For Our Surgical Residents

 

This is a section for surgical residents. All information contained on this website is intended for informational and educational purposes. The information is not intended nor suited to be a replacement or substitute for professional medical treatment or for professional medical advice relative to a specific medical question or condition.


2014 Grand Rounds Pancreatic Cancer lecture:

2014 PanCA lecture.pdf


For presentations click here.

For surgical anatomy here.

Surgical consents click here.


General preOP considerations in surgical oncology:

  1. BulletLMWH (at least 2 hrs before)

  2. BulletpreOP antibiotics

  3. Bulletbowel preparation: typically “1/2 prep”: 1/2 GoLytely or 1/2 Moviprep, or 1 bottle of Mag-citrate

  4. BulletEntereg 12 mg po in the AM of operation (if no obstruction is present)

  5. BulletType & Cross for any major cases

  6. BulletpreOP labs/tests: CBC, CMP, PT/PTT, CRP, prealbumin; consider CXR, EKG. Beta-HCG for all women of childbearing age.

  7. BulletIf patient is on aspirin 81 mg/day - continue, this is not stopped

  8. Bulletall other antithrombotics and anticoagulants are generally stopped

  9. Bulletbeta-blockers are continued


  1. BulletBowel prep:

  2. 1.“small” – most common: Ducolax 10 mg po x1 day before

  3. 2.“half-size” –  Preferred: Mag-Citrate + Gatorade, or ½ of colonoscopy prep (½GoLytely, or ½Moviprep), or

  4. 3.“full-size” – full prep, e.g. full prescription of Moviprep: for colonoscopy

  5. Bulletpatients are encouraged to drink sports drinks (e.g. Gatorade till midnight)

  6. Bulletnutrition drinks (Impact from Nestle is preferred) are recommended for ~ one full week preOP – it decreases infection rate significantly (nearly 50%)


  7. BulletDiet & NPO for major cases:

  8. 4.Generally normal breakfast & lunch. If bowel prep is ordered, start aftr lunch and continue to eat non-carbonated clears, Impact/Ensure drinks & Gatorade till midnight.

  9. 5.all patients should drink nutrition drinks till midnight, including those with bowel preps: Impact (preferred), Boost, Glucerna, Resource


  10. BulletMiscellaneous:

  11. BulletAloka US requires 2hr sterilization in-between cases (if scheduled back-to-back)

  12. BulletAll major cases have Alpha7 Aloka, no compromise with any other surgeon

  13. BulletCompromise is OK for breast & soft tissue cases



PostOP:

  1. Bulletall major cases have immediate postOP laboratory testing, typically including BMP, Mg, P, CBC, ABG, PT/PTT, CXR. Other on demand: LFTs, amylase, amonia, lactate, fibrinogen, cortisol, troponin. “Next AM labs” plan commonly used in general surgery is not acceptable.

  2. BulletSpecific drain labs: drain amylase on POD 1, 3, 5 in case of major pancreatic resection

  3. BulletTotal thyroidectomy or completion thyroidectomy: q6 hrs total Ca2+, ionized calcium is not necessary in most cases (unless profound malnutrition or hypoalbuminemia). All thyroid cases are started on Tums ES po tid and continued for 3 weeks. Inquire about thyroid hormone replacement.

  4. Bulletprophylactic antibiotics are not continued beyond closed incision

  5. Bulletimmediate feeding via jejunostomy is required; preferred starting formula is Pivot 1.5 @ 20 cc/hr (immunomodulating & near-iso-osmolar formula). Typical advancement is very slow, not faster than 10 cc/hr increased per day (jejunostomy feeding intolerance is clinically difficult to recognize). J-tube flush is with water, not saline; typically 20 cc q 6 hrs.

  6. BulletAll surgical feeding tube are secured with two Hollister holders to prevent early dislodgment.

  7. BulletPostOP LMWH: start within 24 of anesthesia completion. Typically continues throughout entire hospital stay. It is my preference to perform early switch to evening dosing. Patients with major operations (esophagectomy, CS-HIPEC, pancreatectomy, retroperitoneal resections, etc) are typically offered to continue LMWH after discharge up to 4 weeks after operation date.

  8. BulletPostOP medications: Entereg 12 mg po bid if started preOP; all Whipple procedure patients are started on erythromycin 200 mg iv q 8 hrs till free from delayed gastric emptying. Beta blockers must be restarted. Metformin is always stopped in any surgical patient requiring hospitalization, and generally resumed with discharge.

  9. BulletDiet progression: Relatively liberal and fast. Clear liquids are always ordered as “non-carbonated clear liquids”. Progress to regular/cardiac/diabetic diet. Ordering of full liquids required approval from Dr. Franko, and is generally discouraged diet.



Surg Onc instrument ordering:


Open hepatectomy: Aloka US (Alpha 7), C-arm, radiolucent OR table, SCDs – knee high compression stockings, Thompson retractor, Aquamantys


Lap hepatectomy: all what for open hepatectomy plus laparoscopic table, bean bag, laparoscopic TissueLink & harmonic scalpel


Whipple or major pancreatic resection (open): Aloka US, radiolucent OR table, SCDs – knee high compression stockings, Thompson retractor.


Staging laparoscopy: Aloka US, radiolucent table, SCDs, Harmonic scalpel.


Esophagectomy: Aloka US, SCDs – knee high compression stockings, bean bag, Thompson retractor, Harmonic scalpel, N-Seal, ECD scope, 2-lumen endotracheal tube, bronchoscopy. Commonly scheduled with possible Right VATS.


CS-HIPEC: Eight Medical perfusion machine, chemo order (JF responsibility), Impact LigaSure, Aloka US, radiolucent OR table, SCDs – knee high compression stockings, Thompson retractor


Endocrine surgery:

1.adrenalectomy is considered a major case (LMW dextran): bean bag, Aloka US, harmonic scalpel, laparoscopy table with kidney rest, Titan table

2.Thyroidectomy: NIMS, small LigaSure, microsurgical bipolar electrocoagulation

3.Parathyroid: iPTH lab notification; no LigaSure and no NIMS. Navigator probe in reoperative case with planned radioguidance.

4.Pheochromocytoma cases: special notification to anesthesia office



Common Surg Onc tests

(from Debbie’s Famous Book)


Adrenal functional testing:

Chromogranin A (CgA); [normal < 36.5 ng/mL]

Aldosterone (PAC) and plasma rennin activity (PRA)

Cortisol production:

oAM cortisol

oLate night salivary cortisol

o1-mg (low dose) dexamethasone suppression test

Plasma free metanephrines [normal < 0.49 nMol/L]

Plasma free normetanephrines [normal < 0.89 nMol/L]

24-hr urine collection:

oFractionated catecholamines [normal: E < 2 mcg/24°; NE 15-80 mcg/24°; D 65-400 mcg/24°; cathecolamines total 15-100 mcg/24°;]

oFractionated metanephrines & normetanephrines [normal: <341 mcg/24° & <444 mcg/24°

oNa & Creatinine concentration

Adrenal imaging:

Non-contrast adrenal CT scan

IV contrast adrenal-specific CT scan (non-contrast + early and 10-min delayed contrasted CT)

Adrenal MRI (in/out of phase, contrasted)

I131-MIBG scan

Liver testing:

US + duplex

Triphasic liver CT with coronal reconstructions

Liver volumometrics (arrange with Shelly Albus in Radiology)

MRI ± MRCP

99mTc denaturated RBC scan

99mTc-sulfur colloid scan

Labs:

oCBC, BMP, LFTs, PT/PTT, Cholinesterase, NH3 (on request)

oHBsAg, anti-HCV

oAMA: anti-mitochondrial antibodies

oLidocaine-clearance test

oIndocyanine green-clearance test


Pancreas testing:

Pancreas protocol CT with coronal reconstructions

EUS ± FNA

EUS-FNA fluid analysis:

ocytology

oAmylase & lipase

oCEA level

oCytology with mucin analysis (MUC1, MUC2, MUC5)

oCA 19-9 level

oRedPath LOH analysis + K-ras mutation (only if requested)

Stool:

oPancreatic fecal elastase

o72 hr stool collection for fat

Serum:

oCA 19-9, CEA, CA 125; always ask for total bilirubin with these tests

o IgG subclass 4

hereditary pancreatitis genetic aberrations:

ocationic tripsinogen - PRSS1,

opancreatic secretory trypsin inhibitory gene - SPINK1,

ocystic fibrosis transmembrane regulator - CFTR, and

ochymotrypsin C - CTRC)


Carcinoid: hold PPI and H2 blockers for 5 days, OK for sucralfate or Tums.

Chromogranin A (CgA); [normal < 36.5 ng/mL]

NSE: neuron-specific enolase

S-100 protein

Plasma serotonin level

Urine, 24-hr collection for 5-HIAA


Neuroendocrine tumor biochemistry: hold PPI and H2 blockers for 5 days, OK for sucralfate or Tums.

Chromogranin A (CgA); [normal < 36.5 ng/mL]

NSE: neuron-specific enolase

S-100 protein

Plasma serotonin level

Urine, 24-hr collection for 5-HIAA

Pancreastin

Pancreatic polypeptide: PP

Functional syndromes: insulin, proinsulin, C-peptide; glucagone; somatostatin; fasting gastrin level; VIP


Thyroid:

Free T4 [normal 0.46-1.31] ng/dl;

TSH [normal 0.34-5.60 mIU/ml].

Thyroglobulin

Thyroglobulin antibodies [IgG IU/mL]

Anti-peroxidase antibodies

Parathyroid:

Serum:

oCalcium [normal 8.5-10.5 mg/dl], Phosphate, Creatinine, Chloride

oiPTH [normal 12 - 88 pg/dl]

ovitamin 25-OH D3 – as requested

Urine 24 hr tests:

oCalcium [mg/24 hr]

oNa & Creatinine concentration – always to be added

Calculated numbers: FECa & chloride-to-phosphorus ratio

NM sestamibi parathyroid localization scan



Porphyrias

Acute intermittent porphyria

Hereditary coproporphyria

variegate porphyria 

porphyria cutanea tarda


AIP, acute attack:

Watson-Schwartz test (urine)


Porphyria, Urine, 24 hr collection:

ALA (delta-aminolevulinic acid),

PBG (porphobilinogen), and

porphyrin concentrations (coproporphyrin , protoporphyrin, uroporphyrin, etc.)

HIAA

Chromogranin A


Erythrocyte enzyme assay (PBGD activity)


Aminolevulinic acid — Normal urinary excretion of ALA is <7 mg/24 hours. In an attack of AIP, urinary ALA excretion is markedly elevated, with typical values being several, or sometimes more than 10 times the upper limit of normal (eg, 25 to 100 mg/day).


Porphobilinogen — Normal urinary excretion of PBG has been variously given as <2 mg/24 hours [57] or <9 microM/L [15]. In an attack of AIP, urinary PBG excretion is markedly elevated, with typical values being several, or sometimes more than 10 times the upper limit of normal (eg, 50 to 200 mg/day). When expressed as mg/24 hours, the excretion of PBG is usually greater than that of ALA.


Erythrocyte enzyme assay — If AIP is suspected, erythrocyte PBGD activity (porphobilinogen deaminase)


Hereditary coproporphyria and variegate porphyria — Measurement of urinary and stool porphyrins will usually differentiate these two conditions from AIP. They can be distinguished from AIP by the following:

•Photocutaneous symptoms occur in HCP and VP, but not in AIP

•Excretion of coproporphyrin is increased in urine and stool in HCP, but is normal in AIP and VP.

•Excretion of protoporphyrin in stool is increased in VP, but is normal in AIP and HCP

•PBGD activity is normal in HCP and VP