SURGICAL REVIEW NOTES FOR THE MEDICAL BOARD EXAM FROM SCHWARTZ

SURGICAL REVIEW NOTES FOR THE MEDICAL BOARD EXAM FROM SCHWARTZ
By Dr. Dean Cyril Y. Catot

LIVER
1. The first imaging test in the evaluation of patients with new onset portal hypertension should be a transcutaneous liver ultrasound with Doppler blood flow assessment.
2. Anticoagulation is the standard immediate therapy in Budd-Chiari Syndrome.
3. The single most important diagnostic and potentially therapeutic procedure to be performed in the cirrhotic patient with upper GI bleed is endoscopy.
4. Esophageal varices are the most common cause of massive bleeding in patients with cirrhosis.
5. The most critical treatment for acute hemorrhage in cirrhotic patients is prompt endoscopic intervention and therapy.
6. Distal splenorenal shunt(DSRS) has been shown to be the most effective in non-alcoholic patients with preserved liver function who require a shunt for the elective treatment of refractory bleeding.
7. In patients with complete intrahepatic portal vein thrombosis, an end -to -side portocaval shunt is the easiest to perform and the most effective shunt.
8. The diuretics furosemide and spironolactone are the mainstays of medical therapy of ascites.
9. A transjugular liver biopsy is the safest method to obtain tissue in Fulminant Hepatic Failure (FHF)patients.
10. Cerebral edema and intracranial hypertension are the complications of FHF most likely to result in adverse outcome and death.
11. Liver transplantation has become the therapy of choice for FHF patients with cerebral edema.
12. Simple hepatic cysts are the most common benign lesions found in the liver.
13. PAIR (percutaneous aspiration, instillation of absolute alcohol and reaspiration) is an excellent first line of therapy in the management of simple, congenital, hepatic cysts.
14. The most common complication specific to surgery for Polycystic liver disease(PLCD) is ascites.
15. Up to 75% of hepatic adenomas may be symptomatic at the time of presentation, with abdominal pain being the most common presenting symptom.
16. Resection remains the standard therapy for hepatic adenoma.
17. In contrast to hepatic adenoma, focal nodular hyperplasia typically is not associated with symptoms and does not pose any risks of rupture or malignant degeneration.
18. Bile duct hamartomas are the most common liver lesions seen at laparotomy which are peripheral in location, firm,smooth and white in appearance.
19. The most common etiologies of pyogenic liver abscesses include biliary tract manipulation, diverticular disease, inflammatory bowel disease and systemic infectionsnsuch as bacterial endicarditis.
20. Since percutaneous aspiration is effective in 80 to 90% of patients, surgical intervention is typically unnecessary.
21. Albendazole therapy is the mainstay in the majority of patients with hydatid disease.
22. Patients with normal hepatic parenchyma and serum liver tests can tolerate resection of as much as 80% of their liver volume.

23. The liver is second only to lymph nodes as a common site of metastasis from other solid cancers.
24. The long term, disease free survival rates for patients undergoing surgical resection of primary or metastatic liver tumors is usually below 40% in the most optimistic reports.
Gallbladder and the Extrahepatic Biliary System
1. The chief symptom associated with symptomatic gallstone is pain.
2. An abdominal ultrasound is the standard diagnostic test for gallstone.
3. Cholesterolosis is caused by the accumulation of cholesterol in macrophages in the gallbladder mucosa producing the classic macroscopic appearance of a “strawberry gallbladder”.
4. Diabetic patients with symptomatic gallstones should have a cholecystectomy promptly, as they are more prone to develop acute cholecystitis that is often severe.
5. Acute cholecystitis is secondary to gallstones in 90 to 95% of cases.
6. A high wbc (above 20,000) is suggestive of a complicated form of cholecystitis such as gangrenous cholecystitis, perforation, or associated cholangitis.
7. Ultrasonography is the most useful radiologic test for diagnosing acute cholecystitis.

8. Focal tenderness over the gallbladder when compressed by the sonographic probe (sonographic Murphy’s sign) is also suggestive of acute cholecystitis.
9. Cholecystectomy is the definitive treatment for acute cholecystitis and laparoscopic cholecystectomy is the procedure of choice.
10. Early cholecystectomy performed within 2 to 3 days of illness is preferred over interval or delayed cholecystectomy that is performed 6 to 10 weeks after initial medical treatment and recuperation.
11. A dilated common bile duct (>8mm in diameter) on ultrasonography in a patient with gallstone, jaundice, and biliary pain is highly suggestive of common bile duct stones
12. Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones.
13. If the stones are deliberately left in place at the time of surgery or diagnosed shortly after cholecystectomy, they are classified as retained; those diagnosed months or years later are termed recuurent.
14. Gallstone are the most common cause of obstruction in cholangitis.
15. The most common presentation in cholangitis is fever, epigastric or right upper quadrant pain and jaundice (Charcot’s triad.)
16. The definitive diagnostic test for cholangitis is ERC (endoscopic retrograde cholangiography)
17. The initial treatment of patients with cholangitis includes intravenous antibiotics and fluid resuscitation.
18. Percutaneous transhepatic drainage is used in patients in whom the biliary obstruction is more proximal or perihilar, or when a stricture in a biliary-enteric anastomosis is the cause, or the endoscopic route is the cause.
19. MRCP and PTC are the mainstays of biliary imaging for cholangiohepatitis.
20. Percutaneous ultrasound or ct-guided cholecystostomy is the treatment of choice for patients with acalculous cholecystitis as they are usually unfit for surgery.
21. In transduodenal sphincterotomy, the sphincter is incised at 11 o’clock position to avoid injury to the pancreatic duct.
22. Type I, fusiform or cystic dilations of the extrahepatic biliary tree , are the most common type, making up over 50% of all choledochal cysts.
23. The risk of cholangiocarcinoma developing in choledochal cysts is as high as 15% in adults and supports complete excision when they are diagnosed.
24. The hepatic duct bifurcation is often the most severely affected segment in sclerosing cholangitis.
25. In patients with sclerosing cholangitis and advanced liver disease, liver transplantation is the only option.
26. The vast majority of biliary duct stricture are caused by operative injury, most commonly by laparoscopic cholecystectomy.
27. Surgery with Roux-en Y cholodochojejunostomy or hepaticojejunostomy is the standard of care with good or excellent results in 80 to 90% of patients with bile duct strictures.
28. Between 80 to 90% of gallbladder tumors are adenocarcinomas and the papillary type are associated with an overall better outcome , as they are commonly diagnosed while localized to the gallbladder.
29. The calcified “porcelain gallbladder” is associated with more than a 20% incidence of gallbladder carcinoma.
30. In gallbladder cancer, there is near-universal agreement that simple cholecystectomy is an adequate treatment for T1 lesions and results in a near 100% overall 5-year survival rate.
31. About two-thirds of bile duct carcinoma are located at the hepatic duct bifurcation.
32. Over 95% of bile duct cancers are adenocarcinomas and the most common type is nodular.
33. Painless jaundice is the most common presentation in patients with bile duct cancers.
34. The most common causes of death for patients with bile duct cancers are hepatic failure and cholangitis.

PANCREAS
1. Two factors, biliary tract stone disease and alcoholism, account for 80 to 90% of the causes of acute pancreatitis.
2. Bile duct stones represent the most common form of associated biliary abnormality in acute pancreatitis.
3. In some patients, the blood from necrotizing pancreatitis may dissect through the soft tissues and manifests as blueish discoloration around the umbilicus (Cullen’s sign) or in the flank (Grey Turner sign)
4. Since serum levels of lipase remain elevated for a longer time than total or pancreatic amylase, it is the serum indicator of highest probability of acute pancreatitis.
5. Abdominal ultrasound examination is the best way to confirm the presence of gallstones in suspected biliary pancreatitis.
6. C-reactive protein (CRP) seems to be the marker of choice for prognosis of acute pancreatitis.

7. Computed tomography (CT) scanning with bolus intravenous contrast has become the gold standard for detecting and assessing the severity of pancreatitis.
8. The presence of air bubbles on CT scan is an indication of infected necrosis or pancreatic abscess.
9. Antibiotic therapy has not proved to be of value in the absence of signs or documented sources of infection in acute pancreatitis.
10. For controlling of abdominal pain in acute pancreatitis, morphine is to be avoided, due to its potential to cause sphinter of Oddi spasm.
11. Infection is a serious complication of acute pancreatitis and is the most common cause of death.
12. Gallstones are the most common cause of acute pancreatitis worldwide.
13. Cholecystectomy and operative common duct clearance is probably the best treatment for otherwise healthy patients with obstructive pancreatitis.
14. Patients who are high risk of surgical intervention are best treated by endoscopic sphincterotomy with clearance of stones by endoscopic retrograde cholangiopancreatography (ERCP).
15. Worldwide, alcohol consumption and abuse is associated with chronic pancreatitis in up to 70% of cases.
16. Pancreas divisum represents a special case of obstructive pancreatitis which is the most common congenital anomaly involving the pancreas occurring in up to 10% of children.
17. ERCP is considered the gold standard for the diagnosis and staging of chronic pancreatitis.
18. Although the primary hormonal deficit is a loss of insulin secretory capacity, the additional deficiencies of glucagon and PP are pathognomonic for pancreatogenic diabetes(Type III Diabetes).
19. The pancreatic endocrine product that correlates most strongly with chronic pancreatitis is the PP (Pancreatic Peptide) response to a test meal.
20. Pseudocysts comprise the most common complication of chronic pancreatitis.
21. If the pseudocyst has failed to resolve with conservative therapy and symptoms persist, internal drainage is usually preferred to external drainage, to avoid complication of pancreatocutaneous fistula.
22. Cystojejunostomy is the most versatile method of internal drainage and it can be applied to pseudocysts that penetrate into the transverse mesocolon, paracolic gutters or lesser sac.
23. Insulinomas are the most common pancreatic endocrine neoplasm presenting with a typical clinical syndrome known as Whipple triad:symptomatic fasting hypoglycaemia, documented serum glucose level less than 50 mg/dl and relief of symptoms with glucose administration.
24. While most of the ulcers are solitary, multiple ulcers in atypical locations that fail to respond to antacids should raise the suspicion for Zollingwer-Ellison syndrome.
25. In 70 to 90% of patients, the primary gastrinoma is found in Pasaro’s triangle, an area defined by a triangle with points located at the junction of the cystic duct and common duct, the second and third portion of the duodenum and the neck and body of the pancreas.
26. Since gastrinomas can be found almost anywhere, whole body imaging is required and the test of choice is somatostatin receptor (Ocreotide) scintigreaphy in combination with CT scan.
27. The VIPoma syndrome is also called WDHA syndrome due to the presence of watery diarrhea, hypokalemia, and achlorhydria.
28. Endoscopic ultrasound (EUS) is the most sensitive imaging method for Vipoma.
29. Diabetes in association with dermatitis should raise the suspicion of glucagonoma.
30. The most common presentation in somatostatinoma are abdominal pain, jaundice and cholelithiasis.
31. A risk factor that is consistently linked to pancreatic cancer is cigarette smoking.
32. K-ras oncogene is the most commonly mutated gene in pancreatic cancer, with approximately 90% of tumors having mutation.
33. About two thirds of pancreatic adenocarcinomas arise within the head or uncinate process of the pancreas, 15% are in the body, and 10% in the tail, with the remaining tumors demonstrating diffuse involvement of the gland.
34. In patients presenting with jaundice, a reasonable first diagnostic imaging study is abdominal ultrasound.
35. For patients suspected of having pancreatic cancer who present without jaundice, ultrasound is not appropriate and CT scan should be the first.
36. The current diagnostic and staging of choice for pancreatic cancer is a dynamic contrast-enhanced spiral CT scan.
37. In pancreatic cancer, invasion of the superior mesenteric vein or portal vein is not itself a contraindication to resection as long as the veins are patent.

SPLEEN
1. A positive direct Coombs’ test confirms the diagnosis of Autoimmune haemolytic anemia(AIHA) and distinguishes autoimmune from other forms of haemolytic anemia.
2. Corticosteroids act as the mainstay of treatment for both primary and secondary forms of symptomatic, unstable AIHA.
3. Hereditary spherocytosis(HS)is the most common haemolytic anemia for which splenectomy is indicated.
4. Splenectomy is curative for typical forms of HS and serves as the sole mode of therapy.
5. The most frequent indications for splenectomy among patients with sickle cell disease are hypersplenism and acute sequestration crises, followed by splenic abscess.
6. The diagnoisis of thalassemia major is made by demonstrating hypochromic microcytic anemia associated with randomly distorted red blood cells and nucleated erythrocytes on peripheral smear.
7. Splenectomy is not indicated in G6PD patients.
8. Although less common than G6PD deficiency overall, Pyruvate Kinase(PK) deficiency is the most common red blood cell enzyme deficiency to cause congenital chronic haemolytic anemia.
9. The common underlying problem leading to splenectomy in patients with myeloproliferative disorders is symptomatic splenomegaly.
10. Chronic lymphocytic leukemia (CLL) and hairy cell leukemia(HCL) are the two leukemias most amenable to treatment by splenectomy.
11. In CLL, the most common finding is lymphadenopathy.
12. In HCL, the most common physical finding is splenomegaly.
13. Hodgkin’s disease(HD) is a disorder of the lymphoid system characterized by the presence of Reed-Sternberg cells, which actually form the minority of the Hodgkin’s tumor.
14. Idiopathic Thrombocytopenic Purpura (ITP) is an autoimmune disorder characterized by a low platelet count and mucocutaneous and petechial bleeding.
15. Thrombotic Thrombocytopenic Purpura (TTP) is a serious disorder characterized by thrombocytopenia, microangiopathic haemolytic anemia and neurologic complications.
16. The first line therapy for TTP is plasma exchange and platelet transfusions are not recommended as severe clinical deterioration has been reported following their administration.
17. In splenic abscess, the most common origins for hematogenous spread are infective endocarditis, typhoid fever, malaria, urinary tract infections and osteomyelitis.
18. Splenectomy is the operation of choice for splenic abscess, but percutaneous or open drainage are options for patients who cannot tolerate splenectomy.
19. The triad of rheumatoid arthritis (RA), splenomegaly and neutropenia is called Felty,s syndrome.
20. Sarcoidosis is an inflammatory disease of young adults, characterized by noncaseating granulomas in affected tissues and the most commonly involved organ is the lung, followed by the spleen.
21. The most common etiology for splenic cysts worldwide is parasitic infestation, particularly echinococcal.
22. The most common primary tumor of the spleen is sarcoma.
23. Lung cancer is the most common tumor to spread to the spleen.
24. Portal hypertension secondary to splenic vein thrombosis is potentially curable with splenectomy.
25. Although rare, splenic artery aneurysm (SAA) is the most common visceral artery aneurysnm which usually arises in the middle to distal portion of the splenic artery.
26. For asymptomatic patients, size greater than 2 cm constitutes an indication for surgery in SSA.
27. The most common bacteria to cause infections in asplenic hosts are Streptococcus pneumoniae( 50-90% of cases), Haemophilus influenze type B and meningococcus.
28. Vaccination is given immediately for emergency splenectomy and at least 2 weeks before elective splenectomy.
29. The most common complication of splenectomy is left lower lobe atelectasis.
30. Antibiotic prophylaxis- usually a single daily dose of penicillin or amoxicillin – is recommended for aplenic children for the first 2 years after splenectomy.

THYROID AND PARATHYROID
1. Thyroglossal duct cysts are the most commonly encountered congenital cervical anomalies with 80% found in juxtaposition to the hyoid bone.
2. The diagnosis of Thyroglossal duct cysts is usually established by observing a 1-2cm. Smooth, well-defined midline neck mass that moves upward with protrusion of the tongue.
3. Treatment of thyroglossal duct cysts involves Sistrunk operation which consists of en bloc cystectomy and excision of the central bone to minimize recurrence.
4. Graves’ disease is the most common cause of hyperthyroidism and characterized by thyrotoxicosis, diffuse goiter and extrathyroidal conditions including ophthalmopathy.
5. Elevated thyroid –stimulating hormone receptor(TSH-R) or TSAb are diagnostic of Graves’ disease and are increased in approximately 90% of cases.
6. Methimazole is also associated with congenital aplasia, therefore, PTU is more preferred in pregnant and breastfeeding women.
7. Subtotal thyroidectomy, leaving a 4 -7 g remnant is recommened for patients with Graves’ disease except for patients with ophthalmopathy where total thyroidectomy is recommended.
8. Surgical resection is trhe preferred treatment method for patients with toxic multinodular goiter, with subtotal thyroidectomy being the standard procedure.
9. Thyroxine is the treatment of choice for hypothyroidism and is administered in dosages varying fro 50 to 200ug per day, depending upon the patient’s size and condition.
10. Streptococcus and anerobes account for more than 70% of causes of Acute suppurative thyroiditis.
11. Lymphocytic(Hashimotos’s) Thyroiditis is the most common inflammatory disorder of the thyroid and the leading cause of hypothyroidism.
12. Fine needle aspiration biopsy has become the single most important test in the evaluation of patients with thyroid masses and can be performed with or without ultrasound guidance.
13. Most patients with thyroid nodules are euthyroid and the risk for malignancy is 1% for patients found to be hyperthyroid.
14. Simple thyroid cysts resolve with aspiration in approximately 75% and unilateral thyroid lobectomy is indicated if the cysts persist after three attempts at aspiration, cysts more the 4 cm and complex cysts with solid and cystic components.
15. For patients with thyroid nodule, total or near total thyroidectomy is recommended for patients who had previous irradiation of the thyroid gland or who has family history of thyroid cancer because of the high incidence of thyroid cancer(>40) and decrease reliability of FNA biobsy.
16. Papillary Thyroid cancer (PTC) accounts for 80% of all thyroid malignancies in iodine-sufficient areas and is the predominant thyroid cancer in children and individuals exposed to external radiation.
17. The most common sites of metastasis for papillary thyroid cancer are the lungs, followed by bone, liver and brain.
18. In general, patients with PTC have excellent prognosis with a greater than 95% 10 year survival rate.
19. Follicular carcinomas account for 10% of thyroid cancers and occur more commonly in iodine deficient areas.
20. In follicular carcinomas, malignancy is defined by the presence of capsular and vascular invasion.
21. Total thyroidectomy should be performed when thyroid cancer is diagnosed.
22. Approximately 95% of patients with persistent or recurrent thyroid cancer of follicular origin will have thyroglobulin levels higher than 2 ng/ml.
23. Medullary thyroid cancers( MTC) account for about 5% of thyroid malignancies and arise from the parafollicular or Ccells of the thyroid.
24. Total thyroidectomy is the treatment of choice for patients with MTC because of the high incidence of multicentricity, more aggressive course and radioactive iodine therapy is not usually effective.
25. Most thyroid lymphomas develop in patients with chronic lymphocytic thyroiditis and respond rapidly to chemotherapy.
26. By far , the most common cause of hypoparathyroidism is thyroid surgery, particularly total thyroidectomy with concomitant central neck dissection.
27. Primary hyperparathyroidism arises from increased PTH production from abnormal parathyroid glands.
28. Secondary hyperparathyroidism occurs in patients with chronic renal failure but may also occur in those with hypocalcemia secondary to inadequate calcium or vitamin intake.
29. Tertiary hyperparathyroidism is seen most commonly in patients with long standing renal dysfunction who undergo successful renal transplantation.

ADRENAL
1. In hyperaldosteronism( Conn’s syndrome), patients typically present with hypertension, which is long standing, moderate to severe and may be difficult to control despite multiple drug therapy.
2. Cushing’s syndrome refers to a complex of signs and symptoms resulting from hypersecretion of cortisol regardless of etiology.
3. Cushing’s disease refers to a pituitary tumor, usually adenoma, which leads to bilateral hyperplasia and hypercorticolism.
4. The most common cause of hypercorticolism is exogenous administration of steroids.
5. In Cushing’s syndrome, progressive truncal obesity is the most common symptom, occurring in up to 95% of patients.
6. Unilateral laparoscopic adrenalectomy is the treatment of choice for patients with adrenal adenomas.
7. The treatment of choice in patients with Cushing’s disease is transphenoidal excision of the pituitary adenoma, which is successful in 80% of patients.
8. In congenital adrenal hyperplasia (CAH) , 21-Hydroxylase deficiency is the most common enzymatic defect, accounting for more than 90% of cases.
9. Congenital adrenal lipoid hyperplasia is the most severe form of CAH, which is caused by cholesterol desmolase deficiency.
10. Pheochromocytomas are often called the 10% tumor because10% are bilateral, 10% are malignant, 10% occur in pediatric patients, 10% are extraadrenal, and 10% are familial.
11. Headache, palpitations and diaphoresis constitute the classic triad of pheochromocytomas and the most common clinical sign is hypertension.
12. Urinary metanephrines are 98% sensitive and are also highly specific for pheochromcytomas.
13. Adrenalectomy is the treatment of choice for pheochromocytomas.
14. The most common sites for metastasis of malignant pheochromocytomas are bone, liver, regional lymph nodes, lung, and peritoneum.

A blog of all sorts… Click and read!