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What’s Up in Surgery?

Live book

The practice update, on flip cards.

The living book of general surgery β€” monthly updates across the 16 divisions of general surgery, distilled from confirmed, trusted, fully referenced sources, with every card passing 3 levels of revision and confirmation.

105 cards Β· 16 divisions Β· 268 referenced sources β€” every card referenced, colour-coded by division, and stamped with its verification state.

This week

The newest cards in the book. Cards still inside the triple-review cycle say so on their face β€” nothing here wears a verification date it has not earned.

Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” dMMR Colon Cancer: Neoadjuvant Immunotherapy Before Colectomy (Β§1.3 Trial 1.5)Test MMR/MSI on every colon biopsy, and route locally advanced dMMR colon cancer into a multidisciplinary pathway offering short-course neoadjuvant nivolumab + ipilimumab before colectomy.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” dMMR Rectal Cancer: Dostarlimab and Non-Operative Management (Β§1.3 Trial 1.6)In dMMR locally advanced rectal cancer, offer single-agent dostarlimab with non-operative watch-and-wait for clinical complete responders β€” only inside specialized multidisciplinary centers or clinical trials with intensive surveillance.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” ICG Fluorescence Perfusion Angiography as an Anastomotic Adjunct (Β§1.3 Trial 1.7)Use intraoperative indocyanine green (ICG) fluorescence perfusion angiography as an adjunct during minimally invasive rectal resection β€” it can change the transection line, but the two randomized trials disagree on leak reduction.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Rectal Prolapse: Match the Approach to Fitness (Addendum Summary, Ch 1)Stratify rectal prolapse repair by fitness: laparoscopic ventral mesh or resection rectopexy for fit adults, perineal repair for the frail elderly.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewCandidate Shift β€” Sigmoid Volvulus & Ogilvie's: Decompress First, Then Definitive Treatment (Addendum Summary, Ch 1)Decompress non-gangrenous sigmoid volvulus endoscopically and resect in the same admission; treat refractory Ogilvie's syndrome with IV neostigmine or colonoscopic decompression.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Acute Pilonidal Abscess: Off-Midline Drainage, Risk-Based Antibiotics (Table 2.1)Drain an acute pilonidal abscess through an off-midline incision over the collection, and prescribe antibiotics by presentation and risk β€” not routinely for every drained abscess.

Chapters

Sixteen shelves, one colour each β€” the colour marks the division; the badge on each card carries the action. Open a chapter to read its cards in full or review them as a deck.

Colorectal, Anorectal & Pilonidal Disease

Chapter 1

Colorectal, Anorectal & Pilonidal Disease

17 cards β€” open chapter β†’

Practice shifts Β· 15

Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” dMMR Colon Cancer: Neoadjuvant Immunotherapy Before Colectomy (Β§1.3 Trial 1.5)Test MMR/MSI on every colon biopsy, and route locally advanced dMMR colon cancer into a multidisciplinary pathway offering short-course neoadjuvant nivolumab + ipilimumab before colectomy.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” dMMR Rectal Cancer: Dostarlimab and Non-Operative Management (Β§1.3 Trial 1.6)In dMMR locally advanced rectal cancer, offer single-agent dostarlimab with non-operative watch-and-wait for clinical complete responders β€” only inside specialized multidisciplinary centers or clinical trials with intensive surveillance.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” ICG Fluorescence Perfusion Angiography as an Anastomotic Adjunct (Β§1.3 Trial 1.7)Use intraoperative indocyanine green (ICG) fluorescence perfusion angiography as an adjunct during minimally invasive rectal resection β€” it can change the transection line, but the two randomized trials disagree on leak reduction.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Rectal Prolapse: Match the Approach to Fitness (Addendum Summary, Ch 1)Stratify rectal prolapse repair by fitness: laparoscopic ventral mesh or resection rectopexy for fit adults, perineal repair for the frail elderly.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewCandidate Shift β€” Sigmoid Volvulus & Ogilvie's: Decompress First, Then Definitive Treatment (Addendum Summary, Ch 1)Decompress non-gangrenous sigmoid volvulus endoscopically and resect in the same admission; treat refractory Ogilvie's syndrome with IV neostigmine or colonoscopic decompression.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Acute Pilonidal Abscess: Off-Midline Drainage, Risk-Based Antibiotics (Table 2.1)Drain an acute pilonidal abscess through an off-midline incision over the collection, and prescribe antibiotics by presentation and risk β€” not routinely for every drained abscess.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewPractice Shift β€” After Healing: Cleft Hygiene, Hair Control, and Selective Laser Epilation (Table 2.1)Counsel every pilonidal patient on gluteal cleft hygiene and hair control after healing β€” and consider adjunctive laser epilation in eligible adolescents and young adults, with the single trial's limits stated.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Chronic Anal Fissure: Topical Therapy Before Sphincterotomy (Table 1.1)Give topical vasodilators for 6–8 weeks first in chronic anal fissure; reserve sphincterotomy for low-risk medical failures.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Diverticulitis: Selective Antibiotic Omission, WSES Stage 0 Only (Table 1.1)Consider omitting antibiotics in strictly eligible WSES Stage 0 uncomplicated diverticulitis β€” and only there.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Fistula-in-Ano: Select by Continence Risk, Not a Sphincter Cutoff (Table 1.1)Choose fistula surgery by individual continence risk β€” never by a sphincter-percentage cutoff alone, and never divide the sphincter in complex tracts.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Hemorrhoids: Office-Based Therapy First (Table 1.1)Start with office rubber band ligation β€” not upfront excisional hemorrhoidectomy β€” for symptomatic Grade I–II and selected Grade III internal hemorrhoids.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Limited Pilonidal Disease: Shared Decision-Making, Not Wide Excision by Default (Table 2.1)In limited primary midline pilonidal disease, decide between minimally invasive and excisional surgery with the patient β€” match the choice to pit distribution, lateral extension, scarring and the recovery-versus-failure trade-off.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Perforated Diverticulitis (Hinchey III): Primary Anastomosis in Selected Patients (Table 1.1)In selected stable Hinchey III perforated diverticulitis, resect with primary anastomosis and a protective loop ileostomy instead of a routine Hartmann.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewPractice Shift β€” Pilonidal Reconstruction: Off-Midline Closure, Not Routine Midline Closure (Table 2.1)When pilonidal excision needs reconstruction, close off-midline (Karydakis, Bascom cleft lift, or Limberg/Dufourmentel) β€” not with a routine high-tension midline closure.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Stage II Colon Cancer: Universal MMR/MSI Testing, ctDNA-Informed Decisions (Table 1.1)Test every resected colon cancer for MMR/MSI, and use postoperative ctDNA to inform β€” never to settle β€” adjuvant decisions in Stage II disease.

Clinical pathway Β· 2

Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” Fistula-in-Ano (Β§1.2)Work the fistula pathway in five stages: exclude Crohn disease and tuberculosis first, map the tract, lay open only simple low fistulas, drain complex ones with a loose seton, then reconstruct sphincter-sparing.
Ch 1 Β· Colorectal, Anorectal & Pilonidal Disease Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” Pilonidal Sinus Disease (Β§2.2)Work the pilonidal pathway in five stages: classify the phenotype first, drain abscesses off-midline with risk-based antibiotics, decide limited disease with the patient, reconstruct complex disease off-midline, and finish with wound care plus selective hair control.
Small-Bowel Surgery

Chapter 2

Small-Bowel Surgery

2 cards β€” open chapter β†’

Practice shifts Β· 2

Ch 2 Β· Small-Bowel Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Exclude Intestinal TB Before Biologics; Run ECF by SNAP (Addendum Summary, Ch 1)Exclude intestinal tuberculosis before any anti-TNF therapy, offer early ileocecal resection alongside infliximab for limited ileocecal Crohn's, and manage enterocutaneous fistula by the SNAP protocol with delayed reconstruction.
Ch 2 Β· Small-Bowel Surgery Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Meckel's Diverticulum: Resect Wide When Symptomatic, Selectively When Incidental (Addendum Summary, Ch 4)For symptomatic Meckel's, resect the segment or a wide wedge that includes the adjacent ulcerated ileum; for incidental Meckel's, resect only when risk factors are present.
Hepatobiliary, Pancreatic & Splenic Surgery

Chapter 3

Hepatobiliary, Pancreatic & Splenic Surgery

16 cards β€” open chapter β†’

Practice shifts Β· 14

Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Bile Leak vs. Major Bile Duct Injury: Two Different Pathways (Addendum Summary, Ch 3)Separate the Strasberg A leak (ERCP stenting and drainage) from Strasberg E1–E5 transection (HPB-center Roux-en-Y hepaticojejunostomy) β€” and keep the index surgeon away from major duct repair.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Choledochal Cysts: Excise Completely, Never Drain Internally (Addendum Summary, Ch 3)Excise the whole extrahepatic cyst with cholecystectomy and Roux-en-Y hepaticojejunostomy β€” internal cyst-enterostomy drainage is abandoned.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” UDCA After Bariatric Surgery: Selective, Not Universal (Β§3.0 / Trial 3.4)Stop promoting prophylactic UDCA as a universal mandate after bariatric surgery; consider 6 months of UDCA selectively in stone-free patients undergoing RYGB.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Acute Cholecystitis: Early Index-Admission Cholecystectomy, Fitness-Triaged (Table 3.1)Do early laparoscopic cholecystectomy on the index admission for fit Grade I–II acute cholecystitis β€” and drain, do not resect, the physiologically unfit.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Acute Pancreatitis: Moderate Fluids, Early Feeding, No Prophylactic Antibiotics (Addendum Β§10.1, Row 1)Resuscitate acute pancreatitis moderately, not aggressively: Lactated Ringer's at 1.5 mL/kg/h with a bolus only if hypovolemic, reassess at 12, 24, 48 and 72 hours, feed early, and give no prophylactic antibiotics for sterile necrosis.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Elective Splenectomy: Vaccinate First, Search for Accessory Spleens, Guard Against PVT (Addendum Β§10.1, Row 6)Vaccinate β‰₯14 days before elective splenectomy, operate laparoscopically, search systematically for accessory spleens in ITP, and give extended LMWH prophylaxis with Doppler surveillance where splenomegaly raises portal vein thrombosis risk.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Gallbladder Polyps: ESGAR 2022 Stratification, Cancer on a Separate Pathway (Table 3.1)Manage true polyps by the 2022 ESGAR thresholds β€” operate at β‰₯10 mm or 6–9 mm with a risk factor, survey the middle group, discharge the smallest β€” and never put a suspected cancer on surveillance.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Hepatic Hydatid Disease: Stage-Matched WHO-IWGE Therapy Replaces Uniform Open Surgery (Addendum Β§10.1, Row 4)Match hydatid treatment to the WHO-IWGE stage: albendazole + PAIR for active unilocular CE1/CE3a cysts, surgery for multivesicular CE2/CE3b or complicated cysts, and watch-and-wait for inactive calcified CE4–CE5 β€” never instilling a scolicidal agent until biliary communication is excluded.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Hostile Hepatocystic Triangle: The Structured CVS Bailout Pathway (Table 3.1)When obliterative fibrosis blocks the Critical View of Safety, stop dissecting and run the bailout sequence β€” never divide structures to finish the case.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Infected Necrotizing Pancreatitis: Antibiotics First, Drain Late, Step Up Only on Failure (Addendum Β§10.1, Row 2)Postpone drainage of infected pancreatic necrosis until it walls off (typically β‰₯4 weeks) on antibiotics first β€” immediate drainage and early open necrosectomy are out; escalate step-up only if drainage fails.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Liver Lesions: Leave Hemangioma/FNH Alone, Resect Adenoma by Rule, Spare Parenchyma in HCC/CRLM (Addendum Β§10.1, Row 5)Leave confirmed hemangioma and FNH alone β€” no biopsy, no resection, no stopping contraceptives β€” resect hepatocellular adenoma by sex-and-size rules, and do parenchymal-sparing R0 resection for resectable HCC and colorectal liver metastases with an adequate future liver remnant.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Mild Gallstone Pancreatitis: Same-Admission Cholecystectomy (Table 3.1)Do the cholecystectomy on the same admission once mild gallstone pancreatitis is recovering β€” do not discharge and rebook it 4–6 weeks later.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Pancreatic Cystic Neoplasms: Kyoto Risk Stratification Replaces Resect-All (Addendum Β§10.1, Row 3)Stratify pancreatic cysts by the 2024 Kyoto rules: observe serous cystadenoma, resect main-duct IPMN and branch-duct IPMN with high-risk stigmata in fit patients, and put worrisome features through EUS and surveillance β€” instead of resecting every branch-duct IPMN β‰₯3 cm.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Suspected CBD Stones: Stratify First, No Routine Diagnostic ERCP (Table 3.1)Stratify suspected CBD stones by ASGE/ESGE risk before touching the duct β€” ERCP is for therapy, and intermediate-risk patients get non-invasive imaging first.

Clinical pathway Β· 2

Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Biliary & HPB Surgery (Β§3.2)Grade acute cholecystitis by TG18 first, then follow the five-step biliary pathway in order.
Ch 3 Β· Hepatobiliary, Pancreatic & Splenic Surgery Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” HPB & Non-Traumatic Splenic Surgery (Β§10.2)Work the HPB pathway in four steps: resuscitate acute pancreatitis moderately and feed early, postpone infected-necrosis drainage until walled-off encapsulation, characterise liver lesions before intervening, and run elective splenectomy as a vaccination-and-search bundle.
Upper GI & Foregut Surgery

Chapter 4

Upper GI & Foregut Surgery

7 cards β€” open chapter β†’

Practice shifts Β· 6

Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Achalasia: Myotomy Tailored to the Chicago v4.0 Type (Addendum Β§9.1, Row 3)Tailor myotomy to the Chicago v4.0 type: Laparoscopic Heller Myotomy + partial fundoplication or POEM for Types I–II, POEM preferred for spastic Type III β€” and stop repeating botulinum toxin injections in fit surgical candidates.
Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Esophageal/GEJ Adenocarcinoma: Perioperative FLOT Replaces Uniform CROSS (Addendum Β§9.1, Row 4)Treat resectable locally advanced esophageal/GEJ adenocarcinoma with perioperative FLOT (4 preoperative + 4 postoperative cycles) plus radical resection β€” not upfront esophagectomy and not uniform CROSS chemoradiotherapy.
Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Gastric Cancer: Staging Laparoscopy, Biomarkers, FLOT and Preserving D2 (Addendum Β§9.1, Row 5)Stage and profile before treating gastric cancer: staging laparoscopy with peritoneal washings, universal biomarker testing, perioperative FLOT (PD-1 blockade if dMMR/MSI-H), and spleen- and pancreas-preserving D2 gastrectomy.
Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Giant Paraesophageal Hernia: Sac Excision, β‰₯3 cm Esophageal Length, Primary Crural Repair (Addendum Β§9.1, Row 2)Repair symptomatic giant paraesophageal hernia properly: excise the sac, mobilise the mediastinal esophagus to β‰₯3 cm tension-free intra-abdominal length, close the crura primarily and add a fundoplication β€” no watchful waiting, no gastropexy alone, no permanent synthetic mesh on the hiatus.
Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” GIST: Profile Before Treating; Refractory Ulcer Bleeding: Embolize Before Gastrectomy (Addendum Β§9.1, Row 6)Profile GIST before treating it β€” EUS core biopsy with KIT/PDGFRA mutation testing, wedge resection with intact pseudocapsule and no lymphadenectomy, imatinib by risk and mutation β€” and for endoscopy-refractory ulcer bleeding go to transcatheter embolization before emergency gastrectomy.
Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Refractory GERD: Objective Testing First, Then a Tailored Anti-Reflux Operation (Addendum Β§9.1, Row 1)Document reflux objectively before any anti-reflux surgery β€” EGD, high-resolution manometry and 24-h pH-impedance β€” then tailor the operation: Nissen or Toupet by motility, Roux-en-Y gastric bypass when BMI β‰₯35 kg/mΒ².

Clinical pathway Β· 1

Ch 4 Β· Upper GI & Foregut Surgery Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” Upper GI, Esophagogastric & Foregut Surgery (Β§9.2)Work the foregut pathway in four steps: prove reflux objectively before any anti-reflux operation, tailor the intervention to BMI and achalasia type, stage and biomarker-profile esophagogastric cancer completely, then run perioperative FLOT around a minimally invasive resection.
Abdominal Wall & Hernia Surgery

Chapter 5

Abdominal Wall & Hernia Surgery

4 cards β€” open chapter β†’

Practice shifts Β· 4

Ch 5 Β· Abdominal Wall & Hernia Surgery Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Rectus Diastasis & Non-Inguinal Groin Hernias: Treat the Diastasis, Cover the Defect (Addendum Summary, Ch 4)Do not mesh an isolated rectus diastasis, do plicate a wide diastasis when repairing a midline hernia, and repair femoral, obturator and Spigelian hernias promptly with preperitoneal mesh.
Ch 5 Β· Abdominal Wall & Hernia Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Complex Ventral/Incisional Hernia (CDC II–III): Make the Four Decisions Separately (Table 4.1)Decide mesh plane, component separation, fascial closure and mesh material separately in complex ventral repair β€” no single rigid rule β€” and in CDC II–III retromuscular repairs with fascial closure, synthetic mesh beats biologic.
Ch 5 Β· Abdominal Wall & Hernia Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Groin Hernia in Women & Bilateral Primary Inguinal Hernias: Cover the Femoral Canal (Table 4.1)Prefer laparo-endoscopic TEP/TAPP covering the whole myopectineal orifice in women and bilateral primary inguinal hernias β€” never explore a woman's groin open without evaluating the femoral canal.
Ch 5 Β· Abdominal Wall & Hernia Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Primary Umbilical Hernia 1–4 cm: Mesh Reinforcement Favored Over Routine Suture (Table 4.1)Reinforce primary 1–4 cm adult umbilical hernias with flat preperitoneal or retromuscular mesh β€” and individualize, rather than mandate mesh, under 1 cm, in contaminated fields, or before planned pregnancy.
Emergency, Trauma, Acute Care & Surgical Critical Care

Chapter 6

Emergency, Trauma, Acute Care & Surgical Critical Care

17 cards β€” open chapter β†’

Practice shifts Β· 15

Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewCandidate Shift β€” Acute Mesenteric Ischemia: Revascularize Before You Resect (Addendum Summary, Ch 4)At first suspicion of acute mesenteric ischemia, get biphasic CT angiography, heparinize, and restore SMA inflow before resecting borderline bowel β€” with a mandatory second look.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewCandidate Shift β€” Fournier's Gangrene & Testicular Torsion: Operate Now, Image Never First (Addendum Summary, Ch 7)Debride Fournier's gangrene within hours without waiting for imaging, and explore a high-TWIST-score scrotum immediately without delaying for Doppler ultrasound.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewCandidate Shift β€” Mammalian Bites: Irrigate, Debride, Leave Open β€” and Never Omit Rabies Immunoglobulin (Addendum Summary, Ch 7)Leave deep puncture, cat, hand/foot and fight-bite wounds open after irrigation and debridement, cover with amoxicillin-clavulanate, and give full rabies PEP including wound-infiltrated immunoglobulin for severe stray-animal bites.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewCandidate Shift β€” Traumatic Hemothorax: Smaller Tubes, Early VATS for Retained Blood (Addendum Summary, Ch 7)Drain traumatic hemothorax with a 28–32 Fr tube (14 Fr pigtail for simple pneumothorax or stable hemothorax), and clear a retained hemothorax with VATS within 3–5 days β€” not a second tube or a late thoracotomy.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Adhesive Small Bowel Obstruction: Exclusion-First Triage & the Prognostic Contrast Protocol (Table 4.1)Exclude strangulation on contrast CT before anything else in ASBO β€” then use water-soluble contrast as a prognostic test after decompression, never as a treatment claim or a stand-alone trigger for laparotomy.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Anticoagulant Reversal: Hemorrhage Control First, Agent by Local Protocol (Table 7.1, Row 4)Control the bleeding first and reverse drug-specifically under your local protocol β€” never wait for laboratory assays, and never let U.S. FDA status decide global availability or make 4-factor PCC a universal substitute.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Blunt Spleen & Liver Trauma: Separate Pathways, 'Stable' Is Not 'Low Risk' (Table 7.1, Row 3)Keep splenic and hepatic non-operative pathways distinct and enforce the institutional prerequisites behind them β€” a hemodynamically stable high-grade injury is not a low-risk injury.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Burns: Start at 2 mL/kg/%TBSA, Titrate to Urine Output, Excise Early (Addendum Β§12.1, Row 6)Resuscitate major burns at 2 mL/kg/%TBSA titrated to hourly urine output instead of unmonitored Parkland 4 mL/kg/%TBSA, perform bedside escharotomy when eschar restricts perfusion or ventilation, and excise tangentially with grafting within 24–72 hours β€” without prophylactic systemic antibiotics.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Massive Transfusion: Early Balanced 1:1:1 Components, Reported Honestly (Table 7.1, Row 1B)Start early balanced 1:1:1 component transfusion in predicted massive transfusion β€” and report PROPPR honestly: its co-primary mortality endpoints were neutral, so the case rests on the hemostasis and exsanguination endpoints.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Massive Transfusion: Monitor Ionized Calcium and Replace It Salt-Specifically (Table 7.1, Row 1D)Monitor arterial ionized calcium every 30–60 minutes during massive transfusion and replace it with salt-specific dosing below 1.0–1.1 mmol/L β€” do not run a massive transfusion protocol empirically and unmonitored.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adapt / Watch⏳ Pending triple reviewPractice Shift β€” REBOA: No Routine Emergency-Department Deployment (Table 7.1, Row 2)Do not deploy REBOA routinely in the Emergency Department where it may delay definitive hemorrhage control β€” selective use belongs in an operating room or hybrid suite, and only under strict institutional prerequisites.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” SSRF, Damage-Control Triggers & Compartment Syndrome: Diagnose Clinically, Fix Flail Early (Table 7.1, Row 5)Fix ventilator-dependent flail chest with SSRF within 48–72 hours, trigger damage-control laparotomy on integrated physiological exhaustion β€” not a 'lethal diamond' score β€” and diagnose compartment syndrome primarily by serial clinical examination, with Ξ”P ≀30 mmHg as the manometry adjunct.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Tranexamic Acid: Two Indications, Kept Separate, Always Within 3 Hours (Table 7.1, Row 1C)Give tranexamic acid strictly within 3 hours of injury β€” and keep CRASH-2 (extracranial bleeding) and CRASH-3 (mild-to-moderate TBI) as two separate indications: never start it late, never extrapolate it across all TBI severities.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adopt⏳ Pending triple reviewPractice Shift β€” Trauma Resuscitation Blood-Pressure Targets: Split by Brain Injury (Table 7.1, Row 1A)Split blood-pressure targets by brain injury: permissive hypotension (SBP 80–90 mmHg) only as a brief bridge in torso hemorrhage without TBI β€” and never in TBI, where age-banded SBP β‰₯100–110 mmHg (MAP β‰₯80 mmHg) protects cerebral perfusion.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Uncomplicated Appendicitis: Appendectomy Standard, Antibiotics a Stratified Shared Decision (Table 4.1)Keep laparoscopic appendectomy the standard for uncomplicated appendicitis β€” offer antibiotic-first therapy only as a shared decision, stratified by appendicolith status, with CODA and APPAC reported separately.

Clinical pathway Β· 2

Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Hernia & Acute GI (Β§4.2)Make the hernia decisions separately, select ASBO patients by exclusion first, and use shared decision-making for uncomplicated appendicitis.
Ch 6 Β· Emergency, Trauma, Acute Care & Surgical Critical Care AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Trauma & Acute Care (Β§7.2)Resuscitate with balanced transfusion, keep the two tranexamic acid indications separate, and do not deploy REBOA routinely.
Endocrine Surgery

Chapter 7

Endocrine Surgery

11 cards β€” open chapter β†’

Practice shifts Β· 10

Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Persistent Lymphadenopathy: Core First, Excise Intact When Lymphoma Is in Play (Addendum Summary, Ch 5)Triage persistent unexplained lymphadenopathy with ultrasound-guided core biopsy, and excise the largest node intact β€” fresh and in formalin β€” whenever lymphoma is suspected or the core is non-diagnostic.
Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Salivary Tumours: Never Enucleate or Incise a Parotid Pleomorphic Adenoma (Addendum Summary, Ch 5)Work up salivary neoplasms with Milan-classified FNA and MRI, and remove parotid pleomorphic adenoma by superficial parotidectomy or extracapsular dissection with a cuff β€” never enucleation or open biopsy.
Ch 7 Β· Endocrine Surgery Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Thermal Ablation for Benign Thyroid Nodules (Β§5.4 Item 3)Offer ultrasound-guided radiofrequency or microwave ablation as a scarless outpatient option for symptomatic, twice-confirmed benign thyroid nodules.
Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Thyroglossal & Branchial Cysts: Sistrunk, Not Simple Cystectomy (Addendum Summary, Ch 5)Excise a thyroglossal duct cyst with the formal Sistrunk procedure β€” never simple cystectomy β€” after confirming a normal orthotopic thyroid and settling any infection.
Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Adrenal Incidentaloma, MACS & Pheochromocytoma: Phenotype + Targeted Hormonal Workup, Alpha-Blockade First (Table 5.1)Evaluate every adrenal incidentaloma by imaging phenotype plus targeted hormonal testing β€” a 1-mg DST for all, metanephrines whenever the lesion is not a classic ≀10 HU adenoma β€” and always block alpha before beta in pheochromocytoma.
Ch 7 Β· Endocrine Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Bethesda III/IV Nodules & NIFTP: Prevalence-Aware Molecular Testing, Histology-Only NIFTP (Table 5.1)Use reflex molecular testing to inform Bethesda III/IV decisions β€” reading its predictive values against your local prevalence β€” and never diagnose NIFTP on cytology alone.
Ch 7 Β· Endocrine Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” DTC >2.0 to ≀4.0 cm (cT2, cN0): Shared Decision Between Lobectomy and Total Thyroidectomy (Table 5.1)Treat low-risk cT2 (2–4 cm) cN0 DTC as a shared-decision category β€” weigh lobectomy against total thyroidectomy with the patient, and default to neither as a universal rule.
Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewPractice Shift β€” DTC ≀2.0 cm: Initial Lobectomy, No Routine Prophylactic Central Neck Dissection or RAI (Table 5.1)Start with lobectomy for selected unilateral intrathyroidal cN0 DTC ≀2.0 cm β€” drop routine total thyroidectomy with prophylactic central neck dissection and empiric RAI ablation.
Ch 7 Β· Endocrine Surgery Adopt⏳ Pending triple reviewPractice Shift β€” IONM, NIRAF vs. ICG, and PHPT Localization: Device-Specific Protocols and Modality Discipline (Table 5.1)Run IONM on device-specific protocols with the full troubleshooting-and-staging algorithm, keep NIRAF (tissue identification) and ICG (perfusion) apart, and choose PHPT localization selectively β€” never by a universal EMG cutoff or a mandatory 4D-CT default.
Ch 7 Β· Endocrine Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Low-Risk Papillary Microcarcinoma (T1a ≀1.0 cm): Structured Active Surveillance as an Option Beside Lobectomy (Table 5.1)Offer strictly eligible low-risk T1a microcarcinoma a shared choice between structured active surveillance and initial lobectomy β€” neither surveillance for every ≀1 cm tumor nor surgery for all of them.

Clinical pathway Β· 1

Ch 7 Β· Endocrine Surgery AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Endocrine Surgery (Β§5.2)Keep active surveillance inside its strict boundaries, size the thyroidectomy by tumour size, and never skip the pheochromocytoma rule.
Breast Surgery

Chapter 8

Breast Surgery

9 cards β€” open chapter β†’

Practice shifts Β· 8

Ch 8 Β· Breast Surgery Adapt / Watch⏳ Pending triple reviewCandidate Shift β€” Gynecomastia: Exclude Cancer and Causes First; Combine Liposuction With Pull-Through Adenectomy (Addendum Summary, Ch 6)Do not excise early gynecomastia: first exclude male breast cancer, drugs and endocrine causes; for persistent fibrous Grade II–III disease, combine liposuction with pull-through subareolar adenectomy.
Ch 8 Β· Breast Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Nipple Discharge & Zuska's Fistula: Classify First, Excise the Diseased Duct (Addendum Summary, Ch 6)Separate physiological discharge (reassure) from pathologic single-duct discharge (image, then microdochectomy), and treat recurrent Zuska's fistula with smoking cessation plus complete duct and fistula excision.
Ch 8 Β· Breast Surgery Adopt⏳ Pending triple reviewCandidate Shift β€” Phyllodes Tumours: Grade-Dependent Margins, No Routine Axillary Staging (Addendum Summary, Ch 6)Excise borderline and malignant phyllodes with >=1.0 cm margins and omit routine axillary SLNB/ALND; benign phyllodes needs complete excision only.
Ch 8 Β· Breast Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Granulomatous Mastitis: Exclude Infection Before Any Steroid or Methotrexate (Table 6.1)Work up suspected granulomatous mastitis by presentation, epidemiology, imaging and core biopsy with targeted stains, lipophilic culture and TB PCR β€” and start corticosteroids or methotrexate only after infection is excluded and IGM is confirmed.
Ch 8 Β· Breast Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Low-Risk DCIS Active Monitoring (Emerging Option) & Exact BCS Margin Definitions (Table 6.1)Keep low-risk DCIS monitoring strictly separate from invasive cancer β€” an emerging shared-decision option for the COMET population only β€” and apply the exact BCS margins: 'no ink on tumor' for invasive carcinoma, >=2 mm for pure DCIS, no routine wider re-excision.
Ch 8 Β· Breast Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Neoadjuvant-First Sequencing in Stage II–III TNBC/HER2+ & Exact HER2-Low Classification (Table 6.1)Refer Stage II–III TNBC and HER2+ disease for neoadjuvant systemic therapy before surgery (clips in first), and report exact HER2 IHC scores β€” HER2-low is a predictive category for T-DXd in advanced disease, not a binary label or an early-stage trastuzumab indication.
Ch 8 Β· Breast Surgery Adopt⏳ Pending triple reviewPractice Shift β€” SLNB Omission Only in the Strictly Eligible Postmenopausal Subset (Table 6.1)Consider omitting SLNB only in postmenopausal patients aged >=50 with unicentric cT1 (<=2.0 cm) Grade 1–2 HR+/HER2- cancer and a negative axillary ultrasound β€” never as a blanket rule for all cN0 breast cancer.
Ch 8 Β· Breast Surgery Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Targeted Axillary Dissection After NST in cN1-to-ycN0 Responders (Table 6.1)Stage the axilla after neoadjuvant therapy with targeted axillary dissection β€” clipped node out plus dual-tracer SLNB with >=2–3 sentinel nodes β€” instead of mandatory Level I–II ALND for every cN1 converter.

Clinical pathway Β· 1

Ch 8 Β· Breast Surgery AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Breast Surgical Oncology (Β§6.2)Omit sentinel node biopsy only in the exact ASCO 2025 population β€” and exclude infection before any steroid in granulomatous mastitis.
Vascular & Venous Surgery

Chapter 9

Vascular & Venous Surgery

7 cards β€” open chapter β†’

Practice shifts Β· 6

Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Acute Limb Ischemia: Heparin Now, Rutherford Class Decides the Route (Addendum Β§11.1, Row 3)Heparinise acute limb ischemia immediately and let the Rutherford class drive the route: CTA and catheter therapy for Classes I–IIa, emergency operating-room thromboembolectomy for IIb, primary amputation for irreversible Class III.
Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” CLTI: Map the Vein First β€” Bypass With Good GSV, Endovascular Otherwise (Addendum Β§11.1, Row 4)Map the saphenous vein before choosing the CLTI strategy: fit patients with an adequate single-segment GSV get open bypass first (BEST-CLI); patients without a usable vein, high-risk patients, and isolated infrapopliteal disease get endovascular-first (BASIL-2) β€” all on full medical therapy.
Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Dialysis Access: Fistula-First Life-Plan, Salvage Steal Without Ligation (Addendum Β§11.1, Row 6)Plan dialysis access by the ESKD Life-Plan β€” mapped autogenous fistula first, distal to proximal, prosthetic graft only when veins are exhausted β€” and salvage a stealing fistula with DRIL, RUDI or PAI instead of ligating it.
Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Extremity Arterial Trauma: Hard/Soft Signs and ABI Triage, Shunt Before Fixation (Addendum Β§11.1, Row 5)Triage extremity arterial trauma by hard and soft signs plus the injured extremity index: hard signs go straight to the operating room β€” and when bone and vessel are both injured and ischemia time is running, shunt first and graft definitively after stabilisation.
Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Saphenous Reflux: Endovenous Ablation First, Stripping Reserved (Addendum Β§11.1, Row 1)Ablate symptomatic saphenous reflux endovenously first β€” outpatient EVLA or RFA under duplex guidance and tumescent local anesthesia β€” and reserve open high ligation and stripping for when endovenous treatment is unavailable or the anatomy is extreme.
Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Venous Leg Ulcer: Early Ablation Within 2 Weeks, Not Compression Alone (Addendum Β§11.1, Row 2)Ablate early in active venous leg ulceration β€” within 2 weeks, on top of multilayer compression, after checking arterial inflow β€” instead of compressing alone and deferring ablation until the ulcer has completely healed.

Clinical pathway Β· 1

Ch 9 Β· Vascular & Venous Surgery Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” Vascular, Endovascular & Venous Surgery (Β§11.2)Work the vascular pathway in four steps: duplex-map and arterially screen before any compression, ablate superficial reflux early in active ulceration, triage acute limb ischemia by Rutherford class under immediate heparin, and choose CLTI revascularization by conduit and anatomy.
Skin, Soft Tissue & Wounds

Chapter 10

Skin, Soft Tissue & Wounds

9 cards β€” open chapter β†’

Practice shifts Β· 8

Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewCandidate Shift β€” Hand Infections & Ganglion: Drain Tenosynovitis Urgently, Incise Felons Safely, Excise the Ganglion Stalk (Addendum Summary, Ch 8)Treat Kanavel-positive flexor tenosynovitis as a surgical emergency (sheath irrigation/drainage), incise felons longitudinally sparing the neurovascular bundle, and excise ganglion cysts down to the joint-capsule stalk.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewCandidate Shift β€” Hyperhidrosis: Climb the Conservative Ladder; Sympathectomy at R3/R4 Only, Sparing T2 (Addendum Summary, Ch 8)Treat focal hyperhidrosis stepwise (topical, iontophoresis, botulinum toxin, oral agents) and reserve VATS sympathectomy for refractory palmar disease β€” at R3/R4, strictly sparing the T2/stellate ganglion.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” Diabetic Foot: Urgent Source Control First, WIfI for Staging β€” Never the Other Way Round (Table 8.1, Pathway 8E)Sequence diabetic foot care by urgency: debride severe infection within 24 hours without waiting for staging or vascular workup, then stage with SVS WIfI, revascularize promptly below the printed pressure thresholds, and pair bone-biopsy-guided antimicrobials with off-loading.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” Hidradenitis Suppurativa: Biologic Continued Through Surgery; Keloid: Never Excise Without Adjuvant (Addendum Β§12.1, Row 5)Treat Hurley II–III hidradenitis with biologic therapy continued uninterrupted through deroofing or wide excision β€” not repeated drainage and short antibiotic courses, and not stopping the biologic for surgery β€” and never excise a keloid without immediate adjuvant therapy.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” High-Risk BCC/cSCC and DFSP: Mohs or Complete Margin Assessment (Addendum Β§12.1, Row 3)Match margin control to risk in non-melanoma skin cancer: standard 4 mm / 4–6 mm excision for low-risk BCC and cSCC, Mohs or complete circumferential margin assessment for high-risk facial tumors and DFSP β€” and PD-1 blockade instead of mutilating resection in borderline-resectable cSCC.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” Melanoma: Excisional Biopsy, Breslow-Set Margins, SLNB for T1b (Addendum Β§12.1, Row 1)Biopsy pigmented lesions by full-thickness excision with a 1–3 mm margin, set wide-excision margins strictly by Breslow thickness, and perform SLNB together with the wide excision for T1b cN0 melanoma β€” no shave biopsies, no 3–5 cm radical margins, no routine elective node dissection.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” Soft-Tissue Mass: MRI and Planned Core Biopsy Before Any Excision (Addendum Β§12.1, Row 4)Image and core-biopsy any deep, firm, fixed or >5 cm soft-tissue mass before touching it β€” contrast MRI and a multiple-pass core biopsy along the planned incision, with multidisciplinary sarcoma planning β€” and never shell out a suspected sarcoma in the office.
Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewPractice Shift β€” Stage III Melanoma: No Routine CLND for Microscopic Disease, Neoadjuvant Immunotherapy for Macroscopic (Addendum Β§12.1, Row 2)Stop completing every positive sentinel node basin: microscopic pN1a melanoma gets nodal ultrasound surveillance plus adjuvant systemic therapy, and macroscopic resectable Stage III disease gets neoadjuvant immunotherapy before resection.

Clinical pathway Β· 1

Ch 10 Β· Skin, Soft Tissue & Wounds Adopt⏳ Pending triple reviewStepwise Clinical Decision Pathway β€” Cutaneous Oncology, Sarcoma, Complex Wounds & Burns (Β§12.2)Work the cutaneous oncology pathway in four steps: biopsy suspicious pigmented lesions whole and stop for MRI + core-needle biopsy on any red-flag soft-tissue mass, run melanoma excision by Breslow margins with the microscopic-versus-macroscopic nodal split, carry hidradenitis biologics through wide excision, and resuscitate burns by the ABA protocol with early escharotomy and excision.
Bariatric & Metabolic Surgery

Chapter 11

Bariatric & Metabolic Surgery

1 card β€” open chapter β†’

Practice shifts Β· 1

Ch 11 Β· Bariatric & Metabolic Surgery Adopt⏳ Pending triple reviewPractice Shift β€” Bariatric Eligibility: 2022 ASMBS/IFSO Clinical Indications, Not 1991 Cutoffs or Administrative Criteria (Table 8.1, Pathway 8A)Judge bariatric eligibility by the 2022 ASMBS/IFSO clinical indications β€” BMI >=35 kg/m2 regardless of comorbidities; consider BMI 30–34.9 kg/m2 (>=27.5 in Asian populations) with inadequately controlled T2DM β€” and choose LSG, RYGB or OAGB (<=150 cm limb) by shared decision-making, not by 1991 NIH cutoffs or a universal 'best' operation.
Perioperative Care & Surgical Optimization

Chapter 12

Perioperative Care & Surgical Optimization

5 cards β€” open chapter β†’

Practice shifts Β· 4

Ch 12 Β· Perioperative Care & Surgical Optimization Adopt⏳ Pending triple reviewCandidate Shift β€” Perioperative Fluids & Nutrition: Balanced Crystalloids, Early Enteral Feeding, Refeeding Guard (Addendum Summary, Ch 8)Resuscitate with balanced crystalloids toward near-zero balance, feed enterally within 24–48 hours, reserve TPN for prolonged intestinal failure β€” and give thiamine before calories in the malnourished.
Ch 12 Β· Perioperative Care & Surgical Optimization Adapt / Watch⏳ Pending triple reviewPractice Shift β€” Perioperative GLP-1 / Dual GIP-GLP-1 Agonists: Risk Stratification Replaces the Blanket Hold (Table 8.1, Pathway 8C)Replace the 2023 blanket one-dose GLP-1 hold with risk stratification: continue therapy in patients without elevated delayed-emptying risk, and jointly choose a 24-h liquid diet, modified anesthesia plan, gastric POCUS, postponement or a targeted hold in those with it.
Ch 12 Β· Perioperative Care & Surgical Optimization Adopt⏳ Pending triple reviewPractice Shift β€” Perioperative SGLT2 Inhibitors: Label Holds Kept Distinct, euDKA Vigilance, Clinical Restart (Table 8.1, Pathway 8B)Keep SGLT2 guidance sources separate: hold to the U.S. FDA label intervals (>=3 days; >=4 days for ertugliflozin) as the conservative default for major surgery, never delay emergency source control to complete a hold, and never let a normal glucose exclude euglycemic DKA.
Ch 12 Β· Perioperative Care & Surgical Optimization Adopt⏳ Pending triple reviewPractice Shift β€” VTE Prophylaxis: Separate Inpatient from Extended 28-Day Post-Discharge Prophylaxis (Table 8.1, Pathway 8D)Separate inpatient prophylaxis from post-discharge prophylaxis: give high-risk abdominopelvic cancer patients 28 days of LMWH after discharge β€” and stop applying extended prophylaxis as a blanket rule to all general and bariatric surgery, with every dose adjusted for weight, CrCl, bleeding risk and epidural timing.

Clinical pathway Β· 1

Ch 12 Β· Perioperative Care & Surgical Optimization AdoptLast verified 2026-11-02Stepwise Clinical Decision Pathway β€” Metabolic & Perioperative (Β§8.2)Run the five perioperative pathways in order β€” bariatric eligibility, SGLT2 holds, GLP-1 risk-stratification, VTE separation, WIfI limb salvage.
Cross-Cutting Clinical Frameworks

Chapter 13

Cross-Cutting Clinical Frameworks

0 cards β€” open chapter β†’

Cards arriving.

Transplantation

Chapter 14

Transplantation

0 cards β€” open chapter β†’

Cards arriving.

AI in General Surgery & the Future of General Surgery

Chapter 15

AI in General Surgery & the Future of General Surgery

0 cards β€” open chapter β†’

Cards arriving.

MIS, Robotic & Endoscopic Surgery

Chapter 16

MIS, Robotic & Endoscopic Surgery

0 cards β€” open chapter β†’

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