Documente Academic
Documente Profesional
Documente Cultură
DEPARTMENT OF SURGERY
By
MATTHEW J. DELANO
1
ACKNOWLEDGMENTS
RICHARD E. DEAN, M.D.
JOHN ARMSTRONG, M.D.
GEORGE SAROSI, M.D.
KEVIN BEHRNS, M.D.
MICHAEL E. MAHLIA, M.D.
WILLIAM CANCE, M.D.
LYLE L. MOLDAWER, Ph.D.
TABLE OF CONTENTS
Page
ACKNOWLEDGMENTS ...............................................................................................................4
CHAPTER
1
Diagnostic Test for Symptomatic Gall Bladder Disease Without Stones Biliary
Dyskinesia ....................................................................................................................34
Segmental Anatomy of the Liver ....................................................................................35
Best Test of Hepatic Biosynthesis ...................................................................................36
Hepatic Acute Phase Response .......................................................................................37
Venous Tributaries of the Portal System .........................................................................38
Susceptibility to Hepatoma (Hepatocellular Carcinoma) ................................................39
Principles Associated with Chemo Embolization of Liver Metastases ...........................40
Location of Anomalous Hepatic Arteries ........................................................................41
Anatomy of Aberrant Right Hepatic Artery ....................................................................42
Prognostic Test of Liver Function Reserve .....................................................................43
Preoperative Treatment of Obstructive Jaundice ............................................................44
Etiology of a Sudden Increase in End Tidal CO2 After Evacuating CO2 in a
Laparoscopic Cholecystectomy Procedure ..................................................................45
Findings Associated with the Hepatorenal Syndrome.....................................................46
Anatomy of Common Bile Duct......................................................................................47
Characteristics Hepatocytes.............................................................................................48
Bile Acid Synthesis .........................................................................................................49
Characteristics of Chylomicrons .....................................................................................50
Biliary Tract Bacteria ......................................................................................................51
Preoperative Measure of Portal Venous Pressure ...........................................................52
Best Test of Hepatic Biosynthesis ...................................................................................53
Abnormal Liver Function Test in Metastatic Colon Cancer ...........................................54
Hepatocellular Cancer in Chronic Hepatitis B (Complications Hepatitis B) ..................55
Pathophysiology of Ascites in Alcohol Cirrhosis ...........................................................56
Basis for Chemoemboliztion of Hepatic Metastases .......................................................57
Etiology of Liver Failure/Diagnosis of Ligation of Hepatic Artery (Unintended
Hepatic Artery Ligation at Operation) .........................................................................58
CHAPTER 1
COURSE DESCRIPTION AND SYLLABUS: BASIC SCIENCE 101
Goals:
1. Understand the historical significance and current purpose of the ABSITE.
2. Understand and comprehend the five fundamental areas of surgery related basic science
knowledge that the ABSITE test.
3. Improve individual ABSITE scores by 10-20%.
4. Promote personal lifelong habits of scientific surgical learning and self education.
Basic Science 101 will focus on building and reinforcing the fundamentals of surgical basic
science knowledge which will serve as a foundation for further clinical and operative knowledge
growth and ABSITE success.
Audience
All categorical and preliminary surgical residents (PGY-1 - PGY-7+)
Review Session Time/Location:
Dates:
Sun. December 7, 2008
Sun. December 14, 2008
Sun. December 21, 2008
Sun. January 4, 2009
Sun. January 11, 2009
Sun. January 18, 2009
Sun. January 25, 2009
Behrns Residence:
Assessment:
1. Course attendance and participation
2. Individual accountability: Pre-course test score, Post-course test score, ABSITE Score
3. Team accountability: Jeopardy Champion
Expectations:
1. Take an on-line learning styles inventory at: http://www.engr.ncsu.edu/learningstyles/ilsweb.html.
2. Attend each review session.
3. Review ABSITE appropriate surgery related basic science for each group session.
4. Be prepared to answer basic science questions during each session.
5. Take pre-course test and post-course test, take the ABSITE.
Course Directors:
Matthew J. Delano, M.D., Ph.D., delanmj@surgery.ufl.edu
cell: 352-514-9451
John H. Armstrong, M.D., F.A.C.S., john.armstrong@surgery.ufl.edu
office: 273-5675, pager: 413-5666, cell: 786-255-4820
George Sarosi, M.D., george.sarosi@surgery.ufl.edu
Course Schedule:
Review Session Date:
December 7, 2008
December 14, 2008
December 21, 2008
January 4, 2009
January 11, 2009
January 18, 2009
January 25, 2009
Topics to be covered:
Course materials:
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Chapter 9
BODY AS A WHOLE
BODY AS A WHOLE
BODY AS A WHOLE
GASTROINTESTINAL TRACT
GASTROINTESTINAL TRACT
CARDIOVASCULAR AND PULMONARY
GU, HEAD AND NECK, SKIN,
MUSCULOSKELETAL, NERVOUS, ENDOCRINE,
HEMATIC AND LYMPHATIC SYSTEMS AND
BREAST
The course is broken down by basic science knowledge category as tested by the
ABSITE. The course material has been concentrated, fermented, and distilled from the past ten
years worth of Michigan State Integrated ABSITE Reviews, by Richard E. Dean. These are not
my topics of interest rather the topics that appear yearly on the ABSITE. Each review session
will concentrate on the information and topics as related in the chapters as listed above from the
aforementioned compiled source. Each chapter contains relevant basic science questions with
answers at the end that frequently appear on the ABSITE in some form from year to year. Use
these to test your knowledge and guide your studies.
Each individual is expected to have covered the relevant information prior to each review
session just as each individual is expected to review the pertinent details of a general surgery
case prior to entering the operating room. No Exceptions.
At the review sessions the information presented in this text will not be covered in a
didactic nauseating fashion allowing you to irresponsibly coast, sleep, hide, flail, flake and slide
away from excellence, rather you will be asked questions directly from the course content
presented here and your answers will immediately impact you, and more importantly your team
members. The team that answers the most questions correct over the seven review sessions will
be the intellectual winner and will also receive a substantial
prize to be decided.
Jeopardy Teams:
Team Dragstedt:
Team Woodward:
Team Copeland
Bo Neichoy, M.D.
Reference Material:
The Physiologic Basis of Surgery. 3rd Ed. by J. Patrick OLeary, 2002, Lippincott Wiliams &
Wilkins, ISBN 0-7817-3839-3.
Sabiston Textbook of Surgery: The Biloigical Basis of Modern Surgical Practice. 17th Ed. by
Courney M. Townsend Jr, R. Daniel Beauchamp, B. Mark Evers, Kenneth L. Mattox, 2004,
Elsevier Saunders, ISBN 0-7216-0409-9
9
CHAPTER 2
AMERICAN BOARD OF SURGERY IN-SERVICE TRAINING EXAM (ABSITE)
Introduction
The American Board of Surgery offers annually to surgery residency programs the In-Training
Examination (ABSITE), a written, multiple-choice examination designed to measure the
progress attained by residents in their knowledge of basic science and the management of clinical
problems related to general surgery. The ABSITE is furnished to program directors as an
evaluation instrument to assess residents' progress. The results are released only to program
directors. It is not available to individual residents and is not required as part of the certification
process.
Reporting of Results
ABSITE results are made available to program directors in early March. The ABS provides
program directors with various reports, including a resident's individual score report. Residents
are strongly encouraged to keep copies of their score report for their records, as the ABS does
not retain this information. The ABS will not provide residents with a score report or
"transcript." Residents who request this information will be directed to contact their general
surgery residency program.
If you have questions once you have received your individual score report, your program director
can help with the interpretation of the results. The ABS will not discuss examination results with
residents. The ABS also will not regenerate any report as a result of miscoding of information,
such as PGY level, name, etc. Any inquiries regarding the ABSITE must come directly from the
program.
Examination Content
Since 2006 the ABS offers the ABSITE as a junior level (PG-1 and -2) and senior level (PG-3 to
-5) examination. Both the junior- and senior-level versions consist of 225 multiple-choice
questions; examinees are given five hours to take the exam. For the junior-level exam, 60% of
the examination focuses on basic science, while 40% centers on the management of clinical
surgical problems. In the senior-level exam, 20% of the exam focuses on basic science and 80%
on clinical management. The relative emphasis on clinical content categories in the two
examinations is shown in the following tables.
Table 1. Junior and Senior ABSITE basic science and clinical medicine breakdown.
Basic Science
Clinical Medicine
Total
Junior ABSITE
Senior ABSITE
% (# questions)
% (# questions)
60% (135)
40% (90)
100%(225)
20% (45)
80%(180)
100%(225)
10
Knowledge Category
Junior ABSITE
Senior ABSITE
% of Test
% of Test
66.60%
10%
7.80%
25%
25%
16.70%
7.80%
16.70%
7.80%
16.7
BODY AS A WHOLE
GASTROINTESTINAL TRACT
CARDIOVASCULAR AND PULMONARY SYSTEMS
GU, HEAD AND NECK, SKIN, MUSCULOSKELETAL, AND
NERVOUS SYSTEMS
ENDOCRINE, HEMATOLOGIC, AND LYMPHATIC
SYSTEMS , AND BREAST
Table 3. Junior and Senior ABSITE basic science and clinical medicine breakdown by
knowledge category.
Knowledge Category
BODY AS A WHOLE
GASTROINTESTINAL TRACT
CARDIOVASCULAR AND PULMONARY SYSTEMS
GU, HEAD AND NECK, SKIN, MUSCULOSKELETAL,
AND NERVOUS SYSTEMS
ENDOCRINE, HEMATOLOGIC, AND LYMPHATIC
SYSTEMS , AND BREAST
Junior ABSITE
# questions
Senior ABSITE
# questions
Basic Science
Clinical Medicine
Basic Science
Clinical Medicine
Basic Science
Clinical Medicine
90
60
15
9
11
6
10
45
10
45
8
30
Basic Science
11
Clinical Medicine
30
Basic Science
11
Clinical Medicine
30
11
NUMBER OF QUESTIONS
47
57
29
9
25
7
11
7
14
7
As you can see the Junior ABSITE is over 60% basic science while the Senior ABSITE is
predominantly clinical medicine.
12
CHAPTER 7
GASTROINTESTINAL TRACT: SESSION 5
Colon/Rectum
Preferred Energy Source Colonocyte
Short-chain fatty acids (SCFAs) are produced in the colon by fermentation of dietary fiber by
colonic bacteria. The major SCFAs produced are acetate, propionate, and butyrate. Butyrate is
the major source of fuel for the colonic epithelial cells. Substrates are metabolized by the
colonic mucosa in the order of butyrate>glucose>ketone bodies>glutamine. A lack of butyrate
has been shown to result in colonic inflammation as seen in diversion colitis. Butyrate enemas
have been used satisfactorily as a treatment for this.
It has been hypothesized that impaired metabolism of butyrate may be present in the colonocytes
of patients with ulcerative colitis (UC). Use of SCFA enemas in the treatment of UC patients has
been promising in early studies.
Roedinger WE. Utilization of nutrients by isolated epithelial cells of rate colon,
Gastroenterology 83:424-9
Ahmad MS, et al. Butyrate and glucose metabolism by colonocytes in experimental colitis in
mice, Gut 46:493-9
Simpson EJ, et al. In vivo measurement of colonic butyrate metabolism in patients with
quiescent ulcerative colitis, Gut 46:73-7
13
14
Colon Bacteria
As opposed to disease-causing bacteria in the small intestine, in which adherence is an important
property, the long transit time in the colon makes adherence a much less important attribute.
Anaerobes are favored 1000:1 versus aerobes in the colon.
The bacterial density increases as one moves down the colon. A perforated appendix contains
about 106 to 107 bacteria per gram of content. Sigmoid colon contains 1010 to 1011 bacteria per
gram of content. The most common components of fecal flora are listed below. One should note
that there are no pathogenic species among the most common 25 organisms.
Relative Frequency of Bacterial
Species in Fecal Flora
Rank
Percent
Organism(s)
1
2
3
4
5
6
7
8
9
10
11
28
29
59-75
76-113
12
7
6.5
6
6
4.5
3.6
3.3
3.2
2.5
2.3
0.7
0.6
0.13
0.06
Bacteroides vulgatus
Fusobacterium prausnitzii
Bifidobacterium adolescentis
Eubacterium aerofaciens
Peptostreptococcus productus II
Bacteroides thetaiotaomicron
Eubacterium eligens
Peptostreptococcus productus I
Eubacterium biforme
E. aerofaciens III
Bacteroides distasonis
B. ovatus
B. fragilis
Streptococcus faecalis
Escherichia coli, Klebsiella
pneumonia
and 37 other bacterial species
15
16
Spleen
Diagnosis/Treatment for Immune Thrombocytopenic Purpura (ITP)
Idiopathic thrombocytopenic purpura (immune thrombocytopenic purpura ITP)) is an acquired
disorder caused by the destruction of platelets exposed to circulating IgG antiplatelet factors.
The spleen is the source of these factors. It is also the major site for sequestering sensitized
platelets. The term ITP should be reserved for a hemorrhagic disorder characterized by a
subnormal platelet count in the presence of bone marrow containing normal or increased
megakaryocytes and in the absence of any systemic disease or history of ingestion of drugs
capable of inducing thrombocytopenia. Female patients outnumber males at a ratio of 3:1.
Platelet counts are generally reduced to 50,000 or less and at times approach zero. Acute ITP
has an excellent prognosis in children under the age of sixteen. Approximately 80% of these will
recover completely without specific therapy.
The generally accepted protocol for managing patients with diagnosed ITP includes an initial 6week to 2-month period of steroid therapy. If the patient does not respond, splenectomy is
performed. If the patient does respond, the steroid therapy is tapered off, and if
thrombocytopenia recurs, splenectomy is carried out. Any manifestations suggestive of
intracranial bleeding demand emergency splenectomy. In one series, 5 of 6 patients with ITP
and life-threatening intracranial bleeding were saved by splenectomy. Platelets should be
available for the procedure but should only be administered in patients who continue bleeding
following removal of the spleen.
Occasionally, the disease recurs and patients achieve permanent cure following removal of an
accessory spleen. Approximately 20% of patients have an accessory spleen. Common sites are
the splenic hilus, adjacent to the splenic vessels and tail of the pancreas, greater omentum, and
gastrosplenic and gastrocolic ligaments. A Technetium scan may be useful in identifying the
accessory spleen.
In most series, the results by splenectomy are significantly more impressive than are the results
from steroids. Approximately 80% of the patients treated with splenectomy respond
permanently and require no further steroid therapy. In most patients, the platelet count rises to
over 100,000/mm3 in 7 days.
Schwartz, Principles of Surgery, 6th Edition
OLeary, Physiologic Basis of Surgery, 2nd Edition
Sabiston, Textbook of Surgery, 15th Edition, p 1196
17
18
19
20
Pancreas
Arterial Supply to the Head of the Pancreas
The blood supply to the head of the pancreas is largely from the anterior and posterior
pancreaticoduodenal arcades. The anterior superior and posterior superior pancreaticoduodenal
arteries arise from the gastroduodenal artery, a branch of the hepatic artery. The superior
mesenteric artery gives rise to the inferior anterior and posterior pancreaticoduodenal arteries to
complete the two arcades. These vessels provide the blood supply to the head of the pancreas
and duodenum.
Hollinshead, Anatomy for Surgeons, 2nd Edition, Vol. 2, pp 418, 430
21
Amylolytic amylase
Lipase and amylase are secreted in their active forms. The proteolytic enzymes and
phospholipase A2 are secreted as inactive zymogens. Activation of trypsinogen to trypsin
occurs when the zymogen is exposed to the duodenal enzyme enterokinase. Trypsin then
converts the other zymogens to their active forms. In the intestine, the proteolytic enzymes
digest proteins into peptides, lipase breaks fats into glycerol and fatty acids, phospholipase A2
catalyzes the conversion of biliary lecithin to lysolecithin, and amylase converts starch to
disaccharides and dextrans.
Secretin is the principal stimulant of pancreatic water and electrolytes secretion. Water and
electrolytes originate from the central acinar and intercalated duct cells. At basal secretory rates
of .2 to .3mL per minute, concentrations of chloride and bicarbonate ions are equivalent to
plasma. However, with neurohumoral stimulation the bicarbonate component increases in
concentration while the chloride concentration falls. The end product is a clear, isotonic solution
with a pH of 8.
Cholecystokinin (CCK) and vagal stimulation (acetylcholine) are the principal stimulants for the
secretion of pancreatic enzymes.
Physiologic Basis of Surgery, 2nd Edition, pp 452-5
22
23
24
25
26
Results of Acinar Cell Injury with Acute Pancreatitis (Pathogenesis of Acute Pancreatitis)
The pancreatic acinar cell synthesizes a number of proteases (trypsin, chymotrypsin,
carboxypeptidase, and elastase, and phospholipases) in an inactive zymogen form. These pro
enzymes are packaged into a cytoplasmic zymogen granule. Through a process of exocytosis,
the zymogen granule is evacuated into the pancreatic duct lumen. The precursors are transported
with water and bicarbonate into the duodenum, where they are converted enzymatically into
active forms by enterokinase at the brush border.
In acute pancreatitis, this normal orderly secretory sequence is disrupted. The zymogen granules
fuse with the lysosomes, to form an autophagic cytoplasmic vacuole (zymogen lakes). These
vacuoles preferentially move to the basal lateral aspect of the acinar cell rather than the luminal
apex. These zymogen/lysosome vacuoles discharged through the basal lateral cell membrane
where the proenzymes are activated resulting in extension of the inflammatory process and
proteolysis of adjacent acinar cells. The increasing activation of the proteolytic enzymes results
in acute pancreatitis.
Collectively, these findings suggest that the outcome of acinar cell injury involves the
intracellular activation of endogenous proteases leading to further injury and local extracellular
discharge of acinar cell contents.
Greenfield, 2nd Edition, pp 874-875
27
Biliary/Liver
Bile Salt Metabolism
Bile salt synthesis requires high-energy expenditure. The body therefore reduces this energy cost
by recycling the bile salt pool (of 2-5gms) 6 to 15 times per day depending on dietary habits. 0.2
to 0.5gm of bile acid is lost each day in the stool and is replaced by the synthesis of bile acids
from cholesterol in the canicular ducts of the liver. The major bile acids are cholic and
chenodeoxy cholic, which are conjugated with glycine and taurine in the bile. Conjugation
creates a more neutral charged molecule, which allows for rapid diffusion into enterocytes of the
terminal ileum. The bile salts combine with a protein in the enterocyte and enter the portal
circulation where they are extracted by the liver with great efficiency (80% in a single pass).
Physiologic Basis of Surgery, 2nd Edition, pp 428-429
Sabiston, Textbook of Surgery, 16th Edition, pp 1008-1009
28
29
30
31
32
hemolysis of RBCs
hereditary defects, i.e. Gilberts Syndrome
neonatal jaundice
transferase deficiencies, i.e. drug inhibition (Chloramphenicol), or hepatocellular disease,
i.e. hepatitis or cirrhosis
B. Jaundice with conjugated bile and with non-dilated ducts is found in:
1.
2.
3.
4.
5.
33
Diagnostic Test for Symptomatic Gall Bladder Disease Without Stones Biliary Dyskinesia
A subgroup of patients presenting with typical biliary colic do not have evidence of gallstones,
and the complete workup excludes any other pathology. The Cholecystokinin-Tc-HIDA Scan
will be useful in confirming the diagnosis of biliary dyskinsea.
Cholecystokinin (CCK) is administered IV after the gall bladder is filled with 99TC-labeled
radionuclide. Twenty minutes later, the gall bladder ejection fraction is calculated. An ejection
fraction less than 35% at 20 minutes is considered abnormal.
A cholecystectomy in these patients brings relief of symptoms in 85 94%.
Sabiston, Textbook of Surgery, 16th Edition, p 1087
34
Caudate Lobe
Lateral Left Lobe Anterior & Posterior
Medial Left Lobe
Right Lobe, Inferior Anterior & Posterior
Right Lobe, Superior Anterior & Posterior
Figure 14. Segmental liver anatomy. Depicted is segmental liver anatomy as originally described by Couinaud. The
right lobe consists of segments 5 through 8, the left lobe of segments 2 through 4, and the left lateral segment of
segments 2 and 3.
36
Response
Leukocyte Migration
Opsonization
Antiproteinase, cytokine transport
Antiproteinase
Transport, such as drugs
Decrease in Production
Albumin
Transferrin
Transport
Transport
37
38
39
40
41
42
43
44
Etiology of a Sudden Increase in End Tidal CO2 After Evacuating CO2 in a Laparoscopic
Cholecystectomy Procedure
CO2 is the preferred agent for most laparoscopic procedures because it is readily available,
inexpensive, readily absorbed, and will suppress combustion. The high diffusion coefficient of
CO2 may also lessen the severity of any gas emboli introduced into the vascular system. Its rapid
clearance from the blood stream results in an extremely fast rate of excretion from the body.
This rapid diffusion property of CO2 allows it to be readily absorbed across the peritoneum,
which may result in a rise in PCO2, which is readily eliminated through the lungs. An increased
ventilatory rate is usually sufficient to compensate for this elevated PCO2 in exhaled air.
The combination of residual CO2 being absorbed within the peritoneal cavity, extubation of the
patient who may be sedated and have diminished respiratory drive, could lead to an elevated end
tidal CO2 in the post cholecystectomy patient.
CO2 embolism resulting from residual intra-peritoneal CO2 entering open (torn or lacerated)
large veins must be considered. The high diffusion coefficient results in rapid clearing from the
pulmonary venous system.
Zucker, Surgical Laparoscopy, pp 313-14
45
46
47
Characteristics Hepatocytes
The hepatocytes perform the major metabolic and excretory functions of the liver. They are
arranged in cords or plates of one cell thickness and are surrounded by the sinusoids. The
function of any individual hepatocyte depends upon the position of the cell within the lobule and
the proximity of the cell to the blood supply. Hepatocytes can be divided into three zones. Zone
1 hepatocytes lie in closest proximity to the periportal region and contain the highest
concentration of enzymes involved in glycogenesis. They also produce the majority of proteins
and are responsible for protein metabolism. Cells in Zone 3, an area with decreased oxygen
tension, are equipped for glycolysis and lipogenesis. Ureagenesis occurs in Zones 2 and 3. The
enzymes responsible for gluconeogenesis are much more abundant in the periportal area.
Hepatocytes replicate rapidly, and it is estimated that the entire cell mass of the liver could be
replaced every 50 days. This accounts for the rapid growth of the hepatic remnant after major
liver resections.
Simmons & Steed, Basic Science Review for Surgeons, 1992, pp 247-8
48
49
Characteristics of Chylomicrons
Chylomicrons consist of an inner core containing 90% triglycerides, a lesser amount cholesterol,
cholesterol esters, and fat-soluble vitamins. The outer layer consists of 80-90% phospholipid
and specialized apolipoproteins. The apolipoproteins, while accounting for only 1% of the mass,
are essential for fat absorption. The intestinal mucosal cells synthesize Apolipoprotein A and B,
and they are added before the chylomicrons enter the golgi apparatus. A congenital disorder,
abetaliproproteinemia, leads to triglyceride accumulation within the endoplasmic reticulum and
leads to the inability to digest fat.
Reformed triglycerides within the golgi apparatus of intestinal enterocytes are transported out of
the cell across the basolateral membrane as chylomicrons, which enter the central lacteal of the
villus. From the lacteals, chylomicrons pass via larger lymphatic channels, draining from
intestine to thoracic duct, eventually into the left subclavian vein. Because of their size,
chylomicrons cannot cross intercellular junctions of the intestinal capillaries and are, therefore,
excluded from the portal blood.
OLeary, 2nd Edition, pp 427-28
50
51
52
53
54
55
56
57
58