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Appendix addenocarcinoma: Multiple choice questions!

A 59 year old woman present with right lower quadrant pain, nausea, and vomiting. She undergoes an uncomplicated laparoscopic appendectomy. Postoperatively, the pathology reveals a 2.5cm mucinous adenocarcinoma with lymphatic invasion. Staging workup, including colonoscopy, chest x-ray, and CT can of the abdomen and pelvis, is negative. Which of the following is the best next step in her management?

a. No further intervention at this time; follow-up every 6 months for two years

b. Chemotherapy alone

c. Neoadjuvant chemotherapy followed by right hemicolectomy

d. Ileocecectomy

e. Right hemicolectoy

The answer is e. (Townsend, pp. 1395-1396; Brunicardi, p. 1134)

Patients with appendiceal adenocarcinoma, a rare neoplasm accounting for less than 0.5% of gastrointestinal tumors, should undergo formal right hemicolectomy. Often affecting older patients, they may present with symptoms mimicking those of acute appendicitis. A thorough initial workup and follow-up are necessary because of the high rate of synchronous and metachronous tumors. Five-year survival is 55% but depends on the tumor stage.

pretest surgery p.204,236

Preoperative Preparation:

- ?? perioperative antibiotics

- ?? bowel prep

Multiple choice questions!

A patient with a nonobstructing carcinoma of the sigmoid colon is being prepared for elective resection. Which of the following reduces the risk of postoperative infectious complications?

a. A single preoperative parenteral dose of antibiotic effective against aerobes and anaerobes

b. Avoidance of oral antibiotics to prevent emergence of Clostridium difficile

c. Postoperative administration for 48 hours of parenteral antibiotics effective against aerobes and anaerobes

d. Postoperative administration of parenteral antibiotics effective against aerobes and anaerobes until the patient’s intravenous lines and all other drains are removed

e. Redosing of antibiotics in the operating room if the case lasts for more than 2 hours

The answer is a. (Townsend, pp 261-262)

The appropriate dosing and timing of antibiotic prophylaxis to prevent surgical site infections in an elective procedure is a single dose, no greater than 1 hour prior to the incision.

Additionally, most textbooks recommend use of an oral, nonabsorbable antibiotic regimen effective against aerobes and anaerobes in combination with a mechanical bowel preparation before elective colon resections.

There is no evidence to support the continuation of antibiotics for more than 12 hours after an elective operation has been completed, and this practice should be avoided to prevent increasing microbial drug resistance.

For complex, prolonged procedures, redosing of antibiotics may be appropriate during the procedure based on the drug’s half-life.

Broad-spectrum antibiotic coverage, including against anaerobic organisms, is required only in cases where such flora are anticipated, such as during colon resections; otherwise, cefazolin is the antibiotic of choice for cases requiring antibiotic prophylaxis.

pretest surgery p.2, 20

In all colectomies, the bowel is either reconnected afterward (which is called an anastomosis) or the surgeon creates an ostomy, an opening of the bowel on the abdominal wall, to allow the contents of the bowel to exit from the body.

http://www.medterms.com/script/main/art.asp?articlekey=12529

Total colectomy / Proctocolectomy

A special variant of colectomy is total colectomy, which is also called proctocolectomy. This is most commonly a treatment considered for people with ulcerative colitis, either because of failure to respond to treatment or because of the cancer risk associated with the disease.

http://www.medterms.com/script/main/art.asp?articlekey=12529

Multiple choice question

A 52 year old woman undergoes a sigmoid resection with primary anastomosis for recurrent diverticulitis. She returns to the emergency room 10 days later with left flank pain and decreased urine output; laboratory examination is significant for a white blood cell (WBC) count of 20,000/mm3. She undergoes a CT scan that demonstrates new left hydronephrosis, but no evidence of an intraabdominal abscess. Which of the following is the most appropriate next step in management?

a. Intravenous pyelogram

b. Intravenous antibiotics and repeat CT in one week

c. Administration of intravenous methylene blue

d. No further management if urinalysis is negative for hematuria

e. Immediate reexploration

The answer is a. (Brunicardi, pp 175, 1606)

The patient should undergo an intravenous pyelogram for a suspected ureteral injury.

After gynecologic surgeries, colorectal surgery is the most common cause of iatrogenic ureteral injuries.

Intraoperatively, intravenous administration of methylene blue or indigocyanine green may facilitate identification of an injury.

However, delay in diagnosis is common, and patients may present with flank pain, fevers, and signs of sepsis, ileus, or decreased urine output.

CT scan may demonstrate hydronephrosis or a fluid collection (urinoma).

Initial diagnosis and management should include urinalysis, although hematuria may not always be present; percutaneous nephrostomy tube or retrograde ureteral catheterization; percutaneous drainage of fluid collections; and identification of the location of ureteral injury.

Surgical management should be delayed if diagnosis is late (10 to 14 days), and operative strategy is dependent on the location of the injury.

Diagnostic imaging such as a pyelogram or nuclear medicine scan may be helpful to identify the site of injury.

pretest surgery p.10, 29,question #30

Multiple choice case

A 60 y/o woman with no previous medical problems undergoes a total colectomy with diverting ileostomy for a cecal perforation secondary to a sigmoid stricture. Postoperatively, she has 2L of ileostomy output per day. Her heart rate is 110 beats per minute, her respiratory rate is 16 breaths per minute, and her oxygen saturation is 98% on 2L NC. Her laboratory values on postoperative day 6 are as follows: Na 128, K 3.0, Cl 102, and HCO3 20. Which of the following statements is true?

a. Her laboratory abnormalities are most likely secondary to a Type IV renal tubular acidosis

b. Her laboratory abnormalities are most likely compensatory for a primary respiratory problem

c. She should be treated with fluid replacement and empiric treatment with oral Vancomycin

d. She should be treated with fluid replacement and stool-bulking agents

e. She should undergo immediate dialysis

The answer is d. (Brunicardi, pp. 50-51)

The patient has a non-gap metabolic acidosis, [Na -(Cl + HCO3)] = 128-(102+20)= 6

sedondary to high output from her ileostomy with gastrointestinal losses of bicarbonate.

This should be managed with fluid replacement and stool-bulking agents.

The ionic composition of small-bowl fluid is Na 140, K 5.0, Cl 104, and HCO3 30.

Patients with large ileostomy outputs are at risk for dehydration with accompanying hyponaremia, hypokalemia, and non-anion-gap metabolic acidosis.

While renal tubular acidosis (RTA) can be associated with a non-anion-gap metabolic acidosis, type IV RTAs are typically associated with hyperkalemia.

Renal failure can result in an anion-gap, uremic acidosis and hyperkalemia, both of which may be indications for dialysis.

Finaly, while C. difficile colitis should be considered in postoperative patients with diarrhea, C. difficile enteritis is less common in a non-immunocomproised host, and Vancomycin is reserved for failures to metronidazole treatment.

pretest surgery, p.16, 34; question #34

Multiple choice questions

A 62 year old man has been diagnosed by endoscopic biopsy as having a sigmoid colon cancer. He is otherwise healthy and presents to your office for preoperative consultation. He asks a number of questions regarding removal of a portion of his colon. Which of the following statements is true regarding the effects of colon resection?

a. Net absorption of water by the rectum has been demonstrated in humans

b. Patients who undergo major colon resections suffer little change in their bowel habits following operation

c. The left colon is better adapted for water absorption than the right colon

d. The right colon is better adapted for electrolyte absorption than the left colon

e. The role of the ileocecal valve in normal fluid homeostasis is well established

The answer is b. (Greenfield, pp1063-1069)

Because the reserve capacity of the colon for water absorption greatly exceeds the normal requirements for maintaining stable bowel function, patients may undergo resection of a large fraction of the colon and suffer little change in bowel habits.

Neither the right nor the left colon appears to be a site of preferential water and electrolyte absorption, nor does the ileocecal valve play a noticeable role in fluid homeostasis.

However, in diseases characterized by increased fluid secretion of the small bowel, the colon is more likely to be overwhelmed by the absorptive demand following partial colectomy than in the intact state

The rectum does not appear to play a role in fluid absorption.

pretest surgeyrr p.214; 248 question 322

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