Perforated PU
🔴 gold Ix ➡️ plain x_ray ➡️ Air under diaphragm
🔴 Rx ➡️ Surgical ER to deal with perforation but ulcer curing surgery is optional according to general state of the patient

GOO
🔴Vomiting ➡️ non bilious
🔴best ix ➡️ Endoscopy (to exclude malignancy by biopsy)
🔴DD OF GOO ➡️ cicatrized DU (M.C of this presentation )
🔴Rx ➡️ laparotomy, truncal vagotomy and Gastrojejunistomy

🔴Penetration in PU ➡️ Rx by Gastrectomy

MCQ on complications of Gastric surgery

🔴 Recurrent ulcer
🔴 Small stomach $
🔴 bilious vomiting ( more with bill roth 1)
🔴 Dumping ( early or late )
🔴 post vagotomy diarrhoea
🔴 Malignant transformation ( stump carcinoma)
🔴Metabolic ➡️ IDA ( M.C complication)


🔴 Complications are more with Bill Roth 2 ➡️لأنها بعيدة أوى عن الاناتومى مقارنة ب bill roth 1

🔴 Blow out ( rupture of the stump) ➡️ M.C cause of Death following gastrectomy

Risk signs in Endoscope :
a. Visible vessel (blue or red)
b. Spurter (arterial)
c. Overlying adherent clot
d. Red or black spot in the base of the ulcer

Goiter

PHTN
أهم النقط كلام د سامر البسة فى الجراحة

Management of HCC

M. C goiter iodine def
2nd hashimoto
3rd graves

M. C enzyme def.. Peroxidase
Dyshormonogenesis is autosomal recessive

Rarest malignancy in thyroid lymphoma

Marine leenhart syndrome.. Graves+nodules:
Type 1: +one hyper func nodule
Type 2: + multiple hyper
Type 3: + multiple hyper and hypo

Pendred disease: dyshormonogenesis goiter plus deafness

Us of nodule;

Benign: fully cystic

Very low risk: spongy >50% cystic
Low risk: hyper or iso echogenecity
High risk: hypo or very hypo
Very high risk: achogenic, taller than wider, irregular borders, microcalcification, extrathyroidal extension, lymph node

Biopsy required for thyroid nodule if:
Benign:no
Very low risk>2cm
Low risk>1.5cm
Intermediate+high risk>1cm

Most important notes in Bariatric surgery 📝
🔴Indications for surgery
▪️BMI >40
▪️BMI >35 + co-morbidities ( 2 O ( osteoarthritis-OSA) / 3D (DM 2 -Disk prolapse -Dyslipidemia )/ HTN)
🔴 Ursodiol➡️ minimize gallstone development
🔴Sleeve gastrectomy ➡️ no metabolic malabsorption
🔴Interval between gastric bypass & plastic surgery procedure ➡️ 12-18 M
🔴DVT is a common risk after barriatric surgery
🔴M.C vitamin deficiency ➡️ Vit B12 ➡️ present by subacute cord degeneration
🔴In GERD ➡️ it is preferred to do Bypass procedure as Sleeve ⬆️ GERD Incidence

Notes on obesity in Endocrine 📝
🔴M.C cause of obesity ➡️simple obesity
🔴 genetic abnormalities in obesity ➡️ laurence Moon / Bradet-Beidl / prader-willi/ Frolich’s
🔴 drugs that lead to obesity ➡️ 3C ( Contraceptive pills - Carbamazepine - Corticosteroids) / ( insulin - TZD) / 2S ( Sulphonyl urea -Sertonin antagonist)
🔴Lateral Nuclei ➡️ Feeding centre
🔴Ventromedial Nuclei ➡️ Satiety centre
🔴Skin fold thickness ➡️ Normal values
F ➡️ 30 mm
M ➡️ 20 mm
🔴Waist circumference ➡️ Normal values
F➡️<80 cm
M➡️< 94 cm
🔴 Waist / Hip ratio
F➡️ <0.75
M➡️<0.85
🔴 Best tool for fat distribution evaluation ➡️CT & MRI
Co-morbidities of obesity
🔴HTN
🔴Atherothrombosis ➡️ obesity is considered a pro-thrombotic state
🔴 restrictive lung disease
🔴 obstructive sleep apnoea
🔴 hypoventilation syndrome➡️ cyanosis
🔴DM
🔴 Hyperuricaemia
🔴 Hyperlipidaemia
🔴NASH
🔴 gallbladder stone
🔴GERD
🔴 F ➡️ irregular menses , amenorrhea and infertility
🔴M ➡️ delayed puperty and hypogonadal manifestation( ⬆️aromatase activity)
🔴 osteoarthritis
🔴Cancer
M ➡️ colorectal + prostte
F➡️ ( breast-ovaries-uterus ) +GB
🔴 idiopathic intracranial hypertension ➡️ headache , tinnitus & vision disorders
🔴 to lose 1 kg , you must burn 🔥 7500 kcal

زيادات ال integrated فى ال obesity
🔴Drugs
1) 1st line ➡️ GLP 1 agonist ( semaglutide)
2) Orlistat
3) phenterimine

🔴Endoscopic management
1ry management ( before surgery)
▪️ Restriction
✅ Intra-gastric ballon
Indications :⬆️ neck circumference
Contra-indications: previouse GIT surgery - pregnancy- large hiatal hernia

✅Tranpyloric shuttle ( كأنها GOO)

✅Transoral gastroplasty (كأننا بندبسها)

▪️Malabsorption
✅implants

▪️Delay emptying
✅Botilinium injection

2ry management (after surgery)

▪️Rx complications
✅Dumping $ ➡️ narrow stomach
✅Widened sleeved stomach ➡️ narrow it


🔴 Surgery
✅ Mini Gastric bypass= Omega loop bypass ➡️ Modification of sleeve gastrectomy

اي حد هيمتحن oncology او head and neck لازم يحفظهم
Levels of cervical LN
L1 A Submental
L1 B sub mandibler
L2 equal (upper deep cervical) from base of skull till hyoid bone divided by spinal acessery nerve to
A inf
B sup
L3 eqal (middle deep cervical) From hyoid to circoid.. between it and L4 omohyoid muscle
So... Supra omohyoid dissection we remove level 1 2 3 only MCQ✅
L4 (lower deep cervical) from circoid to clavicle equal supraclavicler LN MCQ✅
L5 equal post triangle LN
جاتلي في امتحان الروند head and neck MCQ. كان عايز level 5 ده ايه
L6 prelarngal LN=Delphine LN
جاتلي في امتحان روند الoncology كان عايزه مين هي الDelphine LN
L7 mediastinum LN

SURGERY OF integrated