancer; BRCA2 (chrom# 13) is associated with male breast cancer;
higher occurrence of tubular- lobular invasive cancer
Li-Fraumeni Syndrome: AD/ SBLA (Sarcoma, Breast, Leukemia,
Adrenocortical Cancer); Breast cancer is the most common cancer associated with
LFS, but overall accounts for <1% of all breast cancers; caused by germline
mutation in the TP53 tumor suppressor gene>>>protein product is p53.
For patients s/p lump/breast irrad./ALND>>>>would give axillary radiation to
patients with high risk features: >5 (+) nodes, bulky nodes >2cm, extranodal
extension of tumor
Radiation mastitis: Occurs most commonly after XRT and doxorubicin; Tx. of
choice is pentoxifylline
Lobular carcinoma of the breast: uniform cells seen in a single file (Indian
filing)
Slipped capital femoral epiphysis : Always presented with a 10-15 y/o fat child
(male or female) c/o knee pain after after a fall; this is referred pain from the hip;
tx. with immobilization until stable
Torn Achilles: always presented with an athlete (tennis player serving) who after
feels a sudden severe pain in the calf after jumping
Femoral shaft fracture is treated within 24 hours with IM rod fixation; In
children, these are always treated conservatively with traction
Open femoral fractures: operative debridement within 8 hours>>>repeat within
24-48 hours>>>empiric ABX>>>never close these primarily, wait 5-7 days for
secondary closure
RENAL, ADRENAL, PITUITARY
ITP: circulating IgG antibodies to platelets causing their destruction; The spleen
is the source of these antibodies; F:M 3:1; Acute ITP occurs in kids <16 yoa and
over 80% recover without specific therapy (dont wack out their spleen);
However, if they dont improve and in the adult, try 2 months of steroids 1st ; if no
response>>splenectomy; if the patient responds to steroids but recurs
later>>>splenectomy; Dont forget to give pneumovax. For kids, prophylactic
PCN until adolescence (age 12 to 16 y/o).
Hypersplenism: Is a syndrome of splenomegaly and pancytopenia with a normal
BM; peripheral blood smear normalizes after splenectomy
Splenic vein thrombosis: Most commonly seen secondary to pancreatitis and
presents often as an UGI bleed +/- splenomegaly, abd. pain and chronic anemia;
EGD reve als gastric varices; TX: splenectomy
Splenectomy is of benefit for patients with portal HTN when pt. has gastric
varices (only instance)
TTP: hemolytic anemia/decreased platelets/neuro symptoms/ fever/renal
dysfunction (all seen in only 40%); F:M 2:1; poor prognosis, especially during the
1st attack; Initial tx: exchange plasmapheresis + plasma infusions; no benefit for
splenectomy
Sickle cell disease: sequelae include atrophy, infarction, splenomegaly (early)
with later atrophy; no rupture
A patient with splenosis will not have Howell-Jolly bodies on a peripheral blood
smear (splenic remnants removes them from the circulation)
Hereditary spherocytosis : deficiency of spectrin; splenomegaly; AD; dx. by
osmotic fragility test; tx; curable with splenectomy
THORACIC/ MEDIASTINUM / CV
Early stage I, II treated with either XRT or surgery (not both, same outcome) and
advanced stage III, IV are treated with combination XRT+surgery (superior
outcome compared to either one alone)
XRT alone is the best treatment for SCC or BCC of the nose, eye, lip, eyelid,
inner and outer canthi with cure rates of 96% (BCC), 92% for SCC.
SCC of the H + N: stage I and II (up to 4 cm, no nodes) single modality tx. with
either surgery or XRT; stage III, IV combined modality
Freys syndrome: gustatory sweating, most often seen after parotid surgery; pt.
gets sweating/flushing/warm sensation over-pre-auricular area with eating; tx:
botulinum toxin A with response rate close to 100%
Glottic cancer: if the cords are fixed, tx. with surgery and XRT; if not XRT alone
Cholesteatoma: Associated with pars flacida (marginal perforation of the TM)
secondary to OM or eustachian tube obstruction; after TM perf.>>>desquamation
of squamous cells>>>accumulate>>>destroy bone, including ossicles>>purulent
labrynthitis>>>facial paralysis, intracranial infection; you will see white pieces of
crud in the middle ear on exam +/- destruction of the adjacent temporal bone; tx:
radical/modified mastoidectomy
Juvenile angifibroma: purplish polypoid mass in the nose; non- metastasizing but
locally aggressive; pt. is pre-pubescent with frequent nose bleeds; tx: excision
only after pre-op embolization
Salivary gland tumors: benign: pleomorphic adenomas: most common benign
tumor of the parotid; do not enucleate, do a superficial parotidectomy with
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Actinic keratoses: is a pre- malignant lesion and should be resected with adequate
margins; seborrheic keratoses, cavernous hemangioma and junctional nevi
are not
Merkel cell tumor: rare, aggressive tumor of the dermis, neuroendocrine in
origin, high frequency of locoregional recurrence even after adequate 2 cm
margin; highly radiosensitive and should use XRT to the excision site and
regional nodes; 85% express somatostatin receptors and are (+) on octreotide scan
Extremity melano ma: 3.7mm lesion has a >50% chance of nodal involvement
(clinically negative); 1.6 to 3.7mm>>>35% chance; 1.5mm or < has a 15%
chance of nodal involvement
Subungal melanoma: remove the nail and biopsy>>if positive>>amputation at
one joint proximal
The only survival benefit for a prophylactic LND is for males, <60 yoa with a 12 mm lesion without ulceration; All melanoma patients with palpable adenopathy
get a therapeutic LND
Dysplastic nevus syndrome: familial tendency to develop atypical moles and
melanoma; 10% of cases have such a genetic component
Among congential nevi, only the giant congenital nevus (>20cm in diameter) is a
precursor to melanoma
Stage of melanoma has a direct correlation with long term survival; the thicker
the melanoma, the poorer the 5-yr survival
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Any patients with a known h/o melanoma and palpable lymph nodes, confirmed
by FNAB to be melanoma, should undergo a complete, therapeutic LND
Surgical margins: Any lesion <1 mm>>>1 cm margin is adequate; 1-4mm>>>
2cm margin; >4mm>> at least 2cm, 3cm is probably better; For head and neck
and distal extremity, <1mm lesion >>>1 cm margin and >1mm>>>at least 1 cm
margin (no data, this is accepted surgical practice)
Sentinel LNB: Current recommendation are to perform a SLNB on any lesion
>1mm tumor thickness; Overall, if the SLNB is (-), the rest of the LN basin is
also (-) (90-96% of the cases); Remember, the background must be <1/10 the
reading of the sentinel node by gamma probe.
The only known adjuvant therapy for patients that has been shown in some trials
to be beneficial in improving overall and disease free survival in resected stage II
and stage III patients with melanoma is Interferon-alpha (2A) (not gamma), called
INTRON-A. Currently, this is standard of care
Interleukin-2 is FDA approved for treating patients with metastatic melanoma
(stage IV) and metastatic renal cell cancer. It is given IV at 600,000 IU/kg q8
until DLT; the side effects are a systemic leak syndrome causing hypotension;
The SBP can be supported with inotropes in the ICU
Soft tissue sarcoma (STS): All arise from mesoderm/Most common sarcoma
overall is malignant fibrous histiocytoma (MFH), second is liposarcoma/Biologic
aggressiveness is best predicted by grade (not stage)/ survival is best predicted
by grade , not stage/high grade sarcomas (# mitoses per high power field) have a
high metastatic potential and most often spread hematogenously to the lung
STS biopsy techniques do not include FNA/ can sometimes get diagnosis by a
core needle biopsy/ If less than 5 cm, can attempt an excisional biopsy, if >5cm,
try a percutaneous core biopsy or incisional biopsy/The incision on the extremity
is a longitudinal incisional directly over the mass (so if you do a WLE later, you
encompass this scar in it)
STS: Surgery + XRT is better than surgery alone for local control, but no
difference in overall survival; chemo (primarily doxorubicin-based) doesnt work,
so dont give it
Epithelioid sarcomas are high grade sarcomas with a known propensity for
multi- focal disease @ presentation; it occurs in very young males/mostly
limbs/rarely H&N/has a tendency to spread locally
Hyperthermic isloated limb perfusion: Is used for STS in an attempt to preserve
the limb (which would otherwise need to be amputated due to advanced disease);
utilizes melp halan (without TNF) with an overall major tumor response rate of
87% (CR=36%, PR=51%), with limb salvage in 84% of all patients
Retroperitoneal sarcomas: Most common is liposarcoma (42%) and
leiomyosarcoma (26%); CT and MRI are essential before operating; Do not need
to biopsy pre-op except only if you have a suspicion it is a lymphoma, or
unresectable or a metastasis and not a sarcoma primary; Surgical resection with
negative margins remains the standard primary treatment for all patients with
localized retroperitoneal sarcoma
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TRANSPLANT
Hyperacute rejection: This is an antibody (B-cell) mediated event; can test with
the lymphocytotoxic crossmatch (B-cell crossmatch); kidney is the most
susceptible organ; will often see immediately after vascular clamps are released
during surgery
Renal transplant rejection: tenderness over the graft with enlargment, fever,
malaise, HTN, increased WBC, oliguria and increased creatinine; dx. is confirmed
by renal biopsy; tx: high dose IV prednisone, azathioprine and irradiation
OKT3: A monoclonal antibody (made in mice) that binds to the CD3 TCR
complex; Rapamycin: macrolide antibiotic that inhibits T cell activation and
maturation; FK506=Tacrolimus: macrolide antibiotic that acts by
inhibiting/blocking calcineurin-calmodulin complex>>>NF-AT activity
decreased, prevents cytokine transcription of IL-2 gene and therefore arrests Tcell activation; CyA: same action as FK506, but is a fungus; CyA blocks TCR
signal transduction but does not inhibit co-stimulation, T-cell becomes active
again without CyA; Can overcome CyA effects with exogenous IL-2 and thus
CyA is a maintenance agent and not a rescue agent for rejection; ALG:
polyclonal Ab prep. against many different antigens on T-cells. It is made in a
horse (ATGAM), basically removes T-cells from the system; side effects include
severe thrombocytopenia, chills, fever, skin rash
Azathioprine: purine analogue, interferes with DNA synthesis; MTX: inhibits
DHF reductase and prevents conversion of folic acid to THF acid
The most frequent complication after a liver transplant is always the biliary
anastomosis (leak/obstruction/stricture); blood supply for this usually is from the
hepatic artery
Graft thrombosis is the most common complication following pancreatic
transplantation and usually occurs within the 1st 24 hours; tx: remove the
transplant
PANCREAS
Mucinous and serous cystadenomas are benign lesions, but cannot reliably be
differentiated from malignant lesions, therefore you resect all cystic lesions of the
pancreas because of the chance that it may come bacl on path as a mucinous or
serous cystadenocarcinoma; In general, serous has central calcification,high
glycogen levels, low CEA and low CA19-9 with mucinous just the opposite with
peripheral calicification
Primary pancreatic lymphoma: diagnosis based on CT- guided biopsy, if
unsuccessful, can do an open biopsy. There is no role for extensive surgery for
pancreatic lymphoma; treat with chemo (Doxorubicin-based)
Glucagonoma: is a malignant pancreatic islet cell tumor assoc. with decreased
A.As in serum/increased glucagons in serum/weight loss/NIDDM/ severe
mm.wasting/cachexia and a characteristic rash called necrolytic migratory
erythema (this will never appear as an answer); You must identify the rash as a
15
raised, red, pruritic rash that can progress to bullous lesions that slough; increased
risk of DVTs and PEs;
Metastatic glucagonoma: Debulk if possible; if not resectable, treat with
octreotide
Nesidioblastosis: childhood hypoglycemia (~40 mg/dl) with no known etiology;
treatment is with 95% pancreatectomy with sparing of the duodenum; do not do a
splenectomy
Insulinoma: usually found in the tail of the pancreas (not in gastrinoma triangle),
usually solitary and readily curable with enucleation; when malignant (rare),
tumor debulking, streptozotocin and diazoxide is helpful to control the
hypoglycemia; most common islet cell tumor
Factitious insulinoma: check a C-peptide level, if absent>>factitious (almost
always presented with a health care worker with glucose of 40)
Prolactinoma: #1 cause of pituitary adenoma with galactorrhea and irregular
menses; tx. with bromocriptine with >75% response rate, if not transphenoidal
resection
Pancreatic cancer: Almost always presented with a pt. with painless jaundice,
weight loss and back pain; assoc. with k-ras mutations;tx: Whipple vs. biliary and
gastric bypass
Somatostatinoma: steatorrhea and diarrhea +/- stones; VIPoma: diarrhea and
achlorohydria
MEN IIA/IIB: mutation in the ret proto-oncogene; chromosome #10
MEN I: pit/panc/para, most common presentation in over 90% is
hyperparathyroidism, chromosome #11; MEN II: MCT defines MEN II; MEN
IIA: MCT/pheo/para, do not forget about the pheo. because this is what you will
operate on first, before treating the hyperparathyroidism; MEN IIB:
MCT/pheo/mucocutaneous lesions/marfanoid (think of Abe Lincoln), very
aggressive, poor survival
Adrenal incidentaloma: resect all >5cm; prior to resection, check to R/O pheo.
With urine metanephrines and catechols. b/c if present, need to prepare patients
for OR (alpha blockade etc..)
Pheochromocytoma: control the BP with an alpha blocking agent like
phenoxybenzamine, follow this with Beta blockade if they get tachycardic
(always give the alpha blockade before the Beta blockade)
Ransons Criteria: LDH>350, age>55, WBC>16, glucose>200, SGOT>25; after
48 hours: HCT drop>10%, BUN up >5, Ca<8, PO2<60, BD>4, fluid sequest. >6L
Annular pancreas: Abnormal fusion and rotation of the ventral pancreatic
primordium; forms a thin band of normal pancreatic tissue completely around the
2nd portion of the duodenum; do not cut this band, you will get a fistula; tx:
duodenoduodenostomy or duodenojejunostomy (do not do a gastrojejunostomy)
Pancreatic divisum: dorsal and ventral pancreatic ducts dont fuse together
resulting in the main pancreatic duct draining via the minor papilla; results in
development of pancreatitis due to a relative outflow obstruction of the main
pancreatic duct; tx: duodenojejunostomy or gastrojejunostomy
16
HAND
The most common carpal bone fx. by far is the scaphoid bone (80%); this
causes tenderness in the anatomic snuffbox
Swan-neck deformity: usually occurs as a complication of a Mallet finger: blunt
trauma to tip of finger (ball hits end of finger head on) causes avulsion of the
extensor tendon mechanism +/- bony fracture
Kanavels Tenosynovitis (suppurative flexor tenosynovitis): fusiform swelling of
digit/digit held in flexion/ pain evoked on passive extension/tenderness along the
synovial sheath; s.aureus most common, look for Eikenella (not sus cept. To
PCN); treatment of all human bites requires surgical exploration in the OR (I+D)
DeQuervains disease: compression of the extensor pollicic brevis and abductor
pollicus longus in the 1st dorsal compartment; F:M 10:1; cause most commonly
related to overuse; pain and tenderness of radial styloid in anatomic snuff box; +
Finkelstein test tx: initially with rest/splint/steroid injections with improvement
within 6 weeks; if not, surgery
Boutonnieres deformity: disruption of the central tendon slip leads to volar
displacement of lateral bands with a flexion deformity of the PIP (joint stuck in
flexion) and extension deformity of the DIP (hyperextension)
Dupuytrens contracture: Almost always presented with a white, middle-aged,
diabetic, alcoholic; causes contracture of the palmar aponeurosis most commonly
the 3rd and 4th digits/ afflicts primarily northern Europeans/M>F by
2:1/AD/nodule formation within the palmar fascia with fixation to tendons; no
known non-operative tx. therefore operate on all; surgical tx. with open
fasciectomy with partial or complete fasciectomy; can be confused with a lowgrade fibrosarcoma on path
Human bites (including fist to teeth in a fight): 1st step in management is
surgical exploration, I+D in the O.R., leaving the wound open with drainage of
joints; wound heals by secondary intention; most common organisms are s.aureus,
s.viridans, and eikenella corrodens which is an anaerobic GNR sensitive to PCN)
Animal bites: dog bites rarely become infected, however, >50% of cat bites do;
for cat bites look for pasteurella multocida; most require only local wound care,
empiric ABX. and immobilization
Carpal tunnel syndrome: F>M (they will almost always give you a postmenopausal typist or secretary); + phalen test; + Tinels test, compression of the
median nerve with neuropraxia within the carpal tunnel; medical tx. 1st with
steroid injections, splinting of the wrist in a neutral position, NSAIDS, diuretics to
decrease the edema (??); if no improvement, surgery
Thumb apposition and abduction>>median nerve; finger abduction, cross
fingers>>ulnar nn.; extensor mm.of wrist (no intrinsic mm. of the hand)>>radial
nn.
Ulnar nerve injury: claw deformity; radial nerve injury: waiter tip deformity
(cannot extend wrist or thumb)
17
BURNS
18
The effects of a truncal vagotomy are that it abolishes vagally mediated receptor
relaxation, causing an increase in emptying of both solids and liquids; also get an
increase in gastrin, decrease in pancreatic exocrine function, decrease in HCO3,
decrease in bile secretion, increase in fecal fat, decrease in CCK; increase risk of
gallstones secndary to decreased GB emptying; most common side effect after a
truncal vagotomy is diarrhea, controlled with dietary changes +/- somatostatin
Zenkers diverticulum: Occurs most commonly on the left; best test for dx. Is a
barium swallow; pt. c/o regurg. of undigested food and halitosis; can treat with a
crycopharyngeal myotomy only if small, otherwise, need a myotomy and
diverticulectomy (some will suspend it); Approach always from the left neck,
anterior to the SCM; it is a false diverticulum of the pulsion type; Epiphrenic
diverticulum is a false pulsion type, located in the distal esophagus and always
approached through a left thoracotomy
Esophageal cancer: Adjuvant XRT alone>>>no benefit; adjuvant chemo.(single
or multiple)>>> no benefit; periop. Chemo. or XRT>>> no benefit; Data supports
neoadjuvant XRT + chemo. followed by surgery; 3 yr survival is 32% vs. 6%
(surgery alone)
When doing a transhiatal esophagectomy, you must preserve the right
gastroepiploic artery; try to preserve the right gastric, but you can sacrifice if
you need extra lengt h;
The most common cause of esophageal perforation is iatrogenic (45-75%); ??
perf.>>>plain neck and CXR (90% of the time, dx. is made)>>free perf.+<72
hours>>>reinforced primary repair; if walled off perf., minimal symptoms and no
sepsis>>>conservative management>>>if fails>>>reinforced primary repair; free
perf. of >72 hours>>consider resection, cervical esophagostomy, G-tube, J-tube;
if you cant make the dx. with plain films, do a gstrograffin swallow 1 st , followed
by barium
Almost all esophageal perf. of <24 hours are repaired primarily; approach based
on location: cervical>>>left neck, thoracic>>>right posterolat. thoracotomy,
lower 1/3>>>left thoracotomy; Even those >24 hours, primary repair is still the 1st
choice of treatment; debride>>secure clo sure>>drainage>>reinforce with
autologous tissue (Thal flap or fundoplication, omentum, pleura, diaphragm,
intercostal mm., pericardium)
Achalasia: incomplete LES relaxation (<75% relaxation), aperistalsis in the
body, neurogenic degener., beak- like narrowing on esophagram, increased
incidence of cancer/ tx. most effectively with Heller myotomy and fundoplication
(never do a 360 wrap b/c it will be too tight, instead, use a partial wrap like a
Toupe)
Symptoms of achalasia: barium swallow>>motility testing>>EGD>>mild
symptoms>>observe or >>>dilatation (repeat x3) or nitrates and Ca-channel
blockers; if symptoms not controlled or become worse>>>Botox (repeat x3)>>no
relief>>>myotomy and partial wrap
Severe caustic injury: Lye (liquefaction) is worse than acid (coagulation); early
EGD is the gold standard; tx: EXLAP>>>total gastrectomy (for black tissue),
transhiatal esophagectomy, cervical esophagostomy and a J-tube; post-corrosive
21
esophageal cancer is increased a 1000 fold, therefore, must take out the
esophagus; reconstruction with the colon is preferred (vs. the stomach)
Only give neoadjuvant chemo and XRT for patients with T2,T3 or (+) nodes
esophageal cancer; Do not give for T0 or T1 b/c 90% survival with surgery alone
EUS is the gold standard for staging all patients with esophageal cancer;
Squamous cell cancer is the predominant form of esophageal cancer in black
men
Transhiatal: Anast. Leak>>>16%, Chylothorax>>3%, leak in chest,
mortality>>uncommon, recurrent nn. Injury>>11%, gastric necrosis>>yes
Ivor-Lewis: Anast. Leak>>>10%, Chylothorax>>3%, leak in chest,
mortality>>50%, recurrent nn. Injury>>4%, gastric necrosis>>no
STOMACH
the problem; type II and III: V+A with a B-I or B-II; type IV: near total
gastrectomy with R-en-Y esophagojejunostomy
Early dumping can almost always be managed with dietary changes like
decreasing frequent small meals, high protein, low carbs and sugar, low salt and
fluid, lie supine after meals, add pectin
Gastric ulcer: type I: along the lesser curve, nml. to low acid, perforation, blood
group A; type II: body and duodenum, hypersecretion, hemorrhage and
obstruction and perforation; type III: prepyloric, hypersecretion, hemorrhage,
perforation, blood group O; type IV: high on lesser curve near GE jxn., low acid,
hemorrhage and perforation; type V: NSAID use and ASA
Vagotomy and antrectomy has the lowest recurrence rate; V+P has the highest
morbidity; HSV has the highest recurrence rate (15%), but the lowest M+M
Type III paraesophageal hernia: GE jxn. is displaced into the thorax with a
hernia sac containing fundus and body; has both organoaxial and mesoaxial
rotation of the stomach (can get strangulation and perforation of the stomach)
All type II rolling hernias (paraesophageal) should be repaired: Has a normal
G/E junction below the diaphragm (intact angle of His); fundus and body rolls
alongside the esophagus with organoaxial rotation of the stomach; has a
peritoneal sac; repair + fundoplication is the mainstay of tx. with anchoring of the
stomach to the anterior abd. wall and arcuate ligament
Type I sliding hiatal hernia: GE jxn. displaced into the thorax, slides back and
forth, no hernia sac;
Early MALT lymphomas can be effectively treated by eradicating H.pylori,
without surgery; for late, advanced disease, total gastrectomy (probable standard
R2 nodal dissection)
Only 15-20% of all patients with PUD have H. pylori, but almost all (90%)
duodena l ulcers are associated with H.pylori; It is associated with an increased
risk of cancer and is classified as a level I carcinogen
GIST: complete surgical resection remains the primary treatment of choice;
unresponsive to chemo.
GI tract lymphomas : early stage I,II: treat with surgery followed by XRT and
chemo.; for stage III,IV: XRT and chemo., no surgery, resect only for
complicationsm
Gastric lymphoma: curative resection followed by adjuvant chemo and XRT is
the best treatment option
Megaloblastic anemia can be seen secondary to chronic afferent loop
obstruction>>>blind loop>>>bacterial overgrowth>>vit. B12 def.
Duodenal ulcers: assoc. with smoking, HpTH, high calcium, COPD, uremia,
P.vera, and liver disease; treat wit h a V+P without resection of the ulcer (you
oversew the ulcer and place an omental patch); remember, antrectomy without
vagotomy is the accepted standard of tx. for gastric ulcers, but if an antrectomy is
done for a duodenal ulcer, it requires the addition of a vagotomy
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HNPCC (Lynch I, II): AD/familial form of colon and rectal cancer/not assoc.
with FPC/6% of all CRCs; predisposed to right-sided colon cancers by 40-45
yoa; Lynch I: site specific and no extracolonic malignancies and Lynch II (those
with extracolonic malignancies) such as endometrium, ovary, stomach, small
bowel, urinary tract and biliary tree; begin surveillance at 25 yoa; more common
on the right side;tx: subtotal colectomy; mutation in the DNA repair genes
(Mismatch repair genes, MSH2, MLH1,PMS1,PMS2)
The most common complication of a Meckels in the adult is obstruction (not
bleeding as in the child)
Surveillance colonoscopy is advocated at 8 years of disease (not at a specific
age) in patients with UC
The treatment for radiation proctitis is instillation of 4% formalin
Crohns disease: transmural inflammation/granulomas/skip lesions/
cobblestoning/primary sclerosing cholangitis / ankylosing spondylitis/ erythema
nodosum/ pyoderma granulosum/ episcleritis/iridocyclitis
Celiac sprue: are at an increased risk of future malignant GI disease, especially
T-cell lymphomas
Toxic Megacolon: Seen in pt. with UC/ treat with bowel rest/NGT
decompression/high dose steroids/ABX; if no improvement in 48 hours, consider
abdominal colectomy, ileostomy with Hartmanns or mucous fistula
UC: assoc. with increased risk of cancer that increases with the duration of time
having UC(10% at 10 years);
In the non-asian population, 95% of diverticular disease occurs in the left colon;
in Asians, 15-20% occurs in the right colon
FAP: AD/>100 adenomatous polyps in colon/All pts. will develop cancer if not
treated/genetic defect in the APC gene on chromosome #5/polyps begin around
puberty/ must perform EGDs because 70% will develop gastric and duodenal
polyps which are also at risk for cancer/10% get desmoid tumors which should be
resected (if not respectable, tx. with tamoxifen or clinoril (PG inhibitor));
definitive tx. for FAP is colectomy with ileoanal pouch; if you do an ileorectal
anastomosis, you must monitor the anastomosis with bi-annual scopes to look for
recurrence (rectum still at risk); must screen all family members from 10-40 yoa +
EGD q1-2 years after age 30 (look for gastric and duodenal adenomas); tx: total
proctocolectomy with ileostomy or total colectomy with ileorectal anast. (if <50
polyps in rectum and no cancer) or total proctocolectomy with ileoanal anast.
Gardners syndrome: FAP + Osteomas + Epidermal inclusion cysts
Turcots syndrome: FAP + brain tumors
Peutz-Jegher: AD/mucocutaneous melanotic pigmentation/multiple
hamartomatous polyps of the GI tract; no malignant potential
Juvenile polyposis : occurs at any age/AD/adenomatous (neoplastic) and juvenile
(non- neoplastic components)/ anemia/clubbing/ tx. with aggressive polypectomy
with C-scope or total abd. colectomy
Ischemic Colitis: Left sided cramping/seen after surgery, often AAA
repair/abdominal pain/bloody diarrhea/temp./LLQ tenderness/thumbprinting on
contrast enema/submucosal hemorrhage and edema
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Carcinoid: check urine for 5-HIAA levels, the main metabolite of serotonin; most
common site is the appendix, and 90% of small bowel primaries in the ileum; tx.
carcinoid with liver mets with octreotide +/- alpha-INF, hepatic artery
embolization, chemo., resection; Bronchial carcinoids>>>Cushings syndrome,
assoc. with N-myc and c-jun activation; p53 has not been implicated
Malignant carcinoid syndrome : hepatomegaly, diarrhea, flushing, right heart
valvular failure, asthma, malabsorption and pellagra; tx: hepatic resection
(debulking is helpful for symptom control); if unresectable, tx. with octreotide
and niacin (to prevent pellagra)
Hallmark of carcinoid heart disease is : endocardial fibrosis involving the right
heart, in particular the tricuspid valve and chordae
Anal fissures: posterior midline in 95% of cases; best tx. with lateral internal
sphincterotomy; botox. also effective therapy; topical NTG not so good, causes
bad headaches; if lateral fissure, think Crohns disease
Colorectal mets. to the liver: poor prognosis associated with <1cm margins, >3
mets. in any given lobe, bilobar disease, short DFI, Dukes C primary lesion
Celiac disease, Crohns, HIV, transplant patients, AIDS, Wegeners
granulomatosis, RA, Wiscott-Aldrich: All associated with small bowel
lymphomas with almost all being NHL (B-cell)
GU/ OB / GYN-ONC / NEUROSURG.
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large stage II: chemo 1st (cisplatin-based), re-staged, if residual tumor, more
chemo; if not, then surgical resection
Left spermatic vein>>>L renal vein; Right spermatic vein>>>IVC
Left varicocoele after age 40>>>think about a renal cancer b/c remember, the left
spermatic vein drains into the left renal vein; A right varicocoele may mean an
obstruction of the IVC; Varicocoeles present as a bag of worms of worms on
palpation with pain; indications for treatment are persistent pain, low sperm count
and large size; tx: ligation of the spermatic vein and all collaterals
If a young women has an indeterminate, large ovarian mass, it is appropriate to
remove the ovary on that side, fallopian tube and do a complete staging operation;
never perform a complete TAH/BSO; Also , if you see a mass on U/S, you can
watch it for 3 menstrual cycles safely and see if it goes away with serial U/S
exams;
Endometrial cancer: the most common malignancy of the female genital tract;
risk factors: no children/obesity/HTN/DM/late menopause; hallmark is abnormal
vaginal bleeding after menopause; A malignancy must be ruled out in any postmenopausal woman with bleeding
All abnormal PAPs are followed with a colposcopy and biopsy; Any gross
cervical abnormality found on exam (even with a normal PAP) should get the
same; if no diagnosis, then proceed to cervical conization or LLETZ; Further, all
CIN 3 is treated with conization or LEEP
Cryptorchidism: Most testes will descend by 9 months, therefore wait at least
this long to operate; should be surgically repositioned by 2 years old; decreased
fertility and increased testicular degeneration; increased chance of malignancy
even after operative repair with bilateral orchiopexy
Anterior spinal artery syndrome: Bilat. loss of motor fxn., pain and sensation
below the level of the lesion with sparing of position and vibratory sense and light
touch sensation; seen with acute rupture of a cervical disc followed by occlusion
of the anterior spinal artery
Brown-Sequard syndrome: ipsilateral loss of motor fxn. and position/vibratory
sense with contralateral loss of pain, temp and sensation below the level of the
injury
Central cord syndrome: bilateral loss of motor fxn., pain , temp. and sensation
in upper extremities with sparing of the lower extremities; usually due to a
hyperextension injury
There is no benefit to using ABX for basilar skull fractures with otorrhea or
rhinorrhea
A herniated disc b/t L4 and L5 impinges on the L5 nerve root
C1 fracture: Jefferson fracture>>fx. of lateral masses; Odontoid fracture , type
I: tip only, II: across the base (most common), III: across base and extend into the
body of the axis; C2 fracture: posterior elements fracture
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COAGULATION
High dose steroids in the trauma patient are only indicated for patients with blunt
spinal cord injury (give methylprednisolone @ a bolus of 30mg/kg followed by
5.4 mg/kg for 24 hours); Do not give at all if > 8 hours out from the time of the
event
A parasternal stab wound at or around the 5th ICS mandates a DPL (not a
thoracotomy); emergent thoracotomy only if you have a pericardial tamponade,
hemothorax of >1.5L initially or hemorrhage of > 250ml/hr + shock; perform an
anterolateral thoracotomy (not posterolateral)
A left subclavian artery injury is best approached via an anterior thoracotomy
through the 3rd and 4th ICS, or creating a trap door incision using this approach; A
right SCA injury is best approached via a median sternotomy
Never do a cricothyroidotomy on a child <12 y/o; for an emergent airway, do a
needle cric. or trach.
RSBI= breaths/min/L, freq/TV, most sensitive indicator for (un)successful
weaning from vent>>extubation
The only absolute CI to MAST trousers is pulmonary edema
Tumors cannot usually be detected until about 30 doublings = 1 gm of tumor =
10(9) cells; A lethal tumor burden is only 3 more doublings, 10(12) cells
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Patient post-op. with drainage from wound 12-24 hours after surgery: dont forget
about Clostridium perfringens: open wound, send G-stain, if GPRs, give PCN
G (high dose) and take back to OR for Wide debridement to healthy appearing
tissue with return to OR in 24 hours
Cortisol must be present with IL-6 in order to make acute phase proteins
Chronically ill patients on TPN get acalculous cholecystitis
A-aDo2 gradient is normal with hypoventilation and high altitude, it is increased
with V/Q mismatch, diffusion defect and shunt
Hypoxemia: most commonly results from V/Q mismatch secondary to shunting
with an increase in deadspace ventilation; for diffusion abnormalities, V/Q
mismatch and hypoventilation>>>100% O2 will correct the hypoxemia; this will
not correct for shunt
Risk factors for the development of an UGI bleed in the ICU: mechanical
ventilation and coagulopathy (4% risk with either one or both, <0.5% if neither),
SCI, CHI, MSOF, severe burns
Risk factors for post-op. pneumonia: >60 y/o, trauma, CHI, Impaired airway
reflexes, ETT>48 hours, Upper abd or thoracic operation, low serum albumin,
neuromm. disease, use of an NGT, prolonged use of prohylactic ABX
Hemorrhagic shock: peripheral vasoconstriction/decreased CO/increased
ADH/increased glucocorticoids/ increased A-a gradient
Lung compliance: change in volume / change in pressure; compliance is
increased with emphysema and decreased with pulm. edema, ARDS, pulm
fibrosis, pneumonia
RQ= CO2 production/O2 consumption; RQ>1 too many carbs, RQ=0.85 is mixed
fat and carbs, RQ=.6 to .7 is fat consumption; a lower RQ in a septic patient
reflects impaired glucose metabolism, increased gluconeogenesis and a greater
reliance on lipids as an energy source
TPN formulation: Any % solution is 1 gram per 100 ml, always. ie: D20 = 20
gm per 100ml or 200 gm per liter; therefore: 500ml of D40W= 500ml x
40gm/100ml x 3.4 kcal/gm = 680 kcal; 500 ml of 8.5% A.A.s= 500ml x
8.5gm/100ml= 42.5 gm protein; 500 ml of 10% lipids= 500ml x 1.1 kcal/ml =
550kcal; 3-omega fatty acids are better than 6-omega FAs and reduce inflamm.
Mediators; try for a calorie: Nitrogen ratio of 150 kcal per gram of nitrogen;
DEKA are fat soluble vitamins; Fat=9/carbs=3.4/protein=4; growth hormone
given with TPN results in a positive nitrogen balance and positive phosphorous
balance, no effect on potassium, increased wt. gain secondary to H2O and Na
retention
SBP: Ascites with low protein (<1g/dl) are 10X more likely to develop SBP
than those with protein levels >1g/dl; high protein renders resistence to SBP;
duration of ABX based on ascitic PMN count>>>check q48 hours>>>when <250
can stop ABX; high recurrence rate after 1 st episode (50% @ 6 months); This is a
single organism disease with E.coli, step and Klebsiella accounting for 85% of all
cases
ETT size for a child = 16 + age/4; normal SBP= 70 + (2 x age)
Stress ulceration: current indications include pt. on a vent., coagulopathy, SCI,
head injury, MSOF and severe burns
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Secondary HPTH: Occurs in almost all patients with advanced renal failure and
on dialysis; Will have bone disease secondary to HPTH; Increased serum PTH
causing renal osteodystrophy (kidney loses calcium, keeps phosphate, cannot
hydroxylate Vit.D therefore causes decreased absorption of calcium by the gut
which in turn causes PTH levels to increase); tx: 1st with oral calcium
supplements, restrict phosphate in die t to <600mg/d, increase phosphate bindingresins and Vit D analogues; decrease aluminum in dialysis bath and diet (it
accumulates in the bone causing osteomalacia)
Indications for surgery: In pts. with symptoms from secondary HPTH or from
tertiary HPTH and CRF: hypercalcemia in a renal transplant pt./ pathological fx.
secondary to renal osteodystrophy/ secondary symptoms to HPTH like pruritus,
bone pain, soft tissue calcification, and calciphylaxis, Calcium x Phosphate
product >70: Treatment of choice is a 4-gland parathyroidectomy with immediate
autograft in the SCM (fxn. in 87% of pts. @ 20 month f/u)
53 y/o with a 2 cm mass in post. neck, FNAB>>>benign appearing thyroid cells
with papillary features, no thyroid masses, what next? Pt. has metastatic
papillary cancer of the thyroid from an occult thyroid primary. Due to her age,
+ mets, she should have a total thyroidectomy, MRND, followed by post-op. RAI
ablation
If you see a really high calcium (>15), think about parathyroid cancer; Death
from tumor growth is rare, death usually from uncontrollable hypercalcemia
therefore aggressive reoperation required with maximal tumor debulking (often
including the thyroid lobe on the involved side); the only certain sign of tumor
recurrence is a re-occurrence after resection
Hyperthyroidism during pregnancy is usually due to Graves disease; treat with
PTU (not B-blockers, not surgery, not RAI)
Parathyroid glands: the superior glands are from the 4th branchial pouch, blood
supply for both from the inferior thyroid artery; superior gland is anterior to the
recurrent nerve
MCT: R/O MEN IIA; Treat the pheo. 1st ; increased calcitonin/siblings are at
risk/abnormal pentagastrin stim. Test; only the differentiated thyroid cancers take
up RAI (I131), MCT does not
If you see amyloid on pathology, it is diagnostic of MCT
Hurthle Cell Cancer: 3-10% of thyroid cancers/ As size increases, malignant risk
does as well, tumors >4cm>>>65%, 6-10cm>>>80%; very difficult to
differentiate b/t benign and malig. on FNAB; Has a poorer prognosis compared to
follicular and papillary, more aggressive and metastasizes earlier; Does not take
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Wilms tumor: occurs usually b/t 1-5 years old/primary therapy is surgical
resection/good overall prognosis/Bilateral Wilms>>>Bilateral nephrectomy with
safe renal transplant after 1 year/responds well to chemo./associated with the
WT1 tumor suppressor gene/ 3 syndromes: WAGR, Beckwith-Wiedeman and
Denys-Drash/ Tx. of Wilms is with resection for local control and chemo. (XRT
for advanced disease); staging: I: limited to kidney/complete resection, II: still
completely resected, extends beyond the kidney +/- capsular extension or
invasion, III: residual tumor in abdomen or tumor rupture or peritoneal implants +
(+) L.N.s, IV: hematogenous mets.>>>other organs; V: Bilateral renal
involvement; I,II: resection and chemo.; III,IV: resection and chemo and XRT;
All anaplstics: resection, chemo and XRT; if ?? unresectable>>neoadj. Chemo
and XRT>>>resection if shrinkage occurs
Neuroblastoma: neural crest origin; 40% from adrenal medulla, elevated HVA
and VMA (90% have this), increased ratio of VMA/HVA is good prognosis; dx.
Requires histologic confirmation by direct tumor biopsy; stage with CT of C/A/P,
bone scan>>classify into high, intermediate or low-risk groups at diagnosis; high
risk: >1 year old, stage III,IV, unfavorable histology, increased ferritin, increased
LDH, increased NSE; tx. of low risk>>surgery, high risk>>neoadjuvant chemo.
(with initial surgery for dx. and port placement only) with complete gross
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resection reserved for a 2nd look procedure after chemo.; N- myc is a protoncogene seen in 30% of tumors
Omphalocoele: midline at umbilicus/covered with a peritoneal sac/ assoc. with
other congenital abnorm.s/ may contain eviscerated organs such as liver
Meckels diverticulum: caused by a persistent omphalomesenteric duct; can
contain gastric or pancreatic tissue; usually painless rectal bleeding ~2 yoa
Duodenal atresia: prenatal U/S reveals polyhydramnios with fetal distention of
stomach and duodenum; double-bubble on CXR>>do a BE to r/o microcolon +/obstructing meconium; assoc. with trisomy 21 in 30% of cases, 38% with
congential heart defects
Intussusception: repeated bilious vomiting usually in the 1st year of life; currentjelly stools; use abdominal U/S 1st to dx. (accuracy close to 100%); can dx and tx
with BE (30 cm above buttocks)
Gastroschisis: prolonged ileus at birth/ defect is lateral and to the right of the
umbilicus/no peritoneal sac/inflamm. peel from irritation by amniotic fluid/ only
rarely assoc. with congenital abnorms
Pneumatosis intestinalis: is never an indication to take a neonate to the OR for
NEC; portal venous gas, free air, a fixed and dilated bowel loop, abdominal
erythema and mass, bacteria in paracentesis fluid, uncontrolled persistent acidosis
and thrombocytopenia are all indications for Ex Lap.
NEC: Will almost always be presented with a neonate receiving enteral feedings
who becomes intolerant of feeds; prematurity plays a major role in the
development of NEC; most will survive without an operation with bowel rest,
systemic ABX and TPN
Testicular torsion: acute, severe onset of testicular pain assoc. with N/V without
a cremasteric reflex; must operate within 6 hours or risk testicular necrosis
Indications for ECMO: aADO2 diff.>610 for 8 hours; acute deterioration,
barotrauma, cardiac failure, does not stabilize on conventional therapy,
oxygenation index>40 for >2 hours; delayed CDH repair facilaited by ECMO
results in improved overall survival, reduction in pulmonary compliance after
surgical repair and decreased barotrauma
Neonates are obligate nose breathers
Thyroglossal duct cyst: Remnant of thyroglossal duct extending from the
foramen cecum of the tongue to thyroid isthmus; Always midline; +/- if it gets
infected; tx: Sistrunk procedure (complete excision of cyst including central
portion of the hyoid bone)
Urachus connects the bladder to the umbilica cord in utero and incomplete
closure at birth results in either a persistent fistula, draining sinus or urachal cyst;
tx. with I+D followed by elective complete cyst excision
ANESTHESIA
GI bleeding: technetium sulfur colloid scan: can detect a LGI bleed as low as 0.5
ml/min, but patient has to be actively bleeding/ tagged RBC scan detects at 1
ml/min and remains in circulation for up to 24 hours and therefore you can bring
the patient back and look again/ mesenteric angiography detects at 1ml/min; can
infuse vasopressin which stops the bleeding in about 85% of cases, however high
chance for re-bleeding within 48 hours
IMA>>>superior rectal artery; IIA>>>middle rectal artery; IIA>>>internal
pudendal>>>inferior rectal artery
Inguinal ligament is the most inferior part of the external oblique aponeurosis;
All hernias have a defect in the transversalis fascia;
Left vagus>>anterior>>hepatic branch; right vagus>>posterior>>celiac branch
and criminal nerve of Grassi
Ventral pancreas>>>uncinate process and inferior portion of head; dorsal
pancreas>>remainder of the pancreas; uncinate is to the left and behind the
portal vein and SMA, in front of the aorta and IVC, below and ventral to the left
renal vein
Give Vit. A to overcome steroid- induced healing impairment (25,000 IU/ml) or
GHRF or anabolic steroids
Arginine is a conditionally essential AA that promotes collagen deposition,
wound healing, immune function, NO production
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