Part 2 Review PDF

In a normal pattern of defecation (top panel), the subject can generate a good pushing force (increase in intrarectal pressure) and simultaneously relax the anal sphincter. In contrast, patients with dyssynergic defecation exhibit 1 of 4 abnormal patterns of defecation. In type I dyssynergia, the su...

In a normal pattern of defecation (top panel), the subject can generate a good pushing force (increase in intrarectal pressure) and simultaneously relax the anal sphincter. In contrast, patients with dyssynergic defecation exhibit 1 of 4 abnormal patterns of defecation. In type I dyssynergia, the subject can generate an adequate propulsive force (rise in intrarectal pressure ≥ 40 mmHg), along with a paradoxical increase in anal sphincter pressure. In type II dyssynergia, the subject is unable to generate an adequate propulsive force; additionally, there is paradoxical anal contraction. In type III dyssynergia, the subject can generate an adequate propulsive force but there is either absent relaxation (a flat line) or inadequate (≤ 20%) relaxation of the anal sphincter (as seen with this patient). In type IV dyssynergia, the subject is unable to generate an adequate propulsive force together with an absent or inadequate relaxation of the anal sphincter. ● The ABCD rule refers to asymmetry, border irregularity, color variegation, and diameter more than 6 mm. ● Skin cancers are the most common malignancy following transplantation from prolonged immunosuppression, with > 90% being squamous or basal cell cancers (ie, nonmelanoma skin cancers). The incidence of skin cancers is very high, with 50% or more of recipients with white skin color ultimately developing lesions. Therefore, patients should be strongly counseled regarding sun and ultraviolet exposure. ● ● Common Malignancies Developing in Solid Organ Transplant Recipients Type of Solid Organ Transplant Common Malignancies Liver ● ● ● ● NMSC PTLD HCC Cholangiocarcinoma Comments ● ● Early-onset HCC (first 6 months after transplant); unrecognized preexisting tumor in the transplanted liver Late-onset HCC: Recurrent or de novo Lung ● ● ● NMSC PTLD Lung cancer ● Lung carcinoma: highest risk among all the solid organ transplant recipients, especially in the contralateral native lung Pancreas ● ● ● NMSC PTLD Pancreatic adenocarcinoma ● Pancreatic adenocarcinoma is specific to the pancreatic allograft Kidney ● ● ● ● NMSC PTLD RCC Anogenital cancer ● ● Early-onset RCC in the native kidneys with acquired cystic kidney disease Late-onset RCC in the allograft with peak at 4-5 years Heart ● ● ● NMSC PTLD Lung cancer ● Lung carcinoma: second highest among all the solid organ transplant recipients (after lung transplant recipients) HCC = hepatocellular carcinoma, NMSC = nonmelanoma skin cancer, PTLD = post-transplant lymphoproliferative disorder, RCC = renal cell carcinoma. Iatrogenic injury to the common peroneal nerve can occur after incorrect leg placement in the lithotomy position. Other commonly tested reasons for common peroneal nerve injury include fibula head fractures and crossing legs for long periods. There are multiple factors important to determining whether parenteral nutrition should be initiated in palliative care patients with advanced cancer. In patients with malignant bowel obstructions whose expected survival is 2-3 months without nutritional support, there is some survival benefit with parenteral nutrition administration. Cerebral perfusion pressure (CPP) is calculated by the following equation: CPP = mean arterial pressure (MAP) – intracranial pressure (ICP). ● ● ● ● Morbidity and Mortality Associated With Elective Surgery in Patients With Cirrhosis Child Class Risk (%) A 10 B 30 C 75–80 Bacteroides fragilis is the most common anaerobe isolated in perforated appendicitis, while Escherichia coli is the most common aerobic isolate. The patient has a history of alcohol use disorder and developed a lung abscess likely secondary to aspiration. The patient developed the subsequent complication of hemoptysis secondary to erosion of the infection into a blood vessel and airway. Surgical resection is indicated to prevent ongoing bleeding and to prevent airway obstruction. Approximately 80-90% of patients with a lung abscess can be managed without surgical intervention. Patients should be initiated on antibiotics based on the most likely pathogens including anaerobic coverage. If the patient fails to make clinical improvement in 7-10 days, catheter drainage should be considered. Percutaneous (peripheral) or bronchoscopic drainage (central) can be used based on abscess location. Patients that do not respond to antibiotics and drainage should be considered for surgical resection. ● ● Surgical Indications: 1. Bronchopleural Fistula 2. Empyema 3. Bleeding 4. Failure of medical therapy 5. Suspicion of malignancy Cloquet's node is the first of the deep inguinal lymph nodes to receive drainage and is often viewed as the gateway to the deep inguinal lymphadenectomy. ● Commonly tested and high-yield anatomy encountered in a superficial inguinal lymphadenectomy are: Saphenous vein at the junction of the sartorius and adductor muscles (preserved) ● Lateral cutaneous femoral nerve running under the fascia of sartorius (preserved) ● Femoral nerve, artery, and vein within the femoral triangle (preserved) ● Cloquet's node within the femoral canal (excise and close defect in lacunar ligament thereafter) ● Deep inguinal lymphadenectomy is generally performed in the event that Cloquet's node is positive for metastatic disease or if there is evidence of deep inguinal lymph ● node involvement on PET/CT. Most surgical texts advocate for leaving the inguinal ligament intact and accessing the deep inguinal nodes through a separate incision in the lower abdominal musculature. Reflection of the peritoneum medially through this incision will expose the common iliac bifurcation and associated nodal tissue. distal esophageal stents are the most likely to migrate (70.4% of cases), followed by proximal esophageal stents (68.1% of cases), followed by mid-esophageal stents ● (30% of cases), making this patient high risk for migration. Central venous access, Subcutaneous port in the subclavian vein with the catheter tip at the cavo-atrial junction. ● The nasogastric tube mimics vomiting and produces a contraction alkalosis through the loss of hydrogen and chloride ions (hence the hypochloremic metabolic alkalosis). ● While this would lead to the action of mineralocorticoid and renin-angiotensin axis activation and sodium retention at the distal tubules, the ongoing hyponatremic fluid administration (lactated Ringer contains 130 mEq of sodium) will lead to hyponatremia. The action of the renin-angiotensin axis activation also leads to potassium and hydrogen ion loss in the distal tubules (paradoxical aciduria), which is the main mechanism of hypokalemia, contrary to the often misconstrued and incorrect "potassium loss from gastric fluid" theory. ● Options for Troubleshooting During a Difficult Cholecystectomy Initial considerations ● ● ● Conversion to an open procedure "Top-down" approach Intraoperative cholangiogram Transcystic ○ Via a choledochotomy ○ Bailout maneuvers ● ● Subtotal cholecystectomy Cholecystostomy tube placement ● Clostridioides difficile Colitis Treatment Regimen by the Infectious Disease Society of America Severity of Colitis Recommended Treatment Regimen Initial ● ● PO fidaxomicin 200 mg 2 times a day for 10 days Alternative: PO vancomycin 125 mg given 4 times daily for 10 days Fulminant ● ● ● PO vancomycin 500 mg 4 times a day Per rectum vancomycin 500 mg (in 100 mL normal saline) every 6 hours as a retention enema IV metronidazole every 8 hours Recurrent ● ● 1st recurrence: Fidaxomicin 200 mg given twice daily for 10 days, OR twice daily for 5 days followed by once every other day for 20 days 1st recurrence if metronidazole was used for the primary episode: standard 10-day PO vancomycin, 125 mg given 4 times daily by mouth for 10 days > 1 recurrence: Tapered and pulsed PO vancomycin (125 mg 4 times daily for 10–14 days, 2 times daily for 7 days, once daily for 7 days, and then every 2–3 days for 2–8 weeks), fidaxomicin, or standard 10-day PO vancomycin followed by rifaximin Bezlotoxumab is newly recommended as adjunctive for recurrent episodes, 10 mg/kg given intravenously once during the administration of standard-of-care antibiotics Multiple recurrences with failed antibiotics: fecal microbiota transplantation ● ● ● ● Hypotension, peritonitis, severe disease-causing multiorgan dysfunction ● ● Total abdominal colectomy with preservation of the rectum (preferred, strong recommendation, moderate quality of evidence) or diverting loop ileostomy with colonic lavage followed by antegrade vancomycin flushes (weak recommendation, low quality of evidence) When a bladder injury is identified, first, the location of the injury must be determined. CT cystography has become the gold standard for the diagnosis of bladder rupture. Intraperitoneal ruptures will be identified as contrast extravasation into the peritoneum with resulting outlines of loops of the small bowel. Extraperitoneal ruptures will result in contrast in the retroperitoneum, including the space of Retzius and lateral colic areas. It must also be kept in mind that multiple injuries may exist and not be visualized on CT due to incomplete filling of the bladder. Indications for operative management include intraperitoneal rupture, bladder neck injury, concomitant rectal injury or major vaginal injury, open pelvic fractures or those with fragments, or foreign body within the bladder. Nonoperative injuries may be treated with Foley drainage and repeat cystography. For extraperitoneal injuries requiring repair, a Pfannenstiel incision provides excellent exposure. For intraperitoneal injuries, a midline incision should be used. For operative repair, after identifying the injury, the ureteral orifices should be visualized. A concomitant ureteral injury should be ruled out by observing a jet of clear urine from each orifice, intubation with a small catheter, or IV administration of indigo carmine dye. Bladder lacerations are repaired in at least 2 layers using absorbable sutures. The first layer should include the mucosa and muscularis, and the second layer should include the muscularis and the serosa. The bladder is drained for 10–14 days with either a Foley or suprapubic cystostomy. Repeat cystography is performed prior to removal to ensure healing. ● Treatment of Gallbladder Cancer Stage Definition Treatment ● ● ● ● ● ● ● ● ● T1a Invades lamina propria Simple cholecystectomy T1b T2 T3 T1b - invades muscle layer T2a - invades perimuscular connective tissue on peritoneal side T2b - invades perimuscular connective tissue on hepatic side T3 - perforates serosa to invade liver and/or one adjacent organ Extended cholecystectomy, lymph node dissection, with resection of a single adjacent organ if necessary (for T3 disease) T4 Invades main portal vein, hepatic artery, or 2 or more adjacent organs Chemotherapy. Resection is often not possible or feasible; only limited reports of resectable T4 disease have been published Praziquantel is the appropriate treatment for schistosomiasis Amebic liver abscess due to Entamoeba histolytica is an uncommon condition in the United States. However, patients traveling to endemic areas, such as Mexico, may obtain an infection by fecal-oral transmission. Treatment is usually with metronidazole alone. Persistent cases may require aspiration, which has a characteristic "anchovy paste" color. Small (< 2 cm) primary ventral (eg, umbilical, epigastric) hernias can be repaired with sutures with or without mesh reinforcement. Data are conflicted as to whether mesh reinforcement reduces recurrence. Simple suture repair approximates the fascial edges generating tension and is associated with recurrence rates > 50%, which is generally higher than that of mesh repair, although recurrence rates following mesh repair can still be ≥ 20%. Several randomized trials suggested that open mesh repair was superior to simple suture repair with respect to hernia recurrence. Mesh is a required element of laparoscopic ventral hernia repair. The ideal ventral hernia repair for a hernia between 2 and 10 cm is either an open retrorectus (sublay) repair with mesh or a laparoscopic intraperitoneal onlay with mesh (IPOM). Laparoscopic IPOM is also referred to as laparoscopic underlay mesh repair. Malignant non-epithelial tumors of the GI tract are rare and most are GI stromal tumors (GISTs). These tumors arise from the interstitial cells of Cajal and stain positive for c-kit and CD34. Spindle cells are seen on light microscopy. They only rarely affect the colon and are most commonly found in the stomach, followed by the small bowel. If GISTs are found in the small bowel, they are most likely found in the jejunum. Leiomyosarcoma, on the other hand, arises from smooth muscle cells in the muscularis propria. They stain positive for actin and desmin. They are graded by their mitotic activity and are very high-grade tumors. Survival is rare. Iatrogenic sharp dissection injuries to the colon can be repaired primarily at the time of injury if the injury is < 50% circumference of the bowel. Synthetic mesh should not be placed if there is fecal contamination. Depending on the effect at the motor end plates, neuromuscular-blocking drugs are classified as either depolarizing or nondepolarizing. The clinical effect of these drugs is to produce muscular weakness. Muscles of ventilation are the last to be paralyzed but also the first to recover during a neuromuscular blockade. Small facial and hand muscles are blocked before the ventilatory musculature.The abdominal wall is paralyzed after the facial muscles. Total body calcium stores are approximately 1000g, with almost 99% found in bone. Respiratory alkalosis increases the binding affinity of calcium for albumin, leading to a reduction in the serum ionized calcium levels. Normal daily intake of calcium is between 500 and 1500 mg per day. ● Muscle Innervation Function Abductor pollicis brevis Median nerve Abducts the thumb Flexor pollicis brevis Median nerve Flexes the thumb Opponens pollicis Median nerve Opposes the thumb Lumbricals Median (1st and 2nd) and ulnar (3rd and 4th) nerve Flex the MCP joints and extend the IP joints Palmaris brevis Ulnar nerve Wrinkles the skin of the medial (or ulnar) side of the palm Adductor pollicis Median nerve Adducts the thumb Abductor digiti minimi Ulnar nerve Abducts the small finger Flexor digiti minimi Ulnar nerve Flexes the small finger Opponens digiti minimi Ulnar nerve Opposes the small finger Dorsal interossei Ulnar nerve Abducts (away from the middle digit) the index, middle, and ring fingers; flex the respective MCP joints and extends the respective IP joints Palmar interossei Ulnar nerve Adducts (toward the middle digit) the index, middle, and ring fingers; flex the respective MCP joints and extends the respective IP joints IP = interphalangeal, MCP = metacarpophalangeal. ● ● ● ● Type of Anal Cancer Preferred Treatment Squamous cell carcinoma Local recurrences after treatment with radiation therapy and chemotherapy are treated by salvage APR Anal melanoma Local excision Anal adenocarcinoma Combined modality treatment (including APR with adjuvant chemoradiotherapy) is optimal therapy Lobular carcinoma in situ (LCIS) is a marker for increased breast cancer susceptibility but is very different from lesion ductal carcinoma in situ (DCIS). LCIS does not form calcifications and is thus, usually found incidentally on biopsy for another concerning lesion. Features that make LCIS so unusual are that it is a marker for future cancer, in either breast, does not require complete excision, and is not a precursor lesion to lobular cancer (in contrast to DCIS, which is a precursor to ductal carcinoma). Chemoprevention alone would not suffice. Even though it reduces the risk of breast cancer by 47%, it does not completely eliminate it. The patient must resume clinical exams and yearly mammograms as recommended per National Comprehensive Cancer Network guidelines. Metastatic tumors involving the small bowel are much more common than primary neoplasms. The most common metastases to the small intestine are those arising from other intra-abdominal organs, including the uterine cervix, ovaries, kidneys, stomach, colon, and pancreas. Small intestinal involvement is by either direct extension or implantation of tumor cells. Metastases from extra-abdominal tumors are rare. Cutaneous melanoma is the most common extra-abdominal source to involve the small intestine, with involvement of the small intestine noted in more than half of patients dying from malignant melanoma. Common symptoms include anorexia, weight loss, anemia, bleeding, and partial bowel obstruction. Treatment is palliative resection to relieve symptoms or, occasionally, bypass if the metastatic tumor is extensive and not amenable to resection. Patients with known ulcer disease can be stratified into their risk for bleeding based on endoscopic findings using the Forrest classification model. The highest-risk findings include active bleeding and a visible vessel. All high-risk patients should undergo some endoscopic therapy to reduce the chance of rebleeding. An adherent clot is classified as intermediate risk. Low-risk characteristics include ulceration with a black spot or with a clean base. ● Forrest Classification Stage Characteristics Re-bleeding Risk Acute Hemorrhage Ia Spurting Bleed 60-100% Ib Oozing Bleed 50% Signs of recent hemorrhage IIa Non-Bleeding Visible Vessel 40-50% IIb Adherent Clot 20-30% IIc Flat Spot in ulcer crater 7-10% Lesions without active bleeding III ● ● ● Clean Base Ulcer 3-5% A simple fistula can be treated with fistulotomy with very high success rates and a low rate of recurrence. A complex fistula is defined as involving more than 30–40% of the sphincter complex, anterior in women, multiple or recurrent, or occurring in patients with a history of incontinence, pelvic irradiation, or Crohn disease. In these cases, a draining seton is placed into the tract to facilitate drainage and promote fibrosis, allowing for definitive repair at a later date. Alternatively, a cutting seton can be placed, which requires sequential tightening to slowly divide the sphincter muscle overlying the fistula tract in hopes of preserving continence. Following the maturation of a fistula tract with a draining seton, patients may be candidates for sphincter-sparing procedures such as ligation of intersphincteric fistula tract (LIFT), fibrin glue, bioprosthetic plug, or endorectal advancement flap. Mnemonic for Goodsall's rule: Think of a dog with a straight nose anteriorly and a curved tail posteriorly. Penetrating injuries to major coronary arteries are rare (in an analysis of 27,365 cardiothoracic injured patients in the National Trauma Data Bank, only 88 patients had a coronary artery injury). The most commonly injured vessel is the left anterior descending artery (LAD) given its anterior location. The right coronary (RCA) and circumflex arteries are rarely injured. Mortality can be very high with injuries to major coronary vessels. The type of repair depends on the location of the laceration or transection. Ligation leads to poor outcomes due to myocardial ischemia. Definitive repair either with primary suture or coronary artery bypass graft (CABG) in the OR should be performed. The patient described has an incomplete transection of his proximal LAD or one of its branches, and this should be repaired primarily with permanent, interrupted 6-0 or 7-0 sutures. ● ● ● In most patients, it is not necessary to perform a gastrostomy at the time of repair. With typical anatomy (left aortic arch), the repair is performed via a right thoracotomy or thoracoscopy. An extrapleural approach is preferred by most pediatric surgeons. In patients with FAP, the incidence of duodenal adenomas is around 90%, with a risk of duodenal cancer nearing 4.5%. Thus, even after a total proctocolectomy and end ileostomy, patients should undergo EGD every 2 years, given the risk of duodenal cancer. The frequency of surveillance depends on the severity of duodenal adenomas as graded by the Spigelman score. Spigelman Staging System for Duodenal Adenomas Polyp Characteristics 1 point 2 points 3 points Number <4 5–20 > 20 Size, mm 0–4 5–10 > 10 Histology Tubular Tubulovillous Villous Dysplasia severity Mild Moderate Severe ● Duodenal Adenoma Surveillance System Spigelman Stage Total Points 0 ● ● ● ● ● ● ● Frequency of Surveillance 0 ● Every 4 years I ≤4 ● Every 2–3 years II 5–6 ● Every 1–3 years III 7–8 ● Every 6–12 months IV 9–12 ● ● Every 3–6 months Consider surgical evaluation for: Complete mucosectomy or duodenectomy, OR ○ Whipple procedure if duodenal papilla involved ○ invasive ductal carcinoma that is HER2+ and hormone receptor-negative (ER/PR-). The appropriate treatment for this tumor is the administration of trastuzumab and adjuvant chemotherapy, which includes doxorubicin (adriamycin), cyclophosphamide, and paclitaxel. Adjuvant chemotherapy is recommended in patients with breast cancer who show evidence of nodal disease, those with tumors >1 cm, and pathologic specimens with evidence of aneuploidy. Hormonal therapy, eg, tamoxifen, anastrozole, is recommended in patients with hormone receptor-positive (ER/PR+) tumors, and targeted therapy, eg, trastuzumab, are recommended in patients with HER2/neu positive tumors.All of these chemotherapeutic agents, ie, trastuzumab, doxorubicin, cyclophosphamide, and taxanes (paclitaxel), convey a risk of cardiotoxicity. As a result, a transthoracic echocardiogram to evaluate the patient's baseline ejection fraction and cardiac function is recommended prior to the administration of the adjuvant therapy. Primary intention (primary closure) refers to the direct apposition of skin edges of acute surgical or traumatic wounds after appropriate wound preparation with sutures and/or staples. The Centers for Disease Control (CDC) defines primary closure as "any form of approximation of the skin edges." Some surgeons will elect to "loosely" approximate incision, as well as place "wicks" or packing in between loosely approximated skin edges. Secondary intention is where a wound is purposefully left open and fills in with granulation tissue and eventually epithelization over a period of time. At no point are the skin edges brought together by external means. Tertiary intention (delayed primary closure) represents a technique where the skin is left open, treated typically with wet-to-dry or negative-pressure wound therapy for a few days to decrease the microorganism and inflammatory chemical burden, then approximating the skin with sutures or staples in 4-5 days after the index operation. Vacuum-assisted closure (negative-pressure wound therapy) can assist wound healing, such as in the case of sacral decubitus ulcers or a skin incision left open at index operation. Wound healing is enhanced by reducing edema surrounding the wound, removing inflammatory/infectious agents, stimulating circulation, and increasing the rate of granulation tissue formation. Primary fascial closure is recommended by newer literature whenever possible, even in class IV, as long as the abdomen is thoroughly washed out and no ongoing fecal contamination or necrotic tissue is present. If a patient is hemodynamically unstable or damage control laparotomy is being undertaken, typically the fascia is left open in the index operation with delayed primary fascial closure at subsequent surgery. After the fascia is closed, the management of the skin depends on the level of contamination during the case. Dynamic (elastic) abdominal closure is a relatively new technique for managing an open abdomen. It involves gradually bringing the fascia toward the midline using a specialized device. This technique may be employed in situations where the fascia is "too tight" to approximate in the index operation. ● Surgical Wound Classification Class Type Description Risk of Surgical Site Infection (%) I Clean ● ● Uninfected operative wound in which no inflammation is encountered No entry into respiratory, alimentary, genital, or uninfected urinary tract 1-5 II Clean-contaminated ● Controlled entry into respiratory, alimentary, genital, or urinary tracts with minimal contamination 3-11 III Contaminated ● ● Open, fresh, accidental wounds Major breaks in sterile technique (eg, open cardiac massage) or gross spillage from the GI tract Presence of acute, nonpurulent inflammation 10-17 Old traumatic wounds with retained devitalized tissue Presence of pus or necrotic tissue Pre-existing perforated viscera or fecal contamination > 27 ● IV Dirty ● ● ● ● ● Autoimmune pancreatitis (AIP) is a rare type of chronic pancreatitis. Men are affected more often than women (2:1). Autoimmune pancreatitis can affect the pancreas only or involve other organs, including the bile ducts, small and large bowel, salivary and lacrimal glands, kidneys, and lungs. It can cause jaundice, symptoms of inflammatory bowel disease, xerostomia and xerophthalmia, mild renal insufficiency, and pulmonary infiltrates and lymphadenopathy. About a third of patients will present with disease limited to the pancreas. Patients with AIP most often present with jaundice, while abdominal pain is less common. Elevated serum IgG4 is specific, but not sensitive (a normal IgG4 does not rule out AIP).CT may reveal a diffusely enlarged pancreas with little to no peripancreatic fat stranding, and intrapancreatic calcifications are not seen. Occasionally, AIP focally involves the head of the pancreas and appears as a mass on CT. Regional lymph nodes are often enlarged on imaging. The pancreatic duct may be focally, segmentally, or diffusely narrowed. A diagnosis of AIP can be made if the clinical presentation is consistent with AIP in patients with a history of associated autoimmune disorders, elevated IgG4, and radiographic findings consistent with AIP. In some cases, ERCP may provide useful information on the morphology of the pancreatic duct, which is often strictured and in which the right angle ducts are lost. The external branch of the superior laryngeal nerve provides motor innervation to the cricothyroid muscle, which tilts the larynx during speaking to affect pitch.Injury to one or both of the superior laryngeal nerves do not result in airway compromise but affect voice quality. Injury to the external branch of the superior laryngeal nerve affects voice pitch (controlled by the cricothyroid muscle) without affecting the airway. Injury to the recurrent laryngeal nerve can paralyze the vocal cord and result in airway compromise. ● Intra-Peritoneal Seeding Hematogenous Spread Ovarian Melanoma Colon Lung Appendix Breast Gastric Renal cell carcinoma The treatment of hyperkalemia is dependent on the presence or absence of ECG changes and the plasma potassium level. The first step in management of hyperkalemia is to obtain an ECG. If ECG changes such as peaked T waves are present, the priority should be to stabilize the cardiac membrane by administering calcium gluconate. Changes on ECG are rarely present with mild hyperkalemia (< 6.0 mmol/l). Mild hyperkalemia can usually be treated by reducing daily intake. Active treatment to lower the plasma potassium should be started if the potassium has risen acutely to > 6.0 mmol/l. Insulin, kayexalate, and albuterol can be used to lower the plasma potassium. Patients with acute pancreatitis usually present with acute onset of epigastric abdominal pain and elevated serum amylase and lipase. With supportive treatment, most patients recover without local or systemic complications or organ failure and do not have recurrent attacks. Neurogenic shock results from damage to the spinal cord above the level of the 6th thoracic vertebra. It is found in about half of people who suffer spinal cord injury within the first 24 hours and usually does not subside for 1–3 weeks. Advanced Trauma Life Support guidelines recommend using the well-known Parkland formula to guide initial burn resuscitation. Generally, patients who have burns with a total body surface area (TBSA) greater than 15% are given IV fluids, specifically lactated Ringer's. First-degree burns are excluded from this calculation. In the first 24 hours = 4 mL x TBSA x weight (in kg). Half of this volume is given in the first 8 hours, and the rest is given in the subsequent 16 hours. The Parkland formula provides a guideline, and the IV fluid rate should be titrated to 0.5 mL/kg/hr of urine output for adults and 1 mL/kg/hr of urine output for children under 30 kg (66 lb). Rutherford Classification System of Acute Limb Ischemia ● ● ● ● ● Category Description Capillary return Muscle Sensory loss Arterial Doppler Signal Venous Doppler Signal paraly sis I - Viable Not immediately threatened Intact None None Audible Audible IIa - Salvageable if promptly treated Intact/slow None Partial Inaudible Audible Threa tened Salvageable if immediately treated Slow/absent Partial Partial/complete Inaudible Audible Threa tened Primary amputation Absent staining Complete; tense compa rtment Complete Inaudible Inaudible IIb - III Irrev ersibl e ● ● ● ● The surgical approach to these tumors (leiomyoma) depends upon the size, location, and presence/absence of symptoms. Those found in the mid-esophagus are accessed via the right thorax, whereas those in the distal esophagus or esophagogastric junction are best approached via the left chest or potentially through the abdomen. Leiomyomas less than 8 cm without annular characteristics (ie, circumferential involvement of the esophagus) are best treated by surgical extramucosal enucleation and subsequent closure of the myotomy. In this case, the leiomyoma is found in the mid-esophagus, which is best approached via the right thorax, and the operation of choice for a 4-cm non-circumferential leiomyoma is an extramucosal enucleation with closure of the myotomy. Results of these techniques are excellent, with mortality less than 1% and greater than 90% of patients symptom-free at 5 years. In recent years, minimally invasive approaches to enucleation (thoracoscopy and laparoscopy) are becoming increasingly common, particularly for tumors smaller than 5 cm in size. Esophageal resection is used for leiomyomas greater than 8 cm in size and/or with circumferential involvement of the esophagus (annular in character). Mastitis - Dicloxacillin, cephalexin, Antibiotics are usually the first line of treatment with continued breast emptying through breastfeeding or pumping which allows drainage of the engorged area and the poorly drained segment. Antibiotics that are recommended to be avoided during breastfeeding, such as tetracyclines, vancomycin, and clindamycin require breast milk pumping and dumping instead of breastfeeding the infant. Atherosclerosis is the major cause of coronary artery disease and peripheral artery disease. Atherosclerosis affects the supra-aortic trunk vessels, with the subclavian artery being the most frequent site of involvement. The brachiocephalic artery is also a commonly involved artery. Atherosclerosis can develop ulcerating plaques, which may be the source of emboli as in our patient above. tumors > 6 cm should be approached in an open fashion as they have a higher rate of adrenal cancer; however, the limits are being pushed each and every day. Tumors with concerning findings on CT such as lymphadenopathy or loss of local fat planes should be approached in an open fashion as not to spread the tumor within the peritoneal cavity. Tumors < 6 cm with clear fat planes should be approached laparoscopically. Platelet aggregation inhibitors function at different points in the clotting cascade in order to prevent platelet aggregation and thus prevent clot formation. To understand the mechanism of action of these drugs, you must first understand the methods in which platelets are activated. As the image shows below, there are three primary methods of activating platelets (see figure below): 1. Adenosine diphosphate (ADP) receptor 2. Thromboxane A2 (TXA2) 3. Glycoprotein (GP2B/3A) receptor Clopidogrel, prasugrel, and ticagrelor work via the ADP receptor on platelets. Aspirin irreversibly inhibits COX-1, thus inhibiting the production of thromboxane A2 (TXA2). ● Ticagrelor reversibly and non-competitively binds the ADP P2Y12 receptor on platelets. Ultrasound-guided thrombin injection has been utilized with success rates as high as 100% in obliterating pseudoaneurysms. Ultrasound-guided thrombin injection is the ● first approach for patients with pseudoaneurysms > 2 cm. Neck anatomy should also be reviewed, as unfavorable anatomy such as a short and wide neck PSA is at increased risk of arterial thrombosis and should be considered for open repair instead. The Hurley clinical staging system is frequently used to divide patients with HS into 3 disease severity groups: 1. Stage I – abscess formation (single or multiple) without sinus tracts and cicatrization/scarring 2. Stage II – recurrent abscesses with sinus tracts and scarring, and single or multiple widely separated lesions 3. Stage III – diffuse or almost diffuse involvement, or multiple interconnected sinus tracts and abscesses across the entire area. The majority of patients with HS exhibit stage I disease. The Kocher maneuver is the technique of mobilizing the lateral peritoneal attachments of the second portion of the duodenum. It is used for exposure of the pancreatic ● head and duodenum. However, the Kocher maneuver can only identify the distal-most portion of the common bile duct, not the hepatic ducts. The Mattox maneuver is the technique of mobilizing the parietal peritoneum at the white line of Toldt from the sigmoid colon to the splenic flexure. The spleen, tail of the ● pancreas, left kidney, and stomach are mobilized and reflected medially. This maneuver is helpful to expose the aorta in trauma and handle zone 1 and 2 retroperitoneal injuries. The Pringle maneuver is used to minimize blood loss during hepatic surgery. It involves clamping the vascular pedicle, which includes the inflow of blood to the liver via ● the hepatic artery and portal vein. The Pringle maneuver does not control bleeding from the hepatic veins, however. Intraoperative US of the liver is a versatile adjunct to surgical inspection and palpation; it is being used more frequently to identify small (2–5 mm) metastases in patients ● undergoing segmental liver resection. It is also very well suited to defining the biliary anatomy, including aberrant anatomy, as well as identifying the biliary tree. The right upper quadrant, including the liver, is usually bathed or submerged in saline solution for improved acoustic coupling. This technique, known as water standoff, is used for better characterization of superficial lesions in the near field of the liver. ● ● Classification of Hypovolemic Shock ● ● ● Class I Class II Class III Class IV Blood Loss (mL) Up to 750 750-1500 1500-2000 > 2000 Blood Loss (% total volume) Up to 15% 15-30% 30-40% > 40% Pulse Rate < 100 > 100 > 120 > 140 Blood Pressure Normal Minimal decrease Decreased Significantly decreased Pulse Pressure Normal Narrow Narrow Unobtainable/very narrow Hourly Urine Output > 0.5 mL/kg > 0.5 mL/kg < 0.5 mL/kg Minimal Mental Status Slightly anxious Mildly anxious Anxious Confused/lethargic Carcinoembryonic antigen (CEA) is the tumor marker associated with colon cancer. The most important utility of the CEA level is to evaluate for postoperative metastatic or recurrent disease. A baseline level should be checked preoperatively. A normal value can be seen with pathologic colon cancer and still warrants following the postoperative trends. Normal tissues produce CEA during development but stop before birth. Injuries to the left ventricle, left subclavian artery, descending aorta, left pulmonary artery, left lung, left hilum, left internal mammary artery, and distal esophagus are best approached through a left thoracotomy. Injuries to azygos vein, right pulmonary artery, right lung, right hilum, right internal mammary, proximal esophagus, carina, and right main stem are best approached through a right thoracotomy. ● ● ● ● Post-transplant patients, like this patient, are at the highest risk for specifically squamous cell cancer or basal cell cancer. The incidence of skin cancer is very high in post-transplant patients, with 50% or more of Caucasian recipients ultimately developing a skin malignancy. It should be noted that the immunosuppressed patient also has a higher incidence of nodal spread. It is important to recommend that the patient avoid direct sun exposure and have patients receive appropriate preventative screenings. A tracheal injury should be repaired with absorbable sutures in 1 layer and the repair should be buttressed with the strap muscles. Using absorbable sutures lowers the chance of infection, and buttress with strap muscles increases the durability of the repair and lowers the chance of a leak and infection. Repair should only be performed in 1 layer because a 2-layered repair could lead to tracheal stenosis. Absorbable suture should be used to repair tracheal injury because nonabsorbable sutures can become a nidus for infection.High suspicion for concurrent esophageal injury is necessary during exploration for tracheal injury. These injuries can be easily missed and will have disastrous complications if not addressed. Sternal fracture occurs in 5% of patients with blunt chest wall injury, which is most commonly found in an unrestrained driver after a crash that has caused rapid and sudden deceleration. Sternal fractures most commonly occur at the manubrium and are frequently missed on plain chest radiographs; such fractures are better delineated by CT scan. Clinically significant cardiac contusion is rarely associated with sternal fracture, but rib fractures are associated with sternal fractures in up to 40% of patients. Treatment usually involves adequate analgesia. Rarely, a patient with severe sternal fracture, marked displacement, and instability may benefit from operative fixation. Adenomas are the most common benign neoplasm of the small intestine. Other benign tumors include fibromas, lipomas, hemangiomas, lymphangiomas, and neurofibromas. Benign neoplasms account for 30-50% of small bowel tumors. Most small intestinal neoplasms are asymptomatic until they become large. Partial small bowel obstruction, with associated symptoms of crampy abdominal pain and distention, nausea, and vomiting, are the most common mode of presentation. Obstruction can be the result of either luminal narrowing by the tumor itself or intussusception, with the tumor serving as the lead point. Hemorrhage, usually indolent, is the second most common mode of presentation. ● ● ● TEG Parameters Name Meaning Problem Treatment R time Time until clot starts forming (related to clotting cascade) If extended, there is an issue with coagulation factors FFP K time Time until clot reaches amplitude of 20 mm (related to the function of fibrinogen, factor IIa, and platelets) If extended, fibrinogen is forming clot slowly Cryoprecipitate Alpha angle The angle of slope between R time and K time (related to the function of fibrinogen, factor IIa, and platelets) If shallow, fibrinogen is forming clot slowly Cryoprecipitate Maximum amplitude (MA) High amplitude clot achieves (related to function of platelets (80%) and fibrinogen (20%)) If low, clot is small and weak Platelets Lysis at 30 minutes (LY30) Amount of clot lysed at 30 minutes (related to level of fibrinolysis) If high, clot is being lysed too much Tranexamic acid/ aminocaproic acid ● ● The total amount of CO2 produced by systemic metabolism is roughly equivalent to the amount of O2 consumed. The ratio between CO2 produced and O2 consumed is referred to as the respiratory quotient (RQ) and varies slightly depending on whether carbohydrate, protein, or fat is being metabolized. An RQ of 1 or greater suggests that the principal nutrient being metabolized is carbohydrate, whereas an RQ of 0.7 indicates that primarily lipids are being utilized.The definition of the respiratory quotient is CO2 produced/O2 consumed. This may also be written VCO2/VO2. The RQ can give critical insight into the feeding status of a patient, as summarized in the table below. Meanings of Common Respiratory Quotients Value Meaning < 0.7 Underfeeding/starvation 0.7 Pure fat utilization 0.8 Pure protein utilization 0.8-0.9 Mixed substrate utilization (desired) 1.0 Pure carbohydrate utilization > 1.0 Overfeeding ● ● This patient likely has a hepatoblastoma. A hepatoblastoma is the most common primary malignant tumor of the liver in children, occurring mostly within the first 2 years of life. The prognosis of patients is determined by the extent of the tumor, its histology, the presence of metastases, alpha-fetoprotein (AFP) levels, age at diagnosis, and the focality of the tumor. Risk Stratification of Hepatoblastomas Good Prognostic Stratum Intermediate Prognostic Stratum Poor Risk Stratum 3-year EFS, 90% 3-year EFS, 71% 3-year EFS, 49% PRETEXT 1, II, or III (1–3 sections of liver involved) PRETEXT IV (4 sections of liver involved) Any PRETEXT Non-small cell undifferentiated histology Non-small cell undifferentiated histology Small cell undifferentiated histology Non-metastatic hepatoblastoma Non-metastatic hepatoblastoma Metastatic hepatoblastoma AFP > 100 and < 1.2 x 106 ng/mL AFP > 1.2 x 106 ng/mL AFP < 100 ng/mL Age < 5 years Age > 5 years Any age Non-multifocal tumor Multifocal tumor +/- Multifocality EFS = event-free survival, PRETEXT = PRE-Treatment EXTent of tumor, +/- factor may be present or absent. ● ● ● Internal hemorrhoids are graded 1-4, based on the degree of prolapse. Grade 1 internal hemorrhoids do not prolapse. Grade 2 internal hemorrhoids prolapse through the anus but reduce spontaneously. Grade 3 hemorrhoids prolapse and must be manually reduced. Grade 4 hemorrhoids are unable to be reduced. Grade 1 and 2 internal hemorrhoids often respond to conservative measures, such as increases in dietary fiber and modifications in toileting habits. Grade 1 and 2 hemorrhoids that remain symptomatic can be treated with in-office procedures such as rubber band ligation. Rubber band ligation is the most common in-office procedure for internal hemorrhoids in the United States. Operative procedures are generally reserved for patients who fail in-office treatment, have significant external hemorrhoids, or have advanced (grade 3 or 4) internal hemorrhoids. Cryotherapy is associated with significant complications and is not commonly employed. Most undescended testes descend spontaneously during the first 6 months of life. Testes that have not descended by 6 months of age, rarely descend spontaneously and require surgical intervention. Orchiopexy is optimally performed during infancy to improve fertility and testicular growth. Orchiopexy also decreases the risk of testicular torsion as the testis is surgically affixed to the scrotal wall. Testicular cancer risk is also significantly decreased, but not eliminated.Orchiopexy is typically elective in the absence of signs of torsion (eg, tenderness, swelling, discoloration). Free iron (Fe) is highly toxic to the cells due to the formation of damaging free radicals. Therefore, Fe is usually found bound to other proteins including ferritin (for storage) and transferrin (for transport). Ferritin is found intra- and extracellularly, and the serum ferritin correlates well with the overall body iron stores, so ferritin is frequently used to assess the body Fe stores. Ferritin is also an acute-phase reactant, therefore the interpretation of high serum ferritin should be in the context of whether the patient does or does not have an inflammatory process. ● Topical Antimicrobial Agents for Burns Agent Indications Bacitracin ● ● Silver nitrate ● Small of sensitive areas Face ○ Ears ○ Perineu ○ m Graft ○ sites Effective against methicillin-resistant Staphylococcus aureus Superficial burns Contraindications ● ● Adverse Effects Known or suspected bacterial resistance (eg, pseudomonas) ● Eschars (poor penetration) ● ● ● ● Silver sulfadiazine (Silvadene®) Mafenide acetate (Sulfamylon®) ● ● ● ● ● ● Medium to large areas (except near eyes) Full-thickness burns Eschars (good penetration) Known or suspected resistance to other agents (effective against Pseudomonas) ● ● ● ● ● ● Eschars (poor penetration) Burns near eyes Pregnancy Breastfeeding Newborns < 2 months Sulfa allergy ● ● ● Poor pain tolerance (painful) Sulfa allergy ● ● ● ● ● ● ● Renal toxicity (at high doses/large areas) Yeast colonization Electrolyte abnormalities (hyponatremia most common) Methemoglobinemia (rare) Skin discoloration Hypersensitivity Transient neutropenia/thrombocytopenia Methemoglobinemia (rare) Metabolic acidosis (inhibits carbonic anhydrase) Painful on sensate surfaces Yeast colonization Inhibits epithelial regeneration Injury to the duodenum during laparoscopic cholecystectomy most often occurs as a result of direct coupling, as seen in this case. Direct coupling is the transfer of electrical energy by means of direct contact through a conductive medium.In laparoscopic surgery, this occurs when an electrocautery device comes in contact with the metallic surface of an instrument, such as a laparoscopic grasping forceps or camera. This generally happens inadvertently off-screen. During a laparoscopic cholecystectomy, this injury is most likely to occur at the second portion of the duodenum. ● ● ● ● ● ● ● Varicose veins are important contributors to chronic venous disease. Symptoms include lower extremity pain, swelling, superficial thrombophlebitis, bleeding from varices, and ulceration. Patients with chronic venous disease due to great saphenous vein or small saphenous vein incompetence may be treated with radiofrequency ablation or endovenous laser ablation. The Bassini repair describes a non-mesh, open technique, in which the inguinal floor is strengthened/repaired by suturing the conjoined tendon to the inguinal ligament from the pubic tubercle medially to the area of the internal ring laterally. In this case, the repair should be approached with mesh to decrease re-recurrence rates. Tissue repairs are primarily used when the use of mesh is contraindicated (eg, contaminated field due to perforated or ischemic bowel). Lichtenstein repair with mesh while keeping the original mesh is an option; however, recent meta-analyses have demonstrated that patients who underwent an open repair, after recurrence, experience greater postoperative pain and have a higher incidence of chronic pain. In addition, there is a greater risk of inadvertent injury of vital structures including vital nerves due to the presence of extensive scar tissue. The laparoscopic approach is preferred for a recurrent inguinal hernia that was initially performed in an open fashion. The McVay repair is an open, non-mesh repair that can be used for the repair of either inguinal or femoral hernias. In this case, the repair should be approached with mesh as this type of repair has the lowest recurrence rates. In a review of the Danish Hernia Database, 3.1% of patients (187/2,117) had re-recurrence following repair. A significantly lower rate of re-recurrence was seen in patients who underwent mesh repair. The last line of therapy for stress gastritis bleeding is total gastrectomy. ● Gastric variceal bleeding due to splenic vein thrombosis is a rare complication of pancreatitis. The pancreatitis-induced splenic vein thrombosis occurs because the splenic vein lies against the posterior surface of the pancreas. Repeated pancreatic inflammation can damage the vein directly, compress it externally, and lead to thrombosis. Splenectomy decompresses the short gastric vessels by decreasing the inflow from the splenic circulation. The majority of patients with gastric variceal bleeding from splenic vein thrombosis have splenomegaly. ● Periprocedural and Late Complications of Percutaneous Tracheostomy Periprocedural ● ● ● ● ● ● Bleeding Desaturation Decannulation Esophageal perforation Pneumothorax Tube dislodgement ● Late (beyond 7–10 days) ● ● ● ● ● ● ● Bleeding Decannulation Infection Tracheal/stoma stenosis Tracheoinnominate fistula Tracheomalacia Tube dislodgement Chemoradiotherapy (mitomycin +5FU+ radiotherapy) is the primary treatment for patients with anal squamous cell carcinoma. After therapy, patients may continue to respond for up to 6 months post-treatment. Patients should be seen 8 weeks post-treatment and undergo a digital rectal exam and subsequently every 8-12 weeks thereafter to assess for progression or regression.If after 6 months the mass has failed to resolve or shows signs of progression, the options include another round of radiation or salvage abdominal perineal resection. Local excision of the mass could be performed if it is < 1 cm and not involving the sphincter musculature. ● Types of Strictureplasty ● ● Heineke-Mikulicz strictureplasty Short strictures (< 10 cm) Finney or Jaboulay strictureplasty Medium-length strictures (10–20 cm) Side-to-side isoperistaltic strictureplasty Long strictures (> 20 cm) In patients with Crohn disease, bowel resection should be avoided if possible due to future risk of short gut syndrome. Heineke-Mikulicz strictureplasty is particularly well-suited for those who have multiple short, localized areas of chronic stenosis and who are at increased risk for short bowel syndrome due to previous intestinal resection. However, strictureplasty should not be performed in acutely inflamed bowel. ● ● This patient's respiratory quotient (RQ) is > 1.0, and he is in a state of overfeeding. Excessive carbohydrate administration in total parenteral nutrition (TPN) can have many detrimental effects, the most common of which is failure to wean from the ventilator. ● Workup of Nasopharyngeal Carcinoma ● ● ● ● ● ● ● ● Medical history and physical examination Including cranial nerve examination ○ Labs: CBC, serum biochemistry, lactose dehydrogenase (TUMOR BULK) Nasopharyngoscopy with biopsy Including Epstein-Barr virus analysis ○ Imaging CT scan or MRI of nasopharynx and base of the skull and neck (MRI preferred) ○ FDG-PET/CT Consider audiometric testing, dental examination, nutritional status evaluation, ophthalmological and endocrine evaluation Plasma EBV DNA Quality of life assessment ● ● ● The Surveillance, Epidemiology, and End Results program of the National Cancer Institute reports that the most common sites for well-differentiated NETs within the GI tract are the rectum followed by the small intestine, in particular, the ileum. Small bowel NETs are often asymptomatic, but the most common presenting symptom is abdominal pain (40% of symptomatic patients). Axial imaging with either CT or MRI of the abdomen/pelvis is the most effective means of diagnosis. Patients presenting with signs and symptoms suspicious for carcinoid syndrome (as in this patient) should undergo a 24-hour urinary 5-HIAA for diagnostic confirmation. Low output fistulas, such as this one, have an output of < 200 mL/day. Patients with low output fistulas can receive a regular diet. TPN is not necessary until the patient has high output fistulas. TPN decreases the amount of effluent through the fistula, thus promoting healing, and it provides supplemental nutrients to further aid in healing. Acute appendicitis is usually initiated by a luminal obstruction caused by an appendicolith or a fecalith. This causes bacterial overgrowth and increased secretions that lead to luminal distension, which activates visceral pain fibers that cause the initial diffuse periumbilical pain. Once the inflammation irritates ● ● ● ● ● ● ● ● ● ● ● the parietal peritoneum adjacent to the appendix, somatic nerve fibers are activated, which causes the localized right lower quadrant pain.Periumbilical pain is visceral, and right lower quadrant pain is somatic. Bile reflux gastritis is an unfortunate adverse effect of gastric reconstruction. It most commonly occurs in patients who have undergone Billroth II gastrojejunostomy. It also occurs, albeit less frequently, in patients who have undergone Billroth I gastroduodenostomy. Treatment for symptomatic patients is conversion to a Roux-en-Y gastrojejunostomy. Branched duct-intraductal papillary mucinous neoplasms can be observed if they are less than 3 cm in size and lack any suspicious features in CT or MRI. A rectovaginal fistula is an abnormal communication between the anterior wall of the anal canal or rectum and the posterior wall of the vagina. It is classified as low if a repair can be perianally done, and high if a repair can be accomplished only transabdominally. Simple or complex classification is based on location, size, and cause. The fistula in this patient is a simple low fistula likely caused by an injury during the episiotomy. Endorectal advancement of an anorectal flap technique is currently the standard treatment of choice for a simple low fistula and some mid-rectovaginal fistulas. Diagnosis of hepatic metastases of colon adenocarcinoma is typically made by abdominal CT scan. Idiopathic thrombocytopenic purpura (ITP), as in the patient in the clinical scenario above, is a diagnosis of exclusion. It is characterized by isolated thrombocytopenia without an apparent cause. Symptoms include bleeding and petechiae. Medical therapy options for ITP include corticosteroid therapy, platelet transfusion, IgG, rituximab, and the Rho(d) immunoglobulin. High-dose corticosteroid therapy is the first-line treatment. Steroid therapy produces an initial response in most patients in only a few days; however, this response is usually not sustained.IVIG is a second-line therapy for ITP because it takes 3–5 days to show an effect. Instead, steroid therapy should be used as a first-line treatment. The Whipple procedure, or pancreaticoduodenectomy, is divided into 3 overall stages: determination of resectability, resection, and reconstruction. The entirety of the pancreas is exposed by performing a Kocher maneuver, medializing the right and transverse colon, and opening the lesser sac. A cholecystectomy is performed and the hepatoduodenal ligament is dissected to expose the portal triad consisting of the proper hepatic artery, portal vein, and common bile duct. The gastroduodenal artery of the common hepatic artery and common bile duct are ligated and transected. Additionally, the inferior surface of the head of the pancreas should be freed from the superior mesenteric vein. After these maneuvers, resection can begin. The Beger procedure is a duodenum-preserving pancreatic head resection procedure for patients with chronic pancreatitis with head-dominant disease and lack of ductal dilation (as in this patient).The pancreatic head is dissected to the level of the portal vein, and cored out, leaving behind a thin rim of pancreatic tissue abutting the duodenum. This is then reconstructed with 2 anastomoses using a Roux-en-Y jejunal loop to the pancreatic tail remnant (end-to-side) and to the excavated pancreatic head (side-to-side). This is typically reserved for patients with a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilatation. The lack of distal ductal dilatation is key in selecting the Beger procedure over other surgical approaches, as this makes the end-to-side pancreaticojejunostomy the most appropriate anastomosis.The diagram below illustrates a Beger procedure. ● The Puestow procedure (illustrated below) is a longitudinal pancreaticojejunostomy (not a distal pancreatectomy). This is typically reserved for chronic pancreatitis with dilatation of the pancreatic duct (≥ 7 mm). The Puestow procedure has an 80% rate of immediate pain relief, with about 60% of patients achieving long-term pain relief. The Frey procedure (illustrated below) involves coring out the head of the pancreas with a longitudinal dissection of the pancreatic duct toward the tail, followed by a Roux-en-Y pancreaticojejunostomy. This is typically reserved for smaller inflammatory masses of the head of the pancreas and dilated pancreatic ducts (≥ 7 mm), which is not the case with this patient. ● ● ● ● ● ● ● The Whipple procedure (illustrated below; note the pylorus-sparing modification), also known as pancreaticoduodenectomy (not distal pancreatectomy), entails resection of the pancreatic head, duodenum, and distal one-third of the stomach. Reconstruction requires a gastrojejunostomy, pancreaticojejunostomy, and hepaticojejunostomy. The Whipple procedure is typically reserved for neoplasms of the head of the pancreas. In the setting of chronic pancreatitis, pancreaticoduodenectomy is rarely required unless malignancy cannot be excluded. The Bern procedure (illustrated below) is a modification of the Beger procedure that does not involve resection of the pancreatic head. In contrast to the Beger procedure, the pancreas is not transected at the level of the portal vein, which may be advantageous in the setting of extensive inflammation. Reconstruction only requires a single anastomosis with a Roux-en-Y jejunal loop to the pancreas. Longitudinal pancreaticojejunostomy is not a part of this procedure. There is no significant difference in outcomes between the Beger and Bern procedures. The Beger procedure is a duodenum-preserving pancreatic head resection procedure, which is reconstructed with 2 anastomoses using a Roux-en-Y jejunal loop to the pancreatic tail remnant (end-to-side) and to the excavated pancreatic head (side-to-side). This is typically reserved for patients with a large inflammatory mass in the head of the pancreas with no evidence of distal ductal dilatation. The choice of surgical approach in a patient with chronic pancreatitis is largely dependent on 2 key factors: 1) distal ductal dilatation ≥ 7 mm and 2) pancreatic head involvement (ie, by mass or significant inflammation/fibrosis). Although it is more nuanced, one may simplify the selection process as follows: For a dilated duct with head involvement, choose the Frey procedure, For a normal or small duct with head involvement, choose the Beger or Bern procedure, For a dilated duct without head involvement, choose the Puestow procedure Insulinomas are the most common functional neuroendocrine tumor. They are usually benign, < 2 cm, and found anywhere in the pancreas. Two-layer closure with an inner absorbable suture and outer nonabsorbable suture in the transverse fashion is the preferred method of repair of small bowel injuries if < 50% of the circumference is involved and if adequate debridement is attained first. ● ● ● Pressure Injury Staging Stage Features I Intact skin with localized nonblanching erythema II Partial-thickness skin loss with exposed dermis III Full-thickness skin loss with exposed fat and granulation tissue IV Full