Breast Mammary fistula- 2/2 recurrent abscesses from duct obstruction. Associated with smoking - decreased beta carotene - decreased protection of vit A from squamous metaplasia - duct obstruction. Treatment: abx, drainage, then fistulectomy. Subareolar breast abscess Usually in healthy nonlactating women. Damaged, obstructed ducts. S. aureus most common. Dx with US - if thick wall or loculated, may need open I&D. o/w, abx and aspiration successful 85%. Contrast peripheral breast abscesses, which are assoc with comorbidities like DM. Gynecomastia - epithelial ductal hyperplasia and stromal proliferation Puberty 2/2 hormonal changes, adults 2/2 cirrhosis, renal failure, cannabis. Not a risk factor for breast CA Nipple discharge Only worry about bloody, but even bloody is usually intraductal papilloma (single duct) or duct ectasia (multiple). Do physical, mammo. If suspicious (mass) or bloody, biopsy. If no lesion to biopsy, excise the duct from beyond duct up to and including skin. Can do galactography. Bloody discharge from single duct should be biopsied (CA in 10%, higher if assoc with mass). Also get mammo. Diagnosis Screening mammography Recommendation: Starting at 40, every 1-2 years, then annually starting at 50. Ultrasound Factors suggesting malignancy: shape, shadowing, internal echoes, heit/width ratio (architecture): normal is lateral growth, abnormal is taller than wide US categorizes as cysts: sharp, bilat edge shadowing, probable fibroadenoma- sharp and smooth edges, indeterminant, suspicious Breast CA usually indistinct margins and irregular shaowing, heterogenous internal echoes, often taller than wide Stereotactic core bx Contraindication: mammographic radial scar, can't see in the stereotactic suite Fibroadenoma Most common benign tumor of the breast Prophylactic mastectomy - remove nipple-areola complex Option for mod to hi risk - genetic markers/family history - reduces risk by 90% (more in mod than hi risk) Consider for LCIS Male breast CA Risk factors- Klinefelters (47, XXY), African-American, Jewish, obesity, cirrhosis (hi estrogens), BRCA2 (not 1!) 80% ductal, 1% lobular. More likely to be receptor positive compared with women when matched for stage, grade, and age. Treatment similar principles as in women, but more likely to get mastectomy. Adjuvant tx same, men more likely to get hormonal tx, since usually receptor positive. Steroids do not increase risk of male breast CA, but does increase HCC, prostate CA, and renal cell CA. Nipple discharge rare, but often indicative of CA BRCA2 increases risk of breast CA, also prostate, pancreatic, and laryngeal Breast mass during pregnancy US primary test: if asyx simple cyst - observe FNA - fibroadenoma - observe during preganancy, then observe or resect FNA - lactating adenoma- wait until after breastfeeding. Most go away, resect those that do not. Mammo OK in 3rd trimester Management DCIS Lumpectomy or simple mastectomy, maybe XRT (Van Nuys) Don't need axillary dissection - that's for staging, and because it's not invasive, you don't need to look for nodal mets. But, of course, since this is breast disease, sometimes you hould consider it, because breast disease management makes no sense. For instance, SESAP says you should consider if you either have a mass on exam or on mammo. Well, why else would you get a biopsy? Seriously, evaluation of axillary nodes in DCIS (preferably by sentinel node biopsy) should be considered when there is multicentric disease (extensive hi grade DCIS) and you are gonna do a (simple) mastectomy, or if there is suspicion of microinvasion or if there is necrosis. In general, no role for node evaluation or chemo in DCIS. The Van Nuys scoring system gives risk of recurrence without radiotherapy (helps determine if you should give XRT for DCIS). Risk of recurrence: size, histology (comedo or non), margin (positive, <1cm,>1cm) LCIS It's a marker of risk, not a precursor lesion. So surgical removal is not necessary. Risk is about 1% per year, more likely to be ductal than lobular CA, risk equal in both breasts. Options are close follow-up, tamoxifen, or bilateral prophylactic mastectomy - especially if hi risk, like BRCA1/2 positive. If you get a BIRADS-4 mammo, and core biopsy tells you it's LCIS, this is a nonconcordant result (the LCIS does not explain the mammo). You should get more tissue and do a needle loc to see if there is something else. (This is a situation where you get LCIS but you do more surgery). But in general, LCIS does not mandate re-excision for positive margins, XRT, or chemo. Atypical ductal hyperplasia If you didn't get it all out (like if you only did a core biopsy), you gotta get the rest out (excisional biopsy), because the diagnosis is upgraded to DCIS or CA in a significant portion of patients (11-44%). Adenoid cystic carcinoma Rare, good prognosis, does not go to nodes (3%) - don't do ax dissection. Re-excision - high local recurrence. Do simple mastectomy. Tamoxifen For prophylaxis Tamoxifen decreases risk of invasive and noninvasive CA by 50% in patients at hi risk for developing breast CA. Hi risk: 60 or older LCIS Age 35-59 with 5y risk of 1.66% by Gail model - age, 1st degree relatives, menarche (not menopause!), nulliparity or age of first parity, # breast bx, atypical hyperplasia. Options for hi risk If BRCA1/BRCA2: Enhanced screening, tamoxifen, prophylactic mastectomy/oophorectomy Risk for breast (60-80% lifetime) and ovarian CA (15-40% lifetime). BRCA1 may be resistant to tamoxifen (ER/PR negative tumors usually) Sentinel node biopsy Methylene blue - can cause skin necrosis if too superficial Lymphazurin (isosulfan blue) - associated with anaphylaxis, so not methylene blue is used Flase negative rate should be 1-3% Not indicated if node positive by FNA Isolated pulmonary mets after curative resection If pt has already had XRT, further XRT not an option. Open wedge resection give 33% 5y if disease free interval >2y. Isolated hepatic metastasis after curative resection Look hard for other disease (CT.PET) If already had chemo, might not work again If really big, shouldn't do RFA, cryo, or EtOH Resection may give 20% 5y if truly isolated without other disease Locally advanced tumors Greatest risk to life is distant metastatic disease Operation with primary wound closure difficult. Neoadjuvant chemo shinks tumor, allows smaller operation, even BCT. After resection, get XRT and must get more chemo Neoadjuvant chemotherapy Improves rate of BCT. Use if mass too large for lumpectomy and pt wants BCT. Clinical response not a predictor of survival. No dofferences in other things: survival, local control, etc. Breast reconstruction Smokers at increased risk for mastectomy flap necrosis, TRAM flap necrosis, abdominal hernia. "Delay procedure" (ligation of inferior epigastric a), stop smoking 4 wks - can decrease risk. XRT Contraindications: scleroderma or other connective tissue disease of skin, can't get to XRT facility Brachytherapy - hi-dose XRT at lumpectomy site, where 96% of recurrences are. Only 7 days. Eligible if less than 4cm, ductal (not lobular) but not extensive intraductal (cuz then it might go outside the hi-dose area), margins 2-3mm at least, no diffuse microcalcs, 3 or fewer positive nodes. XRT decreases local control, not overall survival, after BCT. Prognosis Node status most powerful predictor In node negative pt, tumor size is next most powerful predictor (after the fact that they are node negative.) Receptor status: ER pos - 10% better 5y (PR positivity predicts response to hormonal tx after recurrence) Male sex: poor prognosis (dx'd later, no difference stage for stage) Women under 35: poorer prognosis after adj for nodes, receptors, histology. Pregnant: poor prognosis - dx'd later. HER-2neu - protein overexpressed in certain breast CAs. Correlated with decreased survival, poorer response to some hormonal and chemo tx, receptor negativity, bad histology. HER-2neu is BAD.

Endocrine Metabolic response to trauma/stress "Glucose intolerance" aka high glucose Increased glycogenolysis in liver and gluconeogensis 2/2 increased glucagon Insulin resistance 2/2 increased cortisol - glucose uptake decreased Insulin concentrations higher Steroids given in acute spinal cord injury and ARDS increase infectious complications. Neuroendocine tumors of pancreas hypervascular ususally indolent radioresistant liver mets not a contraindication to resection of primary (can do wedge resection while at it), don't have to take out mets right away, or at all. Diffuse toxic goiter (Grave's disease) Radioablation is tx of choice Subtotal thyroidectomy less popular - recurrent goiter occurs 10-20% at 10y, 40% at 30y If re-operate for diffuse toxic goiter, increased risk of permanent hypoparathyroidism Substernal goiter - should be resected early (subtotal) to avoid complications - airway obstruction, SVC syndrome, RLN or phrenic n compression. Thyroid storm IVF with glucose (storm accelerates glucose metabolism), steroids (storm causes relative adrenal insufficiency), (ASA worsens storm by displacing T4 from thyroglobulin), B-blockade prevents conversion of T4 to T3, PTU, KI (afterPTU) Intra-op PTH Doesn't affect OR time, cost, stay, morbidity, mortality It does definitively tell you that the abnormal tissue has been removed. Parathyroid CA Rare Presents as hyperparathyroidism Tx: resection of involved gland, ipsilateral thyroid, and regional nodes If recurrent disease, resection usually not curative, but can be used to palliate sx of hypercalcemia If widely metastatic and want to palliate hi Ca - IVF, loop diuretics, bisphosphonates Medullary Thyroid CA Total thyroidectomy + central nod dissection (hyoid to innominate v, between carotids) Papillary thyroid cancer Tx of virtually all papillary or follicular thyroid CA >1.5 cm: total or near total thyroidectomy f/b radioiodine You can ablate an entire lobe with radioiodine, but the radiation required approaches toxic dose, so you limit options for recurrence. Cervical nodal metastases: 50% incidence of micromets to cervical nodes Elective nodal dissection in absence of clinically positive dz not recommended. If lateral nodes detected, modified neck dissection (preserve SCM, spinal accessory, IJ). Don't just remove the enlarged nodes (although that's what Norton does). If nodes appear later (20%), do regional neck dissection then, with no decrease in survival. Node positivity does not impact survival. Node positivity does not affect rate of local recurrence. Risk factor to develop cervical node mets: age > 70, extrathyroid invasion of primary, blood vessel invasion, hi grade Post-thyroidectomy hypocalcemia: risk factors- h/o hyperthyroidism, esp Grave's (hungry bone syndrome), extent of thyroid resection, autotransplantation (takes a while for them to revascularize)

Supraceliac control of aorta

Open gastrohelpatic ligament (lesser omentum)

between lesser curve of stomach and liver

place clamp (make sure you can see that you're not getting esophagus)

Pancreas

Acute pancreatits
Work-up
If unsure of dx of acute epigastric pain, start with gastrograffin swallow to r/o perf'd ulcer, Boerhaave's, gastric volvulus. Could also be acute MI (EKG, enzymes), AAA (will be seen on the US/CT you are gonna do for pancreatitis), ischemic bowel.
abdominal films
EKG
US/CT

Treatment
NPO, NGT, maybe TPN
IVF
H2 blockers
Abx? - when ?
Early ERCP + sphincterotomy in severe cases can help, but has risks, so do only to decompress obstructed CBD in septic pt.
Somatostatin does not help

If pt doesn't get better ...
CT, if necrosis, then needle aspiration and G/S + culture
If sterile but still not getting better in 24h, or if infected, abx + laparotomy.
1. Debride devitalized tissue, lavage
2. Drains in lesser sac, or marsupialize
3. Feeding tube

If CT shows pancreatic fluid collection ...
FNA and culture to distinguisg pseudocyst, sterile fluid, or pancreatic abscess
If it's a pancreatic abscess, IR drain, or surgical external drainage + feeding tube

Pseudocyst
If under 4 cm and asymptomatic, follow with serial US
If 5-6 cm or symptomatic (pain, obstruction, bleeding, infection) ...
ERCP - communicating with pancreatic duct?
If non-communicating, larger than 4cm, not very symptomatic, can do IR aspiration (even repeatedly, 3-4x). If that doesn't work or things get worse, surgical internal drainage.

If larger than 6cm, symptomatic, and communicates with pancreatic duct, make sure it's 6wks old and do surgical internal drainage (not if infected or bleeding). Roux-en Y cystojej is usual choice. Can do distal pancreatectomy if cyst is in the tail. If it's sticking right into the appropriate organ, can do cysto-duo or cysto-gastostomy.

If you operate, biopsy cyst wall to look for CA.

If infected, external drainage (IR or surgery).
If bleeding (sudden pain, shock; CT with IV contrast for dx if stable), go to IR if stable, laprotomy if unstable. Ligate vessel, open cyst, pack, ligate bleeders, external drainage.
Bleeding in a pseudocyst patient can be into cyst (erosion into vessel), into bowel (cyst erodes thru bowel wall), from gastric varices (2/2/ splenic vein thrombosis - do splenectomy). Do A gram if you can!

Pancreatic true cyst
serous or mucinous cystadenoma or cystadenocarcinoma
Mucinous - body/tail, higher malig potl
Serous - head, low malig potl

If suspect true cyst, get FNA and send:
CEA - hi in mucinous, low in serous and pseudo
CA125 - hi in malig, low in pseudo, variable in benign
Amylase/lipase - hi in pseudo
Viscosity - hi in mucinous
Cytology - look for CA
Wall bx - no epithelial lining in pseudo

Treatment
Surgery even if mets

Pancreatic ascites
Pt with h/o pancreatitis/pseudocyst with abdominal distention, fluid wave.

Work-up
CT abdomen
Paracentesis - protein, glucose, amylase, bile, cells
If amylase hi, it's pancreatic ascites.

Conservative treatment
NPO + TPN
somatostatin 150mg sq q8
repeated paracentesis
ERCP to stent across leak (unless significant debris in cyst)
75% success in 4 wks
repeat ERCP in 6 wks if doing well - remove stent if healed

If conservative fails:
pancreatectomy (Whipple or distal)
internal drainage if leak from cyst
Peustow is rare

Chronic pancreatitis
Indicated for complications:
pseudocyst, biliary or GI obstruction, abscess, splenic vein thrombosis with L portal HTN, pain

Factors to consider:
size of duct - large: Peustow; small: pancreatic resection (Whipple better pain results than distal, and not-as-bad diabetes)
failure of drainage procedure: resection
ampullary stenosis: sphincteroplasty and septoplasty

Workup
ERCP/PTC

If biliary obstruction, can treat with choledocho-jej, drainage of pseudocyst, or resection, depending on cause.
GI obstruction can be treated by pseudocyst drainage, or gastro-jej if you know it's not tumor

To differentiate pancreatic CA from localized chronic pancreatitis:
Look for mets with imaging
Best test is ERCP with brushings, biopsies, and fluid cytology
If ERCP inclonclusive, explore and do multiple biopsies

Pancreas divisum

Biliary surgery

Post cholecystectomy jaundice
Work-up and algorithm
H&P - look for peritonitis
Labs - esp LFTs and amylase
Abdominal films
Start abx
U/S RUQ - bil dil, stones, biloma, abscess
HIDA
If CBD occluded, get ERCP. If ERCP shows stone, retrieve. If can't ERCP or shows iatrogenic occlusion, explore.
May repair over T-tube, remove clip, choledocho-jej
IF HIDA shows leak, get CT scan
Drain the biloma, if it's the cystic duct, should close in 1-2 wks. If CBD, get ERCP, stent. Wait 3 weeks (for things to cool down), then OR - repair over T-tube or choldocho-jej (if tissue unhealthy or a lot of tension)
If HIDA shows normal - CT scan. IF CT also normal, look for other causes of jaundice.

Post cholecystectomy cholangitis
Here, the patient is septic, and you need to drain the biliary tree.
Algorithm
ABCs, access, H&P.
Labs, plain films, abx.
Emergent ERCP to drain the CBD. Can remove stone, bx mass.
If that's a no go, PTCD.
If that's a no go, resuscitate patient and go to OR, with the goal of draining the biliary tree.
Explore CBD, extract stone (may use choledochoscope)
If having trouble, or unstabe, put a T-tube in CBD and close.
If patient is stable and you want to drain internally, do a choledochoduodenostomy if porta not too scarred (can leave stone). If porta is scarred, and duo won't mobilize, do sphincterotomy. If still can't get stone, do choledocho-jej.

Post-cholecystectomy syndrome
"Still has pain s/p CCY"
ddx:
GERD, PUD, pancreatitis, IBS
Biliary: CBD stone/stricture, SOD, biliary dyskinesia

Workup
H&P - characterize pain
Labs - including LFTs, amylase/lipase
Tests:
EGD/ERCP
CT if you suspect pancreas
RUQ U/S - CBD >12mm is abnormal
HIDA delayed emptying >2h c/w biliary dyskinesia (remember, there is no gallbladder, so no EF)

Treatment - direct to etiology
Pt may benefit fropm sphincterotomy (ERCP or surgical TDS) if:
HIDA emptying >2h
CBD >12mm
Good wendoscopist can't cannulate ampulla
Pain reproduced by injecting CBD

Choledochal cyst
Types
I - most common - involves CBD

Complications
Malignancy

Treatment
Excision and hepatico-jej
If the dissection is tough, you can enter the cyst and develop a subserosal or submucosal plane, leaving the outside intact.
Also do CCY

Primary sclerosing cholangitis
Associated with IBD, can be idiopathic
Diffuse or localized extrahepatic stenoses
Recurring cholangitis/jaundice
Pts die 2/2 cirrhosis

Treatment
IR stents (can be changed q3 months)
Surgical hepatico-jej or choldocho-jej (place stents pre-op for identification)
Liver transplant


Acalculous cholecystitis
Risk - TPN - biliary stasis
Diagnosis
Portable RUQ US (not HIDA - gotta move pt and could be false neg in acalculous cholecystitis)
Elevated SGPT raises suspicion

Treatment
If sick, percutaneous cholecystomsomy under US guidance by IR
If no IR, do minilaparotomy and open cholestostomy under local

Less sick types with biliary dyskinesia
HIDA with CCK: if GB EF <30%, elective CCY

Biliary cancer
Gallbladder cancer
Stage I Mucosa
Stage II infiltrates subserosal layer, but serosa is uninvolved
Stage III thru serosa (into liver), or lymph nodes I, but <2cm
Stage IV, thru serosa (into liver), or lymph nodes +, but >2cm

Treatment
If I/II - CCY
III/IV - radical CCY - resect 2 cm of liver bed, dissect porta and anterior/inferior panc nodes
Distant mets - no surgery
If you are gonna go back to radicalize the CCY, do mets w/u 1st!

Bile duct cancer
Proximal (Klatskin) - at bifurcation
Middle third - CBD, not intrapancreatic
Distal - intrapancreatic

Work-up
1. r/o other causes of obstructive jaundice (stones, extrinsic compression of CBD by nodes from other cancer, sclerosisng cholangitis)
2. r/o mets
CT abd/chest
ERCP/PTC (can also get bx or brushings)
(Angio)
MR/MRCP

Treatment
Can start with laporoscopy
Look at nodes, liver, surfaces, hepatic plate
If looks unresectable, think drainage - ERCP/PTC, hepatico-jej)
Distal - Whipple
Middle - CCY, resect CBD up to pancreas, hepatico-jej
Proximal - CCY, dissect out porta, may include caudate lobe if involved, hepatico-jej
Post-op - adjuvant XRT, 5-FU