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G55 Gastroenterology Toronto Notes 2023
Table 27. Common Drugs Prescribed in Gastroenterology
Class Generic Drug Trade Name Dosing
Name
Mechanism of
Action
Indications Contraindications Side Effects
Zofran '
Depends on procedure. Selective 5-HT3 AT caused by cancer
generally 8-16 mg PO receptor antagonist in chemotherapy and
central chemoreceptor radiation therapy;multiple
trigger zone and off label uses,including
peripherally on vagus gastroenteritis N/V
nerve
1mg PO BID (for nausea Same as above
from chemotherapy/
radiation)
Morphine,hypersensitivity Constipation,diarrhea.
increased liver enzymes,
headache,latigue.
malaise,cardiac
dysrhythmia
ondanselton
to drug
Kylril - AiV caused by cancer
chemotherapy and
radiation therapy
Same as above Constipation,prolonged
01interval (rarely)
granisetron
Prokinetic
Agents
Motilium Gl motility disorder (e.g. peripherally acting
gastroparesis):10 mg TID D2 receptor blocker.
main effect in the
upper Gl motility disorders hypersensitivity to cardiac arrhythmia
(eg.gastroparesis. domperidone,prolonged (use lowest dose for
subacute gastritis). 0T interval,prolactinoma. shortest duration) and
upper Gl tract (i.e. prevention of nausea electrolyte disturbances. hyperprolactinemia
increased esophageal associated with dopamine- CYP3A4 inhibitors, causing hypogonadism,
peristalsis,gastric agonists mechanical Gl obstruction or breast engorgement,
motility), antiemetic perforation,Gl hemorrhage, and galactorrhea
properties severe hepatic dysfunction.
children <2yr
domperidone
Resotran'
Motegrity:
2 mg POOD high affinity S-HK
agonist,main effect
in the lower Gl
tract(i.e.increased
colonic peristalsis,
ameliorates
gastroparesis)
hypersensitivity to
prucalopride.Gl obstruction dizziness,abdominal
or perforation,severe pain.N/V,diarrhea,
inflammation co-morbidity abdominal distention
(e.g.Crohn's disease.UC.
tome megacolon)
prucalopride chronic idiopathic headache,fatigue.
constipation
Aminosalicylates mesalamme
(5-ASAs)
Pentasa:
Salofalk '
Asacol'
Mesasal7
CD:1g PO TID.'OID
Active UC:1g PO OID
Maintenance UC:1.6 g
PO divided doses daily prostaglandinsand
also as suppositories and leukotrienes
enemas
3-4 g/d PO in divided
doses
5-ASA:Blocks
arachidonic acid
metabolism to
M id tomoderate UC Hypersensitivity to Abdominal pain,
mesalamine salicylates: constipation,arthralgia.
Asacol'
containsphthalate. headache
potential urogenital
teratogenicity for male fetus
sulfasalazine Salazopynn1 Compound composed Mild tomoderate UC
of 5-ASAbound
to sulfapyridine.
hydrolysis by intestinal
bacteria releases
5-ASA.the active
component
Hypersensitivity to
sulfasalazine, sulfa drugs,
salicylates;intestinal
or urinary obstruction,
porphyria
Rash,loss of appetite.
AY.headache,
oligospermia (reversible)
6-mercaptopurine Purinethol:
(6-MP)
CD:1.5 mg/kg/d PO Immunosuppressive IBD:active inflammation
and tomaintain remission
Immunosuppressive
Agents
Hypersensitivity to
mercaptopurine,
priorresistance to
mercaptopurine or
th.oguanine,history of
treatment with alkylating
agents,hypersensitivity to
azathioprine.pregnancy
Same as above
Pancreatitis,bone
marrow suppression,
increased risk of cancer
azathioprine Azasan IBD:2-3 mgfkg > dPO Same as above Same as above Same as above '
Imuran'
prednisone Induction of remission Anti-inflammatory
for acute exacerbations:
20-40 mg P0 once daily:
taper 2.5-5 mg/wk until
discontinued
Symptomatic moderate to
severe CD and UC
Hypersensitivity to Hyperglycemia,
prednisone,systemic fungal insomnia,osteoporosis,
infections weight gain,increased
risk of infections
Biologies Remicade' 5-10 mg/kg IV over 2 h Medically refractory CD Heart failure,moderate to
severe,doses »5 mg/kg
infliximab Monoclonal antibody
toTNFo
Reported cases of
reactivated TB.PCP.
fymphoma, other
infections
Other THFo share similar
serious sideeffects
Headaches,skin rashes,
upper respiratory tract
infection
Humira! CD induction:four 40 mg
SC on day1.then 80 mg 2
wk later (day 15)
CD maintenance: 40 mg
every other wk beginn ing
day 29
RA:2 mg/kgatwkO.
4.and then every 8 wk
thereafter (use with
methotrexate)
UC induction:200 mg
SC at wkO,then100 mg
at wk 2
UC maintenance:50 mg
every 4 wk
CD/UC:300 mg at0.2.6
wkand then every 8 wk
thereafter
Monoclonal antibody
to TNFa
Medically refractory CD or Hypersensitivity to
poor response to infliximab adalimumab
Severe infection
Moderate-to-severe heart
failure
adalimumab
Simponi:
gotimumab Monoclonal antibody
to TNFa
Active ankylosing
spondylitis
Psoriatic arthritis
Moderate-to-severe
active RA (combined with
methotrexate)
UC:medically relractory UC
Hypersensitivity to
gol mumab or latex
Severe infection
Mpderate-to-severe heart
failure
Medically refractory
CD UC.including other
TNFainhibitors and
corticosteroids
Moderate to severe CD
andUC
vedohzumab Entyvio: Monoclonal antibody
to o4fl7 integrin
Hypersensitivity to
vedolizumab
Infections,
liver injury,and
progressive multifocal
leukoencephalopathy
Infections,headaches,
joint pain.fever,H/V
r m
j
Stelara - Induction:single IV
weight- based dose on
day1
Maintenance:90 mg
subcutaneous injection
every 8 wk
Hypersensitivity to
ustekinumab
ustekinumab Monoclonal antibody
to IgGIK.inhibits
signals by 11-12 and
11-23
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G56Gastroenterology Toronto Notes 2023
Table 27. Common Drugs Prescribed in Gastroenterology
Class Generic Drug Trade Name Dosing
Name
Mechanism of
Action
Indications Contraindications Side Effects
Small Molecules tofacitinib S 10 mg BID JAK inhibitor UC IB,hepatitis B Infections,macro'
cardiac events,
thrombosis (e g.PE,DVI)
Xeljanc '
Antibiotics rifaximin Zaxine ' SSO mg BIO or TID Nonabsorbable
antibiotic, affects
dysbiosis of
microbiome
Hepatic encephalopathy Nil
Non-constipation IBS
Traveller's diarrhea
Nil
Landmark Gastroenterology Trials
Trial Name Reference Clinical Trial Details
PEPTIC ULCER DISEASE
Lanccl 2009;374:119-25 Title:Famotidine for the Prevention of Peptic Ulcers and Oesophagitis inPatients Taking low- dose Aspirin (FAMOUS): A Phase III.Randomised.
Double-blind. Placebo- controlled Trial
Purpose:Evaluate the efficacy ol famotidine in the prevention of peptic ulcers and erosive esophagitis.Inpatients receiving low- dose aspirin.
Methods:Patients without erosions or ulcers on upper endoscopy,currently on low dose aspirin,were randomited to lamolidine 20 mg 610
or placebo,(he primary endpoint was development of new stomach ulcers.
Results:At 12 wk,gastric ulcers occurred in 3.4% of famotidinepatients and15% of placebo- matched patients (OR 0.20:95% Cl0.09 to 0.47;
P'0.0002).Duodenal ulcers developed in 0.5% of famotidine patients and 8.5% of placebo patients (OR 0.05:95% Cl 0.01to 0.40:P~0.0045).
Conclusions:Famotidineis effective in the prevention of gastric and duodenal ulcers,and erosive esophagitis in patients taking low-dose
aspirin.
FAMOUS
INFLAMMATORY BOWEL DISEASE
SONIC NEJM 2010:362:1383-95 Title:Infliximab.Azathioprine,or Combination Therapy for Crohn’s Disease
Purpose:Compare the efficacy and safety of infliximab and azathioprine therapy alone or in combination,in patients with CD.
Methods:CD patients who had not undergone previous biologic or immunosuppressive therapy were randomized to infliximab 5 mg/kg IY
infusion or2.5 mgoral azathioprine.or combination therapy of both drugs.
Results:Among patients receiving combination therapy.56.8% were in steroid-free remission, compared with 44.4% of patients receiving
infliximab monotherapy,and 30% receiving azathioprine monotherapy (P<0.001for comparison with combination:P'0.06 for comparison
with infliximab).
Conclusions:Patients' CD treated with infliximab monotherapy or influimab-azalhioprine combination had better corticosteroid-free
remission than azathioprine monotherapy recipients.
Title:A Comparison ol Methotrexate with Placebo for the Maintenance of Remission in Crohn's Disease
Purpose:Evaluate the role of methotrexate inmaintaining remission of CD.
Methods:Patients with chronically active CO who entered remission were randomized to metlioliexate15 mg IM or placebo for 15 wk.Ihe
primary endpoint was rales of remission at wk 40.
Results:At ihe follow- up pciiod ol 40 wk.65% of methotrexate patients werein remission compared to 39% of patients inIhe placebo group
(risk reduction 26.1%;95% Cl 4% to 47.8%;P'0.04). None of the methotrexate patients reported serious adverse events.
Conclusions:Patients with CD in remission saw increased remission rales and fewer relapse treatments at 40 wk.
Title:Adalimumab Induction Therapy for Crohn's Disease Previously treatedwith Infliximab
Purpose:Determine the efficacy of adalimumab insymptomatic CD patients despite infliximab treatment.
Methods:325 adults with moderate-severe active CD were randomized to induction doses of adalimumab 160 mg and 80 mg at 0 and 2 wk
respectively,or time-matched placebo.The primary endpoint was induction of remission at 4 wk.
Results:Remission was achieved at 4 wk in 21% of adalimumab patients compared with 7% of placebo patients (95% Cl 6.7% to 21.6%).
Conclusions:Adalimumab induces remission more frequently than placebo inadult patients with symptomatic CD despite infliximab therapy.
Title:Ustekinumab as Induction and Maintenance Therapy for Ulcerative Colitis
Purpose:Determine the effectiveness of ustekinumab as induction and maintenance therapy in patients with UC.
Methods:961patients with moderate-severe UC were randomized to IY induction ustekinumab (130 mg),or placebo. The primary endpoint
was clinicalremission determinedby the Mayo scale.
Results:Ihe primary endpoint occurred in 15.6% of patients in the intervention group compared with 5.3% of placebo patients (P*0.001). The
incidence of serious adverse events was similar between groups.
Conclusions:Ustekinumab was more effective than placebo for inducing and maintaining remission in patients with moderate lo-sevctc UC.
Title:Vedolizumab versus Adalimumab for Modcrale- to-Severe Ulcerative Colitis
Purpose:Compare efficacy of vedolizumab versus adalimumabinpatients with moderate-severe UC.
Methods:Adults with moderate-severe active UC were randomized to IV infusions of vedolizumab 300 ing or subcutaneous adalimumab 40
mg (total weekly dose 160 mg).Ihe primary outcome was clinicalremission at wk 52 as determined by the Mayo scale.
Results:At wk 52.clinicalremission was observed in 31.3% of vedolizumab patients compared to 22.5% of adalimumab patients (95% Cl 2.5
to 15.0:P-0.006).Steroid- free remission occurred in12.6% ol vedolizumab patients and 21.8% oladalimumab patients (95% Cl18.9 to 0.4).
Conclusions:In patients with moderale-lo-severe UC,vedolizumab wassuperior to adalimumab with respect to achievementof clinical
remission and endoscopic improvement,but nolcorticosteroidfreeclnical remission.
A Comparison of NEJM 2000;342:1627- 32
Methotrexate with Placebo
for theMaintenance of
Remission in Crohn's
Disease
Adalimumab Induction
Therapy for Crohn's
Disease Previously Treated
with Infliximab
Ann Intern Med
2007:146:829 38
UNIFI NEJM 2019:381:1201-14
VARSIIY NEJM 2019:381:1215 26
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G57 Gastroenterology Toronto Notes 2023
Trial Name Reference Clinical Trial Details
LIVER DISEASE
MELD Score as A Predictor Gastroenterology
Of Death in Chronic liver 2003:124:91-96
Oisease
Title:MELD Score as A Predictor 01Death in Chronic liver Disease
Purpose:Assess the capability for the MELD score lo correctly rank potential liver transplant recipients.
Methods:the MELD score was prospectively applied to estimate 3-mo mortality in 3437 adult liver transplant candidates with chronic liver
disease.
Results:Waiting list mortality increased directly in proportion lo the MEID score.Using 3-mo mortality as the endpoint,the ROC curve lor
MEID was 0.83 compared to 0.76 lor the Chlld- Turcotle-Pugli score.
Conclusions:MEID score can be applied lor allocation ol donor livers as it accurately predicts 3-mo mortality inpatients with chronic liver
lailurc.
NEJM 2010:362:1292- Title:tetaprevir lor Previously Treated Chronic HCV Infection
Purpose:Study the efficacy of tetaprevir in patients without a sustained virologic response to pcgmlcrlerontherapy.
Methods:Patients with HCV genotype 1without sustained virologic response topcginlerleron therapy were randomned to one ol lour
tetaprevir and pcginlerleron treatment groups. The primary endpoint was sustained virologic response 24 wk alter the last dose.
Results:Ihe rates ol sustained virologic response in the three tetaprevir groups were significantly higher than the control group rales|14%,
P'0.001.P'
0.001.P'0.02).Discontinuation ol the drugs due to adverse events wasmore frequent in Ihe tetaprevir groups than In the control
group (1S% vs. 4%).
Conclusions:In HCV infected patients m whom initial pcginlerleron therapy failed,retreatment with tetaprevir in combination with
peginterferon andribavirin was mote cllectivc than the latter two atone.
HEJM 2011:364:1196-1206 Title:8oceprevlt lor Untreated Chronic HCV Genotype 11nfection
Purpose:Evaluate virologic response with additional boccprcvir treatment in patients with HCV genotype 1inlection.
Methods:Previously untreated adults with HCV genotype1infection were randomiied lo placebo plus peginlctleton ribavirin or boccprevir
plus peginterleion ribavirin. The primary endpoint was sustained virologic response.
Results:A virologic response was achieved in 40% of group 1.67% in group 2 and 68% in group 3.
Conclusions:Ihe additionolboceprevir to standard therapy ol peginlerleron-ribavirin,compared with standard therapy alone,increased
rales of sustained virologic response in chronically HCV infected adults.
PROVE 3
1303
SPRINT 2
Rifaiimin Treatment in
Hepatic Encephalopathy
NEJM 2010:362:1071-81 Title:Rilaximin Irealment in HepaticEncephalopathy
Purpose:Evaluate the efficacy olrilaximinin the prevention ol hepatic encephalopathy secondary locirrhosis.
Methods:299 patients in remission from recurrent hepatic encephalopathy were randomiied to rilaximin 550 mg SID or placebo lor 6 mo.The
primary endpoint was time lor the first breakthrough episode.
Results:Rilaximin reduced the risk ol a hepatic encephalopathy episode (hazard ratio 0.42:95% Cl 0.28 to 0.64;P'
0.001).A breakthrough
episode occurred in 22.1% of rifaximin-treated patients compared to 45.9% ol placebo patients (hazard ratio 0.5:95% Cl 0.29 to 0.87;
P-0.01). The incidence of adverse events was similar between groups.
Conclusions:The antibiotic rilaximin was successful in maintaining remission from hepatic encephalopathy and reducing hospitalizations.
NEJM 2015:372:1619-28 Title:Prednisolone or Pentoxifylline For Alcoholic Hepatitis
Purpose:To elucidate the benefits olpentoxifylline and prednisolone lor the treatments of severe alcoholic hepatitis.
Methods:Patients with severe alcoholic hepatitis were randomized to one of lour groups:double-matched placebo,prednisolone plus
matched placebo,pentoxifylline plus matched placebo,or prednisolone plus pentoxifylline.The primary endpoint was mortality at 28 d.
Results:Mortality at 28 d was 17% in the first group,14%in the second group,19% in the third group,and13% in the fourth group.At 90 d and
1yt.there were no significant differences between groups.
Conclusions:For alcoholic hepatitis,prednisolone improved survival ata level below statistical significance.Pentoxifylline did not improve
survival.
Prednisolone or
Pentoxifylline For Alcoholic
Hepatitis
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Yapp TR.Hemochromatosis. Clin Liver Ois 2000:4:211 228.
Yu AS,Hu K0.Management of ascites.Clin trver Dis 2001:5:641- 568.
ZuccaroGJr.Management of theadultpatient with acute lower gastrointestinal bleeding.American College olGastroenterology.PracticeParameters Committee.Am JGastroenterol1998;93(8):1202-1208.
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General and Thoracic Surgery
Ryan Daniel,Jacqueline Lim, and Smruthi Ramesh, chapter editors
Vrati M.Mehra and Chunyi Christie Tan, associate editors
Arjan S. Dhoot, HBM editors
Dr. Abdullah Behzadi, Dr. Sayf Gazala, Dr.Jesse Pasternak, and Dr. Faycz Quercshy,staff editors
Acronyms
Basic Anatomy Review
Differential Diagnoses of Common Presentations,
Acute Abdominal Pain
Abdominal Mass
Gastrointestinal Bleeding
Jaundice
Preoperative Preparations
Surgical Complications
Postoperative Fever
Wound/Incisional Complications
Urinary and Renal Complications
Postoperative Dyspnea
Respiratory Complications
Cardiac Complications
Intra-Abdominal Abscess
Paralytic Ileus
Delirium
Thoracic and Foregut Surgery
Approach to the Solitary Pulmonary Nodule
Lung Cancer
Pleura,Lung,and Mediastinum
Complicated Parapneumonic Effusion
Empyema
Pneumothorax
Tube Thoracostomy
Lung Transplantation
Chronic Obstructive Pulmonary Disease
Mediastinal Masses
Thymoma
Esophageal Carcinoma
Esophageal Perforation
Hiatus Hernia
Achalasia
Stomach and Duodenum
Peptic Ulcer Disease
Gastric Carcinoma
Gastrointestinal Stromal Tumour
Bariatric Surgery
SMALL INTESTINE
Small BowelObstruction
Mechanical Small Bowel Obstruction
Paralytic Ileus
Intestinal Ischemia
Tumours of SmallIntestine
Short Gut Syndrome
Abdominal Flernia
Groin Hernias
Appendix.
Appendicitis
Inflammatory Bowel Disease
Crohn's Disease
UlcerativeColitis
URGE INTESTINE
Large BowelObstruction.
Mechanical Large Bowel Obstruction
Functional Large Bowel Obstruction:Colonic Pseudo-Obstruction
(Ogilvie’s Syndrome)
GS2 Diverticular Disease
Diverticulosis
Diverticulitis
Colorectal Neoplasms
Colorectal Polyps
Familial Colon Cancer Syndromes
Colorectal Carcinoma
Other Conditions of theLarge Intestine
Angiodysplasia
Volvulus
Toxic Megacolon
Fistula
Stomas
Anorectum
Hemorrhoids
Anal Fissures
Anorectal Abscess
Fistula-In-Ano
Pilonidal Disease
Rectal Prolapse
Anal Neoplasms
Liver.
Liver Cysts
Liver Abscesses
Neoplasms
Liver Transplantation
Biliary Tract
Cholelithiasis
Biliary Colic
Acute Cholecystitis
Acalculous Cholecystitis
Choledocholithiasis
Acute Cholangitis
Gallstone Ileus
Carcinoma of the Gallbladder
Cholangiocarcinoma
Pancreas
Acute Pancreatitis
Chronic Pancreatitis
Pancreatic Cancer
Spleen
Splenic Trauma
Splenectomy
Splenic Infarct
Breast
Benign Breast Lesions
Breast Cancer
Surgical Endocrinology.
Thyroid and Parathyroid
Adrenal Gland
Pancreas
Paediatric Surgery
Skin Lesions
Common Medications
Landmark General and Thoracic Surgery Trials..
References
GS39
GS2
GS4
GS41
.GS44 GS7
GS8
GS47
GS13
GS51
.GS55
GS25
GS60
.GS29
GS63 GS29
GS65
GS33
GS71
GS35
GS36 GS73
GS75
GS37 GS76 ri
L J
GS37 GS77
GS78
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GS1 General and Thoracic Surgery Toronto Notes 2023
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GS2 General and Thoracic Surgery Toronto Notes 2023
Acronyms
5-FU 5-fluorouracil
AAA abdominal aortic aneurysm
ABG arterial blood gas
ABI ankle brachial index
ALNO axillary lymph node dissection
APR abdominoperineal resection
ARDS acute respiratory distress
syndrome
ATN acute tubular necrosis
AXR abdominal x-ray
BRBPR bright ted blood per rectum
BCS breast conserving surgery
CBD common bile duct
CEA carcinocmbryonic antigen
CF cystic fibrosis
CHD common hepatic duct
CRC colorectal cancer
CVA costovertebral angle
CVP central venous pressure
DCIS ductal carcinoma insitu
DIC disseminated intravascular
coagulation
DPI diagnostic peritoneal lavage
DRE digital rectal exam
EBL estimated blood loss
ERCP endoscopic retrograde
cholangiopancreatography
LCIS lobular carcinoma in situ
LES lower esophageal sphincter
lower gastrointestinal bleed
left lower quadrant
IMWH low molecular weight heparin
LUO left upper quadrant
LVRS lung volume reduction surgery
MALL mucosa-associated lymphoid
tissue
mechanical bowelpreparation
MEN multiple endocrine neoplasia
MIBG motalodobcnzylguanidino
MIS minimally invasive surgery
MRCP magnetic resonance
cholangiopancreatography
MSAFP maternal scrum a- fctoprotcin
NET neuroendocrine tumour
normal saline
OCP oral contraceptive pill
OGD oesophagogastroduodenoscopy URTI
PMN polymorphonuclear neutrophils VATS
POD postoperative day
proton pump inhibitor
PTC percutaneous transhepatic
cholangiography
partial thromboplastin time
PUD peptic ulcer disease
EUA examination under anesthesia
EUS endoscopic ultrasound
FAP familial adenomatous polyposis LGIB
FAST focused abdominal sonography LLO
for trauma
FNA fine needle aspiration
FNH focal nodular hyperplasia
FOBT fecal occult blood test
GERD gastroesophageal reflux disease
GIST gastrointestinal stromal tumour MBP
GU genitourinary
HCC hepatocellular carcinoma
HDGC hereditary diffuse gastric
carcinoma
RAI radioactive iodine
Ringer’s lactate
RIO right lower quadrant
RUO right upper quadrant
SBO small bowel obstruction
SBFT small bowel follow-through
SCC squamous cell carcinoma
SIADH syndrome of inappropriate
anti-diuretic hormone
SMA superior mesenteric artery
SMV superior mesenteric vein
SNLB sentinel lymph node biopsy
TED thromboembolic deterrent
TEE transesophageal
echocardiogram
TTE transthoracic echocardiogram
ulcerative colitis
UGI upper gastrointestinal series
UGIB upper gastrointestinal bleed
upper respiratory tract infection
video-assisted thoracoscopic
surgery
vasoactive intestinal peptide
VTE venous thromboembolism
RL
HIDA hepatobiliary imino diacetic acid
HNPCC hereditary nonpolyposis
colorectal cancer
ISO incision and drainage
IBD inflammatory bowel disease
IPAH idiopathic pulmonary arterial
hypertension
UC
NS
IPF idiopathic pulmonary fibrosis
intrauterine growth restriction
inferior vena cava
IUGR PPI VIP
IVC
IVIG intravenous immune globulin
low anterior resection
large bowel obstruction
LAR PTT
LBO
Basic Anatomy Review
Access to RUQor LUQ contents
i.e. gallbladder,spleen
Kocher’s
(subcostal)
Upper Midline Access to stomach,duodenum,
gallbladder,liver,transverse colon Kocher's
(subcostal)
04
Paramedian Can make similar incision in each
quadrantfor access to eachquadrant's §
contents
Postoperative ventral hernias common s
Not commonly used =
Lateral At outer 1/3 - medial 2/3 border of rectus s
Paramedian Modification of paramedianbutwith
lower risk of dehiscence or ventral hernia s
'
Not commonly used
Lower Midline Access to pelvic organs,sigmoid
colon,and rectum
Suprapubic incision for access to
pelvic cavity
McBurney’s Access to appendix,other RLQ and
LLQ contents
Paramedian
Lateral
paramedian
McBumey's
o
Upper midline
Lower midline
I
Arcuate line
2
Pfannenstiel Pfannenstiel |
3u
©
Figure 1. Abdominal incisions
Lateral Abdominal Wall Layers and their Continuous Spermatic and Scrotal Structures
(superficial to deep)
1. skin (epidermis, dermis,subcutaneous fat)
2. superficial fascia
• Campers fascia (fatty) > Dartos muscle/fascia
• Scarpa'
s fascia (membranous) > Colles'
superficial perineal fascia
3. muscle (see figure 2 and figure 3)
• external oblique > inguinal ligament > external spermatic fascia
• internal oblique > cremasteric muscle/fascia
• transversus abdominis > posterior inguinal wall
4. transversalis fascia > internal spermatic fascia
5. preperitoneal fat
6. peritoneum > tunica vaginalis
Midline Abdominal Wall Layers (superficial to deep)
1. skin
2. superficial fascia
3. rectus abdominis muscle:in rectussheath, divided by linea alba (see figure 3)
• above arcuate line (midway between symphysis pubis and umbilicus)
anterior rectus sheath = external oblique aponeurosis and anterior leaf of internal oblique
aponeurosis
posterior rectussheath = posterior leaf of internal oblique aponeurosis and transversus
abdominis aponeurosis
• below arcuate line
aponeuroses of external oblique, internal oblique, and transversus abdominis all pass in front
of rectus abdominis
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GS3 General and Thoracic Surgery Toronto Notes 2023
4. arteries:superior epigastric (branch of internal thoracic), inferior epigastric (branch of external iliac);
both arteries anastomose and lie behind the rectus muscle (superficial to posterior rectus sheath
above arcuate line)
5. transversalis fascia
6. peritoneum
Transversus abdominismuscle
Internal oblique muscle I
I
Peritoneum i
IC I
artery
-Inferior epigastric
^
vein
“
—Transversalis fascia
5 Deepinguinalnng
_ Membranous layer
of superficial fascia
(Scarpa's fascial
-External oblique muscle
-Internal oblique muscle
-Aponeurosis of internal
oblique muscle
-Aponeurosis of external
oblique muscle (cut edge)
Cremaster muscle
-Spermatic cord
Fatty layer of superficial fascia
(Camper's fascial
Superficial inguinalnng
Tunica vaginalis
Tesos
Internal spermatic fascia
Cremaster muscle
External spermatic fascia
Code's superficialpenneal fascia
Dartos muscle
Skin of scrotum
Figure 2. Continuity of the abdominal wall with layers of the scrotum and spermatic cord
Rectus Skin abdominis Above arcuate line Superficial fascia
(Camper'
s +Scarpa’
s fascial
External oblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Peritoneum
)
Below arcuate line Inferior epigastric artery
Skin
Superficial fascia
Externaloblique
Internal oblique
Transversus abdominis
Transversalis fascia
Preperitoneal fat
Peritoneum
5
J Organ Arterial Blood Supply
S
Lell andright hepatic
(branches of hepatic proper)
Splenic
Cystic (branch of right hepatic)
1. Lesser curvature:right and
left gastric
2. Greater curvature:right
(branch of gastroduodenal)
and left (branch of splenic)
gastroepiploic
3. Fundus:short gastnes
(branches of splenic)
1. Gastroduodenal
2. Pancreaticoduodenal
(superior branch of
gastroduodenal,inferior
branch of superior
mesenteric)
1. Pancreabc branches of
splenic
2. Pancreabcoduodenai5
Superior mesenteric branches:
jejunal,ileal,ileocolic
1. Superior mesenteric
branches:right colic,
middle colic
2. Inferior mesenteric
branches:left colic,
sigmoid,superior rectal
1 liver
V
Spleen
Gallbladder
Figure 3.Midline cross-section of abdominal wall
Stomach
Celiac trunk (1)
i) Common hepatic artery (2)
•Hepatic proper (3)
-left hepatic artery (4)
-Right hepatic artery (5)
•Right gastric artery (7)
•Gastroduodenal artery (81
ii) left gastric artery (6)
iii) Splenic artery (9)
Duodenum
Superior mesenteric artery (10)
i) Middle colic artery (11)
ii) Right colic artery (121
iii) Ileocolic artery (13)
iv) Ileal and jejunal branches 114)
Pancreas
Small
Inferior mesenteric artery (15)
il Left colic artery (16)
iilSigmoid arteries (17)
ii)Superior rectal artery (181
intestine
Large
intestine
5
+ ,Z
-
Figure 4. Arterial blood supply to the Gl tract
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GS4 General and Thoracic Surgery Toronto Notes 2023
Venous Flow
Portal vein (II
Superior mesenteric vein (7)
i) Ileal and jejunal veins(131
ill Ileocolic vein (141
iiil Right colic vein (121
hr) Middle colic vein (II)
v) Pancreaticoduodenal vein (8)
vi) Right gastroepiploic vein (9)
Splenic vein (51
i) I nferior mesenteric vein (10)
(superior rectal vein until crossing
common iliac vessels)
•Left colic veins (15)
•Sigmoid veins (16)
•Superior rectal veins(17)
ii) Pancreatic veins
ml Left gastroepiploic vein
hr) Short gastric veins(6)
Left gastric (coronary) vein (2)
Right gastric vein (3)
Cystic vein (4)
Paraumbilical vein-(within round ligament, notshown) <3
a
a
|
-
?
9
Figure 5. Venousdrainage of the Gl tract
Differential Diagnoses of Common
Presentations
In All Patients Presenting with an Acute
Abdomen.Order the Following:
Ifcy Testsfor Specific Diagnosis
. ALP.ALT.AST. bilirubin
• Lipase/ amylase
• Urinalysis
• R-hCG (in women of childbearing Acute Abdominal Pain age)
• Troponins
• Lactate
Key Testsfor OR Preparation
• CBC.electrolytes, creatinine,glucose
. INR/PTT
• CXR (if history of cardiac or
pulmonary disease)
• ECG if clinically indicated by history
or if >69 yr and no risk factors
Note:Choosing Wisely does not
recommend routine preoperative blood
work for ambulatory/elective surgery
• acute abdomen = severe abdominal pain of acute onset and requires urgent medical attention
• in patients with acute abdominal pain, the first diagnoses that you should consider are those requiring
potential urgent surgical intervention,including:
peritonitis
bowel obstruction
Table 1. Differential Diagnosis of Acute Abdominal Pain
Right Upper Quadrant (RUO) Right Lower Quadrant (RLO)
Hepatobiliary
Biliary colic
Cholecystitis"
Cholangitis
CBD obstruction (e.g.stone, tumour)
Hepatitis (includes perihepatitis'
f itr Hugh Curtissyndrome)
Portal vein thrombosis
Budd -Chiari syndrome
Hepatic abscess(mass
Right subphrenic abscess*
Gastrointestinal
Pancreatitis
Presentation of gastric,duodenal,or pancreatic pathology
Hepatic flexure pathology (e.g. CRC.subcostal incisional hernia)
Genitourinary
Nephrolithiasis’
Pyelonephritis
Renal: mass,ischemia, trauma
Cardiopulmonary
Right lower lobe pneumonia
Effusion/empyema
CHF (causing hepatic congestion and right pleural effusion)
Gastrointestinal
Appendicitis"
Crohn'
s disease
Tuberculosis of the ileocecal junction
Cecal tumour
Intussusception
Mesenteric lymphadenitis(Yersinia)
Cecal diverticulitis
Cecal volvulus'
Hernia:femoral,inguinal obstruction.Amyand'
s(and
resulting cecal distention)
Gynaecological
See'suprapubic'
Genitourinary
See 'suprapubic'
Extraperitoneal
Abdominal wall hematoma,abscess
Psoas abscess
Types of Peritonitis
• Primary peritonitis:spontaneous
without dear etiology
• Secondary peritonitis:due to a
perforated viseus
• Tertiary peritonitis: recurrent
secondary peritonitis more often with
resistant organisms
Localization of Pain
• Most digestive tract pain is perceived
in the midline because of bilaterally
symmetric innervation:kidney, ureter,
ovary,or somatically innervated
structures are more likely to cause
lateralized pain
• Parietal peritoneum:supplied by
somatic sensory nerves of body wall.
Pain is sharp and well-localized
• Visceral peritoneum:supplied by
autonomic sensory fibres. Pain is
colicky and poorly localized
Ml r T
i J
Pericarditis
Pleurilis
Miscellaneous
Herpes roster
Trauma
Costochondritis(Infectious*
)
"indicated need tor urgentsurgical evaluation
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Table 1. Differential Diagnosis of Acute Abdominal Pain
Left Upper Quadrant (LUO) Left Lower Quadrant (LLO)
Referred Pain
• Biliary colic to right shoulder or
scapula
. Renal coSc to groin
• Appendicitis:periumbilicalto RLQ
• Pancreatitis:to back
• Ruptured AAA:to back or flank
• Perforated ulcer to RLO (right
paracolic gutter)
• Hip pain:to groin
• Ovarian torsion:to flank or groin
Pancreatic
Pancreatitis (acute»s.chronic)
Pancreatic pseudocyst
Pancreatic tumours'
Gastrointestinal
Gastritis
Gastrointestinal
Diverticulitis*
Diverticulosis
Colorsigmodrectal cancer
fecal impaction
Proctitis (e.g.UC.infectious:
i.e.gonococcus or Cbbmydio)
Sigmoid votvulus*
Hernia (mcarceraledslrangulaled*)
Gynaecological
See 'suprapubic'
Genitourinary
See 'suprapubic'
Extraperitoneal
Abdominal wall hematoma/abscess'
Psoas abscess
PUD
Splenic flexure pathology
(e.g.CRC.ischemia)
Splenic
Splenic infarcllabscess*
Splenomegaly
Splenic rupture'
Splenic artery aneurysm
Cardiopulmonary (see RUOand Epigastric)
Genitourinary (see DUO) Most Common Presentations of
Surgical Pain
• Sudden onset with rigid abdomen “
perforated visors
• Pain out of proportiontophysical
findings -ischemic bowel
• Vague pain that subsequently
localizes ~ appendicitis or other intraabdominal process that imitates the
parietal peritoneum
• Waves of colicky pain - bowel
obstruction
SeeG»nae::.CTi.Urslinv.Respiroloav,and Cardiology and
Cardiac Surgery for further details regarding respective
etiologies of acute abdominal pain
EPIGASTRIC SUPRAPUBIC DIFFUSE
Cardiac
Aortic dissechonruplured AAA'
Gastrointestinal (see RL0/LL0)
Acute appendicitis*
Gastrointestinal
Peritonitis*
Early appendicitis,perforated appendicitis*
Mesenteric ischemia*
Gasboenteritisi'colitis
Constipation
Bowel obstruction*
Pancreatitis
Ml IBO
Pericarditis
Gastrointestinal
Gastritis
GERD esopha;;s
Gynaecological
Ectopic pregnancy*
Pelvic inflammatory disease
Endometriosis
Threatened/incomplete abortion*
Hydrosalpinx/salpingitis
Ovarian torsion*
Hemorrhagic fibroid
Tubo-ovarian abscess
Gynaecological lumours
Genitourinary
Cystitis (infectious,hemorrhagic)
Hydroureter/urinary colic
Epididymitis
Testicular torsion*
Acute urinary retention
Extraperitoneal
Rectus sheath hematoma
PUD
Pancreabtrs
Malloty-Weiss tear
IBD
Irritable bowel syndrome Acute Abdominal Pain Mnemonic
Ogilvie'
s syndrome
Cardiovascular,Hematological
Aortic dissection*
Ruptured AAA*
Sidde cellcrisis
Genitourinary.Gynaecological
Perforated ectopic pregnancy*
Pehric inflammatory disease
Acute urinary retention
Endocrinological
Carcinoid syndrome*
Diabetic ketoacidosis
Addisonian crisis
Hypercalcemia
Other
lead poisoning
Tertiary syphilis
ABDOMINAL
Appendicitis
Biliary tract disease
Diverticulitis
Ovarian disease
Malignancy
Intestinal obstruction
Nephritic disorders
Acute pancreatitis
Liquor/ethanol
’indicated need tor urgent surgical evaluation
Abdominal Mass
Table 2. Differential Diagnosis of Abdominal Mass
RUO Upper Midline LUO
Gallbladder:cholecystitis,
cholangiocarcinoma,peri-ampullary
malignancy,cholelithiasis
Biliary tract Klatskin tumour
Liver:hepatomegaly,hepatitis,abscess.
Pancreas:pancreaticadenocarcinoma,other Spleeo:splenomegaly,tumour,abscess,
pancreatic neoplasms,pseudocyst subcapsular splenic hemorrhage,can also
present as RLO mass if extreme splenomegaly
Stomach:tumour
Abdominal aorta:AAA (pulsatile)
Gl:gastric tumour (adenocarcinoma,
gaslrointestinal stromal tumour,carcinoid
tumour (hepatocellular carcinoma,metastatic tumour). MALT lymphoma
tumour,etc.)
Pancreatitis can look like a surgical
abdomen,but is rarely an indication for
immediate surgical intervention
RLO Lower Midline LLO
Intestine:stool,tumour (CRC).mesenteric Uterus:pregnancy,leiomyoma (fibroid).
adenitis,appendicitis,appendicealphlegmon uterine cancer,pyometra.hematometra
or other abscess,typhlitis,intussusception. GU:bladder dislention,tumour
Crohn's inflammation
Ovary:ectopic pregnancy,cyst
(physiological vs.pathological),tumour
(serous,mucinous,struma ovarii,germ
cell.Krukenberg)
Fallopian tube:ectopic pregnancy,
tubo-ovarian abscess,hydrosalpinx,tumour
Intestine:stool,tumour,abscess (see RLO)
Ovary:see RLO
Fallopian tube:see RLO
rt
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GS6 General and Thoracic Surgery Toronto Notes 2023
Gastrointestinal Bleeding
• see Gastroenterology. G28 and G30
Indications for Surgery
• failure of medical management (after at least 2 endoscopic attempts at management)
• exsanguinating hemorrhage: hemodynamic instability despite vigorous resuscitation
• recurrent hemorrhage with up to two attempts of endoscopic hemostasis
• prolonged bleeding with transfusion requirement >3 units
• bleeding at rate >1 unit/8h
Indications for Urgent Operation
IHOP
Isc hernia
Hemorrhage
Obstruction
Perforation
Surgical Management of Gl Bleeding
• UC.IB
bleeding from a source proximal to the ligament of Ireitz
often presents with hematemesis and rnelena unless very brisk (then can present with
hematochezia), may present with anemia, hypovolemic shock
initial management with PPls and endoscopy; if fails, then consider surgical management
appropriate to etiology
• PUD accounts for approximately 55% ofsevere UCilB
Overt Bleeding:obvious hematemesis.
hematochezia or rnelena per rectum (i.e.
visible to naked eye)
Occult Bleeding: bleeding per rectum is
not obvious to naked eye (c.g. positive
guaiac FOBT)
Obscure Bleeding:bleeding with no
identifiable source after colonoscopy
and endoscopy (source usually in small
bowel).Can be either overt or occult
. LGIB
bleeding from a source distal to the ligament of T'
reitz
often presents with BRBPR unless proximal to transverse colon, rarely rnelena (right-sided colonic
bleeding)
initial management with colonoscopy to detect and potentially stop source of bleeding
75% of patients will spontaneously stop bleeding, however if bleeding continues, barium enema
should NOT'
be performed
angiography or RBC scan to determine source as indicated
surgery indicated if bleeding is persistent - aimed at resection of area containing source of
bleeding
for obscure bleed conduct wireless capsule endoscopy, may require blind total colectomy if the
source is not found
diverticular bleeding is the most common cause of LG1B (accounting for 40% of cases)
Table 3. Differential Diagnosis of Gl Bleeding
Anatomical Source Etiology
Excess anticoagulation (warfarin, heparin, etc.) DIC
Excess antiplatelet (dopidogrel. ASA)
Epistaxis
Esophageal varices
Mallory-Weiss tear
Esophagitis
Gastritis
Castric varices
Dieulaloy’slesion
Duodenal ulcer
Perforated duodenal ulcer*
Tumours'
Polyps
Ulcers
Meckel's diverticulum
Small bowel obstruction
Colorectal cancer*
Mesenteric tlrrombosis/isthemic bowel*
UC’(subtotal colectomy if failure of medical
management)
Angiodysplasia
Diverticulosis (’if bleeding is persistent)
Diverhculosis ('
if bleeding is persistent)
Sigmoid cancer*
Bleeding postpolypcclomy
Hemorrhoids
Fissures
Pedal cancer*
Anal varices
Hematological
Congenital bleeding disorders
BloodworkforGI Bleeds
CBC (including platelet count), serum
chemistries (electrolytes. BUN,LFTs,
etc,), coagulation studies (INR, PT, PTT),
blood type and crossmatch if anticipate
transfusion
Nose
Aorto- esophageal fistula (generally postendovascular
aortic repair)*
Esophageal cancer
Castric ulcer
Gastric cancer *
Esophagus
Stomach
Duodenum Duodenal cancer’
Jejunum
Crohn'
s disease*
Tuberculosis of ileocecal junction
Crohn’s disease (less frequently presents with bleeding)’
Pancolitis (infectious,chemotherapy,or radiation
induced)
Bleeding post-gastrointestinal anastomosis
Ileum and Ileocecal
Junction
large Intestine
Sigmoid Polyps ('
if not amenable tocolonoscopic polypectomy)
ypsj'
il nolamenable tocolonoscopic polypectomy)
Crohn’s orUC*
Solitary rectal ulcer syndrome
Rectum and Anus Pa Biochemical Signs for Differentiating
Jaundice
Hepatocellular Elevated bilirubin +
elevated ALT/AST
Cholestatic:Elevated bilirubin +
elevated ALP/GGT t duct dilatation upon
biliary UfS
Hemolysis:
*
haptoglobin t LDH
r n
’Managed surgically in most cases L J
Jaundice
+
• see Gastroenterology, G45
Note: cholestatic jaundice is often
surgical
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GS7 General and Thoracic Surgery Toronto Notes 2023
Considerations
Preoperative Preparations m
Bilirubin Levels
• informed consent (see Ethical, Legal, and Organizational Medicine. ELOM11 )
• screening questionnaire to determine risk factors e.g. age,exercise capacity,medication use,allergies,
exposure to people with infection (i.e.COVID-19)
• consider preoperative anesthesia, medicine consult as indicated to optimize patient status
Prc- bitra- Posthepatic hepatic hepatic
Serum Bilirubin
Indited t » N
Owed N t t
• IV-balanced crystalloid at maintenance rate (4:2:1 rule for paediatrics, roughly 100-125 cc/h for
adults): NS or RL (RL most common); bolus to catch up on estimated losses including losses from
bowel prep
appropriate use of fluids perioperatively decreases risk of cardiorespiratory complications
• patients can take their regular medications except for hypoglycemic agents, diuretics, and ACEis
• patients with primary adrenal insufficiency (e.g. Addison'
s disease) or secondary adrenal insufficiency
(e.g. glucocorticoid use) may reuuire additional glucocorticoid stress dose coverage
• anticoagulation /antiplatelet medication must be managed to decrease surgical bleeding but not put
patient at risk for increased thrombotic events(e.g. Bridging:switching from warfarin to LMWH,
easier to start/stop as needed)
• prophylactic antibiotics depending on wound class (immediately/within 1 h prior to incision):
cefazolin (skin flora coverage) ± metronidazole (Gl flora coverage) for contaminated cases
• role of MBP:Current evidence suggests that use of MBP preoperatively has no impact on postoperative
complications, and therefore, routine use of MBP for non-LAK elective colorectal surgery is not
recommended
MBP is indicated in open or laparoscopic anterior resection i.e.rectal resection where
anastomosis is at or below sacral promontory;given with antibiotics
• assess risk for postoperative V I E prior to surgery based on procedure- and patient-related factors;
tools such as Caprini Score can be used
only hold VT'
E prophylaxis if epidural is expected
• smoking cessation and weight loss preoperatively can significantly decrease postoperative
complications
• infection:delay elective surgery until infection managed, including respiratory infection (particularly
in asthma patients)
• when scheduling elective surgeriesfollowing a COVID-19 diagnosis, consider the severity of
COVID-19 illness, the risks of complications, and risks of delaying surgery
Urine
Urobilinogen t
Bilirubin
t
Fecal
Urobilinogen t e
In
m
patients with liver disease and an
acute abdomen,spontaneous bacterial
peritonitis must be ruled out
Surgical Emergencies:Take an AMPLE
History
Allergies
Medications
fast medical/surgical history (including
anesthesia and bleeding disorders)
Last meal
Events - HPI
Best Practice InGeneral Surgery
(BPIGS)
http://www.bpigs.ca/
Best Practice in Surgery is a resource
from the quality improvement program
at theUniversity of Toronto Department
of Surgery.Since its inception,it has
expanded beyond general surgery best
practices and provides EBM guidelines
for a variety of fields and procedures
Table 4. Recommendations for Timing of Surgery following Recovery from COVID-19 with
Consideration of Individual Risk/Benefits
ClinicalSeverity of COVID-19 Infection
Moderate Priority of Surgical
Procedure Mild Severe
Moderalc symptomatic Lung involvement
requiring hospilalnalion
and/or significant
comorbidities and/or
immunocompromised
«7 wk post-infection
consider non- operative
oplionsil sale and
available
7 wkpost infection 7 wk post inlection
Critically ill
Severe C0VID-19 wrlh
ICU admission and/or
meet criteria lor severe
disease and/or severely
immunocompromised
<7 wk post-infection
consider non- operative
options if sale and
available
12 wk postinfection
Mild (suspected or
confirmed) COVID-19 and/ COVID-19 not requiring
or asymptomatic and/or hospitalization and/or
upper respiratory tract persistent symptoms
infection
Urgent orEmergent «2wk Do case urgently/
ACATS and PCATS Urgent emergently
within 3,7 or 14 days
Do case urgently/
emergently Mechanical BowelPreparationStrategies:A
ClinkalPractice Guideline developed bylbe
University olToronto's lestPractice inSurgery
Informed by:Can J Surg 2010:53:385-395
14ICIs (5071participants).8 meta-analyses
1. All open,
'
laparoscopic colorectal procedures
(excluding LAfts tdiverting stoma)
• l
,a MBP
• Ho dietary restrictions before IPO
• fleet enemalor left cotononastomows with
bansrectal stapling
2. Open/laparoscopicIAR
- divertingstoma
- MBP
• Ho dietary restrictionsbefore MBP;cleat
fluids after MBPcomplete
Urgent (28 or 42 days) 4 -7 wk post infection
2-SwkACATS/PCATS
Elective (»43 days) »6wk
ACATS/PCATS
Investigations
• see Anesthesia, A4
• routine preoperative laboratory investigations for elective procedures should be selective
only ASA class and surgical risk have been found to independently predict postoperative adverse
effects
• blood components: group and screen or cross and type depending on procedure
• CBC, electrolytes, creatinine
• INR/PT. PTT
• CXR ( PA and lateral) for patients with history of cardiac or pulmonary disease
• ECG asindicated by history or age>69 and no risk factors
• P-hCG testing in all women of reproductive age
• for patients undergoing low-risk surgery withoutsystemic disease (ASA 1 or II), routine preoperative
chest x-rays,CBC, 1NR, and PTT should be avoided
r 1
L J
+
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