These secrets are 100 of the top board alerts. They summarize the concepts, principles, andmost salient details of surgical practice.

1. Primary goal in treating cardiac dysrhythmias is to achieve a ventricular rate between 60 and100 beats per minute; secondary goal is to maintain sinus rhythm.

2. Clinical determinants of brain death are the loss of the papillary, corneal, oculovestibular,oculocephalic, oropharyngeal, and respiratory reflexes for >6 hours. The patient should alsoundergo an apnea test, in which the PCO2 is allowed to rise to at least 60 mm Hg withoutcoexistent hypoxia. The patient should be observed for the absence of spontaneous breathing.

3. The estimated risks of hepatitis B virus (HBV), hepatitis C virus (HCV), and humanimmunodeficiency virus (HIV) transmission by blood transfusion in the United States are 1 in205,000 for HBV; 1 in 1,935,000 for HCV; and 1 in 2,135,000 for HIV.

4. The most common location of an undescended testicle is the inguinal canal.

5. The most common solid renal mass in infancy is a congenital mesoblastic nephroma, and inchildhood, it is a Wilms’ tumor.

6. Ogilvie’s syndrome is an acute massive dilatation of the cecum and the ascending andtransverse colon without organic obstruction.

7. The best screening method for prostate cancer is digital rectal examination combined withserum prostate-specific antigen (PSA).

8. The most common histologic type of bladder cancer is transitional cell carcinoma.

9. Carcinoma in situ of the bladder is treated with immunotherapy with intravesical bacillusCalmette-Guerin.

10. The most common cause of male infertility is varicocele.

11. The most common nonbacterial cause of pneumonia in transplant patients iscytomegalovirus (CMV).

12. Chimerism is leukocyte sharing between the graft and the recipient so that the graft becomesa genetic composite of both the donor and the recipient.

13. OKT3 is a mouse monoclonal antibody that binds to and blocks the T-cell CD3 receptor.

14. The most common disease requiring liver transplant is hepatitis C.

TOP 100 SECRETSAndrew E. Luckey, MD, and Cyrus J. Parsa, MD

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15. Cystic hygroma is a congenital malformation with a predilection for the neck. It is a benignlesion that usually presents as a soft mass in the lateral neck.

16. In neuroblastomas, age at presentation is the major prognostic factor. Children younger than1 year have an overall survival rate >70%, whereas the survival rate for children older than1 year is <35%.

17. The most feared complication of diaphragmatic hernia is persistent fetal circulation.

18. The three most common variants of tracheoesophageal fistula are (1) proximal esophagealatresia with distal tracheoesophageal fistula, (2) isolated esophageal atresia, and (3)tracheoesophageal fistula with esophageal atresia.

19. Atresia can occur anywhere in the gastrointestinal (GI) tract: duodenal (50%), jejunoileal (45%),or colonic (5%). Duodenal atresia arises from failure of recanalization during the eighth totenth week of gestation; jejunoileal and colonic atresia are caused by an in utero mesentericvascular accident.

20. The two types of aortic dissection are ascending (type A) dissection, which begins in theascending aorta and may continue into the descending aorta, and descending dissection(type B), which involves only the descending aorta.

21. The likelihood that a solitary lung nodule is cancer is the same as the age of the patient; thus,a 60-year-old patient’s nodule is 60% likely to be cancer.

22. Mediastinal staging (mediastinoscopy) is indicated if: (1) the lung nodule is >2 cm; (2) themediastinum is "full" as seen on a computerized tomography (CT) scan; and (3) the nodule is"kissing" up against the mediastinum. A lung resection is contraindicated if: (1) "high" ipsilateralparatracheal nodes are positive; (2) contralateral nodes are positive; or (3) undifferentiated("oatcell") histology is identified.

23. The most common causes of aortic stenosis are now congenital anomalies and calcific(degenerative) disease.

24. In mitral regurgitation, the left ventricle ejects blood via two routes: (1) antegrade throughthe aortic valve, or (2) retrograde through the mitral valve. The amount of each strokevolume ejected retrograde into the left atrium is the regurgitant fraction. To compensatefor the regurgitant fraction, the left ventricle must increase its total stroke volume.This ultimately produces volume overload of the left ventricle and leads to ventriculardysfunction.

25. The indications for coronary artery bypass graft (CABG) are (1) left main coronary arterystenosis; (2) three-vessel coronary artery disease (70% stenosis) with depressed left ventricular(LV) function or two-vessel coronary artery disease (CAD) with proximal left anteriordescending (LAD) involvement; and (3) angina despite aggressive medical therapy.

26. Hibernating myocardium is improved by CABG. Myocardial hibernation refers to the reversiblemyocardial contractile function associated with a decrease in coronary flow in the setting ofpreserved myocardial viability. Some patients with global systolic dysfunction exhibit dramaticimprovement in myocardial contractility after CABG.

27. The surgical treatment of ulcerative colitis is total colectomy with ileoanal pouch anastomosis.

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28. Dieulafoy’s ulcer is a gastric vascular malformation with an exposed submucosal artery, usuallywithin 2 to 5 cm of the gastroesophageal junction. It presents with painless, often massive,hematemesis.

29. The role of blind subtotal colectomy in the management of massive lower GI bleeding is limitedto a small group of patients in whom a specific bleeding source cannot be identified. Theprocedure is associated with a 16% mortality rate.

30. Colorectal polyps<2 cm have a 2% risk of containing cancer; 2-cm polyps have a 10% risk; andpolyps>2 cm have a cancer risk of 40%. Sixty percent of villous polyps are >2 cm, and 77% oftubular polyps are <1 cm at the time of discovery.

31. Patients with colorectal cancer with lymph node involvement (Dukes’ classification) shouldreceive chemotherapy postoperatively to treat micrometastases.

32. Goodsall’s rule states the location of the internal opening of an anorectal fistula is based on theposition of the external opening. An external opening posterior to a line drawn transverselyacross the perineum originates from an internal opening in the posterior midline. An externalopening anterior to this line originates from the nearest anal crypt in a radial direction.

33. Incarcerated inguinal hernia: structures in the hernia sac still have a good blood supply but arestuck in the sac because of adhesions or a narrow neck of the hernia sac. Strangulated inguinalhernia occurs when hernia structures have a compromised blood supply because of anatomicconstriction at the neck of the hernia.

34. Chvostek’s sign is spasm of the facial muscles caused by tapping the facial nerve trunk.Trousseau’s sign is carpal spasm elicited by occlusion of the brachial artery for 3 minutes witha blood pressure cuff. Both signs indicate hypocalcemia.

35. The two surgical options for Graves’ disease are subtotal thyroidectomy or near-totalthyroidectomy.

36. The only biochemical test that is routinely needed to identify patients with unsuspectedhyperthyroidism is serum thyroid-stimulating hormone (TSH) concentration.

37. The surgically correctable causes of hypertension are renovascular hypertension,pheochromocytoma, Cushing’s syndrome, primary hyperaldosteronism, coarctation of theaorta, and unilateral renal parenchymal disease.

38. The "triple negative test" or "diagnostic triad" for diagnosing a palpable breast mass includesphysical examination, breast imaging, and biopsy.

39. Chest wall radiation is indicated after mastectomy in patients with greater than 5 cm primarycancers, positive mastectomy margins, or more than four positive lymph nodes, all of which areassociated with heightened locoregional recurrence rates.

40. Sentinel lymph nodes are the first stop for tumor cells metastasizing through lymphatics fromthe primary tumor.

41. The most common site of origin of subungual melanomas is the great toe. Amputation ator proximal to the metatarsal phalangeal joint and regional sentinel lymph node biopsyare advised.

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42. Ramus marginalis mandibularis, the lowest branch of the nerve that innervates the depressormuscles of the lower lip, is the most commonly injured facial nerve branch duringparotidectomy.

43. Waldeyer’s ring is the mucosa of the posterior oropharynx covering a bed of lymphatictissue that aggregates to form the palatine, lingual, pharyngeal, and tubal tonsils. Thesestructures form a ring around the pharyngeal wall. This may be the site of primary ormetastatic tumor.

44. A patient in whom the head and neck examination is completely normal but fine needleaspiration (FNA) of a cervical node reveals squamous cancer should have examination ofthe mouth, pharynx, larynx, esophagus, and tracheobronchial tree under anesthesia(triple endoscopy). If nothing is seen, blind biopsy of the nasopharynx, tonsils, base oftongue, and pyriform sinuses should be done at the same sitting.

45. The microorganisms implicated in atherosclerosis include Chlamydia pneumoniae, Helicobacterpylori, streptococci, and Bacillus typhosus.

46. The cumulative 10-year amputation rate for claudication is 10%. Vascular disease is systemic,therefore, many of these patients die before amputation.

47. The absolute reduction in risk of stroke is 6% over a 5-year period in asymptomaticpatients with >60% stenosis who undergo carotid endarterectomy (CEA) plus aspirinversus patients treated with aspirin alone (5.1%; surgery versus 11% medical Rx). This isfrom the Asymptomatic Carotid Atherosclerosis Study (ACAS) study (see Required ReadingChapter 1).

48. The average expansion rate of an abdominal aortic aneurysm is 0.4 cm/year.

49. Heparin binds to antithrombin III, rendering it more active.

50. The patient with suspected intermittent claudication should initially be evaluated by obtainingankle brachial index (ABI) or segmental limb pressures at rest. Typically, ABI of 0.6 reflectsclaudication and ABI of <0.3 reflects limb threat.

51. Shock is suboptimal consumption of oxygen (O2) and excretion of carbon dioxide (CO2) at thecellular level.

52. Nitric oxide is synthesized in vascular endothelial cells by constitutive nitric oxide synthase(NOS) and inducible NOS, using arginine as the substrate.

53. Saliva has the highest potassium concentration (20 mEq), followed by gastric secretions(10 mEq), and then pancreatic and duodenal secretions (5 mEq).

54. Basal caloric expenditure equal to 25 kilocalories per kilogram a day with a requirement ofapproximately 1 g of protein per kilogram per day.

55. Six and one-fourth grams of protein contain 1 g of nitrogen.

56. Dextrose has 3.4 kcal/g; protein has 4 kcal/g; and fat 9 kcal/g (20% lipid solution delivers2 kcal/ml).

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57. Maximal glucose infusion rates in parenteral formulas should not exceed 5 milligrams perkilogram per minute.

58. Refeeding syndrome occurs in moderately to severely malnourished patients (e.g., chronicalcoholism or anorexia nervosa) who, with a large nutrient load, develop clinically significantdecreases in serum phosphorus, potassium, calcium, and magnesium levels. Hyperglycemia iscommon secondary to blunted insulin secretion. Adenosine triphosphate (ATP) production ismitigated, and the respiratory failure is common.

59. Glutamine is the most common amino acid found in muscle and plasma. Levels decrease aftersurgery and physiologic stress. Glutamine serves as a substrate for rapidly replicating cells(interestingly, it is also the number one metabolic substrate for neoplastic cells), maintains theintegrity and function of the intestinal barrier, and protects against free radical damage bymaintaining glutathione (GSH) levels. Glutamine is unstable in intravenous (IV) form unlesslinked as a dipeptide.

60. Fever is caused by activated macrophages that release interleukin-1, tumor necrosis factor(TNF), and interferon in response to bacteria and endotoxin. The result is a resetting of thehypothalamic thermoregulatory center.

61. Cardiac output (CO) is equal to heart rate multiplied by stroke volume; normal CO is 5 to 6 L/minand cardiac index is 2.4 to 3.0 liters per minute per square meter.

62. Systemic vascular resistance (SVR) is equal to mean arterial pressure (MAP) minuscentral venous pressure (CVP) divided by CO multiplied by 80; and it is written as: SVR ¼ to[(MAP � CVP)/CO] � 80. Normal SVR is 800 to 1200 dyne�sec/cm�5.

63. The signs of hypovolemic shock are low CVP and pulmonary capillary wedge pressure (PCWP),low CO and mixed venous oxygen saturation (SVO2), and high SVR.

64. The signs of cardiogenic shock are high CVP and PCWP, low CO and SVO2, and variable SVR.

65. The signs of septic shock are low or normal CVP and PCWP, high CO initially, high SVO2,and low SVR.

66. Kehr’s sign is concurrent left upper quadrant (LUQ) and left shoulder pain, indicatingdiaphragmatic irritation from a ruptured spleen or subdiaphragmatic abscess. Anatomically,the diaphragm and the back of the left shoulder enjoy parallel innervation.

67. Rebound tenderness (rubbing the peritoneal surfaces against each other) implies peritonealinflammation (peritonitis).

68. The five Ws of postoperative fever are wound (infection), water (urinary tract infection; UTI),wind (atelectasis, pneumonia), walking (thrombophlebitis), and wonder drugs (drug fevers).

69. Cricothyroidotomy should not be performed in patients <12 years old or any patient withsuspected direct laryngeal trauma or tracheal disruption.

70. The palpable radial (wrist) pulse reflects systolic blood pressure (SBP) >80 mm Hg; palpablefemoral (groin) pulse reflects SBP >70 mm Hg; and palpable carotid (neck) pulse reflectsSBP >60 mm Hg.

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71. A general rule for crystalloid infusion to replace blood loss is a 3:1 ratio of isotonic crystalloidto blood.

72. Raccoon eyes (periorbital ecchymosis) and Battle’s sign (mastoid ecchymosis) are clinicalindicators of basilar skull fracture.

73. Cerebral perfusion pressure (CPP) is equal to MAP minus intracranial pressure (ICP); and it iswritten as CPP ¼ MAP � ICP. Some debate exists on the minimum allowable CPP, butconsensus indicates that a CPP of 50 to 70 mm Hg is necessary.

74. Violation of the platysma defines a penetrating neck wound.

75. Tension pneumothorax is air accumulation in the pleural space eliciting increased intrathoracicpressure and resulting in a decrease in venous return to heart.

76. The most common site of thoracic aortic injury in blunt trauma is just distal to the take-off of theleft subclavian artery.

77. The most common manifestation of blunt myocardial injury is arrhythmia.

78. Indications for thoracotomy in a stable patient with hemothorax include an immediate tubethoracostomy output of >1500 ml and ongoing bleeding of 250 ml/h for 4 consecutive hours.

79. Beck’s triad is hypotension, distended neck veins, and muffled heart sounds (think of pericardialtamponade).

80. The hepatic artery supplies approximately 30% of blood flow to the liver, and the portal veinsupplies the remaining 70%. The oxygen delivery, however, is similar for both at 50%.

81. Pringle’s maneuver, which is used to reduce liver hemorrhage, is a manual occlusion of thehepatoduodenal ligament to interrupt blood flow to the liver.

82. Splenectomy significantly decreases immunoglobulin M (IgM) levels.

83. Ninety percent of trauma fatalities resulting from pelvic fractures are the result of venousbleeding and bone oozing; only 10% of fatal pelvic bleeding from blunt trauma is arterial(most common site is superior gluteal artery).

84. The protocol for intraperitoneal bladder rupture from blunt trauma is operative management,whereas the protocol for extraperitoneal rupture is observant management.

85. Pseudoaneurysm is a disruption of the arterial wall leading to a pulsatile hematoma containedby vascular adventitia and fibrous connective tissue (but not all three arterial wall layers, whichis what defines a true aneurysm).

86. The earliest sign of lower extremity compartment syndrome is neurologic in the distribution ofthe peroneal nerve with numbness in the first dorsal webspace and weak dorsiflexion.

87. Posterior knee dislocations are associated with popliteal artery injuries and are an indication forangiography.

88. Management of suspected navicular fracture despite negative radiography is short-arm cast andrepeat x-ray in 2 weeks; these fractures are also at high risk for avascular necrosis.

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89. The Parkland formula is lactated Ringer’s at 4 ml/kg � percentage of total body surface area(TBSA) burned (second- and third-degree only). Infuse 50% of volume in first 8 hours and theremaining 50% over the subsequent 16 hours.

90. The metabolic rate peaks at 2.5 times the basal metabolic rate in severe burns >50% TBSA.

91. Gallstones and alcohol abuse are the two main causes of acute pancreatitis.

92. Alcohol abuse accounts for 75% of cases of chronic pancreatitis.

93. Isolated gastric varices with hypersplenism indicate splenic vein thrombosis and are anindication for splenectomy.

94. The treatment for gallstone pancreatitis is cholecystectomy and intraoperative cholangiogramduring the same hospital stay once the pancreatitis has subsided.

95. Proton pump inhibitors (PPIs) irreversibly inhibit the parietal cell hydrogen ion pump.

96. Definitive treatment of alkaline reflux gastritis after a Billroth II includes a Roux-en-Y gastro-jejunostomy from a 40-cm efferent jejunal limb.

97. Cushing’s ulcer is a stress ulcer found in critically ill patients with central nervous system (CNS)injury. It is typically single and deep with a tendency to perforate.

98. Curling’s ulcer is a stress ulcer found in critically ill patients with burn injuries.

99. Marginal ulcer is an ulcer found near the margin of gastroenteric anastomosis, usually on thesmall bowel side.

100. The most common cause of small bowel obstructions is adhesive disease; the second mostcommon cause is a hernia.