Week 1

1. Discuss post surgical risks of deep vein thrombosis and prophylaxis against it in surgical patients. See Annals of Surgery, March 2001 233(3) 438-44.
   • Colorectal surgery = highest risk for DVT of all general surgery pts. (30%, with 3.1% fatal PE).
   • LMWH: better bioavailability, 1x daily dosing, lower risk of thrombocytopenia, higher cost.
   • LMWH and heparin equivalent in prophylaxis, but given heparin lower cost, it's preferred.
2. Discuss postoperative fever - its significance, evaluation and treatment. See Surgery 1983 August 94(2) 358-63.
   • > 38.5. Wind, Water, Wound, Walking, Wonderdrug
   • Eval: PE, CXR, Urine (foley), Bl Cx, CBC, but should select based on PE. WBC not validated. IV's impt source.
   • Postop: Mglnt Hyperthermia, transfusion, atelectasis, aspiration, endocrine, thyroid.
   • 15% of pts. have fever, 27% postop infxn.
3. Describe wound healing and epithelialization and implications for scar formation. See Surg Clin North Am 2003 June 83(3): 547-55, vi-vii
   • Inflammation (granulation tissue), epithelialization (sweat glands or hair follicles), fibroplasia, contraction (0.75mm/d, full thick graft stops).
   • Inhibitors: (any immune impairment) malnutrition, anemia, hypoxia, sterioids (vit A prevents), cancer, radiation, (diabetes with ischemia and neuropathy!, hyperglycemia, ischemia), bacteria (>100k/gm)
4. Become technically proficient in tying knots - One handed and two handed. See your intern.

Week 2

1. Describe the derivation of maintenance fluid requirements. See any Surgery text
2. What should you do if you get the flu? See Am J Surg 2004, 187(1): 3-5. *
   • Two viginettes, basicall aimed at demonstration of acknowledging risk and support from colleagues in pt's best interest.
3. How does one know how risky it is to have surgery? See Ann Int Med 2003 138(6) 506-11.
   • Summary showing that preop echo and cardiac index not useful. Better to include risk stratification by clinical variables: high risk procedure, history of ischemic ds, hx of CHF, hx of stroke or TIA, preop insulin therapy, and preop creatine >2. Myocardial perfusion imaging, dobutamine stress echo not helpful. CABG not contraindication unless pt need it. Then stratify as above (after CABG status) and aim to prempt events with beta blockade.
4. Describe in detail the anatomy of an abdominal wall.

Week 3

1. Achieve an understanding of fluids and electrolytes and their use in surgery. .See Effects of Intravenous Fluid Restriction on Postoperative Complications: Comparison of Two Perioperative Fluid Regimens: A Randomized Assessor-Blinded Multicenter Trial. Annals Surg 238(5) 2003. 641-648
   • RCT showed benefit of restricted fluid replacement (no pre-hydration with epidural, no third space replacement). Aim to neutral weight gain (valid for elective colorectal surgery).
2. Discuss evaluation of a patient with lung cancer. See http://research.bidmc.harvard.edu/VPTutorials/
3. Understand current therapy of pancreatitis. See Lancet 2003;361(9367) :1447-55
   • Mechanism is inflammatory cascade (systemic inflammatory response syndrome leads to multiorgan therapy). Starts with inappropriate activation of trypsin.
   • Gallstones leading cause in developed countries.
   • Acute pancreatitis: therapy includes enteral nutrition (no malnutrition), imipenem for cases including necrosis, drainage (can be percutaneous), no strong evidence for pharmacological therapy such as somatostatin, octreotide.
   • Chronic pancreatitis: started by multiple episodes of acute pancreatitis. Progressive. (eg. CF, gene defect). Treatment is management of pain, and exocrine and endocrine insuffiency replacement. Also need to drain pseudocysts. Follow for possible risk of cancer.

Week 4

1. Be able to discuss the three stages of wound wound healing and how they differ from epithelialization. See any surgery text. *
2. Describe risk factors, anatomy and complications of lower extremity arterial disease.
3. Discuss whether a diabetic patient with assymptomatic carotid disease should have surgery.

Week 5

1. Design complete therapy of a 49-year-old woman with a 1.5 cm invasive carcinoma of the right upper outer quadrant of the breast. See NEJM 2002, 347:1227- 1232 and NEJM 2002: 347:1233- 1241
   • RCT with br cr < 2cm showed no diff in survival for radical mastectomy vs breast-conserving therapy (quadrantectomy followed by local radiation).
   • Subsequent 2 year f/up showed no increased risk with lumpectomy and breast irradiation.
2. How do you treat colonic diverticulitis? See NEJM 1998: 338:1521-1526
   • Divertic results from decreased bowel wall strength and increased pressure. 10% prevalence.
   • CT best test.
   • Tx is PO liquid diet and hydration with 7-10 d of broad spectrum abx.
   • Can drain liquid specimens (CT guided) > 5cm.
   • Surgery in fistula formation or recurrent.
   • Emergency surgery indicated by general peritonitis, sepsis, visceral perf, acute clinical deterioration. But healing difficult in sick pts.
3. What are currently accepted screening modalities for colon cancer? Who should be screened and how regularly? On your own. *

Week 6

1. How widely should a melanoma be excised? What are the important prognostic indicators? See NEJM 2004 350(8). Also see the editorial same issue.
   • For melanoma 2mm or greater in thickness, RCT compared 1 and 3 cm margins. 1 cm showed more recurrance, but same overall survival. Low power test, so overall recommend 3cm or more if at least 2mm thick.
2. Your aunt has a breast lesion biopsied . The pathology is lobular carcinoma in situ . What should she do? *
3. Understand the treatment of follicular and papillary neoplasms of the thyroid.

Week 7

1. On rectal exam you find a mass. What are the options for treatment of rectal cancer? See British Journal of Surgery 2003;90:922-933.
   • Can do resection of low rectal tumor with preservation of anal sphincter.
   • Want to maintain as much neorectum as possible to preserve rectal reserve.
2. Are there racial disparities in surgical treatment? See Arch Surg 2004,139:151-156 *
   • Rectal cancer detected at younger age and more advanced disease in blacks, also less likely to undergo sphincter-sparing techniquest than whites.
3. Compare results of laparoscopic and open appendectomy. See Annals of Surgery 2004, 239:43-51
   • Lap appy meant shorter hospital day, lower rate of infections, dectreased GI complications, and lower overall complications, higher rate of routine discharge (but not by a huge amount).

Week 8

1. Is laparoscopically assisted colectomy better or worse than open operation as an oncologic operation in the control colon cancer? See NEJM 350:20 pages 2050-2059 2004
   • Rates of recurrance after median f/up of 4.4 years similar. Hospital stay and pain med use decreased by one day (from 6 to 5).
2. Is laparoscopic hernia repair as good as open anterior repair? NEJM Volume 350 Issue 18 April 20, 2004. Open Mesh versus Laparoscopic Repair of inguinal hernia p 1819-1827 *
   • When limited to mesh repair (direct), open technique superior to laproscopic technique, by odds ratio of 2.2 (measured in terms of recurrances).

Week 9

1. NEJM Volume 350, Issue 14: April 1, 2004 Current Concepts: Treatment of Infections Associated with Surgical Implants
   • Only some post-op wound infections affect implants. Colonization of implant doesn't necessarily mean infection.
   • Biofilms make bacteria resilient to eradication. S. aureus must be removed surgically.
   • Don't use vanco if methicillin-susceptible (sub-optimal). Cover against methicillin-resistant staph for infections of unidentified cause. Use abx proph in subsequent surgery. Long term abx if in grossly infected area. Remove no matter what if no response to appropriate abx. Goal is to ID orgs before replacement.
2. NEJM Volume 350, Issue 14: April 1, 2004Medical Progress: Ductal Carcinoma in Situ of the Breast*
   • Goal of DCIS is eradication before becoming invasive. Local excision now std. of care Pts at risk for recurrance within breast. Lymph node disection not indicated. Radiotherapy administered in tangential fields to whole breast.
3. Do asymptomatic gallstones become symptomatic? See British Journal of Surgery 2004, vol 91,no 6, 734-738
   • 10% of asymptomatic gallstones will lead to sx or events within 5 years. What about operative risk?

Week 10

1. After a laparoscopic cholecystectomy a patient experiences nausea and vomiting in the PACU. How should we treat her? See NEJM Volume 350:2511-2512 2004 and Volume 350:2441-2451 2004 (same issue)
   • Droperidol combined with dexamethasone more effective and cheaper than odansetron. Adding odansetron to the other two of minimal help.
   • Total IV anesthesia (i.e. no inhalation anesthetics) equal to inhallation plus antiemetic. FDA labeling issue with droperidol (QT prolongation) but no clinical significance. NO support for odansetron for routine antiemetic prophylaxis.
2. How common is wound infection after elective surgery? * See Annals of Surgery, Volume 239:(5):pg.599 May 2004
   • Surgical site infection in cohort study by one physician compared to national statistics. Cohort study showed SSIs in 26% of pts (higher than reported nationally).

-- RyanEgeland - 22 Mar 2005