1. Billroth I: 
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-end, duodenum to stomach edge.
-pros: somewhat physiologic-- maintains somewhat normal flow of fluids, no backleak of alkaline fluids into stomach/esophagus
-cons: may be more tension on the anastomosis, since you have to pull the duodenum all the way up to the mid-gastric region.
2. Billroth II: 
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis: end-to-side, jejunum to stomach. The cut end of the duodenum is stapled shut into a blind loop, with the pancreatic and gallbladder drainage intact.
-pros: low-tension anastomosis
-cons: since pancreatic/biliary secretions are now upstream of gastric contents, there can be efflux of bicarb and/or bile into the stomach and up the esophagus. This can be prevented by making an Omega loop, aka Braun entero-enterostomy, where you make a connection between the jejunum proximal to and distal to the stomach anastomosis, providing an alternate path for the alkaline secretions to go directly through rather than into stomach. The omega loop must be at least 40cm in diameter for the fluids to effectively bypass. Additional disadvantages of the billroth II: afferent or efferent obstruction, causing swelling of duodenal loop, and finally mucous ulcer formation from stomach contents moving directly across to unprotected duodenum.

3. Roux-en-y
-resection: distal stomach, pylorus, proximal duodenum (before ampulla of vader)
-anastomosis:
(1) resect distal jejunum, bring up to end-to-side with stomach (limb must be > 40cm long to avoid alkaline reflux.
(2) anastomose original duodenal limb with gastro-jejunal limb with continuing jejunum in a "Y" shape
-pros: fewer problems with efferent/afferent limb obstruction
-cons: erosive ulcer formation still occurs.

4. Lymph node resection for gastric cancer:

-D1: perigastric lymph nodes. For distal gastric cancer, you have to take the omental nodes, and nodes along distal lesser gastric curve. For proximal gastric cancer, you take the peri-gastric nodes around the proximal part of stomach. 

-D2: you take all of the D1 nodes, plus the nodes around the celiac vessels-- common hepatic, proximal GDA, proximal proper hepatic, proximal L gastric, all the ones around the splenic vessels to the spleen. In a Japanese D2, you take the spleen and the pancreas as well. 

5. D1 vs D2 lymph node resections landmark trials: 

-Cuschieri, RCT n=400, randomized to D1 vs Japanese D2 resection, no difference in death from gastric cancer, OS, PFS. Removal of spleen and pancreas independently associated with survival. 

-Bonenkamp, RCT n=711 randomized to D1 vs Japanese D2, similar 5-year OS rates, but more complications (43 vs 25%), longer hospitalizations, and most postop deaths in D2 resection. 

6. FOLFIRINOX is associated with significantly longer OS/PFS compared to gemcitabine, but also higher complication rates, when treating metastatic pancreatic adenocarcinoma: 

From the abstract, {NEJM, RCT, n=342}

"The median overall survival was 11.1 months in the FOLFIRINOX group as compared with 6.8 months in the gemcitabine group (hazard ratio for death, 0.57; 95% confidence interval [CI], 0.45 to 0.73; P<0.001). Median progression-free survival was 6.4 months in the FOLFIRINOX group and 3.3 months in the gemcitabine group (hazard ratio for disease progression, 0.47; 95% CI, 0.37 to 0.59; P<0.001). The objective response rate was 31.6% in the FOLFIRINOX group versus 9.4% in the gemcitabine group (P<0.001). More adverse events were noted in the FOLFIRINOX group; 5.4% of patients in this group had febrile neutropenia. At 6 months, 31% of the patients in the FOLFIRINOX group had a definitive degradation of the quality of life versus 66% in the gemcitabine group (hazard ratio, 0.47; 95% CI, 0.30 to 0.70; P<0.001)." 

(5-FU, leucovorin, irinotecan, oxaliplatin) 

7. Post-op bleeding:

-Don't overinterpret post-op Hb drops: being NPO before surgery likely leads to some degree of hemoconcentration, so Hb's measured intraop or immediately before op may be much higher than a Hb measured post-op and s/p many liters of crystalloids. 

-Look for vital sign changes and changes in urine OP and mental status if you're worried about a bleed. 

-Toradol can make people bleed more, particularly in combination with heparin or lovenox-- if you're worried, hold the anticoagulants for 5-6 hours after you give toradol. 

-If someone has a hematoma and they're stable and it's stable, you can drain it with IR. If it's clotted off and won't drain, you may need to go to the OR to scoop it out. 

-If they are acutely unstable, go to the OR. 

8. Be careful of putting in CABG grafts in people with subclavian stenosis-- if the LIMA is distal to the stenosis, you will get subclavian steal where the distal subclavian is a lower pressure than the coronary system and blood will flow backwards from heart to arm. Consider using RIMA if the stenosis is not bilateral.
9. Be careful of doing sternotomies in people with previous sternotomy scars and incomplete surgical history-- if they had a previous CABG with the RIMA, you may cut the RIMA on entry and give them an MI intraop. Poor form.
10. When putting in a central line in someone with an IVC filter, do not push the guidewire in too far, or it may get tangled with the IVC filter and require a trip to IR to bail you out.