Файл: NMS Surgery_booksmedicos.org.pdf

There are no metastases outside the abdomen.

The tumor has not involved the porta hepatis, the portal vein as it passes behind the body of the pancreas, and the superior mesenteric artery region.

The tumor has not spread to the liver or other peritoneal structures.

Laparoscopy is receiving increased use to rule out peritoneal seeding before proceeding with laparotomy. This is especially indicated in tumors involving the body and tail of the pancreas and in patients with a CA 19 -9 level >400.

Histologic proof of malignancy is obtained by needle aspiration, either before or during surgery. A tru -cut biopsy can be performed through the duodenum after a Kocher maneuver.

The Whipple procedure (Fig. 15 -3) involves removal of the head of the pancreas, duodenum, distal common bile duct, gallbladder, and distal stomach.

The GI tract is then reconstructed with creation of a gastrojejunostomy, choledochojejunostomy, and pancreaticojejunostomy.

The operative mortality rate with this extensive operation can be as high as 15% but should be 2% or lower in centers where this surgery is frequently performed. According to recent publications, the lower mortality rate is realized in institutions doing at least five pancreaticoduodenectomies per year.

The complication rate is also considerable, the most common complications being hemorrhage, abscess, and pancreatic ductal leakage.

Distal pancreatectomy , usually with splenectomy and lymphadenectomy, is the procedure performed for carcinoma of the midbody and tail of the pancreas. Staging for this procedure

P.292

should include laparoscopy. Distal pancreatectomy is often performed for benign mucinous pancreatic tumors or occassionally a cystic pancreatic cancer.

Suspected in patients with abdominal pain and elevated serum amylase and lipase.

Dynamic CT is used to confirm diagnosis and to evaluate anatomy and extent of necrosis.

Admit patient, keep nothing by mouth (NPO), manage fluid requirements, and assess for complications of pancreatic abscess or bleeding.

For gallstone pancreatitis, cholecystectomy after resolution of symptoms and amylase normal.

Chronic Pancreatitis

Fibrosis of gland is associated with alcoholism.

Medical management of pain, diabetes, and pancreatic enzymes.

Surgical treatment is based on duct anatomy, including Peustow (for chain of lakes), distal pancreatectomy, or Duval (distal obstruction).

Pseudocysts can occur (or as sequela of acute pancreatitis) and require drainage procedure for continued symptoms or bleeding.

Pancreatic Cancer

Very poor prognosis. Fourth leading cause of cancer death in the United States.

Patients who present with painless jaundice are usually the only ones considered for curative resection.

CT and ERCP are used to establish diagnosis and stent biliary obstruction

Consider pancreaticoduodenectomy (Whipple) in patients without evidence of distant spread. P.294

Study Questions for Part IV

Directions: Each of the numbered items in this section is followed by several possible answers. Select the ONE lettered answer that is BEST in each case.

1.A 15 -year-old boy is admitted with a history and physical findings consistent with appendicitis. Which finding is most likely to be positive?

A Pelvic crepitus B Iliopsoas sign C Murphy sign

D Flank ecchymosis

E Periumbilical ecchymosis View Answer

2.A 50 -year-old man is admitted with massive bright red rectal bleeding. He recently had a barium enema that demonstrated no diverticular or space -occupying lesion. Nasogastric suction reveals no blood but does produce yellow bile. The patient continues to bleed. What is the next diagnostic step?

A Repeat barium enema B Colonoscopy

C Upper gastrointestinal series D Mesenteric angiography

E Small bowel follow-through with barium View Answer

3.A 15 -year-old boy awakens with sudden onset of right lower quadrant and scrotal tenderness accompanied by nausea and vomiting. Which of the following is the most appropriate diagnosis and represents a surgical emergency?

A Acute prostatitis B Acute epididymitis

C Torsion of the testicle D Acute appendicitis

E Gastroenteritis View Answer

4.A 47 -year-old woman presents with dysphagia to both solids and liquids equally. She has experienced a 10 -kg weight loss over the last several months. A barium swallow reveals a birdlike narrowing in the distal esophagus. What is the underlying cause of her symptoms ?

A Disorganized, strong nonperistaltic contractions in the esophagus B Failure of the lower esophageal sphincter to relax

C Hiatal hernia

D Barrett's esophagus

E Esophageal stricture secondary to untreated gastroesophageal reflux View Answer

5.A 45 -year-old male executive is seen because he is vomiting bright red blood. There are no previous symptoms. The man admits to one drink a week and has no other significant history. In the hospital, he bleeds five units of blood before endoscopy. What is the most likely diagnosis ?

A Gastritis

B Duodenal ulcer C Esophagitis

D Mallory-Weiss tear E Esophageal varices View Answer

6.Massive bleeding from the lower gastrointestinal tract is occurring in a 55 -year-old man who is otherwise healthy. After continued bleeding equivalent to one unit of blood, what should be the initial management ?

A Emergency laparotomy and total colectomy and ileoproctostomy B Emergency laparotomy and colostomy with operative endoscopy

P.295

C Arteriography to identify the bleeding site after anoscopy and sigmoidoscopy have ruled out a distal site D Infusion of vitamin K and fresh frozen plasma

E Colonic irrigation with iced saline solution View Answer

Questions 7–8

A 45 -year -old man is seen in the emergency department after vomiting bright red blood. He has no previous symptoms. He drinks one alcoholic beverage a day.

7.What is the most reliable method for locating the lesion responsible for the bleeding?

A Upper gastrointestinal series B Exploratory laparotomy

C Upper endoscopy D Arteriography

E Radionuclide scanning View Answer

8.After several hours in the hospital, he begins to have recurrent bleeding. He is transferred to a critical care bed and is persistently hypotensive despite trasnfusion of nine units of packed red blood cells. Which is the most appropriate next step in management of this patient?

A Upper endoscopy with attempt at cauterization of bleeding

B Transport to the interventional radiology unit to identify and embolize bleeding source

C Placement of a Blakemore tube to temporarily tamponade bleeding and to allow for stabilization of blood pressure D Laparotomy to control bleeding

E Infusion of vasopressin and additional units of blood View Answer

9.A 45 -year-old woman who has had a hysterectomy presents to the emergency department with abdominal pain and vomiting. A mechanical small bowel obstruction is seen on the abdominal radiograph. What is the most likely cause for this obstruction?

A Carcinoma of the colon B Small bowel cancer

C Adhesions

D Incarcerated inguinal hernia E Diverticulitis

View Answer

10.A 25 -year-old man is admitted with a history of sudden onset of severe midepigastric abdominal pain. Upright chest radiograph reveals free intraperitoneal air. What is the therapy for this patient?

A Upper endoscopy

B Barium swallow

C Gastrografin swallow

DObservation

ELaparotomy View Answer

11.An 80 -year-old male patient is referred for dysphagia with reflux of undigested food. The patient occasionally notices a bulging in his left neck. Which of the following is the most appropriate definitive treatment?

ABarium swallow

BUpper endoscopy

CCricopharyngeal myotomy

DComputed tomography (CT) scan of the chest

ELiquid diet

View Answer

P.296

12.A 42 -year-old female patient is diagnosed with gastroesophageal reflux and is started on medical therapy. Which of the following would be an indication for surgical antireflux procedure?

A Development of esophageal stricture(s)

B Barrett's esophagus with severe dysplasia C Esophagitis by biopsy

D High lower esophageal sphincter pressure demonstrated by esophageal manometry E Slow and uncoordinated swallowing by barium study

View Answer

13.A 75 -year-old male patient presents to the emergency room 2 hours after developing severe chest pain with repeated episodes of vomiting. He is tachycardic and febrile. A chest radiograph demonstrates a left pleural effusion. Emergent barium swallow reveals extravasation of contrast into the left chest. Proper definitive treatment of this patient would include which of the following?

A Observation

B Emergent surgical intervention C Placement of left chest tube

D Intravenous antibiotics and admission to the hospital E Upper endoscopy

View Answer

Questions 14–15

A 65 -year -old patient has been treated with pharmacologic therapy for an antral gastric ulcer for 12 weeks. A repeat upper gastrointestinal series shows approximately 50% shrinkage of the ulcer.

14. What further management should the patient undergo at this time?

A Continued pharmacologic therapy with a repeat upper gastrointestinal series in 8–12 weeks B A change in pharmacologic therapy with a repeat upper gastrointestinal series in 12 weeks C An upper endoscopy with multiple biopsies

D Total gastrectomy

E Surgery with limited excision of the ulcer View Answer

After further diagnostic work -up, the patient is found to have a gastric adenocarcinoma. Metastatic work -up is negative.

15.Therapy with curative intent would involve which of the following?

A Radiation therapy followed by chemotherapy alone

B Distal gastrectomy followed by adjuvant chemoradiotherapy C Total gastrectomy

D Total gastrectomy and splenectomy

E Local excision of the ulcer with clear margins followed by radiotherapy View Answer

16.Which of the following statements is true about the performance of a parietal cell vagotomy?

A It divides the vagus nerve at the gastroesophageal junction.

B It maintains innervation of the pylorus so that a drainage procedure is not required. C The recurrence rate is less than 5%.

D It cannot be performed laparoscopically.

E It is contraindicated for bleeding or perforated ulcers. View Answer

17. What innerves the stomach resulting in parietal cell secretion and gastrin release?

A Phrenic nerve B Vagus nerve

C Greater splanchnic nerves

P.297

D Celiac ganglion

E T4 root

View Answer

18. Which of the following is true regarding intestinal absorption of nutrients?

A Bile or bile salts are essential for absorption of vitamin B 12 .

B An iron -deficient individual can absorb up to 80% of dietary iron.

C Parathormone increases the intestinal absorption of dietary calcium.

D Intestinal epithelial cells resynthesize triglycerides before their release into the portal circulation. E Triglycerides are absorbed intact in a bile salt micelle -dependent process.

View Answer

Questions 19–20

A previously healthy 43 -year -old man presents with a 6-month history of nonbloody diarrhea, fever, and 10 -pound weight loss and now develops urosepsis. On evaluation, an enterovesical fistula (from the ileum to the bladder) is found. At laparotomy, findings include inflammation and “fat wrapping” of three separate segments of ileum. Each segment is approximately 20 cm in length and is separated by less than 20 -cm segments of normal-appearing bowel (skip areas). The distal -most of the three segments is more severely inflamed than the others and involves the terminal ileum all the way to the cecum. This segment of ileum is densely adherent to the right superior aspect of the bladder.

19. Which of the following is true?

AAll of the abnormal -appearing bowel should be resected.

BThis patient has complications of Meckel's diverticulitis.

CAll of the bladder wall involved in the inflammatory process must be removed.

DExtensive resection can reduce the potential for a recurrence to less than 10%.

EClosure of the fistula and resection of the involved bowel are preferred.

View Answer

20. The patient returns to the office 3 years later complaining of abdominal pain, abdominal distention, bloating after meals, and intermittent constipation interspersed with diarrhea. He has lost 20 pounds during the last 3 months, which he ascribes to the aforementioned abdominal symptoms. An upper gastrointestinal series with a small bowel follow-through reveals one area of tight stricture in the distal small bowel. The stricture appears to be 10 cm in length. Which of the following is true?

A All strictures require resection; bypass of the involved segment is not an option.

B Postoperatively, this patient's chance of another recurrence requiring surgery is 50%.

C Because this patient requires surgery for the second time, his risk of cancer is extremely high, and he should have an extensive small bowel resection.

D Postoperative anastomotic strictures typically cause symptoms years later. E Because of the patient's prior surgery, folate replacement is essential. View Answer

Questions 21–23

A 32 -year -old male executive with long-standing Crohn's disease presents with a complete obstruction of the small bowel. At laparotomy, scarring of the distal ileum and cecum cause an obstruction. A 10 -cm segment of mid small bowel shows moderate nonobstructive Crohn's disease.

21. Which operative procedure should be performed at this time?

A Radical resection of the involved segment of mid small bowel, all of the ileum, the cecum, and the right colon B Resection of the distal ileum and right colon with the involved mesentery and lymph nodes

P.298

C Bypass of the obstructing segment with a side -to -side anastomosis between the ileum and the right colon and no resection

D Stricturoplasty of the obstruction plus resection of the short involved segment of mid small bowel E Resection of the distal ileum and cecum

View Answer

22. Postoperatively, the patient requires an indwelling bladder catheter for 5 days to treat urinary retention. He does well until the tenth postoperative day, at which point he develops a fever of 103°F, right lower quadrant pain, and an ileus. The midline wound is not inflamed. Which of the following is most likely to have developed?