Acute Surgery

Question 1

What is meant by pilondial sinus disease?

Answer 1

• Disease of the inter-gluteal region.
• Affects young men 16-30
• Developmentbegins with ahair folliclein the intergluteal cleftbecoming infected or inflamed.

Question 2

Pilondial sinus disease vs pilondial abscess presentation:

Answer 2

Pilonidal sinus diseasemost commonly presents as adischarging and intermittently painful sinusin thesacrococcygeal region. Discharge is typically episodic and of serous fluid, however, this can become bloody or purulent discharge on occasion.

Apilonidal abscesscan form when a pilonidal sinus becomes infected. This will present as a swollen and erythematous region. On examination, there will be afluctuant and tender mass, as well assystemic features of infection.

Question 3

Investigations for pilonidal disease?

Answer 3

Typically examination is enough to diagnose and manage pilondial disease with no imaging required.

MRI used in cases of multiple pit openings or previous surgery to better assess disease and enable planning.

Question 4

How is pilonidal disease managed?

Answer 4

Pilonidal disease can be managedconservativelyand does not always require surgical management.Conservative treatmentof a pilonidal sinus involvesremoving any hairin the affected region (ideally with hair removal cream) and ensuring the area is kept clean whenever possible.

Question 5

How is a pilonidal abscess managed?

Answer 5

For anypilonidal abscessthat develops, these must be treated like any abscess and undergoincision and drainage+/-washout +/-packing. Elective surgery for the pilonidal sinus disease can then be performed at a later date if the patientremains symptomatic.

Question 6

How is chronic pilonidal disease treated?

Answer 6

Surgical removal of the pilonidal sinus tract.
- Excision and primary closure (Karydakis procedure).

Question 7

Symptoms of anal fissure

Answer 7

Intense pain
Bleeding
Itching

Symptoms occur most commonly post defecation.
Differential diagnoses include haemorrhoids, Crohn’s disease, ulcerative colitis, or anal cancer.

Question 8

Risk factors for anal fissures

Answer 8

• Constipation
• Dehydration
• Inflammatory bowel disease
• Chronic diarrhoea

Question 9

Medical management of an anal fissure

Answer 9

1. Increase fibre and fluid intake.
2. Stool softening laxative
3. Topical lidocaine

If patients are still symptomatic, the next line of management isGTN creamordiltiazem cream.

Question 10

How does GTN cream or diltiazem cream treat an anal fissure?

Answer 10

GTN creamordiltiazem cream increases the blood supply to the region and relaxes the internal anal sphincter, putting less pressure on the fissure, promoting healing and reducing pain.

Question 11

Surgical management of anal fissures

Answer 11

Surgical therapy is reservedfor chronic fissures, where medical management has failed to resolve the symptoms after at least 8 weeks.

Botox injectionscan be given into the internal anal sphincter, to relax the sphincter and promote healing of the fissure.Lateral sphincterotomy can be performed, involving division of the internal anal sphincter muscle.

Recurrenceof anal fissures post-surgery is between 1-5%.

Question 12

Define an abdominal aortic aneurysm

Answer 12

Dilatationof the abdominal aortagreater than 3cm.

Question 13

What is the UK NAAASP?

Answer 13

In the UK, the national abdominal aortic aneurysm screening programme (NAAASP) offeranabdominal US scan for all men in their 65th year.

Question 13

Monitoring frequency for this with an abdominal aortic aneurysm?

Answer 13

• 3.0 – 4.4cm: yearly ultrasound
• 4.5 – 5.4cm: 3-monthly ultrasound

Question 14

Summary of the surgical intervention for an abdominal aortic aneurysm:

Answer 14

The main treatment options are open repair or endovascular repair

• Open repairinvolves a midline laparotomy or long transverse incision, exposing the aorta, and clamping the aorta proximally and the iliac arteries distally, before the segment is then removed and replaced with a prosthetic graft
• Endovascular repairinvolves introducing a graft via the femoral arteries and fixing the stent across the aneurysm (Fig. 3)

Both open repair and endovascular repair have similar long term outcomes.

Question 15

When should surgery be considered for those with an abdominal aortic aneurysm?

Answer 15

Surgery should beconsidered for an AAA >5.5cmin diameter,AAAexpanding at >1cm/year, or asymptomaticAAAin a patient who is otherwise fit.

In unfit patients, the AAA may be left until 6cm or more prior to repair, due to the significant risk of mortality from an elective repair compared to the risk of mortality if not repaired.

Question 16

Endovascular repair vs open repair for AAA

Answer 16

Endovascular repair does have an improved short term outcome in terms of decreasing hospital stay and 30 day mortality, yet has a higher rate of reintervention and aneurysm rupture. After 2 years the mortality for both procedures is the same, therefore in young fit patients an open repair may be more appropriate .

Question 16

Outline of endovascular leaking

Answer 16

An important complication for EVAR is endovascular leak, whereby an incomplete seal forms around the aneurysm resulting in blood leaking around the graft.

Endoleaks are often asymptomatic hence regular surveillance (usually ultrasound unless a complication is noted) is needed. If left untreated, the aneurysm canexpand and subsequently rupture. As such, any aneurysm expansion following EVAR warrants investigation for endoleak.

Question 16

Common presentation of ruptured AAA

Answer 16

Around 50% patients present with the ‘classic triad’ of ruptured AAA (flank or back pain, hypotension, and a pulsatile abdominal mass).

Question 17

Where do AAA typically rupture into?

Answer 17

20% of AAA ruptures will rupture anteriorly into the peritoneal cavity (whichare associated with a very poor prognosis), whilst 80% rupture posteriorly into the retroperitoneal space.

Question 18

Ruptured AAA managment

Answer 18

Any suspected AAA rupture warrants immediatehigh flow O2,IV access(2x large bore cannulae), andurgent bloodstaken (FBC, U&Es, clotting) withcrossmatchfor minimum 6U units.

Anyshock should be treated very carefully. Raising the BP will dislodge any clot and may precipitate further bleeding, therefore aim to keep the BP≤100mmHg (termed ‘permissive hypotension’, preventing excessive blood loss). As long as the patient is cerebrating, the BP is generally adequate.

The patient should betransferred to the local vascular unit, with the vascular registrar, consultant, anaesthetist, theatre, and blood transfusion lab informed.

• If the patient is unstable, they will require immediate transfer to theatre for open surgical repair
• If the patient is stable, they will require a CT angiogram to determine whether the aneurysm is suitable for endovascular repair

Question 19

What trial showed benefit of EVAR over Open AAA repair?

Answer 19

• The IMPROVE trial randomised patients suitable for EVAR or open AAA repair, showing no 30 day or 1 year difference in survival, but an increase in patients returning to their own homes, short hospital stay, and lower cost in the EVAR cohort. The 3 year results show a significant survival benefit for EVAR, particularly when performed under local anaesthesia.

Question 20

What is aortic dissection?

Answer 20

Anaortic dissectionisatearintheintimal layerof the aortic wall, causing blood to flow between and splitting apart the tunica intima and media.

Question 21

Retrograde aortic dissection:

Answer 21

Retrograde dissectionspropagate towards the aortic valve (at the root of the aorta).

Retrograde dissections can result in prolapse of the aortic valve, bleeding into the pericardium, and cardiac tamponade.

Question 22

Where do anterograde dissections progress towards?

Answer 22

Anterograde dissectionspropagate towards the iliac arteries .

Question 23

How are aortic dissections classified?

Answer 23

Aortic dissectionsare classified anatomically by two systems, DeBakey and Stanford.

Question 24

Stanford classification:

Answer 24

TheStanford classificationdivides aortic dissection into two groups, A and B:

• Type A– involves the ascending aorta and can propagate to the aortic arch and descending aorta (i.e. DeBakey Types I and II) ; the tear can originate anywhere along this path
• Type B– does not involve the ascending aorta, occurring in any other part of the aortic arch and descending aorta (i.e. DeBakey Type III).

Question 25

DeBakey Classification

Answer 25

TheDeBakey classificationgroups aortic dissections anatomically (Fig. 2):

• Type I – originates in the ascending aorta and propagates at least to the aortic arch
  
  • They are typically seen in patients under 65yrs and carry the highest mortality, quoted at 1% per hour in the acute setting
• Type II– confined to the ascending aorta
  
  • Classically in elderly patients with atherosclerotic disease and hypertension
• Type III– originates distal to the subclavian artery in the descending aorta
  
  • Further subdivided into IIIa which extends distally to the diaphragm and IIIb which extends beyond the diaphragm into the abdominal aorta

Question 26

Imaging for aortic dissection

Answer 26

CT angiogram

Atransoesophogeal ECHOcan also provide useful information, especially in proximal or retrograde cases where there is concern regarding valvular involvement, but is operator dependent.

Question 27

Aortic dissection management:

Answer 27

Urgent initial assessmentis required, as for any other critically ill surgical patient. Starthigh flow oxygenand gainIV access(x2 large bore cannulas);fluid resuscitationshould be done cautiously*.

• In the setting of a rupture, then the target pressure should be sufficient for cerebral perfusion only, whilst in the setting of an uncomplicated dissection then the target systolic pressure should be kept below 110mmHg systolic.

StanfordType A dissectionsshould bemanaged surgicallyin the first instance under the care of a cardiothoracic surgery. They carry a worse prognosis of 1% mortality per hour in the initial phase, considerably worse than Type B dissections. Anyuncomplicated Type B dissectionscan usually bemanaged medically. Penetrating aortic ulcer and intramural haematoma or also typically managed medically unless they progress.

Following initial management, all patients need lifelongantihypertensive therapyandsurveillance imaging*, due to the high risk of developing further dissection or other complications.

• *Imaging would usually be at 1, 3, and 12 months post-discharge, with further scans at 6-12 month intervals thereafter depending on the size of the aorta.

Question 28

Intervention for a Type A aortic dissection:

Answer 28

Type A dissections carry ahigh mortalityif left untreated and these cases should be discussed urgently with a cardiac or vascular surgeon. They will most likely requiretransfer to acardiothoracic centre.

The surgery involvesremoval of the ascending aorta(with or without the arch) andreplacement with synthetic graft.If the dissection has damaged the suspensory apparatus of the aortic valve, this will also require repair.

Anyadditional branches of the aortic archthat are involved will require reimplanation into the graft (i.e. brachiocephalic artery, left common carotid artery, left subclavian artery), with long Type A dissections involving the descending and possibly abdominal aorta may require staged procedures.

Question 29

Nitrates are contraindicated in aortic stenosis.

Answer 29

Nitrates are contraindicated in aortic stenosis.

Question 30

Symptoms of aortic stenosis:

Answer 30

• Chest pain
• Dyspnoea
• Syncope / presyncope (e.g. exertional dizziness)
• Murmur
  
  • Anejection systolic murmur(ESM) is classically seen in aortic stenosis
  • Classically radiates to the carotids
  • This is decreased following theValsalva manoeuvre

Question 31

Principles of managing aortic stenosis:

Answer 31

• If asymptomatic then observe the patient is a general rule.
• Ifsymptomatic then valve replacement (TAVI or open heart surgery).

Question 32

Options for valve replacement in aortic valvular disease include:

Answer 32

• Surgical AVR is the treatment of choice for young, low/medium operative risk patients. Cardiovascular disease may coexist. For this reason, anangiogramis often done prior to surgery so that the procedures can be combined
  
  • Transcatheter AVR (TAVR) is used for patients with a high operative risk
• Balloon valvuloplasty
  
  • May be used in children with no aortic valve calcification.
  • In adults limited to patients with critical aortic stenosis who are not fit for valve replacement.
• TAVI stands for Transcatheter Aortic Valve Implantation. It is used for patients with a high operative risk.