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GSM General and Thoracic Surgery Toronto Notes 2023
Splenectomy
Indications
• splenic trauma (most common reason for splenectomy), hereditary spherocytosis, primary
hypersplenism, chronic immune thrombocytopenic purpura (1TP),splenic vein thrombosis causing
esophageal varices,splenic abscess,thrombotic thrombocytopenic purpura (TI P), and sickle cell
disease
• does not benefit all thrombocytopenic states (e.g.infection, most malignancies involving the bone
marrow, drugs/toxins)
• probability of cure of IIP by splenectomy is 60-70%, maybe predicted by response to 1VIG
Indication of Splenectomy
SHIRTS
Splenic abscess/splenomegaly
Hereditary spherocytosis
Immune thrombocytopenic purpura
Rupture of spleen
Thrombotic thrombocytopenic purpura
Splenic vein thrombosis
Complications
• short-term
injury to surrounding structures(e.g. gastric wall, tail of pancreas) and their vascularsupply
postoperative thrombocytosis,leukocytosis
thrombosis of portal,splenic, or mesenteric veins
subphrenic abscess
• long-term
post-splenectomy sepsis (encapsulated organisms): 4% ofsplenectomized patients(highest risk
<16 yr)
splenosis:intra-abdominal “seeding"of splenic tissue during removal
increased risk of malignancy, DVT,and PH
• 50% mortality
Prophylaxis
• vaccinations, ideally 2 wk pre- or postoperative (pneumococcal, H. influenzae,and meningococcus)
• liberal use of penicillin especially in children <6 yr
Splenic Infarct
Pathophysiology
• splenic artery occlusion or oxygen-delivery insufficiency leading to parenchymal ischemia and
necrosis
• can occur in sickle cell disease, thromboembolism, myelofibrosis, CML, and hypercoagulable states
Clinical Features
• patient can be asymptomatic or can have LUQ pain (70%), N/V,fever, chills, and Kehr’ssign
Investigations
. CT with contrast;MRI
• peripheral blood smear abnormalities
Treatment
• non-operative:close follow-up, analgesia
• indicationsforsplenectomy: complicationssuch as rupture, abscess, persistent pseudocyst, bleeding,
orsepsis
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GS65General and Tlioracic Surgery TorontoNotes 2023
Breast
Apical
Deltopectoral
Internal jugular v.
Thoracic duct Lateral
Axillary a.
/
Lett bronchomediastinal
trunk
— Axillary v.
Subscapular a.
- Posterior
Levels of Axillary Lymph Nodes
LevelI:lateral to pectoralis minor
LevelII:deep to pectoralis minor
LevelIII:medial to pectoralis minor
(higher level of nodal involvement*
worse prognosis)
Interpectoral
Pectoralis minor m.
Pectoralis major m.
/
Central
7s
Anterior
v
—Lateral tlioracic a.
/
Internal thoracic
JL J
Level3 Level2 LevelI
Medial to Deep to Lateralto
pectoralis pectoralis pectoralis
minor minor
DDx for Breast Mass
Benign
Fibrocystic changes
Fibroepithelial lesions (fibroadenoma
most common: benign phyllodes)
Fat necrosis
Papilloma/papillomatosis
Galactocele
Duct ectasia
Ductal/lobular hyperplasia
Sclerosing adenosis
Lipoma
Neurofibroma
Granulomatous mastitis (e.g. TB.
granulomatosis with polyangiitis,
sarcoidosis)
Abscess
Silicone implant
Malignant
Breast cancer (likely invasive, DCIS
rarely forms a breast mass)
Malignant phyllodes
Angiosarcoma (rare)
1 rur © Merry Shiyu Wang 2012
Figure 27. Anatomy of the breast
Benign Breast Lesions
Three Categories
1. non-prolifcrative
2. proliferative without atypia
3. atypical hyperplasia
NON-PROLIFERATIVE LESIONS
• benign breast condition characterized by fibrous and cystic changes in the breast (fibrocystic changes/
disease)
• most common: breast cysts
• other lesions include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia
of the usual type
• no increased risk of breast cancer
• age 30 to menopause (and after if hormone replacement therapy (HRT) used)
clinical features
• breast pain,focal areas of nodularity or cysts often in the upper outer quadrant, frequently
bilateral, mobile, varies with menstrual cycle, and nipple discharge (straw-like, brown, or green )
• treatment
» evaluation of breast mass(U/S, mammography as indicated) and reassurance
analgesia (e.g. ibuprofen, ASA)
• forsevere symptoms: DCF, danazol, bromocriptine
PROLIFERATIVE LESIONS - WITHOUT ATYPIA
Table 29. Proliferative Lesions - Without Atypia
Clinical Features Diagnosis Treatment Risk of Breast Cancer
Fibroadenoma Most common breast
tumour in women
<30 yr
Modules:lirm,rubbery,discrete,
well-circumscribed,non-tender,mobile.
Core or excisional biopsy Generally conservative serial observation Increased if complex,
sometimes required if concerned Consider excisionif size 2-3 cm and growing adjacent atypia or strong
on serial U/S (q6 mo x 2 yr is usual follow-up), family history olbreast
U/S and FNA alone cannot IIsymptomatic,formed alter age 35.patient cancer
differentiate fibroadenoma from preference or features on corebiopsy
suggestive of a phyllodes tumour
Surgical excision olinvolved duct to ensure
no atypia
hormone-dependent (unlike cysts),needle about malignancy
aspiration yields no fluid
phyllodes tumour
Solitary intraductal
benign polyp
Can presentas nipple discharge (most
common cause ol spontaneous,unilateral,
bloody nipple discharge ~ pathologic nipple
discharge),breast mass,nodule on U/S
Incidental finding on biopsy of
mammogiaphic abnormalities or breast
masses
Mass or mammogiaphic abnormality
Can harbour areas of
atypia or DCIS
Intraductal
Papilloma r T
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Usual Ductal
Hyperplasia
Increased number of
cells within the ductal
space
lobular lesion with
increased librous tissue
and glandular cells
Generally low-risk,slightly
increased if moderate or
florid hyperplasia
low-risk
None required
Sclerosing +
Adenosis
None required
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GS66 General and Thoracic Surgery Toronto Notes 2023
ATYPICAL HYPERPLASIA
• can involve ducts (atypical ductal hyperplasia) or lobules (atypical lobular hyperplasia )
• cells lose apical-basal orientation
• increased risk of breast cancer
• diagnosis: core or excisional biopsy
• treatment: complete resection, risk modification (avoid exogenous hormones), close follow-up
OTHER LESIONS
Fat Necrosis
• uncommon,result of trauma (may be minor, positive history in only 50%), after breastsurgery (i.e.
reduction)
• firm, ill-defined mass with skin or nipple retraction, ± tenderness, ± ecchymosis
• regressspontaneously, but complete imaging ± biopsy to rule out carcinoma
• oil cysts on mammography are pathognomonic for fat necrosis
Mammary Duct Ectasia
• obstruction of a subareolar duct (see Obstetrics. Mastitis, OB48)
Abscess
• lactational vs. non-lactational (periductal/subareolar) (see Obstetrics. Mastitis,UB48)
Breast Cancer
Epidemiology
• leading cancer diagnosis in women in North America, 2nd leading cause of cancer mortality in
women
• 1 in 8 (12.9% lifetime risk) women in Canada will be diagnosed with breast cancer in their lifetime
• I in 31 women in Canada will die from breast cancer
• all age relative survival is 87%
Female sex.followed by age. are the two
greatest risk factorsfor breast cancer
Risk Factors
• sex (99% female)
. age (83% >50 yr)
• personal history of breast cancer and/or prior breast biopsy (regardless of pathology)
• family history of breast cancer (greater risk if relative was first degree and premenopausal)
• estrogen exposure
nulliparity,first pregnancy >30 yr, menarche <12 yr,or menopause >55 yr
decreased risk with lactation, early menopause, and early childbirth
>5 yrHRTuse, >IOyrOCPuse
• high breast density
• radiation exposure (e.g. mantle radiation for Hodgkin’
s disease)
• BRCA1 and BKCA2 gene mutations
• alcohol use, obesity, and sedentary lifestyle
Male Breast Cancer (<1%)
• most commonly invasive ductal carcinoma
• often diagnosed at later stages
• stage-for-stage similar prognosis to breast cancer in females
• consider genetic testing: most often hormone receptor positive
Any palpable dominant breast mass
requiresfurther investigation
Breast Lymphatic Drainage:
Axillary lymph nodes
Internal mammary lymph nodes
lnfra-/supra-davicular lymph nodes
Investigations
• see margin for physical exam findings
• mammography
indications:screening guidelines(see f amily Medicine, l
'MT)
findings indicative of higher risk of malignancy
mass that is poorly defined,spiculated border
» microcalcifications
architectural distortion
interval mammographic changes
normal mammogram does not rule outsuspicion of cancer based on clinical findings
• other radiographic studies
U/S:differentiate between cystic and solid
• MR I : high sensitivity, low specificity. Use annual MRI and mammography for patients with 25%
lifetime risk of breast cancer
Digital Breast Tomosynthesis (DBT):improved lesion localization and characterization in
noncalcified lesions
• galactogram/ductogram (for nipple discharge): identifies lesions in ducts
metastatic workup indicated in Stage 11-1V disease:bone scan,abdominal U/S,CXR (or CT chest/
abdomen/pelvis), CT head (ifspecific neurological symptoms)
Physical Exam Findings in Breast
Cancer:
Lump/mass:Often firm, irregular, nonmobile,unilateral
Pain: Usually thought of as painless,
however pain may be present
with rapidly expanding tumours or
inflammatory cancer
Inflammation (and peau d’orange):
There are many benign causes of
inflammation, however inflammatory
cancer can presentsimilarly
Nipple or skin retractions/changes:
Nipple or skin retractions/changes:
Attachment of the tumour to skin/nipple
may cause retraction/distortion
Nipple discharge:Majority due to
benign causes, bloody spontaneous
discharge should be investigated for
malignancy
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GS67 General and Thoracic Surgery Toronto Notes 2023
Diagnostic Procedures
•
"
triple test "
for diagnosis of breast cancer:
• clinical breast exam
imaging
>30 yr: mammography and U/S
<30 yr or lactating or pregnant: U/S (high breast density)
pathology ( biopsy)
U/S or mammography guided core needle biopsy:most common
needle aspiration: for palpable cystic lesions;send fluid for cytology if blood or cyst does not
completely resolve
excisional biopsy: only performed assecond choice to core needle biopsy;should not be done
for diagnosis if possible
Genetic Screening
• consider testing for BKCAI/2 if:
• young patient (<35 yr)
bilateral breast cancer in patients <50 yr
patient diagnosed with breast AND ovarian cancer
• strong family history of breast/ovarian cancer
family history of male breast cancer
Staging
patients are assigned a clinical stage preoperatively (cl'
NM);following surgery the pathologic stage is
determined (plNM)
• clinical
tumour size by palpation, mammogram, U/S, and/or MR1
nodal involvement by palpation, imaging
metastasis by physical exam, CXR, abdominal U/S (orO'
chest/abdomen/pelvis), and bone scan
(usually done postoperative if node-positive disease)
• pathological
• tumour size and type
grade: modified Bloom and Richardson score (1 to 111) - histologic, nuclear, and mitotic g
• number of axillary nodes positive for malignancy out of total nodes resected, extranodal
extension, and SLNB positive/negative
tumour biology: estrogen receptor (ER), progesterone receptor ( HR), and HER2/neu oncogene
status
margins:for invasive breast cancer, negative margin issufficient;for DC1S prefer 2 mm margin
lymphovascular invasion (LV1)
extensive in situ component (E1C):DC1S in surrounding tissue
involvement of dermal lymphatics (inflammatory) - automatically Stage Illb
Phyllodes tumours are rare
flbroepithelial breast tumouisthat can
be benign or malignant that mostly
affect women from 35-55 yr
rade
Table 30. TNM Classification System for Staging of Breast Cancer (AJCC 2017)
Unfavourable
Features
Favourable
Features
Primary Tumour (T) Regional Lymph Nodes ( N) Distant Metastasis ( M)
TX Primary lumout cannot be assessed
10 No evidence of primary tumour
tis Ductal carcinoma insitu
NX Regional lymph nodes cannot be assessed MO Ho dislanl metastasis
NO No regional lymph node metastasis
HI Involvement ol 1-3 axillary lymph nodes
and/or clinically negative internal
mammary nodes on sentinel node biopsy
• "
2 cm
• Grade I (low
grade)
• Node
negative
• ER positive
• Mucinous
pattern
•
»5cm
• Grade III (high grade)
• Node positive
• ER negative
• Inflammatory cancer
• Her2i'Neu positive
• Positive maigins
• lymphovascular
invasion
• Epidermal indusion
Ml Distant metastasis
11 Tumour s2 cm in greatest dimension
N 2 Involvement ol 4-9 axillary lymph nodes or clinically
positive ipsilateral internal mammary lymph node
12 Tumour >2cm but <5 cm in greatest dimension
T3 tumour >5 cm in greatest dimention
T4 Tumour of any size with direct extension to chest wall
and/or skin
cyst
• Dermal lymphatics
involved
Pathology
Analysis of Circulating Tumour DNAto Monitor
Metastatic Breast Cancer
NEJM 2013:368:1199 1209
Study: i i : in • : ok
, . . '
ONA, lancer anbgei 15- 3 (CA 15 3).and circulating
tumour celsin 30 women with metastatic breast
cancel leceiving systemic therapy.Ihe results were
compaied with radiographic imaging of tumours.
Results/Conclusions:Circulating tumour DNA was
detected in 97% ot women and showed greater
correlation with changes in tumour burden than did CA
15-3 nr circulating tumourcells. proving the earliest
measure of treatment response in 53 » of women.
CA15-3and circidatng tumourcellswere detected
in 78% and 81% at women,respectively.Circulating
tumour ONA may therefore he an informative
biomarker for metastatic breast cancer.
NON-INVASIVE
Ductal Carcinoma in situ (DCIS)
• proliferation of malignant ductal epithelial cells completely contained within breast ducts,often
multifocal
• 80% non-palpable; detected by screening mammogram as microcalcifications
• risk of invasive ductal carcinoma in same breast up to 35% in 10 yr
• treatment
lumpectomy with wide excision margins + radiation (5-10% risk of invasive cancer)
mastectomy if large area of disease, high grade, or multifocal (risk of invasive cancer reduced to
1%)
possibly tamoxifen as an adjuvant treatment
99% 5 vr survival
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GS68 General and Thoracic Surgery Toronto Notes 2023
Lobular Carcinoma in situ (LCIS)
• neoplastic cells completely contained within breast lobule
• no palpable mass and no mammographic findings; usually incidental finding on breast biopsy for
another indication
• LCIS is a risk factor for invasive carcinoma (approximately 1%/yr)
• treatment
if diagnosed on core biopsy, excisional biopsy necessary to rule out malignancy
• if diagnosed on excisional biopsy, wide excision not needed since LCIS is often multicentric and
not managed as precursor lesion
clinical follow-up and surveillance; consider chemoprevention (e.g. tamoxifen)
10 Year Survival after ItmlConstning Surgery
Plus Radiotherapy Comparrdwith Mastectomy
i it tally Breast Cancer in hit Metherlaads: A
Population-Based Study
Lancet Oncol 201G;17(8|:11S8
See landmark General and Thoracic Surgery Trials
table for mnre Wormation on tie10-year sanriral
alter breast-conserving surgery plus rai otherapy
compa red with mastectomy in early breast cancer.
INVASIVE
Invasive Ductal Carcinoma (most common 80%)
• originatesfrom ductal epithelium and infiltrates supporting stroma
• four types: tubular, mucinous, medullary, and inflammatory
• characteristics: hard,scirrhous, inliltrating tentacles, and gritty on cross-section
• divided into three grades based on cytologic and architectural features: well differentiated (grade
1), moderately differentiated (grade 2), poorly differentiated (grade 3)
Invasive Lobular Carcinoma (8-10%)
• originatesfrom lobular epithelium, 20% bilateral
• subtle thickening originating from lobes/lobules; usually positive for estrogen and progesterone
receptors
• harder to detect on mammography due to lack of microcalcifications (may benefit from MR1)
Paget’s Disease of the Breast (1-3%)
• ductal carcinoma that invades nipple with scaling, ulceration, erythema, and eczematouslesion
Inflammatory Carcinoma (1-3%)
• most aggressive form of breast cancer
• ductal carcinoma that grows in nests (vs.solid tumour);invades and blocks dermal lymphatics
• clinical features: erythema,skin edema, warm,swollen, and tender breast ± lump, nipple changes
• peau d orange indicates advanced disease (Illb-IV)
Sarcomas:rare
• most commonly phyllodes tumour, a variant of fibroadenoma with potential for malignancy
• can also be angiosarcomas- after previous radiation
Lymphoma:rare
Other
• papillary'
, medullary, mucinous, and tubular cancers
• generally better prognosis
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GS69 General and Thoracic Surgery Toronto Notes 2023
Treatment
Table 31. Breast Cancer Treatment by Stage
Stage Primary Treatment Options Adjuvant Systemic Therapy
BCS * radiotherapy
BCS alone il margins >1cm and low nuclear grade
Mastectomy * » SLMB
8CS * axillary node dissection •radiotherapy
Mastectomy*
’
axillary node dissection/SIN 6
Consider postoperative tamosilen lor ER*. Iraslurumab lor
HER 2-*
0 [in situ)
lis. NO, MO
May not be needed; discuss rislrs/benelits of chemotherapy
and tamoxifen
I
IA: T1. MO. MO
IB:11, N1ml, MO
BCS > axillary node dissection * radiotherapy
Mastectomy* axillary node dissection/SLNB
Chemotherapy lor premenopausal women or
postmenopausal and ER negative,followed by tamoxifen
if ER
-
II
A:10. N1. M0
11. N1, MO
12. NO. MO
8:12. N1, MO
13. NO. MO
III likely mastectomy - axillary node dissection +
radiotherapy after chemotherapy (neoadjuvanl)
Neoadjuvant therapy should be considered (i.e.preoperative)
especially if not resectable chemotherapy and/or hormone
therapy.Adjuvant radiation and chemotherapy may also be
appropriate (i.e. postoperative)
A:10. N2.M0
11. N 2, MO
12. N 2. M 0
13. N1. M0
13. N 2. MO
6:14, NO, MO
14. N1. M0
I4. N 2. M 0
Inflammatory Mastectomy * axillary node dissection radiotherapy
Surgery as appropriate lor local control
Neoadjuvant therapy
Primary treatment Is systemic therapy (i.e.chemotherapy)
and/or hormone therapy
IV
any 1, any N. Ml
BCS - breast conserving surgery: SLNB •sentinel lymph node biopsy
'llno reason to select mastectomy,the choice betwvcnBCS •radiotherapy andmastectomy can be made according to paUenl s preference since
choice ollocal treatment does not significantly affect survival If local control Is achieved
PRIMARY SURGICAL TREATMENT
Breast Conservation Surgery (BCS)
• lumpectomy must be combined with radiation for survival equivalent to mastectomy
• contraindications include
• high-risk of local recurrence (e.g. extensive malignant-type calcifications on mammogram), and
multifocal primary tumours
failure to obtain tumour-free margins after re-excision
not suitable for radiation therapy (pregnancy, previous radiation, and collagen vascular disease)
• large tumour size relative to breast
BCS can be offered to most women with
stageI/ll disease
There is no survival benefit of
mastectomy over lumpectomy plus
radiation for stageIand II disease
Mastectomy
• radical mastectomy (rare): removes all breast tissue,skin, pectoralis muscle, and axillary nodes
• modified radical mastectomy (MRM):removes all breast tissue,skin, and axillary nodes
• simple mastectomy: removes all breast tissue and skin
• see Plastic Surgery. PL38 for breast reconstruction
Sentinel Lymph Node Biopsy (SLNB)
• performed in women with clinically node-negative invasive breast cancer and those with extensive
DGIS who are undergoing mastectomy
• patients with clinically suspicious nodes should get U/S i I
'
NA prior to decision to proceed with SLNB
• technetium-99 ± blue dye injected at tumour site prior to surgery to identify sentinel node(s)
• intraoperative frozen section evaluated can be considered
• proceed with A1.N1)
if >3 positive nodes, with 1 -3 nodes whole breast radiation therapy maybe an
alternative
• 5% false negative rate
Axillary Lymph Node Dissection (ALND)
• perform in patients with:
locally advanced (T4a, b, c) or inflammatory breast cancer
clinically node-positive axilla, confirmed by INA or core biopsy, in a patient for whom
neoadjuvant chemotherapy is not planned
• several other specific cases (sentinel or axillary nodes, which remain positive after neoadjuvant
chemotherapy, axillary recurrence following previous breast cancer treatment, among others)
• side effects: risk of arm lymphedema (10-15%),especially if getting radiation therapy, decreased arm
sensation, and shoulder pain
Effect of Radiotherapy after Mastectomy and
Axillary Surgery on 10 Tear Rccurience aad 20
Yeai Breast Cancer Mortality: Meta-Analysis ol
Individual Patient Data for 8135 Women in 22
Randomised Trials
EBCICG (Early Breast Cancel lilalists'Collaborative
Group)
lancet 2014; 383|993S|:2127-2135
Study:Assessed the elied of radiotherapy <t
women with one to three positive lymph node alter
mastectomy and an lary dissection ina meta - analysis
o!8135 women in 22 trials.
Results:for 300 women with axillary detection
and no positive nodes,radiotherapy had no
significant effect on local tegional recurrence, overall
recurrence,or breast cancer mortality.For 1314
women with axillary dissection and one to three
positive nodes, radiotherapy reduced local regional,
overall recurrence, and breast cancer mortality.1133
of these 1314 women were in trialsin which systemic
therapy (cyclophosphamide, methotrexate,and
fluorpjtacj . ot tamoxifen) was given in both tiial
groups and radiotherapy again reduced local regional
recurrence,overall recurrence, and breast cancer
mortality,for1732 women with axillary dissection
and four ocmoie positive nodes, radiotherapy
reduced local regional recurrence,overall recurrence,
and breast cancer mortality.
Conclusion:Post mastectomy and axillary
dissection, radiotherapy reduced both recurrence
and bieast cancer mortality in the women with one to
three positive lymph nodes in these trials even when
systemic therapy was given.
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GS70 General and Thoracic Surgery Toronto Notes 2023
ADJUVANT/NEOADJUVANT
Radiation
• indications
decrease risk of local recurrence; almost always used after BCS,sometimes after mastectomy
• inoperable locally advanced cancer
• axillary nodal radiation may be added if nodal involvement
Effect of Axillary Dissection vs.No Axillary
Dissection on 10-Year OverallSurvival Among
Women With Invasive Breast Cancer and Sentinel
Node Metastasis:The ACOSOG 20011 (Alliance)
Randomized Clinical Trial
JAMA 2017;318(10):918-926
Purpose:Assessed whether the10 yr overall survival
of patients with sentinel lymph node metastases
treated with breast-corserr ng therapy and sentinel
lymph node dissection (SIND) alone without axillary
lymph node dissection (AUDI is non inferior to that of
women treated with axillary dissection.
Results:The 10 yr overall survival was 86.3% in
the SLND alone group and 83.6% in the ALNO group.
The 10 yr disease-free survival was 80.2% in the
SUD alone group and 28.2% in the ALNO group.10
yr regional recurrence did not differ significantly
between the 2 groups.
Conclusion:Among women with T1or12 invasive
primary breast cancer, no palpable aitllary
adenopathy,and 1or 2 sentinel lymph nodes
containing metastases.10-yr overallsurvival foe
patients treated with SIND alone was noninferiot to
oveiall survivalfor those treated with ALNO.
Hormonal
• indications
• ER positive plus node-positive or high-risk node-negative
selective estrogen receptor modulators (SERM) if premenopausal (e.g. tamoxifen) or aromatase
inhibitors if postmenopausal (e.g. anastrozole); optimal duration 5-10 yr
• other options include ovarian ablation (e.g. goserelin/GnRH agonist, oophorectomy), progestins
(e.g. megestrol acetate), and androgens (e.g. fluoxymesterone)
• palliation for metastatic disease
Chemotherapy
• indications
ER negative plus node-positive or high-risk node-negative
• triple-negative disease (ER/PR and HER2-negative) - more common in younger and AfricanAmerican women
• ER positive and young age
stage 1 disease at high-risk of recurrence ( high grade,lymphovascular invasion )
• palliation for metastatic disease
• for HER2 positive breast cancer, add trastuzumab ± pertuzumab to the chemotherapy regimen
FOLLOW-UP
Post-Treatment Follow-Up
• assessment and physical exam q3-6 mo x 3 yr, q6-12 mo x 2 yr, and annually thereafter
• following BCS mammography q6- 12 mo; can reduce to annual once stable, no other routine imaging
unless clinically indicated
• women who receive tamoxifen should have regular gvnaecologic follow- up (increased risk of
endometrial cancer)
Local/Regional Recurrence
• recurrence in treated breast or ipsilateral axilla
• 1% per yr up to maximum of 15% risk of developing contralateral malignancy
• 5x increased risk of developing metastases
Metastasis
• bone > lungs > pleura > liver > brain
• treatment is palliative: hormone therapy, chemotherapy, radiation
• overall survival of metastatic breast cancer is 36-60 mo
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GS71 Genera!and Ihorack Surgery Toronto Notes 2023
Surgical Endocrinology
Thyroid and Parathyroid
• see Endocrinology. E24
Thyroidectomy
• indications:some thyroid cancers or suspicious thyroid nodules, metastases to thyroid,large
(substernal) or symptomatic thyroid goitre, toxic nodules, or some patients with Graves’
disease (not
candidatesfor RA1)
• preoperative workup:thyroid U/S for thyroid nodules, ENA for nodules >1 cm with suspicious U/S
features or for most nodules >1.5 cm with low suspicion U/S features, and Cl'
neck for preoperative
staging when advanced disease issuspected
• complications
• lobectomy: recurrent laryngeal nerve palsy (hoarseness or swallowing issues), neck hematoma
total thyroidectomy:same as above plus hypoparathyroidism/hypocalcemia, bilateral RLN palsy
(requiring tracheostomy)
20-75% of patients need thyroxine after lobectomy and 100% need thyroxine after total
thyroidectomy
Parathyroidectomy
• elevated calcium found for any reason as an outpatient (but also incidental finding asinpatient) is
likely primary hyperparathyroidism and should be investigated further
• indications:symptomatic primary hyperparathyroidism (osteoporosis/stones), asymptomatic
primary hyperparathyroidism with specific laboratory criteria (profoundly elevated serum Ca2+,
hypercalciuria/asymptomatic kidney stones, Cr clearance <30% normal, <50 yr)
• contraindications: familial hypocalciuric hypercalcemia
• preoperative localization to find parathyroid adenoma. Localizing studies include:99mTc sestamibi
scanning with ± SPLCT, U/S, contrast CT
• complications: recurrent/superior laryngeal nerve injury, postoperative hypocalcemia,infection, and
bleeding
Adrenal Gland
•see Endocrinology, E35 and E40
•functional anatomy
• cortex:glomerulosa (mineralocorticoids), fasciculata (glucocorticoids), and reticularis(sex
steroids)
medulla:catecholamines (epinephrine, norepinephrine)
•types of adrenal tumours:functional (e.g. Cushing’
s syndrome, Conn’
s syndrome,
pheochromocvtoma) or non-functional
INCIDENTALOMA
•adrenal mass discovered by investigation of unrelated symptoms/issues
Epidemiology
•benign adenoma (70-80%) > metastases to adrenal (22%) »cyst carcinoma,pheochromocvtoma,
neuroblastoma
•metastasis to adrenal gland from:lung > breast, colon, lymphoma, melanoma, and kidney
•peak incidence of carcinoma:females ages 50-60, risk decreases with increasing age and male gender
Investigations
•CT:size >4-6 cm isbest predictor of primary adrenal carcinoma (92% are >6 cm), MRI is not as good
as CT and does NOT need to be done after CT
•functional studies
pheochromocvtoma:plasma metanephrines (highly specific and sensitive).If not available, 24 h
urine catecholamines
Cushing’
s:24h urine cortisol or 1 mg overnight dexamethasone suppression test
• aldosteronoma:electrolytes, AM aldosterone, AM plasma renin activity level, ARR (AldosteroneRenin-Ratio). If inconclusive,saline suppression test if appropriate
not routinely - only if clinical suspicion: adrenal androgens: 17-OH progesterone and
dehydroepiandrosterone (DHEAS)
•ENA biopsy: NOT APPROPRIATE in most cases. Diagnostic adrenalectomy by high volume endocrine
surgeon ideal if diagnostic uncertainty
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GS72 General and Thoracic Surgery Toronto Notes 2023
Treatment
• functional tumour: resect
• non-functional tumour
>4 cm:consider resection
• <4 cm:follow-up imaging in 6-12 mo, resect if >1 cm enlargement
genetic testing important for ALL Pheochromocytoma/paragangliomas as >30% are related to
genetic syndrome
Pancreas
INSULINOMA
• tumour that secretes insulin
• most common pancreatic endocrine neoplasm; 10% associated with MENI syndrome
Clinical Features
• Whipple'
s triad
• palpitations, trembling, diaphoresis, confusion,seizure, and personality changes
Investigations
o
• blood work: decreased scrum glucose and increased serum insulin and (.
'
-peptide, pro-insulin
• CT, HUS, MKI:insulinomas evenly distributed throughout head, body, tail of pancreas
Whipple'
s Triad
• Symptomatic fasting hypoglycemia
• Serum glucose <2-8 mmol/l
• Relief of symptoms when glucose is
administered Treatment
• only 10% are malignant
• enucleation ofsolitary insulinomas may be done endoscopically
• tumours >2 cm located close to the pancreatic duct may require pancreatectomy or
pancreaticoduodenectomy Zollinger-Ellison Syndrome
Characterized by gastric acid
hypersecretion caused by secretion
of gastrin from gastrinomas: patient
experiences diarrhea and abdominal
pain,as well as peptic disease and reflux
disease
GASTRINOMA
• tumoursecreting gastrin;cause of Zollinger-Ellison syndrome,associated with MEN1
Clinical Features
• abdominal pain, PUD,severe esophagitis
• multiple ulcersin atypical locations refractory to antacid therapy
Investigations
• blood work:serum gastrin levels (usually >1000 pg/mL),secretin stimulation test
• endoscopy:90% of patients develop peptic ulcers
• CT,EUS, MRI:70-90% found in Passaro’striangle (head of pancreas medially, 2nd portion of
duodenum inferiorly,and the confluence of the cystic and CBD superiorly)
• somatostatin receptor scintigraphy scan
Hypertrophic Pyloric Stenosis
Non-bilious emesis in infants isthe
classic presentation
Treatment
• 50% are malignant
• surgical resection of tumour dependent on location
• non-surgical treatment:high dose PPI, octreotide (somatostatin analogs)
• radiation therapy may be considered for nonsurgical candidates
Rule of 2sfor Meckel's Diverticulum
• 2% of the population
• 2:1 male-tofemale ratio
• Symptomatic in 2% of cases
. Found within 2 feet (10-90 cm) of the
ileocecal (1C) valve
• 2 inches in length
• 2 inches in diameter
• 2 types of tissue (ileal or ectopic
gastric, pancreatic)
• Often present by 2 y/o
VASOACTIVE INTESTINAL PEPTIDE-SECRETING TUMOUR
• tumoursecreting VIP; commonly located in the distal pancreas and most are malignant when
diagnosed
Clinical Features
• severe watery diarrhea causing dehydration, anorexia, weakness, and electrolyte imbalance
(hypokalemia)
Investigations
• blood work:serum VIP levels
. CT, MRI, EUS
Treatment
• repletion of fluid and electrolytes
• somatostatin analogues
• surgical resection/palliative debulking LJ
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GS73 General and Thoracic Surgery Toronto Notes 2023
Paediatric Surgery
Clinical Features Physical Exam Investigations Treatment
and History
Condition Epidemiology and Pathophysiology
Risk Factors
Prognosis
U/S if suspect
pathology
t-2%oflivebvths
Majority resolve
spontaneousbylyr
MF-61
Prematurity
Communicating hydroceles: Painless scrotaImass Transiilummalion
processus vaginalis connects Communicating suggests
peritoneumwithtunica hydroceles increase hydrocele
vaginalis, so peritoneal fluid in sire with standing Silk glovesign:
flows freety between the two or valsalva,may be gentlypupating
with potential for abdominal absent in the morning hydroceiesac
contents to enter groin (Le. and large inthe overpubic
inguinal hernia) evening tubercle feels
Noncommunicatinghydroceles:
processus vaginalis isclosed
and more fluid produced
than absorbed in tunica
vaginalis:inolder children,
may be secondary to testicular
pathology (e.g.reactors
hydrocele)
Most resolve spontaneously *
2%recurrence
bylyr
Surgical repair if:
Persistence »2 yr
Hydrocele
(seetl'ology.U32)
Pain
Fluctuatingin sire which
suggests communication
Cosmetic reasons
like rubbingsilk Infection
on silk
Hypertrophic
PyloricStenosis
0.031.Che of live Acquired pyloric circular Projectile non-bilious Smooth oblong
muscle hypertrophy results in vomiting T2cm“olive"
gastric outlet obstruction Vomiting 30-60 min mass palpable
Hypovolemia causedby emesis after feeds above umbilicus
Electrolytes (assess Fluidresuscitate with NS. Pytoromyotomy
hypochloremia. correct electrolyteand acid,1
curative
dehydration) base abnormalities with
U/S showspyloric OS.V2MS * 20mEqilKCI at
length17 mm.musde maintenance rate
thickness >4 mm NG lube decompression
UpperGI series
(necessary only when
U/S is unavailable or
non-diagnostic)will
show “stringsip"
births
Can present at
I20 wk.most
commonly at 6 8 wk ol gastric contents causes
hypochloremic,hypokalemic
metabolic alkalosis
Electrolyte exchangebased
volume retention inkidneys
results In paradoxical acitfciria
Hungry after vomiting intheSUQ
Dehydration (variable Visible left toseverity)
M:F-4:1
Early erythromytin
exposure (*13 d old)
right gastric
contraction
unnecessary
Pyloromyotomy,open
(Ramstedt vs.tiansumbilical or
laparoscopic approach) isthe
definitive treatment
Alternative therapies such as
IPR wait or atropine impractical
due to long time course of effect
“waves"after
feeding
Congenital
Diaphragmatic
Hernias
3 types:
Posterolateral
(Bochdalek)
Left-sided (85%)
Right-sided (13%)
Bilateral,rare,
often fatal
1in 2000 to 5000live Combinations of smal bowel.
large bowel,stomach,and
Presents vnthn hours solid viscera (spleen,liver)may Cyanosis
of life althoughsome herniate into thorax
cases of delayed
presentation
Early respiratory
distress
Decreasedair
entry r bowel
soundsinthe
Scaphoid abdomen chest
Prenatal diagnosis (hsp
’
acedheart
sounds
Prenatal USMRI Intubatei'ventilate
Orogastric suction
Period of respiratory
Better outcomes in
later presentations
Neurodevelopmental
stabilization due to associated impairment
pulmonary hypoplasia (may
require extracorporeal
membrane oxygenation)
Scxgical repair after stable by andscoliotic defects as
hernia reduction and closure ol potenbal complications
diaphragmatic defect open vs. of thoracotomy
thoracoscopic vs.laparoscopic long-term surveillance
nth or without prosthetic or for potential recurrence
muscular patch
depending on sice of defect
births ABO
CXR (bowel loopsin
hemithorax.shifted
heart)
Echocardiography
Genetic consultation
if warranted
Hearing defrat(40%)
Varying degrees of puhnonary AssocatedGERD
hypoplasia and pulmonary
»10= areassociated hypertension possible
with other congenital
anomalies
M-F MSKdefects chest wall
Prenatal diagnosis
common Anterior IMorgagm)
Fibre to thrive
Chronic lung disease if
severe hypoplasia
Hiatus
1-3%of population
M:F-3:1
Present most
Failure of vitelline duetto
regress 5-7 wkrncrfero:
50% containheterotopic
Tenderness and
distension (lower
abdomen) near
umbilicus
Stabilize,resectionby
laparotomy or laparoscopy t
incidental appendectomy
Meckel's
Diverticulum
Most common
remnant ol vitelline
duct that connects
yolk sac with
primitive midgut
BRBPR (heterotopic
gastric mucosa in
Meckel'scausing
frequently during first tissue (e.g. gastric mucosa. mucosal ulceration
5 yr of kfe ectopic pancreas):other andbleedingin
Symptomatic m 2% associated anomalies include adjacent small bowel
of cases omphalomesenteric fistula. mucosa)
umbilical sinus,umbilical cyst Abdominal
sepsis (Meckel’
s
AXR Resection curative
Meckel scan:scan
for ectopicgastric
mucosa with
technetium Tc99m
pertechnctateIV
(sensitivity 85%.
specificity 95%)
and fibrous band
diverticulitis ±
perforation)
Small bowel volvulus
aroundfibrous band
Intestinal obstruction
symptoms
Matrotation 1:500live txrttis failure of gut lonormally
1/3 present byInk rotatearoundSMA with
ofage.34by1mo associated abnormal intestinal rlabdomen
of age.90%bylyr attachments and anatom
positions *
Represent a spectrum of
Higher incidence rotational abnormalities
among patients with including complete noncardiac anomalies or rotation (which Isnot at
heterotaxy syndromes high-risk (or volvulus)
Cardinal sign:bilious Bilious drainage
emesis (especially fromNG tube
Tachycatdic.pale
nondistended) Diaphoretic
If bilious emesis with Flat abdomen
distended abdomen. Tenderness
consider surgical
exploration to raleout
volvulus
Rectal bleed(late/
ominous signs)
Intermittent
symptoms
AXR:obstruction
of proximal S80.
double-bubble
sign,intestinal wall
thickened
Immediate UGt
dilated duodenum,
duodenojejunal
segment (Ligament
of Treitz) right of
midline and not
fixed posteriorly
over spinalcolumn,
“corkscrew"sign
indicating volvulus
U/S:“whirlpool"
sign,abnormal SMA
SMV relationship
indicates UGI to
rule out rotational
anomalies
tv antibiotics
Fluid resuscitation
EMERGENUAPAROfOMYLadd
procedure:counterclockwise
reduction of midgut volvulus,
division of Ladd's bands,
division of peritoneal
attachments between cecum
and abdominal wall that
obstruct duodenum,broadening
of themesentery (open folded
mesentery likea book and
dhnde congenital adhesions),r
appendectomy
Positioning the bowel into nonrotation(SB0inright abdomen.
LS0inleft abdomen)
Mortality related to
length of bowel loss:
W% necrosis 100%
survivalrale.75%
of age necrosis 35%survival
M:F-1:1 rate
Recurrence 2-6%
r m
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GS7‘
IGeneral and Thoracic Surgery Toronto Notes 2023
Condition Epidemiology and Pathophysiology
Risk Factors
Clinical Features Physical Exam Investigations
and History
Treatment Prognosis
Gastroschisis 1:2000 live births Delect of abdominal wall near Hot associated with Hollow viscera Prenatal U/S
Antenatal diagnosis umbilicus,with free extrusion genetic syndromes |slomach. small Elevated MS AFP
common of intestine intoamniotic cavity 10% withintestinal and large bowels)
No specific environmental atresia Delect lateral
factor identified Some cases
Defect in embryogenesis associated with short right)
unclear bowel syndrome due Bowel may
be inflamed,
thickened.
NG lube decompression
IV fluids
IVanlibiotics
Keep viscera moist and
protected until surgical
reduction with primary
abdominal closure or staged
closure with silo
May have bowel dysmotility
requiring motility medications
>90% survival rale
Increased risk with
younger maternal
age andassodated
withIUGR
Rate slightly higher in
male infants
Smoking
to cord (usually
to antenatal volvulus
andnecrosisof
herniated bowel mailed,
foreshortened
Defect siie
variable
1:5000 live births
Antenatal diagnosis
common
Defect of abdominal wall and 30-70% associated
umbilical ring,with extrusion with genetic
of sac-covered viscera (amnion, syndromes (e.g.
Lower gestational age Wharton’s jelly,peritoneum) Pentalogy of
Increased maternal through the umbilicalring Cantrell,congenital
Duhamel's theory failure of heart disease,
body wall morphogenesis
Commonly associated with
rotational abnormalities of the Associated pulmonary
hypoplasia
Hollow viscera Prenatal Ur’S
(stomach,small Elevated MS AFP
and large bowels,
often liver)
Sac present with
cord attached
40- 70%survival rate
Higher survivalrales
most likely related to
antenatal mortality
of fetuses with giant
omphaloceles
Omphalocele NG tube decompression
IV fluids,IVanlibiotics
Small defect [<2cm):
Primary closure
Medium (2-4 cm) and large
(>4 cm) defects:silver
sulfadianne coupled with
compression dressing (toallow
eptlhelialitation and gradual
reduction) or Silon Silo Pouch,
followed by future repair tmesh
Repair if not spontaneously
closed by age 5
Earlier repair of large
“ptoboscoid"hernias with
extensive skin stretching may
be warranted lor cosmetic
reasons
Simple primary closure of
fascial defect
III
MF-1 5:1 Beckwith Wiedemann
syndrome,fnsomy 18)
intestine
Incidence 2-14%
Increases with
prematurity
Decreases with
Increasing age
UmbilicalHernias Majority
peritoneal and fascial layers asymptomatic
within umbilicus by 4 yr Majority (95%)
Hernia isperitoneum-linedand spontaneously resolve less common
abdominal wall
Incarccralionpriorlo herniasthaldo
ageSveryrarc not spontaneously
Mostsymptomsoccur resolve (e.g.
inlate adolescence or epigastric
hernias)
Most defects >1.5
cm in infancy
will not dose
spontaneously
Incidence 2-14% Duodenal failure ol bowel to Gastric distension Complete physical Conlrasl enema $ NP0
May be antenatally recanabre after endodermal and vomiting (usually Special attention UGI with small bowel NG tube decompression
diagnosed by dilated epithelium proliferation(wk bilious) to abdominal follow through(S8FI) Fluid resuscitation
bowelloopsor 8-10) Duodenal maybe exam,perineum. Group and screen IPN
‘
‘double-bubble"sign Jejunal/ileal acquired as a associated with andanus
on x-ray for duodenal result of vascular disruption » other anomalies Include evaluation surgery
atresia ischemic necrosis
*
resorption (tracheoesophageal of respiratory
of necrotic tissue -•blind distal fistula,cardiac. distressand
renal,and vertebral signs ol volume
Colonic mechanism unknown, anomalies).24-28% depiction
Ihoughl lobesimilar to small have Down syndrome Congenital
Jejunal/ileal within anomalies
2 d of birth,may be Jaundice
associated with CF
Colonic within3 d
of birth
Incomplete closure of Protrusion from
umbilicus
Different from
None if
uncomplicated
Rarely become
incarcerated
Low risk of recurrence
skin- covered by age 4
Sire of fascial defect
determines chances ol
spontaneous closure
adulthood
Long-term survival:
Duodenal 86%
Jejunal/ileal 84%
Colonic100%
Intestinal Atresia
INR andPIT if for Broad spectrum antibiotics
Duodenal
duodenoduodenostomy or
duodenojejunostomy
Jejunal/ileal primary
anastomosis:or if atresia
associated with short bowel
then may createend stoma
or defer surgery for bowel
lengthening procedures
Colonic primary anastomosis
Decreasedwith
increasing age and proximal ends
bowel atresia
1:5000births
M:F-3:1 to 4:1.
approaches1:1when resulting in aganghomc bowel spontaneously within Squirt/blast sign aganglionosisand
whole coloninvolved that (ails to perislalseand 48 h of life (95%pass
Canhave internal sphincter that fails to meconium within 24
aganglionosis of small relax (internal anal sphincter h,5% within 48h)
bowel as well achalasia) causing functional Symptoms of
Familial and partial mechanical
Hirschsprung's in <5% obstruction,respectively
of cases
Deled in migrationof
neurocrcst cells to intestine
Congenital
Aganglionic
Meirschsprung's
Disease
Failure to pass
meconium
t Abdominal Rectal biopsy (gold
standard) look for
Duhamel pull-through
procedure: surgicalresection ol near-normal anorectal
aganglionic intestinal segment function
and anastomosis ofremaining
intestine to anus
Either innewborn period
or staged if extensive
aganglionosis
Mosl have normal/
distension
neural hypertrophy Complications:
fecal incontinence
and constipation,
postoperative
enterocolitis (medical
emergency if
progresses to sepsis)
Contrast enema to
find narrowrectum
and transition cone
Anal manometry
unreliable ininfants
classic finding is
absence of redoanal
inhibitory reflex
bovrel obstruction:
abdominal distension,
constipation,bilious
emesis
Starts in the rectum and
variable involvement
proximally:REI mutation Enterocolitis/sepsis
failurelothrive
Cryptorchidism Most common
congenital
abnormality of the
GU tract
2-5%of termmales
moslol these descend
spontaneously by 6
moolage
1% ol males do
not spontaneously
descend
Suspect in
prematurity
Palpable testicle Scrotal
Descent is mediated by INSL3 within inguinal canal asymmetry
ortestidewhichcan Bi-annual
be milked down into testicular exam
hCG to stimulate testosterone
production and descent
Orchidopexy especially if
undescended byage
6 mo-2yr
Orchidopexy
Decreasedrisk of
torsion and blunt
trauma to testicle
No effect on malignant
potential of testicle
Descent can preserve
spermatogenesis rl
performed by1y»
Idiopathic Depends onageof
presentation
Older child:LH.FSH.
Mullerian inhibiting
the scrotum (called with palpation substance. hCG
retractile testis) Distinguish truly stimulation test
Occasionally no undescendcd lor gonadotropin
palpable testis as itis testis Irom production
intra abdominal retractile testis Infant:U/S. FSH.
Consider other (whichis “high" LH,karyotype,
congenital testis dueto MIS.17-hydrojcyabnormalities hyperactive progesterone
cremasteric If non-palpable:
muscles) exam under
and testosterone
Descent usuallybegins at
28 wk
i. J
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laparoscopy
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GS75 General and Thoracic Surgery Toronto Notes 2023
Condition Epidemiology and Pathophysiology
Risk Factors
Clinical Features Physical Exam Investigations
and History
Treatment Prognosis
Intussusception Most common cause Usually idiopathic
of bowel obstruction Usually startsat Ileocecal
between 6-36 mo junction
26:100.000 newborns Telescoping ol bowel intoitsell pain
causing an obstruction and
Pathologic lead vascular compromise
points:enlarged
Payer's patches due
to viral infections of
the Gl tract,polyps.
Meckel's diverticulum
CF.lymphoma andI8D
may increase risk
Abdominal exam AXR for signs of
Palpate
1«masses
(especially
sausage shaped
upper abdommal
mass) and
tenderness
Signs olbowel
obstruction:
distended
abdomen
Look for localized
peritonitis
which suggests
transmural
ischemia
Abdominal
distention
If peritonitis,consider operative 10%recurrence rale
If recurent - more
likely nonidiopathic
If successfully reduced
by enema in older
childrenallow 2 wk
resolution of edema
before performingSBFT
to ruleout pathologic
lead points
Acute onset
abdominal pain
Episodic "colicky"
bowel obstruction or management
perforation
U/S if suspect
pathology
Hon operative management
involves reduction via air
M:F-3:2 Vomitingt bilious
Abdominalmass
Currant- jelly stool
suggests mucosal
neuosisand
contrast enema
Operativeiedudion (open or
laparoscopically)
Resection of involved colon
if failure to leduce or bowel
sloughing appears compromised
Tracheoesophageal 1:3000 1:4600 Defect inthe lateral seplatron Varies with type of
Fistula (TEF) Typically occurs with ollive foregut into the
esophageal atresia esophagus and trachea causing May have history
connection between the of maternal
polyhydramnios
May present after
several months
(ifno associated
esophageal atresia)
of non-bilious
vomiting,coughing,
cyanosis withreeds,
respiratory distress,
recurrent pneumonia,
frothy bubbles of
mucus in mouth,and
nose that return after
suctioning
X-ray:anatomic Investigate for other congenital Complications:
abnormalities.HG anomalies
tube curled in pouch Early repair by surgical ligation reaebseaitways
loprevent lung damage and disease
maintain nutrition and growth Following repair:
esophageal stenosis
andstricturesat
repair site.GERD,
and poor swallowing
(i.e.dysphagia,
regurgitation)
Ml pneumonia,sepsis.
esophagus and trachea
Associated anomaliesin 50%:
VACTERL association
Inguinal Hernias 5%of all term
newborns
All infant hernias are indirect:
descent of intra-abdominal
2x risk andmore likely contents through the internal
bilateral if pre-term
M:F-4:1
low birth weight
increases risk
1/5 inguinal hernias
will become
incarceratedif patient
is «1yr
Incarcerationis more
common in females
Associated with other
conditions:androgen
insensitivity,
connective tissue
diseases
Palpate far
presentation:painless “bag of worms" standard
intermiltent mass
in groin,may also
note extensioninto varicocele
scrotum (scrotalmass Biannual
in absence of inguinal testicular exam • difficult)
massisa hydrocele) palpation along
IIincarcerated:
tender,vomiting,firm evaluate for any
mass,erythema then masses
cyanosis of mass may "Silk sign"
palpable
thickening of cord
Mass palpated
alexternal
inguinalringand
reducible through
inguinal canalinto
abdomen
Must always
try reduction
to confirm that
hernia is not
incarcerated
Physical exam isgold Manualreduction in the ER lo Risk of recurrence after
relieve acutesymptoms
suggests U/S only if physical For reducible hernia:repair
possible testicular exam uncertain within a few wk (if «1yr) vs.
(e.g. in small infants elective repair (rl >1yr)
where exam can be For incarcerated hernia:repair was incarcerated/
immediately (emergency) strangulated
Herniorrhaphy (laparoscopic or
open) definitive treatment by
reduction of herniated contents
and highligation of sac for
indirect hernias
Most common
surgicalreduction
<3%.higher if repair
done inpremature
infants or if hernia
inguinalring Ihrougha patent
tunica vaginalis
Inguinal hernia can be
reducible,incarcerated
lunreducible).or strangulated
inguinal canal to
be noted
Skin Lesions All inguinal hernias of infancy and
childhood require repair at the earliest
convenience: emergent repair if
• teePerinatology.08;Emergency Medicine.EK43;Plastic Surgery. PL5 incarcerated/strangulated
rt
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GS76 General and Thoracic Surgery Toronto Notes 2023
Common Medications
Types Drugs and Dosing
Antiemetics dimenhydrinate (Gravol- ) 25- 50 mg P0/IV/IMq4-6hprn
prochlorperazine (Stemetil ®) 5-10 mg POT'
/.'IM BID-TID prn
metodopramide [Maxeran - ) 10 mgIV,
'
IM q2-3 h prn.10-15 mg P0 010 (30 min before meals andOHS)
ondansetron (Zofran 5) 4 8 mg P0 q8 h prn
granisetron (Kytril:
)1mg P0 810 (for nausea from chemolherapy/radiation)
acetaminophen t codeine (Tylenol 43/plain)12labsq4-6 h P0/PR pin
hydromoiphonc1-2 tabs P0 q4 h prn.0.5-2 mg IV q3- 4 h prn
ibupiofcn 200 400 mg P0 q4-6 h prn
morphine 2.5 -10 mg IM/SC <|4 6 li pm » 12 mg IVglhprn for breakthrough
ketorolac (loradol ' ) 30 60 mg IM/IV q6 h prn
acclammophcn/oxycodone (Percocet 1325/5mg.12 labs P0 q4 6 h pin
heparin 5000 units SC BID. it cancelpatient thenhepaiin 5000units SC TI0/BID
daltepaim fFiagmin -
) 5000 units SC daily
enoxapann (Lovenox ;
) 40 mg SC daily
loperamide (Imodium!
) 4mg P0initially,then 2mgP0 after each loose stool up to 16 mg/d
diphenoxylate -
'
atropine (Lomotil -
) 2 tabs/10 mLPO 0ID
sennosides (Senokol -
) 12 tabs OHS
docusate sodium (Colace - )100 mg P0 8ID
glycerine suppository 1 tab I
’
ll pin
lactulose 15-30ml P0 010 pin
milk olmagnesia (MOM) 30 - 00 ini P0 010 prn
bisacodylIDulcolax '
110-15 mg P0 pin
zopidone (Imovane '
) 5- 7.5 rng P0 OHS prn
loiaicpam (Alivan '
) 0.5-2 mg P0/SL OHS prn
celatobn (Ancef )1gIV/IM on call to OR or q8 h - CP except Interococcus.GN only f.call , Klebsiello, and Pioteus
cefalexm (Keflex ’) 250-500 mg P0 0ID -listeria.GP except Interococcus, GN only l, cob.Klebsiella,andPioteus
ceftriaxone1-2 g IM/IV q24 h broad coverage includingPseudomonos
ampicillin1-2 g IV q4 -6h-listeria,GP [ Interococcus) except Streptococcusmb 6. coli, oral anaerobes except
gentamicin 3-5 mg/kg/d IM/IV divided q8 h:monitor creatinine,gentamicin levels GN includingPseudomonas
ciprofloxacin 400 mg IV g12 h. 500 mg P0 810 -Gil includingPseudomonas
metronidazole (Flagyl- ) 500 mg PO/IV BIO (500 mg P0 TID lor C.difficile) - anaerobes
clindamycin 600-900 mg IV qS h.150 400 mg PO 0ID - GP except Interococcas.anaerobes
pipcracillin/lazobadam 3.375 g IV qG h - GP.GK.and anaerobes
vancomycin 1g IV q12 h - GP and MRSA
sulfamclhoxazoleftiimdhoprliri OS ISeptra '
) PO 810 - GP. GN including Hocoidia
bismuth subsalicylate (I
’
cplo-Bismol ) 2 tubs or 30mlPO q30 mm 1 h up to 8 doses /d
side effects:black stools,risk of Reye's syndrome in children
ASA •citrate * bicarbonate (Alka -Seltzer '
) 2 labs in 4 oz wafer P0 q4 h prn, max 8 labs
aluminum hydroxide « magnesium hydroxide (Maalox ) 10 20 ml or 1- 4 tabs P0 prn
calcium carbonate (Turns -
)1-3 g P0 q2 h prn
calcium carbonate and magnesium hydroxide (Rolaids'
-) 2 4 tabsP0 q1h prn. max 12 tabs /d
Analgesics
DVT Prophylaxis
Anlidiarrheals
Laxatives
Sedatives
Antibiotics
Bacteroides
Over-the-Counter
Medications
r “t
c. J
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GS77 General and Thoracic Surgery Toronto Notes 202.1
Landmark General and Thoracic Surgery Trials
Trial Name Reference Clinical Trial Details
GROIN HERNIAS
Outcomes of
Laparoscopicvs.Open
Repair of Primary
Ventral Hernias
JAMA Surg 2013;148:1043-1048 Title:Outcomes of Laparoscopic vs.Open Repair of Primary VentralHernias
Purpose:To compare outcomes olpatients undergoing laparoscopic ventralhernia repair (LVHR) vs.open ventral hernia repair (OVHR).
Methods:Single centre,retrospective study of S32 consecutive patients who underwent an elective PVH repair.The outcomes of the LVHR
and OVHR were compared in terms of the primary outcomes olinterest SSI.hernia recurrence,and bulging.
Results:T9 patients with LVHR matched lo 79 patients with OVHR with mesh with a median follow-up of 56 mo.LVHR was associated with
fewer SSIs (7.6 o vs.34.1%) but mote cases of bulging (21.5% vs.1.3%) and port
-site hernia (2.5% vs.0.0%).No differences in recurrence
were observed.
Conclusions:LVHR isassociated with fewer SSIs bulmore clinical cases ol bulging and risk of developing a port-site hernia,compared to
OVHR.
ACUTE CHOLECYSTITIS
Title:laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis inhighrisk patients (CH0C0LA1E):
multicentrc randomised clinicaltrial
Purpose:To assess whether laparoscopic cholecystectomy issuperior to peicutaneous catheter drainage inhigh risk patients with acute
calculous cholecystitis.
Methods:142patients were randomiced to either the laparoscopic cholecystectomy group or to the percutaneous catheter drainage group.
Results:Although rate of death did not differ significantly between the laparoscopic cholecystectomy and percutaneous catheter drainage
group,the complication rate in the laparoscopic cholecystectomy was significantly lower than that of the percutaneous catheter drainage
(12% vs.65%).The drainage group compared to thecholecystectomy group required reintervention ata higher rate,had recurrent biliary
disease more frequently.and had longer lengths of stay.
Conclusions:Laparoscopic cholecystectomy comparedwith percutaneous catheter drainage reduced the rale of ma|or complications in high
risk patients with acutecholecystitis.
CHOCOLATE BMJ 2018:363:1(3965
BREAST CANCER
Title:10 Year Survival aftci Breast-Conserving Surgery Plus Radiotherapy Compared with Mastectomy in Early 8reast Cancer in The
Netherlands: A Population-Based Study
Purpose:To evaluate10 yr overall and bieasl cancer -specific survival after breast conserving surgery plus radiotherapy compared with
mastectomy in Dutch women withearly breast cancer.
Methods:Population study of women from the Netherlands Cancer Regisliy diagnosed with primary,invasive,stage 11-2,NO 1,MO breast
cancer,undergoingeither breast-conserving surgery plus radiotherapy or undergoing mastectomy.
Results:Breast-conserving surgery plus radiotherapy showedimproved10 yr overall and relative survival compared with mastectomy in
early breast cancer,but 10 yr distant metastasis-free survival was improved with breast-conserving surgery plus radiotherapy compared
with mastectomy in theUNO subgroup only,indicating a possible role of confounding by severity.
Conclusions:Breast-conserving surgery plus radiotherapy is al least equivalent to mastectomy with respect to suvrval and may influence
treatment decisions for patients.
10 Year Survival
alter Breast
Conserving Surgery
Plus Radiotherapy
Compared with
Mastectomy in Early
Breast Cancerin
The Netherlands:A
Population-Based
Study
lancet Oncol 2016;17(8):1158
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