Ce ee ee) APPLET ON & LANGE fia. REVIEW SURGERYREVIEW EVERYTHING YOU NEED TO SCORE HIGHER ON THE SURGERY SECTION OF THE USMLE STEP 2 SU ne ecu na aes eat Cae mC Cue Uc ney TCU UR Ue ec eRe esc uC cy eee ean eee meme cue eR eeu Dee Te uur aie) Oe Ue ae Re Re aii pe ee We Mea Cue eu kere The most time-effective and thorough way to prepare for the surgery shelf exam Emu eto * Learn more in less time See RU mT OC cue Ree aed De era OR aCe dl Sa RR eee ee ee ete See Cane cea Visit us at ——_— accessMedBook:fourth edition ES APPLETON & LANGE REVIEW OF SURGERY _ Simon Wapnick, MBChB, MD, FRCS(Eng), FACS Director of Postgeaduate Clinical Anatomy Courses Department of Cell Biology and Anaiomy New York Medical College Valhalla, New York C. Gene Cayten, MD, FACS, MPH Professor of Surgery New York Medical College Director of Surgery Our Lady of Merey Medical Center Bronx, New York Max Goldberg, MBBCh, MD, FRCSI, FACS Department of Surgery Long Beach Medical Center Long Beach, New York Nanakram Agarwal, MD, MPH, FACS Professor of Surgery New’ York Medical College Chief of Surgical ICU Our Lady of Mercy Medical Center Bronx, New York John A. Savino, MD Professor and Chairman Department of Surgery New York Medical College Valhalla, New York Appleton & Lange Reviews/McGi Medical P jing Division New York Chicago San Francisco Lisbon London Madrid) Mexico City Milan New Delhi Sun Juan Seoul Singapore Sydney Torunto.ern ees Appleton & Lange Review of Surgery, Fourth Edition Copyright © 2008 by The McGraw-Hill Companies, Inc. All rights reserved. Printed in the United States of Amer- ica, Except as permitted under the United States Copyri ght Actof 1976, no part of this publication may be repro- duced or distributed in any form or by any means, ors he publisher. red in a data base or retrieval system, without the prior svritten permission ol Copyright 1993 by Appleton & Copyright 1989 by Appleton & Lange, A Publishing Division of Prentice Hi Copyright 1981 by Arco Publishing, Ine xe, Simon & Schuster Business and Professional Group. iL 4567890 CUS/CUS 098765 ISBN O.07-1378146 Notice Medicine isan ever-changing science, As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required, The authors and the publisher of this work have checked with | sel to be reable it their efforts to provide information that is complete and generally sn accord |. ssith the stands cepted at the tine of publication, Hlscever, view ofthe possibityof human eror or | Changes m medical scents neither the authors nor the publisher aor anyother party who has Been involved in in with other sources. For example and in particular, readers are advised to check the product infor- | mation sheet included in the package of each drug they plan to administer to be certain that the information Contained in this work is accurate an that changes have not been made in the recommended dose or in the con traindlications for administration. This recommendation is of particular importance in connection with new or | intrequently used drugs. L _ This book was set in Palatine by Circle Graphics. The editors were Catherine A. Johnson, Janene M. Oransky and John M. Morriss The production supervisor was Lisa Mendez. The cover designer was Elizabeth Pisacrota and binder This book is printed on acie-free paper. Von Hoffmann Graphics was printe Library of Congress Cataloging-in-Publication Data cton & Lange review of surgery / Simon Wapnick. fetal |—4th ed. poem ISBN 0417-17816 (alk. paper) 1. Surgery—Esaminations, questions, et. Title: Appleton and Lange review of surgery. Il Tithe: Review of surgery. IIL Wapnick, Simon. RD37.2.W37 2008 617/007 —de2t ‘2002067173,Contents Contributors : . v Preface vii Introduction x 1. Trauma : 1 C. Gene Cayten, Kenneth A. Falvo, and Rao R. loatury Answers and Explanations . 20 2. Shock and Homeostasis 31 Nanakram Agarcoal Answers and Explanations , 46 3. Stomach, Duodenum, and Esophagus 59 Max Goldberg, Simon Wapnick, and Jolin Savina Answers and Explanations : %6 4. Small and Large Intestines and Appendix 97 icholas A. Balsamo, Rao R. Featury, and C. Gene Cayten Answers and Explanations . . 102 5. Pancreas, Biliary Tract, Liver, and Spleen mt Khawaja Azinuddin and C. Gene Cayten Answers and Explanations 128, 6. Cardiac and Vascular 3 Zahi E. Nassoura, Mayank Patel, and Simon Wapnick Answers and Explanations 7. Hernia and Breast Andrew Ashikari and Max Gi Answers and Explanations dberg 8, Male and Female Genitourinary Systems Scott 1. Zeitlist, Haroon Durrani, and Simon Wapmick Answers and Explanations 204 9. Thorax, Head, and Neck m Alan Berkowwer, Jarostacw Bilaniuk, and Simon Wapnick Answers and Explanations 226fv Contents 10. Neurosurgery fo A. TorresCiluck and Viran Huynh Hillard Answers and Explanations 11, Surgical Endocrinology, Skin, and Wound Healing .. C. Gene Cayten, Haroon Ducrani, and Sioront Wapnick Answers and Explanations 12, Practice Test Jaros Bilanind, C. Gente Cayton, and Sinton Wapnick Answers and ExplanationsContributors Nanakram Agarwal, MD, MPH, FACS. Professor of Surgery New York Medical College Chief of Surgical Intensive Care Unit Our Lady of Mery Medical Center Bronx, New York Andrew Ashikari, MD Assistant Professor of Surgery New York Medieal College Our Lady of Mercy Medical Center Bronx, New York Khawaja Azimuddin, MD, FACS Assistant Clinical Professor of Surgery University of New Mexico Espanola, New Mexico, Nicholas A. Balsano, MD Clinical Associate Professor of Surgery New York Medical College Chief of Vascular Surgery Our Lady of Merey Medical Center Bronx, New York Alan Berkower, MD, PhD Assistant Professor of Otorhinolaryngology New York Medical College Chief of Otolaryngology Our Lady of Merey Medical Center Bronx, New York Jaroslaw Bilaniuk, MD Assistant Professor of Surgery New York Medical College Valhalla, New York C. Gene Cayten, MD, FACS, MPH Professor of Surgery New York Medical College Director of Surgery Our Lady of Mercy Medical Center Bronx, New York Haroon H. Durrani Department of Radiology New York Medical College Westchester Medical Center Valhalla, New York Kenneth A. Falvo, MD, FAAOS Department of Surgery Our Lady of Mercy Medical Center Bronx, New York Max Goldberg, MBBCh, MD, FRCSI, FACS Professor of Surgery New York Medical College Valhalla, New York Department of Surg Long Beach Medical Center Long Beach, New York Virany Huynh Hillard, MD Department of Neurosurgery New York Medical College Valhalla, New York Rao R. Ivatury, MD, FACS Professor of Surgery Director, Trauma /Critical Care Surgery Medical College of Virginia Virginia Commonwealth University Richmond, Virginiavi Contmbiors Zahi E. Nassoura, MD, FACS San Fernando Valley Vascular Group Tarzana, California Mayank Patel, MD Department of Surgery Our Lady of Mercy Medical Center Bronx, New York John A. Savino, MD Professor and Chairman Department of Surgery New York Medical College Valhalla, New York Jose A. Torres-Gluck, MD Department of Neurosurgery Our Lady of Merey Medica Bronx, New York Center Simon Wapnick, MBChB, MD, FRCS(Eng), FACS Director Postgraduate Clinical Anatomy Courses Department of Cell Biology and Anatomy New York Medical College Valhalla, New York Scott I. Zeitlin, MD, FACS, Assistant Professor Surgery Department of Urology University of California, Los Angeles Los Angeles, C:Preface ‘The popularity of the previous editions of Appleton & Lange Review of Surgery has encouraged this revised fourth edition, The questions have been selected from the most current pertinent topics, facets, and. principles of the wide range of general surgery and its specialities. ‘The main format of question presentation has been changed to coincide with that recommended by the USMLE guidelines, The material is presented in the form of clinical cases with appropriate answers to mirror the focus of the USMLE Step 2, Appleton & Lange Review of Surgery, Fourth Edition, will also help equip and familiarize students preparing for the Sur- gery Miniboard Examinations. Surgical residents have found both the questions and the annotated answers useful in preparation for various inservice examinations leading to the qualifying and certify- ing exams of the American Board of Surgery and equivalent examinations in other parts of the world ‘Surgeons in practice and those preparing for recerti- fication in their specialty have found this book to be useful addendum to their armamentarium of sur- gical knowledge, ‘The types of questions have been arranged into two major groupings: one best answer (usually out of four to five possible answers) and the selection of one ‘or more possible answers (choose N) froma given list ‘of seven of more items. These question types are ex- plained further in the introduction, The questions are divided into 11 chapters not including the practice test. The reader is encouraged to tackle each chapter in full before referring to the corresponding answer section, Fach question should be completed in less than 1 minute, When correcting a chapter, the reader should review the answer and refer back to the question to consolidate knowledge gained during test preparation. Incorrect answers should be reviewed and attempted at a later date. If you have any comments as to the contents o useful- ness of this book, e-mail simon_wapnick@nymc.edu ACKNOWLEDGMENTS We would like to thank Professor Terence A. 5. Matalon, Chairman and Professor of Radiology New York Medical College and Westchester Med- ical Center, for permission to use the numerous radiological images included. Dr. H. Durrani par- ticipated in the preparation of these radiographs. Isabelle Wapnick made valuable contributions to editing this bookIntroduction This book has been designed to help you review surgery for both examination and patient manage- ment, Here in one package is a comprehensive re- view with over 1,000 multiple-choice questions with paragraph-length discussions of each answer. The whole book has been designed to help you assess your areas of relative strength and weakness. Appleton & Lange Review of Surgery is divided into [2 chapters, Eleven chapters provide a review of the major areas of surgery. The last chapter, a Prac- tice Test, integrates diverse specialities into one sim- ulated examination. This introduction provides information on ques tion types, question-taking strategies, various ways you can use this book, and specific information on the SMLE Step 2. QUESTIONS The USMLE Step 2 now contains only two different types of questions. In general, most of these are “one-bestanswer-single-item” questions; whereas, the remainder require selection of a stated number of answers from a list of seven or more items (choose N), “Multiple true-false item” and “com- parison-matching set” questions have been ex- ixied!, Questions that are negatively phrased! (“AI of the following are correct EXCEPT. ..”) have bee sposed of im accordance with current USMLE ws. In some cases (in both types of ques- guid tions), a group of two or three questions may be related 10 a situational theme. Certain questions have illustrative material (diagrams and x-rays) that require understanding and interpretation on your part, Some illustrations, however, are in cluded mainly for their instructive value in clinical ical practice. Questions are stratified into three levels of diff culty: (a) role memory questions; (b) memory que tions that require more understandingof the question; and (¢) questions that require understanding. and jusdgment, Because the NBME and other examination bodies are moving away from the rote memory ques- tions, we have tried to emphasize judgment cases throughout this text One-Best-Answer-Single-Item Question This type of question presents a problem or asks a question and is followed by five or more choices, only one of which is entirely correct. The directions preceding this type of question will generally appear as follows DIRECTIONS: (Questions 1 through 82): Each of the numbered items or incomplete statements in this section is followed by answers or by comple- tions of the statements. Select the ONE lettered answer or completion that is BEST in each case. An example for this item type follows: 1. Anobese 21-year-old woman reports increasest growth of coarse hair on her lip, chin, chest, and abdomen. She also notes menstrual irregular- ity, with periods of amenorrhea. What is the most likely cause is? (A) polycystic ovary disease (B) an ovarian tumor (C) anadrenal tumor (DC s disease In this type of question, choices other than the correct answer may be partially correct, but there canXx telrodvction only be one best answer. In the question above the key word is “most.” Although ovarian tumors, adrenal tumors, and Cushing's disease are causes of tism (described in the stem of the question), polycystie ovary disease isa much more common cause. Famil- ial hirsutism is not associated with the menstrual irregularities mentioned. Thus, the most likely cause of the manifestations described can only be “(A) polycystic ovary disease.” ase. ‘TABLE 1, STRATEGIES FOR ANSWERING ONE-BEST- ANSWER-SINGLE-TEM QUESTIONS" 41, Remember that only one choice can be the correct answer. 2, Road the question caretuly 1 be sure that you understand wnat is being asked, 3. Quickly read each choice for famlanty (This important step is often not done by test takers.) Go back and consider each choce indidually, ta choice is parialy coroct,tentawely consider itto be Inconcet. (This stop wil help you lessen your choices and ‘norease your odds of choosing the correct answer.) 6. Consider the remaining choices and select the one you tink is the answer Al ths pont, you may wanl to quickly sean te stem tobe sure you understand the question ang your answer. 7. Select the appropriate answer. (Even if you donot know the answer, you should at least guess. Your score fs based onthe rhumiber of corce: answers, 59 do not skip any questions.) * Note that stops 2 through 7 should take an average of 50sec: fonds total. The actual examination is timed for an average of One (or More)-Best-Answer-Matching-Set Questions These questions are usually accompanied by the fol- lowing general directions. DIRECTIONS: (Questions 83 through 100): Each set of matching questions in this section consists of a list of lettered options followed by several num- bered items. For each numbered item, select the appropriate lettered options(s). Each lettered option may be selected once, more than once, or not at all. EACH ITEM WILL STATE THE NUMBER OF. OPTIONS TO SELECT. SELECT EXACTLY THIS, NUMBER. An example for this item type iss Questions 83 through 84 In each condition listed, select the most appropriate (A) tetracycline (B) chloramphenicol (©) clindamycin (D) ceftriaxone and doxycycline (E) penicillin (F) metronidazole (G) ciprofloxacin (H) chloroquine (D fluconazole 83. Bone marrow suppression. SELECT ONLY ONE, Answer. (B) 84. A 34-year-old woman complains of lower abdo- minal pain and vaginal discharge due to gonor- thea, SELECT ONLY THREE. Answer. (D), (E), (G). Each one of THE THREE DIF- FERENT choices would be appropriate treatment of this condition. TABLE 2, STRATEGIES FOR ANSWERING ONE (OR MORE)-BEST-ANSWER-MATCHING-SET QUESTIONS" 1, Remember that the leteree cnoices are followed by the num: ‘bored questions. 2. Apply steps 2 through 7in Table 1 but select EXACTLY ONLY (ONE, TWO, THREE (OR MORE) ANSWER(S) as slated. = lemember, you only have an average of 60 seconds per question. ANSWERS, EXPLANATIONS, AND REFERENCES In each of the sections of Appleton & Lange Review of Surgery, Fourth Edition, the question sections are fol- lowed by a section containing the answers and ex- planations for the questions. This section: (a) tells you the answer to each question; and (b) gives you an explanation and review of why the answer is cor- rect, background information on the subject matter, and/or why the other answers are incorrect, We en- courage you to use this section as a basis for further study and understanding, If you choose the correct answer to a question, you can then read the explanation: (a) for reinforce- ment; and (b) to add to your knowledge about the subject matter. If you choose the wrong answer toa question, you can read the explanation for an instructional review of the material in the question. PRACTICE TEST The 98-question Practice Test at the end of the book covers and reviews all the topics covered in Chap- ters 1 through 11, The questions are integrated ac- cording to question type (one-best-answer-single item, one (or more)-best-answer-matching sets.) HOW TO USE THIS BOOK There are two logical ways to get the most value from this book. We call them Plan A and Plan B. In Plan A, you go straight to the Practice Test and complete it. Analyze your areas of strength and weakness. This will be a good indicator of your ini- tial knowledge of the subject and will help to iden- tify specific areas for preparation and review. You ‘can now use the first [1 chapters of the book to help. you improve your relative weak points, In Plan B, you go through Chapters 1 through 11 checking off your answers, and then comparing your choices with the answers and discussions in the book. Once you have completed this process, you can take the Practice Test and see how well prepared ‘you are, If you still have a major weakness, it should be apparent in time for you to take remedial action. In Plan A, by taking the Practice Test first, you get quick feedback regarding your initial areas of strength and weakness. You may find that you have a good command of the material, indicating that per- haps only a cursory review of the first 11 chapters is necessary. This, of course, would be good to know early in your examination preparation, On the other hand, you may find that you have many areas of weakness, In this case, you could focuson these areas in your review-not just with this book, but also with textbooks. However, it is unlikely that you will not do some studying before taking the USMLE (especially because you have this book). Therefore, it may be more realistic to take the Practice Test after you have Introduction x reviewed the first 11 chapters (as in Plan B). This will probably give you a more realistic type of testing sit- uation, because very few of us sit down to a test without study. In this case, you will have done some reviewing (from superficial to in-depth), and your Practice Test will reflect this study time. If, after ro~ viewing the first 11 chapters and then taking the Practice Test, you still have some weaknesses, you can then go back through chapters | through 11 and supplement your review with your texts. ‘SPECIFIC INFORMATION ON THE STEP 2 EXAMINATION The official source of all information with respect to the USMLE is the National Board of Medical Exam- iners (NBME), 3750 Market Street, Philadelphia, PA 19104. Established in 1915, the NBME isa voluntary, nonprofit, independent organization whose sole function is the design, implementation, distribution, and processing of a vast bank of question items, cer tifying examinations, and evaluative services in the professional medical field. To be eligible to sit for the USMLE Step 2, a per- son mustbe either officially enrolled in or a graduate ofa USor Canadian medical school accredited by the LCME; officially enrolled in or a graduate of a US osteopathic medical school accredited by the AOA; or officially enrolled in or a graduate of a foreign medical school and eligible for examination by the ECFMG for its certificate. It is not necessary to con plete any particular year of medical school in order to be a candidate for Step 2; neither is it required to take Step 1 before Step 2. SCORING Because there is no penalty for guessing, you should answer every question. Do not skip any questions. Each question answered correctly counts as one point, and partial credit may be given to partially correct answers. Information on the USMLE is posted on the NBME's web page, www.usmle.org.CHAPTER 1 Trauma Questions C. Gene Cayten, Kenneth A. Falvo, and Rao R. Ivatury DIRECTIONS (Questions 1 through 85): Each of, the numbered items or incomplete statements in this secti is followed by answers or by comple- tions of the statement. Select the ONE lettered answer or completion that is BEST in each case. \ 40-year-old man is involved in a car crash, presenting with blood pressure of 80 mmHg The patient is found to have subdural hema- toma and a supracondylar fracture of the left femur, He is taken to the operating room, where intra-abdominal bleeding is controlled, and the subdural hematoma is drained. The femur frac- ture (Figure 1-1) should be treated by which of the following? Figure 1-1. Comminuted fracture o the distal femur. (Reproduced. ssh permission tom Way. LW: Current Surgical Diagnosis & Treatment, T0th ed, Appleton & Lange, 1994.) (A) long leg cast (B) Steinmann pin insertion and traction (C) operative reduction and internal reduction (D) aspiration of knee joint (F) operative reduction with internal fixation An 18-year-old man is brought to the emer- gency department with a stab wound just to the right of the sternum in the sixth inter- costal space. His blood pressure is 80 mmHg, Faint heart sounds and pulsus paradoxus are noted. Auscultation of the right chest reveals decreased breath sounds. The initial manage- ‘ment of this patient should be which of the following? (A) aspiration of the right chest cavity (B) aspiration of the pericardium (C) echocardiogram (D) pericardial window (E) insertion of central venous access line A 60-year-old woman runs her car off the road and it hits a telephone pole. She presents to the emergency department with severe ante riorchest pain and a blood pressure of 110/80. A chest x-ray shows a questionably widened mediastinum. The next step in management should be which of the following? (A) transthoracic echocardiogram (B) pericardiocentesis, (©) aortogram (D) central venous access line (E) computed tomography (CT) of chest2 Fe Teauma An 18-year-old man presents to the emergenc department with a gunshot wound to the left chest in the anterior axillary line in the seventh intercostal space. A rushing sound is audible during inspiration. Immediate management is which of the following? (A) exploratory laparotomy (B) exploratory thoracotomy (©) pleurocentesis (D) closure of the hole with sterile dressing {E) insertion of chest tube A 25-year-old man is shot in the left lateral chest. In the emergency department, his blood pressure is 120/90, his pulse rate is 104 bpm, and his respiration rate is 36 breaths per minute. Chest s-ray shows air and fluid in the left. pleural cavity. Nasogastrie aspiration reveals blood-stained fluid. What is the best step to rule out esophageal injury? (A) insertion of chest tube (B) insertion of nasogastric tube (©) esophagogram with gastrografin {D) esophagoscopy (E) peritoneal lavage A 32-year-old female falls from the 10th floor of her apartment building in an apparent suicide atlempt. Upon presentation, the patient has obvious head and extremity injuries, Primary survey reveals that the patient is totally apneic. By which method is the immediate need for a definitive airway in this patient best provided? (A) orotracheal intubation (B) nasotracheal intubation (C) percutaneous cricothyroidotomy (D) intubation over a bronchoscope (E) nevile ericothyroidotomy A 17-year-old girl presents to the emergency department with a stab wound to the abdomen and a blow to the head that left her groggy. Her blood pressure is 80/0, her pulse is 120 bpm, and her respiration rate is28. Her abdomen has stab wound in the anterior axillary Tine at the right costal margin. Two large-bore intra- “ogastrie tube, and a Foley 9. 10. catheter are inserted. The blood pressure rises to 85 mmHg after 2 L. of Ringer's lactate. The appropriate management is which of the fol- lowing? (A) peritoneal lavage (8) ultrasound of the abdomen (©) laparoscopic assessment of the peritoneal cavity (D) exploratory laparotomy (E) CT of the head A 22-year-old woman presents to the emer gency department with a chief complaint of severe left upper quadrant (LUQ) pain after being punched by her husband. Her blood pressure is 110/70, her pulse is 100 bpm, and her respiration rate is 24 breaths per minute. ‘The best means to establish a diagnosis is which of the following? (A) four-quadrant tap of the abdomen {B) physical examination (©) CTof the abdomen (D) peritoneal lavage (E) upper gastrointestinal (Gl) series A 60-year-old man is attacked with a baseball bat and sustains multiple blows to the abdo- men. He presents to the emergency depart- ‘ment in shock and is brought to the operating, room (OR), where a laparotomy reveals mas- sive hemoperitoneum and a stellate fracture of the right and left lobes of the liver. Which of the following techniques should be used immediately? (A) Pringle maneuver (B) packing the liver (C) suture ligation (D) ligation of the right hepatic artery (£) ligation of the proper hepatic artery A L2year-old girl presents to the emergency department following a skiing crash in which the left side of her midtorso hit a tree. She presents with left side lower chest and upper abdominal pain. She also complains of left shoulder pain. The most likely diagnosis is which of the following?nL. 2, 13. (A) rib fractures (6) Ii {C) ruptured diaphragm (D) splenic injury (E) ruptured stomach er injury 23-year-old man is shot with a handgun and found to have a through-and-through injury to the right transverse colon. There is little fe- cal contamination and no bowel devascular- ization. At operation, what does he require? (A) right hemicolectomy with ileotransverse colon anastomosis {B) right hemicolectomy with ileostomy and mucous fistula (C) debridement and closure of wounds with exteriorization of colon (D) debridement and closure of wounds (B) segmental resection with primary anastomosis, A 20-year-old woman presents to the emer- gency department with a stab wound to the abdomen. There is minimal abdominal tender- ress. Local wound exploration indicates that the knife penetrated the peritoneum. What is the ideal use of antibiotic administration? (A) preoperatively (B) intraoperatively, ifa colon injury is found (©) postoperatively, if the patient develops fever (D) postoperatively, based on culture and sensitivity of fecal contamination found at the time of surgery (F) intraoperatively, if any hollow viscus found to be injured A 70-year-old woman is hit by a car and injures her midabelomen. The best way to rule out a rupture of the second part of the duode- hum is by which mode? (A) repeated phys (B) ultrasound al examinations, (© repeated amylase levels (D) CT with oral and intravenous contrast {B) peritoneal lavage 1. 15, 16, 17. Questions: 4-17__3 Questions 14 and 15 35-year-old woman was punched in the right side of the abdomen and chest, There was some right upper abdomen tenderness but no guard- ing or rebound, Results of a gastrografin upper Glstudy showed a coiled-spring (stack of coins) appearance of the second and third part of the duodenum. What is the most likely diagnosis? (A) rupture of the duodenum (B) contusion to the head of the pancreas (©) intraluminal blood clot {D) retroperitoneal hematoma (F) duodenal hematoma Which would be the appropriate management of the patient described above? (A) exploratory laparotomy and drainage (B) duodenal diverticularization. (© pyloric exclusion {D) repeat upper GI seri intervals (F) CT-guided percutaneous drainage at to 7-day A.15-year-old girl had an injury to the right re- troperitoneum with duodenal contusion. What is the test required to exclude a rupture of the duodenum? (A) serum amylase {B) dimethyliminodiacetic acid (HIDA) sean (©) gastrografin study (D) intravenous pyelogram (IVP) (F) endoscopic retrograde cholangiopancre- atogram (ERCP) A 33-year-old man presents to the emergency department with a gunshot injury to the ab- domen. At laparotomy, a deep laceration is found in the pancreas just to the left of the ver~ tebral column with severance of the pancreatic duct, What is the next step in management? (A) intraoperative cholangiogram (B) debridement and drainage of defect (© distal pancreatectomy {D) closure of abdomen (F) vagotomy