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2:46

and gentlemen, welcome back to

2:49

Behind the Knife's website review.

2:51

We are thrilled to

2:53

have you. Hopefully you're still listening and you

2:55

haven't gotten too annoyed of us. We have

2:57

a rapid fire review for you today. I'm

3:00

here with our prolific surgical education

3:02

fellows, Nina Clark and Dan Sheese. Seriously,

3:05

we love them. If you love surgical education too, you

3:07

should think about joining our team. We

3:09

are going to do a rapid fire review. So

3:11

we're going to rip through some topics and

3:14

we're going to think about keywords and associations, things

3:16

that are going to help you get that question

3:18

right now. We're going to start with Nina and

3:20

we're going to start with breast.

3:23

There are five key nerves that we think about

3:25

when it comes to breast surgery. What are those

3:27

nerves and what happens when you injure those nerves?

3:31

Yeah, Patrick. So the most commonly injured nerves

3:33

in breast surgery is the intercostal brachiocutaneous nerves.

3:35

So this is the one that's going to

3:37

impact your inner arm sensation and that's what

3:39

you're going to look for in your post-operative

3:42

visit with those patients. Next

3:44

up, you've got the long thoracic nerve. This is

3:46

more medial in the axilla and innervates

3:49

the serratus anterior which can result in

3:51

that classic winged scapula picture that you're

3:53

going to see on ab site. Next

3:56

up, a little bit more dorsal to that

3:58

is the thoracodorsal nerve. This innervates the. The

4:00

Christmas or say injury to this nerve results

4:02

a week adoption and internal rotation of the

4:04

It's Ladder arm the last. You are less

4:06

commonly thought of when you think about breast

4:08

surgery and please. Classic nerve injuries are, but

4:11

they can't. You have an Ad site in

4:13

those are the Medial Petra on Earth which

4:15

innervate it's both the Pack Major, her and

4:17

the Pack minor and actually live more lateral

4:19

on his chest wall. Which is a little

4:21

bit confusing because the Lateral Pectoral Nerve only

4:24

innervate the Pack Major and actually lies more

4:26

medial. That's. A perfect as a person

4:28

isn't it? Was. Our bathrooms.

4:30

Texas. What Is it? Past. And

4:32

plants. as the involvement theme parks. a

4:34

direct humid hide in a spread of

4:36

breast cancer to the spine says you

4:39

see some use my man, That's usually.

4:41

I got their. About you

4:43

described different know nibble discharge and there's

4:45

as usual disease. Oh yes,

4:47

always a funnel And and kind of

4:50

terrifying to think about it. So green

4:52

discharged typically is in the context of

4:54

fibrosis exchanges. And. That can often

4:56

show up as that more said, geologic discharge

4:58

said. think about bilateral multiple thought, that kind

5:00

of thing. Bloody. To search has

5:02

more concerning in general are most commonly

5:04

it shows up in the context of

5:06

an introduction Papilloma. I which is

5:08

not free malignant and but still generally warrants

5:11

a reception. There. Is discharged

5:13

can raise concern for malignant causes as

5:15

well, especially if it's spontaneous and in

5:17

general when you're thinking about discharge, get

5:20

breast imaging tracker, prolactin level, do the

5:22

normal work up for rust matters. That.

5:24

As can be in the context of not malignant

5:27

clauses, Unilateral discharge should always prompts

5:29

press imaging because this is more often

5:31

in that context of Milligan or a

5:33

pre malignant diet since any breath imaging

5:35

if you find something that looks abnormal,

5:37

biopsied yet and yet or for work

5:39

at yet when you do think about

5:41

this Brescia Sergio, sometimes T.tick sessions or

5:43

terminal duct excursions, that's really a last

5:45

resort that you'll go to have every

5:47

other imaging work out that you've done

5:49

so far as negative and you're so

5:51

concerned about discharge. Fantastic! So L

5:53

C I S decision marker for

5:56

increased risk of cancer. or

5:58

in either breast national guards were you find

6:00

it. So what are some other key points for

6:02

lobular carcinoma in situ? LCIS is this

6:04

marker for risk of cancer. That's how I

6:06

think about it. It's not pre-malignant in

6:09

and of itself. There's typically no imaging findings

6:11

with LCIS, which I think is a little

6:13

tricky. It's often just found incidentally when somebody

6:15

is getting a biopsy or imaging for something

6:18

else. And in general, you

6:20

should do an excisional biopsy for a patient

6:22

with a diagnosis of LCIS. But the nice

6:24

thing about this is because it's more a

6:26

risk factor for cancer, you generally don't

6:29

have to re-exize even if you end

6:31

up with positive margins after doing an

6:33

excisional biopsy for LCIS. So you do

6:35

not generally have to re-exize for a

6:37

positive margin. The only exception to

6:39

that rule is pleomorphic subtype of LCIS,

6:41

which we treat more like DCIS, which

6:44

we'll talk about I think next. And

6:47

we would re-exize if you have a

6:49

positive margin. So pleomorphic LCIS treated as

6:51

a pre-malignant lesion. The rest you can

6:53

generally leave even if you have a

6:55

positive margin. Okay. So how about

6:57

DCIS? I'm wondering some of the key findings and things we

6:59

need to worry about there. Yeah. So

7:01

DCIS is the classic more of a

7:04

pre-malignant finding. And so it's therefore treated

7:06

more aggressively. So for these cases,

7:08

you're doing a formal oncologic resection of the

7:10

primary tumor and DCIS has a two millimeter

7:12

margin that you want to get on that

7:14

lumpectomy. If you do breast

7:17

conserving therapy with a lumpectomy, you do follow

7:19

that up with radiation therapy

7:21

postoperative lays, just like you do with

7:23

an invasive cancer. If you

7:25

do a breast conserving surgery with DCIS,

7:28

you do not generally have to do

7:30

a sentinel node biopsy. Again, because DCIS

7:32

is pre-malignant, it's not invasive. However,

7:35

if a patient is receiving a

7:37

simple mastectomy or mastectomy for DCIS,

7:40

then you do your sentinel node because you are

7:42

basically getting rid of all the breast tissue that

7:44

you would otherwise use to get a sentinel node.

7:46

And if your pathology comes back as malignant in

7:48

that case, you've kind of screwed the fusion,

7:51

you can't get that sentinel node biopsy after the

7:53

fact. Postoperatively, patients with

7:55

DCIS should also get adjuvant endocrine

7:57

therapy as their tumors are ERPR

8:00

There. As. An intersex Henri so I'll

8:02

see I see don't necessarily need those negative

8:04

margins. a letter to play a more accent

8:06

I D C I S two millimeter margins

8:08

and you really? yeah. I talked about the

8:10

overall treatment strategy a very clearly so at

8:12

thank you for that. a promise around the

8:14

same. The rest of this is not as

8:16

hard as the breath for starting off with

8:18

a good stuff, so I mean it. going

8:20

on with another really complicated question, but really

8:22

were talking about just the beginning and of

8:24

the work up. A for ah, an individual

8:26

with abreast lump in We want to cut

8:28

that into folks with let him or less

8:30

than thirty. Years old and patients are great. In

8:32

thirty years old were some of the bay is empty.

8:34

thoughts there in terms of the approach you younger. Beast

8:37

and Sentence press. So generally your

8:39

first finalising steadiness. Patience is an

8:41

ultrasound. You. Can also consider it an

8:43

M R I N. Basic stations should also

8:45

get a mammogram just as yes it is

8:47

showing up on mammogram if there's an apple.

8:50

A mass. If. A patient over

8:52

thirty years old has a couple let us get

8:54

a mammogram as your standard of care and an

8:56

odd meant that with an ultrasound. That.

8:58

Ask. What? Are the breast

9:00

cancer screen rex now for the

9:03

average risk patient This multiple correct.

9:06

There are so many a and generally they awful

9:08

and it seems on a yearly basis. Said this

9:10

is definitely something I would have to look up

9:12

right? The for add say. This. May sound

9:14

kind of on the right track. So. There's probably

9:16

no exact hot often. Most of these

9:19

questions won't ask you directly like right

9:21

on that faster were some of changing

9:23

that many since then. But. The

9:25

American College of Surgeons recommend that you

9:27

sir annual nanograms at each fourteen So

9:29

most of the as well start with

9:31

annual mammograms or every to your manner

9:33

grams around ages of forty to Forty

9:35

farm and you to see that as

9:37

your general Aca gym. And

9:39

as it's so there's level one, two, and

9:41

three lymph nodes. and we talk about breast

9:44

and breast surgery. Were those located?

9:47

Yeah. So level one as lateral to

9:49

the pack minor level to is Denise the

9:51

tech minor and level three is medial said

9:53

attack minor. The. standard for a

9:55

modified radical mastectomy only remove this

9:58

levels one and she'll only

10:00

level 3 gets removed if it's clinically positive. So

10:02

if you're in the operating room and you seek

10:04

a positive note but otherwise you leave it alone.

10:06

Alright, where does breast cancer most

10:08

commonly metastasize to? That is

10:11

the bone Patrick. Alright, so we have

10:13

a we're thinking about hormone therapy and

10:16

what's the difference between premenopausal and postmenopausal patients?

10:18

What type of drug classes or specific drugs

10:20

do we need to know? Yes,

10:22

so this has been studying a

10:24

couple of randomized trials. Premenopausal patients

10:27

should generally be treated with a

10:29

CIRM which is the tamoxifen or

10:31

the reloxifene and these medications are

10:33

associated with an increased risk of

10:35

endometrial cancer and being a thromboembolic

10:37

event. Postmenopausal patients on the

10:40

other hand should get those aromatase inhibitors

10:42

and that's your anastrozole and your leftrozole.

10:45

Those that are associated with osteoporosis that

10:47

you should generally be watching for

10:49

anyway in this population. Yeah, I feel

10:51

like that's a good question right? The CIRMs associated with

10:53

endometrial cancer and VTE, I've seen that

10:56

numerous times. So what is

10:58

a treatment for

11:00

invasive carcinoma when it

11:02

comes to the neoagivant aspect of care?

11:04

This is something I have all again have

11:06

to review almost every single year is who

11:09

gets neoagivant treatment for breast cancer. So these

11:11

are going to be the patients who have

11:13

an inoperable primary with distant metastasis, locally

11:16

advanced disease, so it's stage 3

11:18

with lentinode involvement or really bulky

11:20

primary. Patients with inflammatory breast

11:22

cancer all get neoagivant treatment, a large

11:24

tumor that with a patient who wants

11:26

breast conservant therapy, so the idea of

11:28

being there being that you want to

11:30

shrink that tumor so that they can

11:32

be a candidate for lymphectomy and

11:35

patients with early stage triple negative

11:37

breast cancer all generally will be

11:39

changing towards getting neoagivant therapy. And

11:42

this generally involves chemotherapy as well as

11:44

endocrine therapy if the tumors ERP are

11:46

positive and trastosumab or perceptin if it's

11:48

her to positive. So what's the rundown

11:51

of some basic or the surgical approaches for primary

11:53

tumors and breast cancer again kind of a big

11:55

picture for you? Yes I

11:57

love this question because I feel like this is one of the

11:59

very few things that is kind of simple

12:01

about breast cancer. But you basically have two

12:03

options at all times. You have a breast

12:06

conserving therapy which is a lumpectomy that

12:08

always goes along with post-op radiation and in

12:10

for very, very few circumstances. So post-op radiation,

12:12

just think of it as a must if

12:14

you're doing a lumpectomy. The

12:17

confusing part there, I guess, is that

12:19

the margins for an invasive breast cancer

12:21

is no tumor on ink as opposed

12:23

to DHCIS, which remember that was a

12:25

two millimeter margin. So for invasive cancers,

12:27

you just don't want tumor on your

12:29

ink. The other option for

12:31

patients with primary breast cancer is mastectomy,

12:33

which only needs radiation if the tumor

12:35

was extremely large or if there are

12:37

other complicating factors. How about taking

12:40

us to have a lymph nodes when it comes

12:42

to breast cancer? So there's going to be a

12:44

mouthful and I think we have it nicely summarized

12:46

here. So why don't you go through it for

12:48

everyone? Yeah, so this is where the

12:50

surgery for breast cancer gets complicated. Generally,

12:53

in patients who are clinically node negative, which

12:55

means they have nothing on their exam or

12:57

on any ultra-percents that you've gotten, they get

12:59

a sentinel lymph node biopsy. The way you

13:02

manage that is this ACODZ11 and the AMARS

13:04

trial that you've heard of eight million times

13:06

for a residency. So if the patient has

13:09

a sentinel node biopsy, one to

13:11

two of their nodes come back positive and

13:13

they have an early stage T1 or T2 primary

13:15

and they got a lumpectomy, then

13:17

you're all good. You can just do radiation

13:19

like you would any way for breast cancer,

13:21

if you're in therapy, and the patient does

13:24

not require any additional axillary surgery. If they

13:26

have one or two positive lymph nodes on

13:28

a sentinel node biopsy and they got a

13:30

mastectomy, you also can generally do radiation therapy.

13:33

This is out of AMARS trial and they

13:35

don't need any additional axillary surgery. If

13:38

a patient, however, has three or more

13:40

positive nodes or a very large primary

13:42

or for whatever reason they can't get

13:44

radiation after surgery, then you

13:46

would proceed with an axillary lymph node

13:48

dissection. In a patient who's clinically node

13:51

positive, then you think getting neoadjuvant therapy

13:53

on board early. After neoadjuvant, if they've converted

13:55

to becoming clinically node negative and if they had early

13:57

stage T1, then you would have a T1 or T2

13:59

primary. prior to getting a neoadjuvant so not

14:19

you would do an axillary node dissection in those

14:21

cases. Right, so I think the most common question

14:23

that would come up on the test is for a patient

14:25

who's clinically node negative

14:28

you do a sentinel lymph node biopsy and they're gonna

14:30

give you some results and if

14:32

they have one to two nodes positive and

14:34

they have a small tumor then you're good

14:36

with your lumpectomy. If

14:39

they have one to two positive and

14:41

they did a mastectomy but you're also

14:43

looking at radiation therapy for those patients

14:45

if they're three or more nodes positive

14:47

or there's a really large primary tumor

14:50

then you're thinking axillary lymph node dissection.

14:52

I think I got that correct. I think you

14:54

do too. Okay, so let's go on the

14:56

adjuvant therapy. So what kind of adjuvant therapy

14:58

are out there and options for breast cancer

15:01

patients? So this falls into

15:03

four categories in my mind. Hemo,

15:05

radiation and hormone therapy and anti-griture

15:07

therapy. Hemotherapy generally of a

15:10

patient has positive nodes or a

15:12

greater than one centimeter primary unless

15:14

they're really low risk and hormone

15:16

receptor positives they're gonna get chemotherapy

15:18

after surgery. Radiation again this is

15:20

always going to go alongside breast

15:22

conserving therapy so if you see

15:24

somebody with a lymphectomy give them

15:26

radiation after surgery. After mastectomy

15:28

patients still may need radiation if they had

15:31

a lot of nodal disease or if they

15:33

had nodal disease that you weren't

15:35

able to surgically address so those are like the

15:37

internal mammary nodal the test disease that you might

15:39

see sometimes. Anybody with skin

15:42

or chest wall involvement a positive

15:44

margin or in preliminary breast cancer

15:46

should also get post-op radiation therapy.

15:48

Hormone therapy generally think

15:50

about this for anybody who has those

15:52

ERPR positivity on their tumors even if

15:54

it's DCIS. This Generally works as

15:56

a five to ten year treatment

15:58

course with either. The from or it

16:01

or a I ah depending on their each

16:03

group. And. Then finally the and

16:05

take her to at Therapy. It is directed

16:07

therapy for patients who have her to positive

16:09

tumors and it generally it's use for a

16:11

year after surgery. Or event

16:13

as again we're going to hard to hide it

16:16

away. Or. What is Stooge

16:18

Read Syndrome or Spartacus to

16:20

address it? I like

16:22

that you wrote still be translated,

16:24

com and done Airline stewards to

16:26

travel south and. And.

16:28

This is a limp angiosarcoma of the upper

16:30

extremity that happens after an accelerant and it's

16:32

actions. This is reader and I'll look for

16:34

piecing. It comes into clinic post operative late

16:36

when it is spreading your kind of brews

16:38

like looking with ease and or where he's

16:40

purplish reddish leash and on their skin other

16:42

arm. And so am I. Can

16:44

you describe the by Rads classification system. Also,

16:47

highly testable. authored by Ran Zero. It's

16:50

not a diagnostic any that another type

16:52

of imaging side or a diagnostic mammogram

16:54

or an ultrasound. I read:

16:56

one is the normal an anagram

16:58

phased array appear normal screening. Parents

17:01

to as a benign finding on a

17:03

mammogram. Service also goes back to normal

17:05

swinging. Pirates. Three, it's probably

17:07

been. I have these patients where you're going

17:09

to coordinate short interval fall are generally and

17:11

about six months with another mammogram. I

17:14

ran has for as a suspicious finding that you're

17:16

gonna get by on a feature that. Iran

17:19

five. It's highly suspicious and it's also going

17:21

to get a biopsy. And by read

17:23

six it's feathers. Turkey ones. Where are you already know

17:25

that they have a little they can see, it's biopsy

17:27

proven and years or three imaging and. Great.

17:30

When it comes to live node staging was

17:32

in. He got pregnant basins. Yes,

17:35

It is is also often on

17:37

and site so you can use

17:39

your Technetium Radioactive injectable for your

17:41

sentinel lymph node biopsy. And pregnant

17:44

nations however, do not use blue

17:46

dye so avoid Methylene Blue isn't

17:48

any pregnant decent. Are right

17:50

we didn't d brother Dan that you are

17:52

on. Was. Move on. Abdominal

17:54

wall. Or you have a hernia between

17:57

the last the a sterile weekend. Ilia Crests what

17:59

is the name? This is a

18:01

petite hernia. okay a her yeah, just

18:03

lateral to the erectus usually below the

18:05

argue that like this is your spaghetti

18:07

and hernia. Gases. So much easier

18:09

than unisex him. And. You have out

18:11

a little piece about the not the whole

18:13

thing in earnest and a half speed anti

18:16

mesenteric side of about it is the Richter

18:18

is hernia. A Right and the

18:20

incarcerated Mack Michael's hernia. I'd love to

18:22

see the still a trace hernia. okay

18:24

and the last. the Upper Lumbar for

18:27

yeah, the Borders A twelfth read: Director

18:29

Spiny Muscles and the post year border

18:31

of the In Fear oblique. This

18:33

is Green Seltzer Mia. Okay, now this

18:35

is a really hard on: the most

18:37

common salad. A mental tumor that's a

18:40

metastasis. us. Are going into your back

18:42

at united of that and a grammar come back to

18:44

the it for you then I hate. This. Either

18:46

three types of congenital Adrenal Hyperplasia Ch

18:48

that we need to know. The first

18:51

is Twenty One Hydroxyl A Deficiency when

18:53

you see with that Nina. says.

18:55

Is the most common that we see

18:58

an inefficient you'll have thought we think

19:00

hypertension and precocious puberty and males and

19:02

ending see nothing out there. Allegation. Again,

19:05

what about deficits in eleven? A beta

19:07

hydroxyl is. This lens

19:09

that not thought we'd thing. So you've got

19:11

a precocious puberty and males and realisation and

19:14

he knows about it made the said he

19:16

misses. right? And and last

19:18

is seventeen Alpha hydroxy least as isn't.

19:21

Yet citizens also night sodium way saying

19:23

that these patients or at ambiguous male

19:25

genitalia athletes remember that this is that

19:28

one's been arrows sunday get chart with

19:30

the first column being A for Eldar

19:32

throne and the said including t for

19:35

testosterone. And. Then for each when you just

19:37

draw a little like to boo and then it

19:39

up era of and sell for twenty one is

19:41

that. Normal L, the austro

19:43

around and then high testosterone. For

19:46

example, for eleven the about high

19:48

and for seventeen. In. The A

19:50

column throughout our thrive in it's High Energy

19:52

is Not. Okay, so that narrows

19:54

for the ones. Yeah. So

19:56

Cushion Syndrome is almost certainly had a

19:58

question about that the past. How do

20:00

we start that work of how do

20:02

we verify Hypercard Salzman his patients. Yeah,

20:05

Realizing that this one I really need my assaults

20:07

do a lot of painful work or it turned

20:09

out to just answer a bunch a hernia tape.

20:11

To work out somebody was suspected cussing syndrome you

20:13

for it's one of verify that they actually have

20:15

hyper cortisol. it's M C. are gonna get it

20:17

twain for our the or inquiries. All. You'd.

20:19

Expect that city three times the upper limit

20:22

of normal or higher. He. Also can

20:24

get it late night salivary cortisol if

20:26

the during the says you can use

20:28

your low dose decks aggression chance to

20:30

and you would still see a levels

20:32

of cortisol after getting decks madison those

20:34

would still be I. Don't need

20:36

one a localized is it in adrenal source

20:38

or an actor adrenal source Of all this

20:41

extra cortisol flown around so that's where you're

20:43

gonna get your your M A C T

20:45

H if it's working corrupt correctly. Ac th

20:47

should work to decrease cortisol production from and

20:50

adrenal gland. Said. Your easy ch

20:52

is low. you're looking at an adrenal

20:54

source, as are some. If

20:56

you're a speech huge remains high when you

20:59

start looking for things like a topic. Sources

21:01

are pituitary. I don't know. That.

21:03

Are stop it if you have to look like

21:05

your act or gentle source another sex or cortisol

21:08

so you're in a perform in high dose exmouth

21:10

insolence. The person. In case of

21:12

it but she were to resource you're going to

21:14

seats depression. However, an ectopic source

21:16

will not be suppressed, said the Try.six suppression

21:19

test and so there's something that's gone completely

21:21

rug usually a lung tumor in that case.

21:24

And as or first woman to verify court for

21:26

cortisol isn't that was convoys of the twenty four

21:28

your cortisol was would be three times over limit

21:30

of normals. That. Is inclusive. we can

21:32

try that low dose ducks Madison suppressant as

21:34

we'd been want to localize. This

21:36

leasing whether it does figure out whether to

21:39

drain or extra adrenal. We do this with

21:41

Serum A C T H. And.

21:43

If we think is x for adrenal

21:45

for the localized with a high dose

21:47

x amount his own suppressant us. We.

21:49

Can also the on m rise of had or

21:52

they can pituitary and then cities games of chance.

21:54

To. Talk

21:59

source. positive

24:00

lymph nodes, capsular invasion, medullary

25:04

thyroid carcinoma and pheochromocytomas.

25:07

All right. And 2B. The

25:09

kind of wonky one. So this

25:11

also has medullary thyroid carcinoma and

25:13

pheochromocytoma, but you also get those

25:16

cozyl neuromas and the marfanoid habitus.

25:18

How about the blood supply to all four

25:21

parathyroid glands? As you wrote in your

25:23

slide here, all four of the little bastards

25:25

are served by the inferior of your thyroid

25:27

artery. Yeah, they are little bastards.

25:29

I hope to never see them again. That's true.

25:31

What does PTH do and what does vitamin D

25:34

do? So PTH serves

25:36

to increase calcium and decrease phosphate.

25:38

So it increases your osteoclasts activity,

25:40

increases renal uptake of calcium, decreases

25:43

renal uptake of phosphate and

25:45

increases vitamin D activity. Vitamin

25:47

D helps us to absorb calcium. So

25:50

it increases calcium in general and increases

25:52

phosphate. All right. Primary

25:54

hyperparathyroidism. What is that? Primary

25:57

is the easiest one to remember. This is your

25:59

parathyroid. adenoma, it's like

26:02

autonomously making too much PTH. Right

26:05

versus secondary? Secondary

26:07

is going to be a patient in renal failure so

26:09

your kidneys are really bad at activating vitamin D and

26:11

you lose calcium as a result of it and your

26:14

parathyroid is trying to make up for it in my

26:16

mind at least by over producing

26:18

PTH. Right and then

26:20

tertiary? Tertiary is like after

26:22

a patient has already had secondary type so

26:24

you've had renal failure your parathyroid are used

26:26

to cranking out PTH all the time and

26:28

then all of a sudden in a single

26:31

day you get into kidney it works and

26:33

your parathyroid have like way too much momentum and

26:35

they forget to stop. You got

26:37

a question stem where you can't find the

26:40

parathyroid, where is it? I

26:42

thought this was your dream Patrick. My nightmare. But

26:44

you're gonna

26:47

go looking in the thymus and really just

26:49

think about the anatomic places where a parathyroid

26:51

glands can hide and the thymus is most

26:53

common so generally you're gonna do a cervical

26:56

thymectomy. If they don't give you

26:58

that as an option and also look in

27:00

the retro esophageal tracheostalgeal groove carotid

27:02

sheath or embedded in the thyroid. Alright

27:05

last question what is the half-life of PTH?

27:09

The end is in sight so PTH has

27:11

a half-life of 10 minutes and this is

27:13

really important because when you're measuring your intraoperative

27:15

PTH to make sure that you

27:17

remove the right amount or the right number of

27:20

parathyroid glands your dual criteria means that

27:22

you're gonna have to wait 10 minutes for the

27:24

PTH level to drop so the first of those

27:26

is it has to drop by 10 minutes by

27:28

about 50% and the second

27:30

criteria is that it has to drop to a level

27:33

of near normal. Dan let's talk.

27:35

Alright put me in coach and fall asleep on the

27:37

bench. What's the normal length this

27:39

way not ultrasound? So for this I

27:41

think of less than 13 centimeters. So

27:45

what are how old the jolly bodies and what are Heinz bodies

27:47

what's the difference between the two? So

27:49

how jolly bodies are nuclear remnants and

27:51

erythrocytes and usually the way they ask

27:53

this on ab site is ask you

27:55

do a splenexomy on a patient and

27:58

then you still see how jolly body on

28:00

the blood smear which means that they may

28:03

have an aberrant spleen or there's still a

28:05

remnant present. Hinds body disease you

28:07

see with a oxidized hemoglobin and

28:09

so we see this more thalassemia

28:12

or G6PD deficiency. Right. So when

28:14

it comes to ITP what's our

28:16

treatment? So ITP we think first

28:18

line would be steroids followed by

28:20

IVIG. If both of these are

28:22

failing to work then at that

28:24

point we consider splenectomy. If we're

28:27

considering splenectomy we want to try

28:29

to give the three vaccines prior

28:31

to surgery being H. flu, meningococcal

28:33

and pneumococcal vaccines prior and then

28:35

post-splenectomy you'll most likely see increased

28:37

red blood cells, white blood cells

28:39

and platelets and you want to think

28:42

about starting aspirin if that platelet count gets over a million.

28:44

And when do we want to

28:46

give those vaccines ideally for an elective splenectomy? So

28:48

elective we want to try to do two weeks

28:50

prior. In the trauma world we

28:52

try we'd love to give it two

28:54

weeks after is an ideal time point

28:57

but oftentimes we'll give the patients before

28:59

the discharge to ensure they get those

29:01

splenectomy vaccines. What's another common indication or

29:03

relatively common indication for splenectomy when it

29:05

comes to these hematologic issues? Yeah so

29:07

one big one is a hereditary spherosytosis

29:10

and in this we always try to wait until

29:12

the patient's at least five years old prior to

29:14

splenectomy. You can think of

29:17

other more rare things such as

29:19

a lip dutasytosis, thalassemias, whiskata eldritch,

29:22

autoimmune hematologic anemia, TTP

29:25

and lymphoma. Alright that

29:27

wraps it up for today. We hope you find these

29:29

little tips and tricks useful. Dan and

29:31

Nina our abscitases will be back with

29:33

some more high yield reviews in our

29:35

next episode. Dominate the day. Thanks

29:38

for listening and thank you to Medtronic for

29:40

supporting surgical residents preparing for the 2024 abscite.

29:42

Since 1949 Medtronic

29:46

has relentlessly pursued therapies that change

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lives. Today we thank Medtronic for

29:50

supporting surgical residents as they relentlessly

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pursue their dreams. From all

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of us behind the knife in Medtronic, dominate

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