Renal Physiology

• Bicarb replacement: 0.5(body wt.)  x {target HCO3-} – {actual HCO3-}
• Bicarb risks:

• 1meq Na in every bicarb

• Hyperosmolar
• Volume overload
• Increased pCO2 with ventilation needs
• Hypokalemia

• Metabolic Acidosis:

• Gap= Methanol, Uremia, DKA, Propylene glycol, INH, Lactate, Ethylene glycol, Salicylates
• Nongap= Diarrhea, panc fistula/biliary fistula, RTA (2, 1, 4), acetazolamide, TPN, NaCl

• Metabolic Alkalosis

• Increased bicarb= High pCO2, Fluid contraction with inc prox tubule bicarb reabsorption, Steroid excess, low K+, massive blood transfusion
• decreased H+= vomiting, NG suction, diarrhea, diuretics, hypercalcemia, mineralocorticoid excess

• Hyponatremia= gives confusion, sz, coma, anorexia, nausea, vomiting

• If Una < 25 suggest volume depletion
• If Uosm < 100 suggest polydipsia
• SIADH= euvolemic, Uosm high, from pul dz, cns, SS lung Ca, major surgery

• Tx: water restriction

• Na need (meq)= 0.5 x Kg x (120-current Na)
• Correct less than 10meq/L/d to avoid central pontine myelinolysis

• Potassium

• 90% excreted in distal tubule, increased with urine flow, Na deliver, high K, B-agonists
• 10% excreted in feces
• Hyperkalemia tx: IV calcium, insulin, bicarb, diuretics, kayexelate

• Calcium

• 50% ionized (physiologically important)
• Fall/rise by 0.8mg/dl for every decrease/increase in albumin by 1g/dl
• Hypocalcemia: sx cramp, tingling, paresthesia, tetany, sz, Chvostek sign
• Hypercalcemia cases: hyper para, ca, Vit D, thiazide diuretics, immobilization, granulomatous dz, thyrotoxicosis, milk-alkali syndrome

• Sx: fatigue, weakness, hypertension, psych disorders, nausea, vomiting, abdominal pain, coma

• Magnesium

• Hypomagnesemia sx neuromuscular hyperexcitability
• Hypermagnesemia sx neuromuscular depression

Cardiac Physiology

• Starling’s Law

• Compliance= change in volume / change in pressure

• Swan Ganz

• Normals:

• CVP 0-6
• RV 20/0-6
• PA 15-30/2-8
• PCWP 6-12
• CO 2
• SVR 700-1300

• Hypovolemia: dec CVP, dec PCWP, dec CO, inc SVR
• Cardiogenic shock: inc CVP, inc PCWP, dec CO, inc SVR
• Septic: dec CVP, dec PCWP, inc CO, dec SVR
• Major PE: inc CVP, dec PCWP, dec CO, inc SVR
• Tamponade: inc CVP, inc PCWP, dec CO, inc SVR
• Neurogenic: dec CVP, dec PCWP, inc CO, dec SVR
• Want swan catheter in zone 2 or 3 (where PA is > alveolar presseure)

• IABP

• Placed distal to L SCA
• Inflated during diastole: increased diastole to exceed systolic, lowers systolic with deflation

 Respiratory

• Oxyhemoglobin dissociation curve.

• Saturation or O2 content for PO2
• Shunting is perfusion without ventilation

• Physiologic shunting=

• Right to left from perfusion of unventilated alveolus (upper lobes get underperfused)
• Bronchial a. goes to bronchial v. then pulmonary v. = blood supply of lungs does not get ventilated
• Left ventricle collects veins from inner surface of ventricle (Thebesian veins)

• O2 content = (Hgb x 1.36 x SaO2) + (0.0031 x PaO2) SaO2

• Anemia or carboxyhemaglobin will give high Po2 but low O2 delivery

• Right shift of curve= higher saturation for given Po2, decreased affinity for O2 (lets go of O2 easier, better oxygenation of tissue)

• Fever
• acidosis

• Left shift of curve= lower saturation for given Po2
• 25% of oxygen in removed

• Venous spo2 is 75% if arterial is 100%
• Venous PO2 is 40mmHg

• Lung volumes

• VC= maximum
• TV= normal respiration
• FRC= end of quite expiration (decreases with ARDS; increases by using PEEP)
• RV= end of max expiration

• FEV1

• Should be 12cc/kg for good postoperative course
• Restrictive lung disease has decreased
• Obstructive lung disease has change in curve

• PEEP

• Barotraumas
• Decreased CO from decreased venous return
• NaCl retention
• Increased ICP

• Capnography (CO2 monitor)

• Increases with MH
• Decreases with Air embolism or PE

 Anatomy that matters

• Cranial Nerves

• Fixed dilated pupils= CN3, on side of lesions
• Bells Palsey= can’t close eye on affected side
• Dropped shoulder= loss of spinal accessory nerve
• Tounge deviation= points to lesion

• Cord syndromes

• Brown Sequard= Heicord lesion; ipsilateral motor and proprioception loss, contralateral pain and temperature loss
• Central cord syndrome= upper extremity weakeness worse than lower
• Anterior spinal syndrome= bilateral motor, pain, temp loss; preservation of proprioception

• Brachial plexus

• Ulner n is lowest, pinched with TOS, involved in proximal ulnar fractures; ‘pope’s blessing,’ weak little finger pinch; sensory- all 5th, half 4th in palmar and dorsal
• Radial n= wrist drop (Saturday night palsy), and numbness 1st, 2nd, 3rd, half of 4th finger dorsal hand, occur with humerus fxr
• Medial n= numbness in 1st, 2nd, 3rd, half of 4th finger palmar hand; OK sign
• Long thoracic n= c5,6,7 results in winged scapula

• Lateral femoral cutaneous n= lateral thigh numbness
• Peroneal n= numbness in dorsal foot and great toe, foot drop
• Nerve of Latterjet= crow’s foot in antrum of stomach, must preserve when doing highly selective vagotomy
• Renal vessels= artery above vein, vein anterior to artery, renal pelvis is posterior
• Azygos vein= acts as collateral to IVC if occluded above azygos
• Pulmonary sequestration

• Intralobar= drain to pulmonary v, get infected, connected to bronchial tree
• Extralobar= drain to systemic (create L->R shunt)

• TEF

• Type C (common)= proximal blind pouch with distal TE fistula; (get air in stomach)
• Type A= atresia without fistula
• Type E= H type

• Ortho

• Chance= lumbar spine, from seat belt, a/w pancreatic and SB injuries
• Posterior shoulder dislocation= axillary n
• Posterior hip dislocation= sciatic n
• Jefferson fxr= C1 posterior arch, pts usually ok
• Hangman’s fxr= C2

• Pancreas

• Accessory duct (from ventral bud) located cranial, duct of santorini (connects to wirsung)
• Main duct, duct of Wirsung

• Triangle of Calot= cystic duct, CHD, liver (cystic a is in the triangle)
• Femoral triangle= sartorious, adductor longus, inguinal ligament

 GI Physiology

• Anatomy

• Esophagus begins at cricoid C6
• UES= cricopharyngeus
• Intrathoracic esophagus has negative pressure
• LES= functional high pressure zone (not anatomic)

• 15-24 mmHg normal resting pressure
• At 40-45cm from incisors
• Increased tone with

• Gastrin
• Caffeine
• Alph stim
• Cholinergics
• Protein
• Gastrin

• Decreased tone with (VIP)

• Secretin, cck, estrogen
• Alpha blockers
• Anticholinergics
• B-blockers
• Etoh
• Nicotine
• Fatty meal

• Intraabdominal esophagus= positive pressure, helps LES
• Upper 1/3 striated
• Lower 2/3 striated muscle

• Swallowing

• Mediated by VIP (nitric oxide)

• Peristalsis

• Primary= normal swallowing
• Secondary= esophageal distention resulting from food bolus
• Tertiary= uncoordinated / dysfunctional

• Stomach

• Receptive relaxation mediated by vegas n
• Major source of carbohydrate absorption
• Stretch and chemoreceptors begin acid secretion
• Fundus & body= acid and IF from parietal cell (oxyntic gland mucosa)

• 2L/day acid via H/K ATPase
• Stimulated by vagus; cephalic from sense, gastric phase from gastric stim, stretch receptors in stomach (decreased gastric emptying)
• Inhibited in antrum by decreased pH, somatostatin, fat in intestine

• Body & antrum= pepsinogen from chief cell (oxyntic & pyloric)

• Activated by acid and other pepsin

• Antrum= gastrin from G-cell (decrease gastric emptying)

• Increases gastric epithelium (protection)

• Gherlin stimulates appetite (increases with wt loss)

• Small intestine

• Directly absorbs carbs, protein
• Chylomicrons for lipid absorption
• Enteric nervous system

• Motility- myenteric plexus
• Secretion/absorption- submucosal nervous sys
• Duodenum is slowest
• Peristaltic wave:

• Substance P causes circular smooth m contraction (propagates)
• VIP causes relaxation
• Normal transit time from intestine to colon is < 4hrs
• Migrating motor complex= only in fasting state; stomach to TI in 75-90min

• Duodenum

• Stimulated by protein  CCK, gastrin, GIP increase mixing
• Low pH  secretin  pancreatic bicarb
• Fat  increase CCK, decrease gastric emptying

• Glutamine primary fuel for enterocytes
• MCTG are water soluble
• Fat absorbed in duodenum and jejunum
• Bile salts resorbed in ileum

• Pancreas

• Secretin= bicarb secretion from low pH in duodenum

• Inc bicarb, fluid; dec Cl

• CCK= enzyme secretion from fat in duodenum

• GB contraction, sphincter of odi relaxation

• Vitamin absorption (specific transporters)

• Ca++= binds at bruch border, requires vit D & PTH
• FeSO4= helped by acid, vitC

• Colon

• Absorbs Na, water, Cl, some amino acids, some lipids
• Short chain fatty acids are fuel for enterocytes
• Transverse colon is primary storage site

• Intestinal hormones:

• Gastrin= gastric acid secretion, gastric epithelium, stimulated by protein
• CCK= panc enzyme secretion, contraction of GB
• Secretin= H2O and bicarb from pancreas (from acid in intestine)

 Ortho for Gen Surg

• Osteomyelitis

• S aureus is most common
• Salmonella is most common in sickle cell dz
• Surgery for dead tissue

• Septic arthritis

• S aureus most common
• Monoarticular arthritis in young may be gonorrhea
• Tx- aspiration, arthroscopy if not improved; hip and shoulder need surgery immediately

• Fight bite= treat with irrigation and abx
• Flexor tendon sheath infection

• Signs: fusiform swelling, pain with passive extension, tenderness along sheath, finger held flexed

• Nec Fasciitis

• Grp A strep

• Compartment syndrome

• Pressure > 30mmHg
• Lower leg Tx= anterolateral incision and posteromedial incision
• Thigh Tx= anterior, posterior, and medial compartment release
• Forearm Tx= volar, dorsal, mobile wad of 3

• Fat embolus

• Rash, acute hypoxemia
• Decreases with early fxr stabilization

• Shoulder dislocation

• Anterior- risk axillary n injury; externally rotated
• Posterior- seen with sz, diabetics, electrocution; arm internally rotated; risk axillary a injury

• Volkmann’s contracture= supracondylar humerus fxr, occluded interosseous a, median n affected by swelling
• Colles’ fxr= distal radius fxr
• Replantation

• Contraindicated- single digit, multilevel injury
• Indications- thumb, multiple digits, child, single digit beyond FDS

• Femoral fxr

• Femoral neck in elderly gets prosthesis b/c poor blood supply
• Intertrochanteric fxr can get fixation b/c better blood supply
• Femoral shaft fxr gets rod

• Knee dislocations

• Risk peroneal n injury along with pop a injury

• Lower leg soft tissue injuries

• Proximal 1/3= gastroc flap
• Middle 1/3= soleus flap
• Distal 1/3= free flap

• Bone tumors:

• Most common = met

• PB KTL: prostate (blastic), breast, kidney, thyroid, lung

• Multiple myeloma is most common primary bone tumor

 Breast Diseases

• Blood supply

• Subclavian  IMA 60%
• Axillary a  Lateral thoracic 30%
• Thoracic aorta  Intercostals 10%

• Mastodynia

• 66% of women
• Cyclic with mass is usually cyst a/w fibrocystic dz
• If > 35yo get mammogram
• Tx: reassurance, Primrose oil, Danazole (causes masculinization)

• Nipple discharge

• Galactorrhea is bilateral
• Spontaneous, unilateral, single duct, a/w mass is most concerning for malignancy
• Only observe discharge during pregnancy or postpartum
• Dx: mmg, get terminal duct excision for dx

• Fibroadenoma

• Tx observation, can excise to r/o cystersarcoma phyllodes

• Cystosarcoma Phyllodes

• Benign- excise to free margin
• Malignant- no nodal met, 3cm margin or mastectomy; no chemo/xrt

• BIRAD 3= 1-2% risk of malignancy, get 6mo f/u
• BIRAD 4= 20% risk of malignancy, need biopsy
• BIRAD 5= 85-90% risk of malignancy, need excision (can still get bx)
• US

• Solid v cystic
• Screening for young patients, dense breasts, high risk
• Fibroadenoma= well defined, no shadowing
• Cyst= dark
• Cancer= poor defined; posterior shadowing; taller than wide

• Breast mass management

• Cyst

• aspirate and observe
• recure more than 2x or bloody get excision
• Mass after aspiration of cyst get excision
• Intracystic lesion on US get excision w/o aspiration
• Positive cytology of cyst aspiration get excision (only send fluid if not clear fluid)

• Solid mass observed if bx, exam, mmg/US all c/w benign, otherwise excise

• NPV is 100%
• PPV is 75%

• FNA

• False positive 1-18%
• False negative 1-35%
• Do not treat ca only based on FNA

• Core needle Bx

• False negative 5%
• False positive very rare

• Stereotactic core bx

• Do open bx if get:

• Atypical dutal hyperplasia (false negative 20-50%)
• LCIS (may have adjacent carcinoma)
• Papillary lesion (can’t differentiate benign from malignant)
• BIRAD 5 – get excision
• Pseudoangiomatous stromal hyperplasia (need negative margin)
• Radial scar
• Phyllodes tumor (can’t differentiate benign v malignant)

• Risk factors for Br CA

• h/o Br ca
• Estrogen

• OCP no increased risk
• HRT has increased risk

• Diet
• EtOH
• Histology

• Fibrocystic change

• No atypia has very small increased risk
• ADH has 4x cancer risk

• Gail Model: risk assessment

• # of 1st degree relatives
• Age at menarche, 1st live birth, race
• Number of breast biopsies and histology

• BRCA 1

• Q arm of chromosome 17
• Tumor suppressor gene
• Lifetime risk of 50-80% breast Ca
• 40-60% risk of bilateral cancers
• Ovarian cancer in 15-45%

• BRCA 2

• Q arm of chr 13; AD
• 50-85% breast cancer
• 10-20% ovarian cancer
• 6% male breast cancer

• Li Fraumeni= p53 mutation

• Sarcomas, brain ca, leukemia, adrenal ca, br ca

• LCIS

• 1% per year risk of cancer
• 2/3 develop IDC
• Tx:

• Observe
• Chemoprevention
• Bilateral prophylactic mastectomy

• DCIS

• Present with microcalcification, mass
• Tx:

• Total mastectomy
• Lumpectomy with XRT
• Lumpectomy alone if <1cm, negative margins, well differentiated cytology
• NO ALND, SLNB only for mastectomy with extensive disease, palpable disease, micro-invasion

• Breast Ca stage

• T1 < 2cm
• T2 2-5cm
• T3 >5cm
• T4 chest wall, skin, inflammatory
• N0 no nodes

• N1 ipsilateral
• N2 fixed nodes, internal mammary nodes
• N3 infraclavicular, internal mammary and axillary, supraclavicular

• pN (pathologic axillary nodes)

• pN1= 1-3 nodes
• pN2= 4-9 nodes
• pN3= >10 nodes

• Staging

• 1= T1N0
• 2a= T2N0 or T1N1
• 2b= T3N0, T2N1
• 3a= T3 N1-2
• 3b= T4 N0-2
• 3c= N3

• Tx Stage I&II

• MRM
• Breast preservation

• SLNB or Level 1&II axillary nodes
• XRT up to 45-50Gy
• Contraindications

• Pts choice
• Positive margins on 3 margins
• Diffuse malignant calcs
• Multicentric disease
• 1st or 2nd trimester
• Inadequate radiation

• XRT

• Can avoid with >70yo, T1, and ER+
• Do XRT after total mastectomy for:

• T3-T4 (>5cm)
• > 4 positive lymph nodes
• Inflammatory carcinoma

• Local recurrence is 4x higher without xrt

• SLNB

• Methylene blue causes skin necrosis
• Lymphazurin causes anaphylaxis
• Contraindications:

• Palpable lymph node (not absolute, can bx node)
• Disruption of lymphatic drainage

• Prior breast surgery
• Prior ALND
• XRT

• Breast reconstruction

• TRAM
• Lat dorsi
• Timing:

• Immediate v delayed

• depends on comorbidities of patient
• Flap preferred with XRT

• Inflammatory carcinoma

• Dermal invasion
• Tx: Neoadjuvent chemo mastectomy XRT
• 45% 5yr survival

• Paget’s disease= DCIS or IDC of nipple

• Eczematoid lesion of nipple
• Paget’s cells in epidermis
• Tx: mastectomy, central lumpectomy

• Br ca in Men

• 1%
• Presents later stage and older age
• Tx MRM, tamoxifen if ER positive

• Side effect of tamoxifen impotance
• Prognosis similar to women

• Pregnancy after breast cancer

• No survival disadvantage
• Rx wait 1yr after diagnosis

• Tamoxifen / Reloxifen

• Increased endometrial cancer, DVT, stroke, catact, inc potency of Coumadin
• Reduces 2nd breast ca by 50%

• Prophylactic mastectomy

• Has 90% risk reduction of breast cancer        

• Neoadjuvent chemo

• Locally advanced (size > 5cm, or >4 LNs)
• Can change stage 2 to breast conservation (still can’t do extensive calcifications or multicentric)
• Better response with high grade, ER-, non lobular

• Skin sparing mastectomy

• No increased local recurrence rate (from TM – 0-7%)

 Colon diseases

• Colon Polyps

• Neoplastic= adenomatous
• Non neoplastic= hamartomatous, inflammatory, hyperplastic
• Pedunculated
• Sessile
• Microscopic

• Villous
• Tubular villous
• Tubular

• High Risk: severe dysplasia, >1cm (>9% Ca risk), >25% villous, >3 synchronous adenomas
• Polypectomy risk        

• Perforation 0.1-0.3%
• Hemorrhage 0.7-3.3%
• More with right sided, sessile polyp, or large

• Adenoma with invasive cancer

• Further tx depends on risk of LN or local recurrence
• Unfavorable factors require formal resection (colectomy)

• Cancer within 2mm of margin
• Poorly differentiated
• Lymphovascular invasion
• Incomplete resection of polyp
• (Sessile tumor resected piecemeal?)

• Haggitt Levels of invasive cancer

• 1= head of polyp
• 2= neck
• 3= stalk
• 4= below stalk or sessile polyp
•  all level 4 need resection

• Colon cancer

• 2/3 colon, 1/3 rectal
• 50% left sided
• Risk factors:

• Family hx
• IBD
• Diet (fat, calcium, selenium, etoh)
• Xrt

• HNPCC= autosomal dominant

• I= colonic
• II= extracolonic features
• Amsterdam criteria= 3 pts, 1 1st degree relative, 1 < 50yo
• Right sided, high metachronous risk
• Screen 10yrs younger than earliest dx

• Genetics

• Loss of heterozygosity: APC, DCC, p53, Kras
• Replication error pathway: HNPCC; better prognosis

• Screening: at 50yo; FOB annually, AFOB + sigmoidoscopy q5yrs; ACBE q5yrs; colonoscopy q 10yrs; (all equal)
• Right side bleeds, left side obstructs
• Colectomy

• > 15 lymph nodes (need at least 12 for pathologic staging)
• 5cm margins (1-2cm for rectal)
• Evaluate ovaries (2-8% synchronous mets)

• Chemotherapy for stage 3 disease: 5FU, Leukovorin, Oxaliplatin

• Avastin (antiEGF ab; increases survival and response to chemo; increased bleeding and decreases wound healing, should not be started within 3 wk after surgery or surgery 6wk after avastin)

• Follow up:

• Colonoscopy yearly then q3-5yrs
• CEA q3-6 months

• Ulcerative Colitis

• Mucosal inflammation
• 30% ultimately require surgery
• Extraintestinal:

• Primary sclerosing cholangitis (can give cholangiocarcinoma, doesn’t improve with colectomy)
• Ankylosing spondylitis (doesn’t improve with colectomy)
• Ocular problems
• Arthritis
• Anemia
• Pyoderma gangrenosum (50% improve with colectomy, tx with steroids)

• Urgent indications for surgery:

• Hemorrhage
• Fulminant UC (can still try steroid, cyclosporine, bowel rest)

• Elective indications for surgery:

• Refractory to medical management
• Intolerable side effects of medical tx
• Any dysplasia
• Carcinoma

• 1% risk per year
• Should have colonoscopy if have dz > 10yrs

• Growth retardation in children

• Surgery for UC:

• Subtotal colectomy with end ileostomy

• For emergency
• Take rectum at level of sacral prominory (can bring distal margin out as mucus fistula)

• Pan-Proctocolectomy with IPAA (gold standard)

• Contraindications: anal dysfunction, cancer below middle rectum, obesity
• Can do stapled IPAA versus hand sewn with mucosectomy of anal transition zone

• If do stapled, need life long survailance of ATZ

• Pouchitis: inflammation, tx with cipro/flag

• Kock Pouch (continant ileostomy)- no longer used
• Ileorectal anastamosis

• Rarely used (rectal sparing in US is rare)

• Crohn’s disease

• Transmural inflammation
• Dx: extent of dz, skip lesions, granulomas, serologies
• Indications for surgery

• Intractability
• Growth retardation
• Obstruction, fistula, abscess, bleeding
• Fulminant colitis

• 8-10% recurrence / year after surgery
• Resect gross disease
• DO NOT DO panproctocolectomy with IPAA – need end ileostomy
• Surgery:

• Dx with appendectomy – leave crohn’s, can do appy if cecum nl
• Ileosigmoid fistula – leave sigmoid (take down fistula bluntly and repair), take out ileum (usually ileal CD)
• Colojejunal fistula – leave jejunum (usually colon CD)
• Do not do bypass of stricture

• Fistula in crohn’s

• Short fistula is usually wide and poor resolution
• Long fistula is usually narrow and resolves

• Return of bowel motility:

• Small bowel – stomach – colon

• Polyposis syndromes:

• Familial polyposis (AD)

• Rectosigmoid, but go throughout GI tract (gastric polyps benign, small bowel polyps need excision (precursors))
• Tx: total colectomy with mucosectomy; total colectomy with ileorectal anastamosis (has risk of rectal ca)

• Gardner’s syndrome (AD)

• Extracolonic (osteoma, desmoids, lipoms)
• Treat desmoids with WLE, antiestrogen, and NSAID
• High duodenal and periampullary small bowel carcinoma
• Tx: prophylaxis TAC with ileorectal anastamosis (survey rectum and Upper endoscopy yearly)

• LAR v APR

• Need to keep proximal margin of anal canal (surgical anal canal)
• Dentate line is variable and is lower than sphincter (anatomic anal canal)
• 2cm distal margin required

 OBGYN

• Acute abdomen in female

• Quantitative B-HCG
• PID with pain starting with onset of menses

• Gonococcal, chalmydia, mixed bacteria
• TOA usually polymicrobial

• Larger size needs drainage

• Sx: bilateral adnexal pain, cervical motion tenderness, abdominal tenderness

• Start with pelvic US
• Ectopic pregnancy is B-HCG > 2000 w/o intrauterine pregnancy

• Suspect ectopic if B-HCG < 1500 w/ severe pain and no adnexal mass
• PID gives risk
• Previous ectopic is highest risk factor

• Splenic artery aneurysm in pregnancy
• Mittleshmertz – mid cycle pain (ovulation)
• Ovarian torsion

• Intermittent before finally getting stuck
• a/w cysts
• dermoid most common mass to torse
• more common in pregnancy
• Tx: untwist if viable

• Ovarian tumors:

• Dermoid- benign germ cell tumor
• Krukenberg tumor- metastatic from stomach (or any bowel)
• Fibroids removed for pain, infertility, rapid growth in postmenopausal, bleeding (not size alone)

• Pregnancy

• Increased blood volume (dilutional anemia)
• Elevated wbc
• Hypercoagulable
• Euthyroid, diabetogenic

• Hyperthyroidism treated with PTU (radioiodine or total thyroid after birth)

• Cholestasis
• Surgery:

• No indomethcin (closes ductus)
• Cholecystitis is treated conservatively if possible in 1st & 3rd trimester; lap chole in 2nd trimester

• Chemotherapy can be used in 2nd trimester

• Ovarian Cancer

• Primary determinant of survival is degree of cytoreduction
• Tx: peritoneal washings, TAH, BSO, omentectomy, peritoneal resection

 Adrenal and Endocrine Pancreas

• Adrenal

• Aorta, renal, phrenic aa
• L- renal; R – IVC
• HPA axis

• Stress  CRH  ACTH  cortical stim steroids
• ACTH produced in cortex and in small cell lung ca
• Steroid formation starts with cholesterol

• Cushing syndrome (usually iatrogenic)

• 70% pituitary adenoma (cushing dz)
• 20% adrenal adenoma
• 10% lung / thyroid
• Dx: serum cortisol, urinary 17-OHCS; low dose dexamethasone test;
•  24hr urine free cortisol shows hypercortisol state
•  Low dose dexa test:

• 0.5mg qid for 2 days OR 1mg overnight and measure serum cortisol level = will not suppress in cushings

• High dose dexa test:

• Elevated ACTH is pituitary or paraneoplastic
• suppresses cortisol in pituitary adenoma
• no suppression with adrenal or paraneoplastic

• Hyperaldosteronism (Conn syndrome)

• Sx: HTN, low K, polyuria, high Na, metabolic alkalosis
• Dx: low rennin, high aldosterone, metabolic alkalosis

• Secondary hyperaldosteronism (cirrhosis, CHF) get high rennin and HTN
• K < 3
• Usually single adenoma, rare bilateral hyperplasia, <1% unilateral hyperplasia
• Salt loading test needed if on antihypertensives

• Salt load should suppress aldosterone
• Conn syndrome has non suppressed aldo

• Localization:

• CT
• Selective venous sampling used if bilateral adrenal nodules, adrenal hypertrophy, or no lesions seen on CT

• Tx:

• Prep- Na restriction, correct alkalosis, K, spironolactone for 4 wks
• Adrenalectomy for adeoma
• NO surgery for bilateral hyperplasia.

• Pheochromocytoma

• Arise from chromafin cells (neural crest ectoderm)

• Sx: Paroxysmal HTN, sweating, headaches, tremors, palpitations, chest pain, fever, anxiety, HTN

• Familial: MEN IIa &b
• 10% bilateral, malignant, children, extra-adrenal, no HTN
• Extraadrenal: zucharcandle, bladder, suprarenal, mediastinum
• Dx:

• 24hr urinary free catecholamines, metanephrines, normetanephrines, VMA
• Plasma metanephrines, normetanephrines (sensitive but higher false positive)
• Only pheo’s and zuckerkandle paragangliomas can secrete epinephrine

• Localization:

• CT
• MIBG
• MRI

• Tx:

• Alpha-blockade 1-2wks prior; then b-block
• Correct volume depletion
• Surgery- 1st isolate vein, remove adrenal with capsule

• Adrenal Incidentaloma

• Adrenalectomy  for:

• all > 6cm
• all functional
• if 3-6cm and pt preference / low operative risk

• Observation is 6mo CT with yearly biochemical testing
• Can be metastasis

• Usually bilateral
• Lung, renal, melanoma, GI, breast, lymphoma, HCC

• Adrenal Cancer

• Usually functional
• 35-40% 5yr survival with complete resection

• Adrenal insufficiency

• Exogenous steroids
• Waterhouse freiedrichsen syndrome from meningococcal infection and bilateral drenal hemmhorage
• Sx: Hypotesnsion, fever, Low Na, High K

• Pancreatic endocrine tumors

• Usually malignant (except insulinoma) , mets to LN and liver
• Metastatic treatment with streptozotocin results in DM
• Formal resection except insulinoma (and gastrinoma if localized)
• Die from endocrinopathy and spread
• Localization

• US #1- ab, intraop, endoscopically
• CT
• MRI
• Octreotide scan – gastrinoma

• Insulinoma= from B-cell; most common; 20% are functional; most benign

• MEN 1 (30-50% have insulinoma)
• Usually small, anywhere in pancreas
• Rare mets to liver, LN
• Sx: Whipples’ triad

• 1- Fasting hypoglycemia < 40
• 2- Hypoglycemic symptoms
• 3- Relief with glucose
• Can get seizures, coma, tachycardia, angina, wt gain
• Visual changes is #1

• Dx:

• Elevated Insulin, elevated C-peptide levels, no insulin Ab
• Insulin/glucose ration < 0.3 at 72hr fast
• Intraop US (90%) > endoscopic US (80%)
• CT – only 60% seen
• Portal v sampling (80-90% localized)

• Tx:

• Enucleation- small or solitary
• Subtotal Pancreatectomy – large, multiple, nesidioblastosis, MEN1 (multiple)
• Paliation: streptozotocin, diazoxide, octreotide

• Gastrinoma= ZE syndrome; 2nd common tumor of panc

• Islet cells
• MEN I in 20% of ZE pts
• 60-80% solitary, 60% malignant, 30-80% with mets to liver
• APUDoma
• Sx:

• Pain, ulcers, esophagitis, diarrhea, wt loss
• Especiall with:

• Ulcers in distal duodenum or jejunum
• Multiple or recurrent ulcers
• Ulcers a/w diarrhea
• PUD with MEN-1

• Dx:

• Gastrinoma triangle- duodenum, head of pancreas
• Must stop PPI and H2 blocker before test
• Fasting serum gastrin > 100
• High basal acid secretion, pH<2.5
• Secretin stim test

• Increase gastrin in response to secretin

• EUS, EGD(80%)
• CT (70%)
• MRI
• Octreotide (85%)
• Intraoperative US (cannot see duodenal gastrinomas)

• Tx:

• Must R/O MEN I (tx differs and must tx HyperPara 1st)
• PPI, H2 blockers, Octreotide
• Complete gastrinoma triangle exploration, nodal sampling, duodenotomy, IOUS  enucleation
• metastatic dz:

• total gastrectomy
• metastatectomy
• octreotide
• streptazotatin

• in MEN-I, resect disease that is imaged (2cm)

• Glucagonoma= Alpha cell islet tumor

• Increased serum glucose, catabolism of fat, carbohydrate protein
• Usually solitary in body and tail
• Likely malignant
• Sx:

• Skinny, diabetic
• Rash= Migratory Necrolytic erythema; resolves with octreotid or tx
• Anemia
• Glossitis

• Dx:

• Glucose, glucagon level
• Skin bx
• CT, MRI

• Tx:

• Reverse catabolism; TPN, insulin, vitamins
• Pancreatic resection
• Streptazotatin (kill alpha and beta cells)
• Octreotide

• VIPoma= usually from pancreas

• Solitary, malignant
• Stimulate cAMP
• Sx: WDHA syndrome

• Watery (secretory) diarrhea
• Hypokalemia
• Achlorhydria

• Dx:

• Serum VIP level >200

• Somatostatinoma= delta cell of pancreas and gastric antrum

• Inhibits insulin, glucagon, cck, secretin, tsh, GH
• Solitary and malignant
• Sx:

• DM
• Cholelithiasis
• Steatorrhea

• Dx:

• Usually found during gastrectomy
• Elevated somatastatin levels (RIA), low insulin, low glucagon

• Tx:

• Pancreatic resection

• Non functioning islet cell tumors

• Large, metastatic
• Tx resection, debulking
• streptozotocin

 Liver, Biliary tract, GB

• Liver

• Divided by left, right, middle hepatic veins
• Portal vein

• Splenic meets SMV and IMV
• Left and right gastric veins branch off PV (L= coronary v)

• Assessment of liver

• Functional liver remnant need 20% in nl liver; 40% in compromised parenchyma; determined on CT volumetry
• Right trisegmentectomy may remove 85% of liver
• Want Child-Pugh < 7

• Simple Cysts= female, >40yo, can rarely bleed or get infected

• Dx: US
• Tx: observe asymptomatic < 8cm

• Widely unroof if >5cm and symptomatic
• Aspirate if <5cm and symptomatic

• Cystadenoma= malignant potential

• Dx: CT multilocular, septated, irregular, calcifications, mural nodules
• Tx: cyst wall enucleation (remove epithelium)

• Hepatic rsxn if cystadenocarcinoma

• Hydatid cysts= echinococcal cysts; risk anaphylactic shock if rupture

• Dx: US- thick walls, calcifications, debris, septations, daughter cysts

• Serologic test
• Eosinophilia on cbc

• Tx: complete cyst enucleation

• Mebendazole adjuvant
• Can do evacuation, sterilization, and then pericystectomy

• Hemangioma= benign vascular tumor; a/w high estrogen state; female > male; don’t bleed

• Dx: CT with delayed contrast shows peripheral nodular enhancement
• Tx: observation

• Enucleation rarely

• FNH=

• Dx: CT central scar from vascular pedicle, (normal liver tissue on bx)

• Arteriogram- spoke wheel pattern
• Liver-spleen scan – sulphur colloid positive

• Tx: observation

• Can resect for sx or diagnostic uncertainty

• Adenoma= a/w OCP use, can rupture

• Dx: CT heterogeneous, mixed fat/hemorrhage/necrosis, contrast enhancing; (hepatocytes on bx)
• Tx:

• Stop OCP (alone if <5cm adenoma); Re-image in 6 mo and during pregnancy
• Surgery- enucleation with 2cm margin, resection, epatic a embolization as neoadjuvent (ex- while pregnant)

• Pyogenic Abscess= biliary infection most common, multiple abscess

• Streptococcal, Ecoli, Klebsiella,
• Sx: fever, jaundice, RUQ pain
• Tx: Abx, drainage

• Surgery if drainage fails

• Amebic abscess=  enteroameba histolitica

• Dx: serology for E histolytica

• CT- can’t tell pyogenic v. amebic
• Tc 99 has ‘cold’ amebic or ‘hot’ pyogenic
• Aspiration can r/o pyogenic

• Tx: metronidazole

• Surgery only for free rupture or peritonitis

• HCC:

• Dx:

• No biopsy for:

• AFP>400 with >2cm lesion with arterial hypervascularization
• AFP <400 with >2cm lesion on 2 separate imaging modalities

• PV thrombosis and vascular invasion included in staging

• Tx:

• Transplant

• Single tumor  up to 5cm
• < 3 tumors each <3 cm

• Resection
• Loc-regional therapy (arrest dz)
• Chemotherapy

• Cholangiocarcinoma: adenocarcinomas, neural and vascular invasion

• Tx: Biliary drainage, then resection (hepatobiliary resection with hepaticoJ)

• Can do Palliative resection

• Metastatic Liver tumor

• Colorectal
• Neuroendocrine- increase survival

• Portal Hypertension:

• Postsinusoidal= CHF, Budd-Chiari
• Sinusoidal= cirrhosis
• Pre-sinusoidal= parasites, portal v thrombosis
• Tx:

• Surgical Shunts= endoscopic/medial failure with child A cirrhosis, Budd Chiari, non-cirrhotic portal HTN
• Selective Shunt= distal splenorenal shunt= distal splenic v to left renal v) and ligate left gastric v. (Warren Shunt)

• Decompress short gastric-splenic v- L renal axis
• Decrease recurrent variceal bleeding
• Less encephalopathy
• No effect on ascites

• Non-selective= porto-caval or meso-caval shunt, side-side spleno-renal shunt

• Keep partial by making anastamosis < 1cm diameter
• Decrease recurrent variceal bleeding
• Decrease ascites
• Increase encephalopathy

• Medical:

• TIPS= partial portal-calval shunt; bridge to transplant
• B-blocker

• Variceal bleeding

• Acutely treat with endoscopic ligation, sclerotherapy, octreotide
• Recurrent treat with TIPS, shunt
• Prevent with B-blocker

• Gallbladder cancer

• a/w stones, porcelain GB
• Tx:

• T1a (invades lamina propria) cholecystectomy only
• T1b (invades into muscle) chole and offer radical rsxn
• T2 (invades perimuscular connective tissue) chole with GB bed and 2cm of hepatic parenchyma
• T3 (perforate serosa) T4 (invades PV/HA or 2extrahepatic) chole with segment 4 and 5 rsxn

• GB polyp should have cholecystectomy if:

• >1cm
• Broad base
• Age >50

 Appendicitis, diverticulitis, anorectal

• Small bowel= usually benign

• Leiyomyoma is #1 tumor
• Metastatic tumor is most common malignancy
• Adenocarcinoma: duodenum most common primary
• GIST: most common mesenchymal tumor of small bowel

• Sx: Bleeding and abdominal pain
• Dx: enteroclysis, CT, angiogram blush

• CD1177 positive,
• Malignancy coorelates with number of mitosis; >4 is malignant
• Duodenum is more likely malignant

• Tx:

• Resection
• GleeVac (imatinib)
• No role for xrt

• Desmoid: seen with gardner’s syndrome (risk colon ca)

• Tx: NSAID, antiestrogen

• May not be able to do WLE in small bowel

• Appendix

• Appendicitis on US- >7mm, fluid, non compressible
• Appendicitis on CT- >6mm, peripappendiceal stranding, non-filling
• Can do initial non-operative tx of perforated appendicitis

• Not immunosuppressed
• Localized pain and tenderness
• Tx: Abx, abscess drainage, consider colonoscopy, interval appy

• Carcinoid- appendix is most common site (most common GI malignancy in children)

• Dx:

• 5HIAA
• Chromogranin A
• Octreotide scan

• Tx: <1cm not involving base get appy with excision of mesoappendix

• 1-2cm can get appy but should get R hemi
• >2cm get right heicolectomy
• Base of appendix get right hemicolectomy

• Diverticulitis

• Microperforation from hypersegmentation
• Must r/o colon cancer / mucosal abnormality
• Surgery for:

• Free perforation (peritonitis)
• Multiple episodes interfering with life
• Symptomatic stricture or unable to survey proximal colon
• Fistula

• Hinchey

• I- pericolonic abscess
• II- larger abscess walled off
• III- purulent peritonitis
• IV- feculent peritonitis

• Tx:

• If sigmoidectomy, do resection to rectum

• Anorectal Disease

• Dentate line- transition from columnar to squamous epithelium (rectum to anus)
• Internal sphincter becomes circular muscle of bowel
• Perianal skin is from verge to 3-5cm
• Sensory innervations is below dentate line (only external hemorrhoids cause pain)
• Anal pain

• Thrombosed hemorrhoids (usually external)
• Fissures
• Cancer

• Rectal pain

• Deeper, less specific pain
• Proctitis

• Fissure-in-ano= tear in anoderm at anal verge; usually from trauma, ischemic ulcer (midline where blood supply poorest)

• Sx: pain with BM, blood on TP, sentinel tag can look like hemorrhoid
• Tx: sitz, NTG/diltiazem, botox

• Lateral internal sphincterotomy

• Perianal abscesses= from anal crypts at dentate line; congenital; 50% result in fisutal

• If rectal origin consider crohns, cancer
• Ischiorectal- drain
• Intersphincteric- difficult to visualize externally; drain internally
• Spuralevator- may be of intraabdominal origin

• Fistula-en-ano= goodsaw rule to ID internal opeing is posterior external to posterior midline internally,  anterior directly anteriorly internal; consider crohns with multiple internal openings

• Simple intersphincteric – tx with fistulotomy

• Anterior, women, or incontinency should have seton

• Transphincteric fistula – if < 30% of sphincter can do sphincterotomy; otherwise do seton
• Suprasphincteric (above sphincters) - do seton
• Extrasphincteric (above dentate line) – drain, look for etiology

• Hemorrhoids= anal ptosis

• Tx: stool softeners

• Grd 1-2: Banding, injection, laser,
• Grd 3 (manually reduced): excisional hemorrhoidectomy; stapled hemorrhoidectomy- staple above dentate line and pexy anal canal back in place

• Rectal Prolapse= anal canal remains intact, levators spread

• High recurrence, avoid treatment if possible
• Tx:

• Perineal approach less invasive, fixes redundancy but doesn’t fix underlying cause

• Full thickness resection (altemeier)
• Mucosal resection (Delorme)

• Abdominal approach resect and pexy sigmoid, can fix levator hernia; lower recurrance

• Anal Cancer

• Squamous, basal, adenosquamous cells
• Tx:

• <2cm and superficial (anal margin)  excision
• >2cm is NIGRO protocol; APR for recurrence
• Basal cell gets excision to 3mm margins

• Bowen’s disease= squamous ca in-situ

• Tx: WLE

• Paget’s disease= adenocarcinoma in-situ

• TX: WLE,  SLNB groins

• Rectal Cancer: rectum is 15 cm long, intraperitoneal rectum is below peritoneal reflection, extraperitoneal rectum is below peritoneal reflection possibly below levators

• DRE- anal tone, location, fixation
• Dx:

• CT- (T85%, N40%)
• TRUS- (T90%, N60%)
• MRI – (T95%, N65%)

• Tx:

• T3- neoadjuvent chemoxrt for improved local control, improved sphincter salvage (?inc survival?)
• LAR- if >2cm above spincters (top of anal canal), no sphincter involvement
• APR
• Local excision

• T1 Well differentiated, no lymphovascular invasion
• T2 has 25% recurrence, don’t do
• NOT THE SAFE ANSWER

• Surgery

• Sharp TME 5cm below tumor
• 2cm distal margin
• Clear lateral margin

• Rectal Trauma

• Diversion if >50% circumference, above peritoneal reflection, or neurologic injury with incontinence
• Diversion for severe perineal injury or sphincter injury
• Injury scale:

• I- hematoma or partial thickness laceration – Primary repair
• II- <50% laceration – Primary repair
• III- >50% laceration -- Diversion
• IV- intraperitoneal rectal injury – Primary repair
• V- devascularized segment – resection

• Follow up rectal trauma with assessment of continance
• Preop abx for 24hrs

 Endoscopy

• Evaluation

• Can to dx, bx on ASA
• Fleets phosphosoda- do not use in renal failure or obstruction
• Go lytely- safe

• Colonoscopy

• If < 20cm from anal verge, need confirmation
• Lipoma- do not biopsy or recommend, risk perforation, very broad based
• Complications

• Caudery has <5% risk of perforation

• Large polyps can be removed piecemeal or in repeat sessions
• ERCP complications:

• Pancreatitis 5%
• Cholangitis 6%
• Perforation 1%

• ERCP Stone tx

• < 1cm just need sphincterotomy
• 1-2cm need extraction
• >2cm need fragmentation

• ERCP for gallstone pancreatitis:

• Signs of persistant choledocholithiasis
• Significantly elevated bilirubin that doesn’t resolve
• Elevated AP that isn’t improving
• Amylase that doesn’t resolve

 Thyroid and Parathyroid

• Parathyroid

• Lower glands from 3rd parapharyngeal pouch
• Upper glands from 4th parapharyngeal pouch
• Blood supply to both from inferior thyroid artery
• PTH from parathyroid chief cell

• Has Ca receptor coupled to Gproteins – cAMP – decreased PTH synthesis
• Bone, intestine, kidney calcium resorption
• Activates vit D (hydroxylation)

• Calcitonin from C cells

• Inhibit osteoclast action to inhibit bone resorption (decrease serum ca)

• Primary hyperparathyroidism:

• Disease of parathyroid, increased PTH, increased Ca
• Causes:

• Adenoma most common cause (85%)
• Hyperplasia (does not have rim of normal parathyroid)
• Parathyroid Carcinoma – need ipsilateral thyroid lobectomy and neck dissection

• Sx: fatigue, weakness, polydipsia, polyuria, bone pain, constipation, depression, nausea, nephrolithiasis, fractures, gout, ostopenia, PUD, pancreatitis, HTN
• Ddx for hypercalcemia: familial hypocalciuric, hypercalcemia (need to check urine ca), milk alkali, malignancy, hypothyroid, thiazides, lithium, tamoxifen, immobilization, paget’s dz, sarcoid, Tb, Histoplasmosis, excess VitD/A
• Dx:

• Inc Ca, inc PTH, nl or high urinary Ca
• Ratio serum Cl/PO4 > 33
• Low serum PO4
• US, sestamibi scan (must stop synthroid)

• Tx:

• Hypercalcemic crisis: (Ca >14, confusion, vomiting, arrhythmia)  lower Ca, volume expansion
• Lasix
• Calcitonin
• Dialysis
• Surgery:

• Ca > 1 above nl; urine Ca > 400; creatnine clearance decreased by 30%; t-score <2.5 SD (osteoporosis); age > 50; complications of HPT
• Bilateral neck exploration
• Focused neck exploration based on preop imaging and IOPTH

• IOPTH (3min half life)

• Baseline
• At manipulation
• After excision of adenoma
• Need 50% drop from max

• Parathyroid exploration for:

• IOPTH doesn’t drop
• Target gland appears normal
• Unable to find target gland

• Bilateral neck exploration:

• Superior glands

• Located at insertion site of RLN, posterior to sup and inf thyroid vessels – if descend go posterior to RLN

• Inferior glands (inc variability)

• Located inf pole of thyroid gland around inferior thyroid arter – if descend go anterior thymus

• Stop once :

• 4 glands ID’d and one or more abnormal
• Only 1 gland abnormal and another normal gland ID’d (except in familial HPT)

• Keep exploring if:

• < 4 glands ID’d and no abnormal gland found
• More than 1 gland abnormal and not all 4 found
• All 4 glands found and none abnormal

• Ectopic glands

• Intrathyroid and intrathymic are usually inferior glands
• Undescended inferior glands can be high in neck
• Missing Superior gland – look superior thyroid pole, consider lobectomy
• Missing Inferior gland – mobilize thymus, explore carotid sheath, palpate thyroid, consider thyroid lobectomy

• Can’t find missing gland

• Stop (NO STERNOTOMY)        
• Confirm diagnosis (repeat labs)
• Imaging
• Selective venous sampling for PTH

• Familial HPT

• MEN 1
• MEN 2a
• Always get urinary catecholamines (could be men2a)
• Tx:

• Total parathyroid with autotransplant
• Subtotal parathyroidectomy
• Always cryopreserve

• Secondary HPT

• Overproduction of PTH (vit D deficiency, renal failure)
• Inc PTH, low/nl Ca

• Tertiary HPT

• Longstanding secondary PTH leads to autonomous inc PTH
• Inc PTH, inc Ca

• Thyroid gland

• From 1st-2nd pharyngeal pouch
• Inferior thyroid a from thyrocervical trunk
• Superior thyroid a from external carotid
• RLN         

• On L- loops around aorta, more medial, in TE groove
• On R- loops around subclavian, more lateral (can miss tissue)
• 1% incidence of nerve injury

• Superior laryngeal n more commonly injured with subtle voice change

• Internal branch – sensory innervation of larynx
• External branch – motor to cricothyroid muscle

• Nerve of Galen= connection of RLN and superior laryngeal n
• Thyroid nodules: need to determine if malignant or benign

• Risk factors for ca

• Ionizing radiation
• Fhx, MEN
• Toxin
• Age < 20 or >70
• Male

• Dx: TSH, T4, T3

• Thyroglobulin to follow pOp cancer
• Antithyroid peroxidase ab- dx Hashimoto’s
• Calcitonin- check only for MEN or MTC
• US worrisome features for cancer:

• Irregular boarders
• Absence of halo (halo is compressed thyroid around benign nodule)
• Punctate Calcifications
• Increased vascularity
• Adenopathy

• US results:

• Nodule < 0.8cm observe
• Nodule 0.8-1.5cm with risk factors or worrisome features get FNA
• Nodule > 1.5cm get FNA

• Age is most important prognostic factor
• Low risk:

• Women <50, men < 40
• Well differentiated
• Tumor < 4cm
• Confined to thyroid
• No distant mets

• Papillary thyroid cancer= most common (usually <300

• Indications for total or near total thyroidectomy (can always do total with papillary):

• Age < 15 or >45
• h/o XRT
• known distant mets
• bilateral disease
• extrathyroid extension
• multifocal disease
• tumor >1cm
• cervical LN mets
• Fhx of papillary ca

• Need completion total thyroidectomy if:

• Aggressive variant
• Multifocal disease
• Positive margins

• If lobectomy alone, need thyroxine suppression (keep TSH<1.5)
• Lymph node management

• Do total thyroidectomy if LN enlarged
• Functional node dissection for clinically positive nodes

• MRND:

• Level 1= submandibular
• Level 2= superior IJ
• Level 3= middle IJ
• Level 4= lower IJ
• Lever 5= posterior triangle

• Also:

• Level 6= central neck
• Level 7= mediastinum

• Followup:

• 6mo thyroglobulin, whole body scan,
• I -131 for residual disease after thyroidectomy for ablation (if have high thyroglobulin level, TSH, or positive radioiodine scan)
• Can resect solitary metastatic disease to brain

• Follicular thyroid cancer= 20%, need capsular invasion or invasion into vessels to ID (can’t see on FNA)

• More common in iodine deficiency
• Tx similar to PTC

• Thyrogen= recombinant TSH

• Stimulates I-131 uptate
• Allows pt to be euthyroid while awaiting ablation

• Hurthle cell carcinoma= 60yo, FNA and frozen section not reliable

• No sensitive to radioiodine
• Tx:

• Total thyroidectomy with central node dissection
• MRND if adenopathy
• Can follow with sestimebe or octreotide scan

• Medullary Thyroid Carcinoma= c-cell cancer, usually sporadic, a/w MEN 2a/2b, familial

• MEN2a thyroidectomy at 6yo
• MEN2b is most aggressive have total thyroidectomy at 1yo with central node dissection if has protooncogene
• Familial MTC has thyroidectomy at 10yo
• Dx: urinary catecholamines calcitonin, CEA, chromogranin a
• Tx:

• <1cm Total thyroid with central neck
• >1cm total thyroid central neck with MRND (contralateral MRND if has contralateral LAN)

• Follow with calcitonin, CEA, chromogranin A
• Dx laparoscopy prior to neck dissection for persistent hypercalcemia (may not see on CT)

• Anaplastic thyroid cancer= 70yo, from endemic goiter

• Lymph node mets 84%
• Systemic mets 75%
• Tx: total thyroid with MRND (prolong life)

• Palliative trache
• May need more aggressive surgery for long standing goiters