Case Files Surgery

BREAST MASS:

- radiation therapy is indicated for pt with stage I dz tx with breast conservation therapy

- this reduces the rate of recurrence from 30% to 9%

- post-menopausal or non-lactating women with red/tender breasts should be assumed to have breast cancer until proven otherwise

- tamoxifen therapy assoc with uterine cancer

- systemic therapy is given when widespread mets is dx or when pt is high risk for distant mets

GERD:

- if hoarseness and wheezing, suggests pharyngeal reflux with silent aspiration

- if dysphagia and/or weight loss  think malignancy

- do endoscopy to evaluate for esophagitis, 24-hour pH monitoring can quantify severity

- H2 blockers may provide sx'atic relief, PPIs are superior for decr acid production

- ~50% of pts with GERD develop complications such as peptic strictures, Barrett's esophagus, and extraesophageal complications

- when LES is abnormally located, as in hiatal hernia, anti-reflux mechanism may be compromised at the GE junct

- std workup prior to surgery = endoscopy, 24-hour pH, barium esophagography (evaluates for gastric outlet obstruction - fundoplication is contraindicated)

- pts with esophagitis or significant sx  PPI therapy

- std surgery = Nissen fundoplication

- diagnostic endoscopy when pts have long-standing GERD and when sx's are refractory to medical tx

- pts with GERD may develop pulmonary and laryngeal sx

- adenocarcinoma of esophagus is a complication of barrett's (from longstanding GERD)

- surgery is indicated if persistent sx's while taking max PPI dose, can't tolerate PPIs, does not wish lifelong medications

ESOPHAGEAL PERFORATION:

- spontaneous esophageal perf = Boerhaave syndr; most are iatrogenic and in distal 1/3 of esophagus

- typically, have acute onset chest pain after an episode of vomiting; also may have shoulder pain, dyspnea, midepigastric pain

- 75% present with pleural effusion, usu left sided (from disruption of the mediastinal pleura)  often leads to mediastinitis and chest pain; delay in tx can lead to sepsis

- perforation into the mediastinum  pneumomediastinum and subcut emphysema (may not present with lower perforation)

- best initial diagnostic test = water-soluble contrast (gastrografin) esophagram; if no leak discovered, must do barium contrast

- tx principles = surgical drainage, debridement, repair and diversion

- outcome for esophageal perforation is directly related to amount of time elapsed b/w dx and tx

MALIGNANT MELANOMA:

- Suspicious lesions  perform an excisional bx

- A: asymmetry; B: border irregularity; C: color change; D: diameter increase; E: enlargement or elevation

- 4 types = superficial spreading, nodular sclerosis, lentigo maligna, acral lentiginous

- superficial spreading is most common; radial growth phase predominates (as in lentigo maligna)

- nodular sclerosis has no radial growth phase, but aggressive vertical growth phase

- acral lentiginous is freq in colored people

- Breslow depth is considered more accurate in reflecting prognosis

- interleukin-2 therapy has been found to be somewhat helpful, but surgery remains the best tx

- melanoma in situ  margins = 0.5cm; 4mm  >2cm

BENIGN PROSTATIC HYPERTROPHY

- best therapy = transurethral prostatectomy (TURP)

- prostate capsule restricts expansion of prostate gland as it expands in BPH  bladder neck and prostatic urethra become compromised; leads to bladder outlet obstruction

- have freq urination of small amounts, incomplete voiding, slow flow, nocturia, hesitancy

- ddx = urethral stricture dz, uti, prostatitis, prostate ca, neurologic dysfunction

- when there is a nodularity or an increase in the PSA, bx is indicated

- check UA, PSA, serum Cr (to r/o prostatism with renal compromise)

- initial tx is often medical  alpha agonists (cause relaxation of the prostate smooth muscle); also have meds that cause reduction in prostate size by blocking metabolite of testosterone

- in asx'atic with significantly elev PSA, do prostate bx

- for overflow incontinence (urinary retention)  immediate drainage and hospitalization

- alpha agonists  relaxed smooth muscle within arterial wall; decrease blood supply may result in dizziness or syncope

- mild elevations of PSA may occur after DRE

SBO:

- first steps = NGT, IVF, Foley

- can have strangulation, necrosis, sepsis; prerenal azotemia from fluid loss

- persistent pain  small bowel dilation or ischemia secondary to strangulation

- obstruction in child most likely result of hernia, malrotation, meconium, meckle's diverticulum, intussception, atresia

- in adult, likely adhesion, hernia, crohns, gallstone ileus, tumor

- in mechanical obstruction have crampy pain, nausea, bilious vomiting

- init may have low grade fever and tachyc (b/c o dehydration and inflamm changes); high