A 56-year-old man comes to the hospital. For the past 5 days he has had colicky abdominal pain, vomiting, abdominal distention, and constipationDuring definitive surgical treatment of the lesion shown on the barium enema, the left ureter is accidentally transected at the level of the pelvic brim. What is the most appropriate management of this complication?
Answer(s): C
This patient presents with classic symptoms of a bowel obstruction. The diagnosis is often made by a thorough history and physical examination. Following the initial evaluation, an acute abdominal x-ray series should be obtained, which includes supine and erect views of the abdomen. The diagnosis is confirmed with the presence of dilated loops of bowel with the presence of air-fluid levels. These plain films may also suggest the location of the obstruction (small vs. large intestine). Abdominal ultrasonography has limited role in the diagnosis or management of intestinal obstruction. Serum electrolyte determination helps in identifying the electrolyte disturbances that have taken place. Fluid loss needs to be corrected with rehydration, and nasogastric suction helps in decreasing abdominal distention. Upper GI endoscopy would increase distention, and is contraindicated. Antiemetics should not be given until a definitive diagnosis is made, and then only if indicated; promotility agents have little to no role in the management of a patient with bowel obstruction, and may even be contraindicated.An annular constricting lesion with overhanging edges is typical of annular carcinoma of the colon. Mechanical small bowel obstruction results in multiple air-fluid levels in distended small bowel loops. Intussusception produces a "corkscrew" appearance on barium enema, and sigmoid volvulus produces a "bird's beak" appearance. In diverticulitis, extravasation of barium outside the lumen of the colon typically is seen.
A60-year-old woman presents with an abnormal cluster of microcalcifications on a routine mammogram, and undergoes a needle-localized excisional biopsy. The pathology is shown in Figure. When counseling the patient regarding her surgical options, which of the following statements would be correct?
Answer(s): A
The Halsted radical mastectomy involves removal of all breast tissue, lymphadenectomy, and removal of the pectoralis major. The modified radical mastectomy preserves the pectoralis major muscle thus decreasing the morbidity of the surgery with the same survival. The modified radical mastectomy does include a lymph node dissection. The anatomic limits of the modified radical mastectomy include the sternum medially, the subclavius muscle superiorly, the inframammary fold inferiorly, and the latissimus dorsi muscle laterally. The surgeon must identify the thoracodorsal nerve and the long thoracic nerve, which innervate the latissimus dorsi muscle and the serratus anterior muscle, respectively. Damage to the long thoracic nerve results in a "winged scapula." After a complete dissection of level I, II, and III lymph nodes, the use of radiation therapy needs to be critically evaluated because of the long-term morbidity of lymphedema.
A 45-year-old man undergoes a distal esophagectomy for Barrett's esophagus. During his hospital course, a left chest tube is placed for an effusion. Milky white fluid is found to come out through the tube.Which of the following statements is most accurate about this condition?
Damage to the thoracic duct can be seen as a complication following distal esophagectomy or any procedure that involves dissection into the cervical region. It is most commonly seen on the left if iatrogenic. Aspiration of an odorless, milky fluid from the chest cavity is diagnostic, although increased lymphocyte counts nd triglyceride levels in the fluid help confirm the diagnosis. Normal chyle flow is around 2 L a day. Therefore, a chylous leak can result in nutritional depletion as well as decreased systemic lymphocytes to fight infection. The first therapy is placement of a chest tube to drain the chyle and to allow for approximation of the lung against the mediastinum. Stopping oral intake and starting total parental nutrition is usually tried for 710 days to see if there is spontaneous resolution of the leak. If conservative measures fail, ligation of the thoracic duct can be performed.
A 60-year-old man with hypertension, hyperlipidemia, and peripheral vascular disease requires coronary artery bypass graft surgery.Which of the following vessels would be the most appropriate conduit for his coronary artery bypass graft?
Answer(s): B
Finding a conduit for use in coronary artery bypass grafting can sometimes be a challenge since these patients often have diffuse atherosclerotic disease. The left internal mammary artery is most commonly used. Bilateral internal mammary arteries can be used, however this increases the chances of sternal healing problems. Saphenous vein grafts are used in patients with multivessel disease, although this may not be an option in patients with deep vein thrombosis (DVT), venous insufficiency, or arterial insufficiency to the legs (because they will not heal the harvest wound). Radial arteries, the right gastroepiploic artery, and inferior epigastric arteries have also been used.
The family of a patient recently diagnosed with esophageal cancer requests more information regarding the disease.You tell them which of the following?
Esophageal cancer is increasing in incidence in North America, largely due to the rise in incidence of esophageal adenocarcinoma. Premalignant lesions for esophageal cancer include: Barrett's changes, radiation esophagitis, caustic esophageal burns, Plummer-Vinson syndrome, leukoplakia, esophageal diverticula, ectopic gastric mucosa, and tylosis. It is more common in men, and smoking is clearly a risk factor along with alcohol. Barrett's esophagus requires frequent surveillance examinations with biopsies and increases the risk for adenocarcinomas of the esophagus at the gastroesophageal junction.
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