1. The two most effective chemotherapy regimens for advanced pancreatic cancer are gemcitabine-abraxane and FOLFIRINOX (folate, 5-FU, irinotecan, oxaliplatin). Gem-abraxane is less toxic, but less effective; if the person is relatively young and healthy, go for folfirinox; gem-abraxane if they can't take it.
2. Most common presenting symptom of cholecysto-duodenal fistula: gallstone ileus (the enlarged stone pressing upon the small bowel is thought to lead to erosion and fistula formation). Most common presenting symptom of cholecysto-colonic fistula: bile in the stool (bypasses absorption in terminal small bowel)
3. Subcostal vs vertical incision: subcostals offer better lateral access (distal panc, splenectomy, liver) but cutting the rectus muscles leads to more pain, and later on there can be problems with muscle pooching during engagement of the abdominal muscles. Studies focusing on the effect of subcostal incisions (theorized effects on wound healing, incidence of respiratory complications post-op) have not found conclusive evidence.
4. Fecal elastase < 200 indicates pancreatic insufficiency, <50 will lead to steatorrhea.
5. Neuroendocrine tumors: definitive classification requires positive staining with chromogranin and synaptophysin. These tumors are clinically sub-categorized-- i.e. gastrinoma is defined by elevated levels of blood gastrin, not histological staining for gastrin. These tumors are often hypervascular on CT, rendering them easily confused for vessels. They are often slow growing.
6. PNET tumors: Ki67 expression is associated with worse outcomes: >20% is associated with significantly increased mortality (i.e. poor 5-year survival) relative to <5% (excellent 5-year survival). The liver is a common site of metastasis/recurrence after resection; visible lesions can be resected, however dissemination is often widespread. These tumors grow slowly, but invariably. Tumors <2cm with no radiographic evidence of spread and no symptoms can be watched at 6-mo screening intervals. Larger ones should be resected-- enucleation to manage symptoms in benign masses, oncologic resection with margins for more malignant tumors. For patients with small tumors who request surgery out of nervousness; consider the fact that the point of surgery is to either manage symptoms or prevent recurrence. If they do not have symptoms (i.e. non secreting tumor), they will gain no benefit if you do not attempt a full oncologic resection with an attempt to get negative margins (i.e. whipple); a compromise in the form of an enucleation still subjects them to surgical risk with no proven benefit.
7. You can treat unresectable liver metastases with isolated hepatic perfusion: cannulate GDA to IVC above liver, clamp common hepatic artery to prevent back-flow, run high-dose chemotherapy through circuit. Percutaneous veno-veno bypass IVC below liver to subclavian to maintain preload, clamp portal vein. This has morbidity, including possibility of liver failure-- screen patients well before for pre-existing liver pathology. Liver transplant is a possible treatment for pancreatic neuroendocrine tumors with liver mets.
8. Clavicle fractures: do angiogram and neuro exam on extremity to r/o neurovascular damage (brachial plexus, subclavian). Middle clavicle fractures- closed reduction, figure of 8 brace. Distal clavicle may need ORIF.
9. Ankle-brachial index (compare dorsalis pedis or posterior tibial to brachial aa, leg/arm systolic pressure): normal is 1-1.3, <0.9 is sensitive and specific for >50% occlusion of artery, <0.4 is c/w limb ischemia. Measure with a sphingomanometer and doppler distal: instead of listening, you use the doppler. Inflate cuff, when you see the signal first return that is the systolic pressure.
10. Post-cholecystectomy jaundice ddx: 
-Retained stone in CBD
-Stricture
-Bile leak
-Cholestasis 2/2 other disease process (i.e. sepsis)
-Cut the CBD instead of cystic.