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FRCS General Section 1/2 > Evidence > Flashcards

Evidence Flashcards

1
Q

What is the evidence for LARS?

A

LOTUS trial 2011 JAMA vs BMT - less reflux symptoms, more dysphagia, bloating flatulence
REFLUX trial 2013 BMJ vs MBT - Better QoL, less anti reflux meds,
Rickenbacker Meta-analysis - less symptoms, better QoL, but significant still on antacids

Watson 20 year follow up - no benefit to short gastric division
Nissen probably has less reflux but more side effects than anterior wraps (Rudolph Stringer 2020)

Anti-reflux outcomes summary

LOTUS 5 year symptom remission of 90%
REFLUX 30% taking PPIs at 5 years
WATSON 20 year follow up
-Satisfaction 90%
-Would have surgery again 90%
-Revision 10%

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2
Q

What evidence for POEM vs Heller vs PD

A

Ponds 2019 JAMA - 2 year treatment success 92% POEM 54% PD

Werner 2019 NEJM - 2 year treatment success equivalent POEM/Heller+Dor
Higher reflux POEM, Higher complications Heller

European Achalasia Trial 2013 LHM vs PD - no difference

Yaghoobi Meta-Analysis - LHM >PD (less adverse effects, higher response rate)

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3
Q

What is the optimum management of Caustic ingestion?

A

Type 1 -2 (CT) –> NOM
If deterioration, repeat CT
Grade 1 - discharge 24-48 hours no follow up
Grade 2a - <20% risk of strictures
Grade 2b - >80% risk of strictures

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4
Q

In what circumstances can a T1b AC of the esophagus be managed by ESD?

A

ESMO guidelines 2016
SM1 - <500um invasion, L0,V0, G1/2, <20mm diameter)

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5
Q

Which trials are investigating the treatment of presurgery complete responders to CRT in AC oesophagus?

A

ESOstrate and SANO

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6
Q

What is the RCT evidence for a minimally invasive approach to oesophagectomy?

A

TIME Trial (2012 Lancet) – open vs MIO (56 vs 59) – Pulmonary infection RR 0.30

MIRO Trial (2019 NEJM) – open vs hybrid (104 vs 103) – major complications OR 0.31, pulmonary 18 vs 30%. Survival not different QOL better up to 2 years post-surgery (when most patients die)

ROMIO trial awaited

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7
Q

When might an endoscopic approach be appropriate for gastric cancers?

A

JGCA
- T1a non ulcerated, differentiated <2cm - EMR/ESD
- T1a with ulceration <3cm - ESD

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8
Q

What is the lymph node metastasis rate for T1b oesophageal tumours?

A

sm1 = 6% AC 27% SCC
sm2 = 23% AC 36% SCC
sm3 = 58% AC 55% SCC

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9
Q

When is a PET CT not useful for OG cancers?

A

-Obvious metastatic disease
-T1a Oesophageal cancer
-Gastric cancer unless suspecting occult metastatic disease

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10
Q

When should staging laparoscopy be undertaken for OG cancers

A

Gastric cancers and where it will change management in OG cancers. (BSG Guidelines 2011)

Probably T3/T4 tumours Of GOJ - 15% peritoneal mets (ESMO 2016)

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11
Q

When should splenic hilum dissection/splenectomy be undertaken in patients with gastric cancer?

A

With greater curve tumours where the lymph node positivity rate will be higher
BSG 2011

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12
Q

When should peritoneal washings be performed for gastric cancer?

A

No clear consensus in BGS, ESMO or JGCA guidelines - not mentioned in NICE guidelines

These patients probably have a worse outcome than negative, but probably not a contraindication to surgery.

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13
Q

What is the evidence for minimally invasive approach for gastric cancer?

A

LOGICA trial 2020 - JCO
115 Lap vs 112 open
Similar results
Not clear where anastomosis performed

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14
Q

What is the evidence for D1 vs D2 resection?

A

Cuschieri 1995 Lancet - No better, worse morbidity
Dutch D1D2 1999 - No better worse morbidity
Dutch D1 D2 2010 FU - better long term survival

Now recommended in BGS 2011 (Stage2/3), ESMO/JCGA/NICE (all)

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15
Q

What is the recommended treatment for Type 3 achalasia

A

POEM (ASGE 2020)

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16
Q

What is the treatment of choice after a failed Heller myotomy?

A

Pneumatic dilatation (ASGE 2020, ISDE 2018)

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17
Q

What is the evidence for mesh placement in giant hiatal hernias?

A

Limited - but RCT by Watson 2020 (Ann Surg)
Suture vs Absorbable mesh vs Non-absorbable mesh
Similar recurrence rate, worse symptomatology with mesh

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18
Q

Tell me about the FLOT4 trial?

A

360 ECF/ECX vs 356 FLOT
Adenocarcinoma cT2/N+ Gastric/GOJ (50/50)
50% received Post op
FLOT OS 50months vs 35 months

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19
Q

Tell me about the CROSS trial?

A

NEJM 2012
178 CRT vs 188 Surgery GOJ (22%)/Oesophagus
T2+N+ 75% AdenoCa, 23% SCC
Median survival 49.4 vs 24.0mths

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20
Q

What is the evidence for ROBOTIC oesophagectomy?

A

RAMIE trial from china, Ann Surg 2022.
183RAMIE vs 179MIE
Roughly equivalent, RAMIE quicker

However - SCC, China, low rate of neoadjuvant (15%)

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21
Q

When should oesophagectomy be performed after neoadjuvant treatment?

A

3-6 weeks chemo
6-10 weeks CRT

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22
Q

What is the Hinchey classification of diverticulitis

A

1a) Pericolic inflammation
1b) Pericolic abscess
2a) Distant abscess amenable to drainage
2b) Complex abscess +/- fistula
3) Purulent peritonitis
4) Faecal peritonitis

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23
Q

What evidence is there for laparoscopic washout in diverticulitis?

A

The LADIES, SCANDIV and DILALA trials looked at this.

There was a lower permanent stoma rate, but much higher reintervention rate than patients undergoing a Hartmanns

Risk of missed perforation 30% and missed cancer 10%

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24
Q

What are the relevant trials associated with treatment of diverticulitis?

A

DIVER - ambulatory treatment safe Hinchey 1/2a<3cm
AVOD/DIABLO - Antibiotics can be avoided, RF CRP >170, younger
LADIES/SCANDIV/DILALA - laparoscopic lavage higher rate of reintervention/complications

DIRECT - elective surgery, 20-30% permanent stoma, 11% leak rate

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25
Q

What is the evidence for stent usage in large bowel obstruction secondary to cancer?

A

CREST trial
246 patients
Lower stoma rate with stent
Same 1 year survival, QoL, mortality

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26
Q

What is the evidence for treatment of infrainguinal occlusive disease (3) ?

A

Lundgren - surgery vs exercise - favours surgery when exercise fails

STILE - Surgery vs Thrombolysis - favours surgery
BASIL trial - surgery vs angioplasty - Bypass vein > angioplasty >bypass PTFE

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27
Q

What is the evidence for lap vs open for perforated peptic ulcer repair?

A

Met-analysis by Cirrochi looked at 8 RCTs with total of 615 patients

Less post op pain/infections with lap, no difference in mortality or leak or abscess

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28
Q

What medical treatment should patients with Barrett’s oesophagus receive?

A

High dose PPI (80mg esomeprazole)
?Aspirin

ASPECT trial 2018 says better for high dose PPI than low dose in preventing composite of HGD, OAC and death.

?Aspirin

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29
Q

What evidence is there for Bariatric surgery for T2DM

A

STAMPEDE trial
2017, NEJM
Bypass vs Sleeve vs BMT for DM
29 vs 23 vs 5% HbA1c ≤6 at 5 years with less meds

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30
Q

What is the evidence for lap vs open appendicectomy?

A

Multiple RCTs/Meta-Analyses

Recent 2017 by Day - 3600 patients
LA –> lower wound infection, complications, shorter LoS, earlier return to normal activity

Previous evidence of increased intra-abdominal abscess not repeated
Recommended by WSES Jerusalem guidelines

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31
Q

What guidelines can be used to guide management of GISTs?

A

UK clinical practice guidelines 2017
- Investigation if >2cm
- Biopsy if neoadjuvant treamtment planned
- NIH risk classification - high risk if >10cm or >5 mitoses
- Dose escalation of Imatinib for KIT exon 9 mutation, Regorafenib if exon 17
- High risk patients should receive imaging 3-6 months for duration of treatment

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32
Q

What clinical practice guidelines are applicable to GORD?

A

Leon Consensus BMJ 2018
-Conclusive evidence of reflux
—Endoscopy = LA Grade C/D, Long segment Barrett’s, Peptic stricture
—pH = acid exposure time >6%, good SAP

ICARUS Guidelines Gut 2019
-Selecting patients for surgery
—All require OGD within 1 year + Mannometry +/- pH if no strong evidence on OGD +/- barium
—reflux responding to PPIs or regurgitation good candidates
—-BMI>35, connective tissue disease, substance abuse, eosinophilic oesophagi’s poor candidates
-Technique
—tailored rap if hypo contractile oesophagus

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33
Q

What clinical practice guidelines are applicable to Achalasia?

A

ISDE 2018
—Recommend HRM and Chicago classification
—OGD to exclude malignancy
—Record Eckardt score
—POEM/LHM reasonable for I/II
—POEM favoured for III

Treatment failure
– PD –> LHM/POEM
–LHM –> PD first line
– POEM prob –> PD

No recommendation on endoscopic follow up

34
Q

What guidelines apply to groin hernia repair?

A

European Hernia Society 2019
- Indicated if symptomatic, asymptomatic may be watched (emergency risk low), but likely to eventually require surgery
- Lap has faster recovery, earlier return to normal activity fewer wound complications and possibly less chronic pain, but higher rate of major vascular/visceral injury
- Use large pore (1-1.5mm) monofilament with burst strength of 16Nm2
- Antibiotics consider only for high risk open approaches
- Anaesthetic - risk of MI/VTE/Pneumonia higher over 65 with regional as opposed to general

35
Q

What guidelines apply to emergency groin hernia repair?

A

European Hernia Society guidelines 2019
- Give antibiotics
- Use mesh even if bowel present, may be able to if bowel resection performed
- Increased risk for females, femoral R>L

36
Q

What is the evidence for use of SEMS for obstructing cancer?

A

The CREST trial (2019) - better short term outcomes and lower permanent stoma rate

37
Q

What evidence is there for a laparoscopic approach to perforated peptic ulcer disease?

A

Meta-analysis of 8 RCTs by Cirocchi
Concluded less pain/wound infections, but similar major outcomes

38
Q

What is the recommended first line treatment for C.Diff

A

Oral Vancomycin (NICE 2021)

Then PO Fidaxomicin
Then PO Vancomycin + IV Metro

39
Q

What guidelines/evidence apply to management of appendicitis?

A

WSES Jerusalem guidelines 2020
- Recommended use of Appendix inflammatory response score for reducing imaging in low risk patients
- Do a CT if >40 +/- colonoscopy
- avoid irrigation, avoid drains
- suture ligation
- Abx for 3-5 days if complicated

APPAC trial
- Antibiotics 8% failure, 27% at 1 years 40% at 5 years
- Avoid if appendicolith
- APPAC 2 PO Abx not non-inferior to 2 days of IV

40
Q

What are the guidelines for management of gallstones?

A

NICE 2020
- MRCP if LFTs abnormal or dilated CBD
- Early lap whole <1 week for acute cholecystitis (PONCHO trial - decreased biliary complications)

WSES 2020
—–CBD Stones
- CBD stones in 5-15%, less than unselected
- GGT most reliable LFT.
- CBD diameter in AC without CBDS 5.8mm vs 7.1mm
- can use Maple classification
- Bili >68.4 or 30.8-68.4 + dilated CBD –> Investigation
—–Non operative management
- APACHE 7-14 consider (even though CHOCOLATE)
Tokyo guidelines - avoid if septic shock and arrange drainage

41
Q

What guidelines management of gallstones in pregnancy?

A

WSES 2020
- Generally favour surgery as risk of miscarriage is less with surgery than NOM for AC
- Lap > Open, can do subtotal cholecystectomy

42
Q

What guidelines for SSIs?

A

NICE 2020
- Do not routinely remove hair (use clippers)
- Alcohol based chlorhexidine e.g. 2% in 70% alcohol >aqueous chlorhex >alcoholic iodine
- Avoid diathermy for incisions
- Consider using triclosan coated sutures
- shower after 48 hours

43
Q

What guidelines are appropriate for SBO?

A

WSES Bologna guidelines 2017
- Trial cons mx 70% success
- No contrast after WSCI in colon at 24 hours highly predictive of failure
- consider use of seprafilm or adept
- consider lap approach when ≤2 laparotomies and expecting single band - can reduce LoS (LASSO Trial)
- WCC >10 and CRP >75 concerning

44
Q

What guidelines apply for VTE?

A

NICE 2018
- Critical care –> LMWH
- Use TEDS or IPC until mobile after surgery
- Consider at least 7 days of LMWH and 28 days for malignancy

GAPS 2020
- LMWH not worse than LMWH + TEDS

45
Q

What guidelines exist for management of perforated peptic ulcer?

A

WSES 2020
<2cm - primary repair +/- patch
>2cm - ?Ca, resection&reconstruction or
—-pyloric exclusion + gastric decompression + biliary diversion
- Antifungal if high risk
- Can feed early if young and low risk
- Gastric –> 6 weeks OGD

46
Q

What guidelines are used for diverticulitis management?

A

ACPGBI Emergency colorectal guidelines 2020
–Hinchey 1a/1b - usually ambulatory
–Abscesses >4cm –> IR
–Ix 6 weeks post complicated (unless already 2 years)
–Weight loss advice only

WSES 2020
–1a maybe avoid Abx

47
Q

How should adrenal incidentalomas be managed?

A

European Society of Endocrinology Clinical practice guidelines 2016
- non contrast CT Benign (<4cm and HU≤10) –> discharge
- if indeterminate –> hormone assessment
—1mg low dose dexamethasone test (excluded if ≤50nmol/l)
—plasma free metanephrines or urinary fractionated metanephrines
—if hypertensive/hypokalaemic –> aldosterone/renin ratio
—if signs of adrenocortical carinoma –> measure sex hormones/steroid precursors
-Surgery
—lap if ≤6cm and not invasive
- If indeterminate - repeat imaging at 6-12 months
- If history of extra-adrenal malignancy –> PETCT

48
Q

What patients are suitable for day case surgery?

A

BRITISH ASSOCIATION OF DAY SURGERY

—Patient factors - ASA 1-3, home support for 24 hours, stop smoking for 6 weeks (nb not Age/weight criteria)
–Surgery - specific operations with known recovery and low risk of complications
–Preassessed by trained pre-op team
–Anaesthetic set up with drugs to reduce PONV

49
Q

How should bile duct injuries be treated if detected intra-operatively?

A

WSES guidelines 2020
If no vascular injury
Minor BDIs (Strasberg A-D) –> direct repair +/- T-Tube +/- drain
Major BDIs –> Hepaticojejunostomy
If vascular injury –> CTA

50
Q

What guidelines are available for incisional hernia repair?

A

Expert Consensus Ann Surgery 2017
—Criteria
- Avoid smoking for at least 4 weeks before elective repair
- Avoid elective surgery in BMI ≥50 and high risk BMI ≥30
- Avoid elective surgery with HbA1c of ≥8%, high risk ≥6.5%
—Technical
- Mesh if ≥2cm defect in sublay position
- Use component separation if necessary to obtain wound closure (Anterior = high rate of wound complications)

51
Q

When should mesh be placed in an emergency hernia repair?

A

European Hernia Society guidelines
WSES Emergency repair of hernia guidelines

Clean, clean-contaminated fields (i.e. including ischaemic but non perforated bowel)
Consider in contaminated fields, or primary repair if defect <3cm or biological/vicryl mesh

52
Q

What is the evidence for minimisation of and treatment of parastomal hernia?

A

EHS 2018
- minimise aperture for stoma
- no preference of pararectus/through rectus
- use synthetic mesh when making elective colostomy

53
Q

What is the evidence for neoadjuvant treatment of resectable colorectal Liver metastasis?

A

EPOC - FOLFOX + Surgery better than Surgery alone
NewEPOC- Cetuximab + FOLFOX worse than FOLFOX only

54
Q

What is the evidence for adjuvant chemotherapy in pancreatic cancer?

A

ESPAC 1 5-FU > CRT/Surgery
ESPAC 3 GEM = 5-FU
ESPAC 4 GEM/CAP > GEM
ESPAC 5 NA > Surgery alone in borderline resectable

55
Q

What guidelines direct treatment for acute pancreatitis?

A

NICE 2018
- Feed within 72 hours, enterally unless contraindicated
- Endoscopic drainage > Percutaneous
- Chronic
—Need to monitor for exocrine function, malnutrition, DEXA every year
—drain pseudocysts EUS if symptomatic, pressure effect, risk of rupture, associated with duct disruption

IAP/APA 2013
- USS x 2 then EUS, MRCP and CT
- Use SIRS criteria at presentation and 48 hours to predict outcome (transient 8%, persistent 25%)
- Goal directed fluid resuscitation at a rate of 5-10ml/kg/hr (increased rates –> sepsis, ventilation and mortality) - aim UO
- WON –> LAMS +/- stent for 4 weeks

WSES 2019
Atlanta criteria
- Mild 80-85%, interstitisal oedematous pancreaitis
- Moderate transient <48hr organ failure, local complications
- Severe persistent organ failure

56
Q

What is the evidence for feeding in pancreatitis?

A

Bakker NEJM 2014
—compared tube feeding within 24hours to oral diet at 72hours in predicted acute severe pancreatitis – no difference in outcomes
—69% of patients with predicted severe pancreatitis tolerated oral diet and did not require tube feeding

57
Q

What evidence is there for SCPRT in rectal cancer?

A

Swedish trial (1997) SCPRT + Surgery > Surgery
Dutch Trial (2005) SCPRT + TME Surgery > TME Surgery
CR 07 (2006) SCPRT better than selective postopCRT

58
Q

What evidence is there for LCCRT in rectal cancer?

A

EORTC/FFCD trials (2005) - LC-CRT>SCRT

59
Q

What treatments do NICE recommend for rectal cancer?

A

Preoperative/non-surgical treatment
T1-2 N0 –> Choice of TME, ESD, TAMIS/TEMS, no preop treatment
Advanced –> preoperative radiotherapy or chemoradiotherapy
– if complete response can offer to defer treatment (risk of recurrence) as part of a trial

Surgery
–Offer laparoscopic
–perform 10/unit, 5/surgeon
– if obstructed offer emergency surgery or stent

Adjuvant pStage 3 –> CAPOX 3/12 or FOLFOX 6/12

60
Q

What NA/A treatments do NICE recommend for colon cancer?

A
  • preoperative FOLFOX for cT4

Adjuvant pStage 3 –> CAPOX 3/12 or FOLFOX 6/12

61
Q

What treatments do NICE recommend for metastatic colorectal cancer?

A
  • Test for RAS and BRAF
  • Consider resection of asymptomatic primary tumour 20% chance of primary tumour complication (obstruction, perforation, bleeding)
  • Consider resection of CRLM and tumour after preopchemo (simultaneous or staged), ablation if unsuitable
  • Consider metastatectomy, ablation or stereotactic radiation for lung metastases
62
Q

What is the evidence for lap vs delayed cholecystectomy?

A

ACDC study Ann Surg. 2013
Morbidity ELC 11.8% vs DLC 34.4%, lower cost and LoS with ELC

Guruswamy KS et al Cochrane Rev. 2013 J
No sig difference, but reduced LoS in high bias trials

63
Q

What guidelines are used for treatment of primary hyperparathyroidism?

A

NICE Guidelines 2019
- Test PTH if Ca>2.5 x 2 + suspicion or >2.6 x 2
- Excude familial hypocalciuric hypocalcaemia using urinary Ca 24hr or random CrCl:Ca ratio (>0.01)
- Assess symptoms, do DEXA and renal USS
- refer if >2.85, symptomatic or end-organ damage
- Use USS and Sestamibi

64
Q

What guidelines are used for the treatment of thyroid cancer?

A

BTA guidelines 2016
- USS + FNAC for all nodules with suspicious features or >1cm
- CT/MRI if retrosternal/fixed (nb contrast and delaying ablation)
- Thy3f/Thy4 –> Diagnostic hemithyroidectomy
- Total thyroidectomy if >4cm, multifocal, familial disease, nodes
- Central compartment dissection for PTC can be omitted if small tumours and young
- Post op total –> 2ug/kg Levo or 20mcg Lio TDS
- for tumours >1cm and total thyroidectomy –> I 131 ablation
- For suspected MTC, phaeo should be excluded
- MTC –> central LN and if involved selective lateral

65
Q

What guidelines exist for treatment of soft tissue sarcoma?

A

UK guidelines 2016
- Lumps >5cm, painful or rapidly increasing in size should have USS
- Biopsy +/- incisional, remove tract at time of surgery (usually after MDT)
- Grade according to FNCLCC - differentiation + necrosis + mitotic count
- Margin should be at least R0, ideally >1cm
- NA if borderline resectable
- Radiotherapy as adjuvant 60-66Gy
- Follow up for up to 10 years

66
Q

What is the evidence for different types of haemorrhoid treatment?

A

II-III —-HuBBLe 2016 - HALO vs RBL – reduced recurrence with HALO (but can repeat band and lower pain)

III-IV ETHOS 2016 - Open > Stapled haemorrhoidectomy QoL

67
Q

What guidelines exist for the preoperative management of patients following oesophagectomy?

A

The ERAS society 2019 - Don Low
–Preop nutritional assessment
–Surgery 3-6 weeks following NACT and 6-10 weeks following NACRT
–No evidence for pyloroplasty
–3 field Lymphadenectomy for upper 1/3 SCC
–NG drainage, consider early removal (D2)
–Passive single chest drain
–Feeding by Feeding J or NJ/ND tubes
–Low Tidal volume ventilation with 5mm PEEP
–Thoracic epidural (or paravertebral blocks) + paracetamol +/- NSAIDS, opioid sparing
– Early mobilisation

68
Q

What guidelines are important for management of pancreatic cystic neoplasms?

A

European Study Group 2018.
-MRI/MRCP probably better, especially for follow up (CT better for preop assessment of vasculature)
-EUS if considering surgical resection but no absolute indication
-CEA≥192 = mucinous cyst, also do lipase/amylase, consider KRAS/GNAS
-FNA specific but not sensitive
-IPMN
—very high risk of malignancy if jaundice, mural nodule ≥5mm or solid, MPD ≥10mm.
—increased risk of malignancy if 5-9.9mm MPD, raised 19.9, small mural nodules, cyst ≥40mm or >5mm growth in a year
—if not undergoing surgery, 6 month follow up for 1 year then annually (MRI, 19.9, clinical)
—manage MT-IPMN as MD-IPMN
—MD-IPMN –> PD + F/S, BD-IPMN oncological resection
— if surgery, 6monthly for 2 years follow up
-MCN
—MCN ≥40mm –> resection, relative 30-40mm
— repeat imaging 6 monthly if not operating, usually Distal Panc + splenectomy if necessary
-SCN - stellate scar, benign, discharge
-If unclear aetiology and small (<15mm), image annually for 3 years if >15mm, 6monthly
-Solid pseudopappillary neoplasm should be resected
-PNET
–>20mm or symptomatic –> surgery

69
Q

What evidence exists for the prevention and repair of incisional hernias?

A

HART trial - no difference with Hughes near far repair vs mass closure
STITCH trial - reduced incisional hernia rate elective slim
EHS 2015- closure with slowly absorbable monofilament with small bite closure, can consider prophylactic mesh elective. Repair lap trocars >10mm

Cumulative incidence of 12.8%
—Tanaka 2010 suggest progressive pneumoperitoneum if Hernia Sac Volume/Abdominal Contents volume = ≥25%
—Luijendijk 2000 NEJM Mesh repair 24% vs 43% suture
—Burger 2004 Ann Surg Mesh repair 17% vs 67% suture
—Demetrashvili 2017 Onlay vs Retromuscular - recurrence 2-5% (low follow up), less wound complications with retro muscular
—-Meta-analysis Awaiz 2015 - lap vs open comparable

69
Q

What evidence exists for the prevention and repair of incisional hernias?

A

HART trial - no difference with Hughes near far repair vs mass closure
STITCH trial - reduced incisional hernia rate elective slim
EHS 2015- closure with slowly absorbable monofilament with small bite closure, can consider prophylactic mesh elective. Repair lap trocars >10mm

Cumulative incidence of 12.8%
—Tanaka 2010 suggest progressive pneumoperitoneum if Hernia Sac Volume/Abdominal Contents volume = ≥25%
—Luijendijk 2000 NEJM Mesh repair 24% vs 43% suture
—Burger 2004 Ann Surg Mesh repair 17% vs 67% suture
—Demetrashvili 2017 Onlay vs Retromuscular - recurrence 2-5% (low follow up), less wound complications with retro muscular
—-Meta-analysis Awaiz 2015 - lap vs open comparable

70
Q

What guidelines exist for the use of sedation?

A

NICE 2010 for children
Academy of royal colleges 2013
- Adequate monitoring
- Titrate dose to effect
- Change dose in elderly/frail
BSG 1999
ASGE 2018 - routine monitoring of BP, SPO2, HR

71
Q

What guidelines govern use of antibiotics and anticoagulants in endoscopy?

A

Abx BSG2009
–No indication for prophylaxis for infective endocarditis
- Single dose for ERPC if cholangitis or other complex situations (Cipro/gent)
- Co-amox for PEG/PEJ/FNAC (inc pseudocysts)
- Give if neutropenic

Anti-coag BSG 2021
-Low risk (Diagnosis +/- biopsy +/-stent) –> continue Clopidogrel, continue warfarin if INR therapeutic, Omit DOAC on morning
- High risk (Poypectomy, ERCP, EMR, Dilatation)
—High risk indication (Clopidogrel (stents) - cardio r/v, Warfarin (metallic heart valves, high risk AF) - stop 5/7 bridge LMWH, DOAC stop 3/7)
—Low risk indication (Clopidogrel 7 days (1/2 after), Warfarin Stop 5/7 no bridge, DOAC stop 3/7)

72
Q

What are the NICE guidelines for AAA?

A

2020
- Report inner-inner max AP diameter on USS
- Preoperative CTA in elective setting
- Restrictive fluid resuscitation during transfer
- Consider CPET - avoid risk prediction scores
- Generally offer open operation unless hostile abdomen, horseshoe kidney, stoma or high anaesthetic risk

  • Rupture
    —EVAR >Open for >70 and all women
    —Open >EVAR for <70 men
    — do not offer complex EVAR
73
Q

What guidelines exist for Bariatric Surgery?

A

NICE – Indications
- >35 + CM or >40. Fit for surgery, failed other, in tier 3 + FU
- Consider if 30-35 and new onset T2DM
- Consider asians at lower than normal BMI if new onset T2DM

BOMMS - nutrition
- Preop Nutritional assessment and micronutrients + HbA1c
- Postop - monitor 3,6,9,12 and annually thereafter
–Inc FBC, U&E, Folate, B12, Vit D, Ca ADEK
– For malabsorptive procedures –> supplement B12 3 monthly, Ca, Vit D, Folic acid, Iron + ADEK

EAES - general
- Prefer SG/RYGB over AGB
- SG - staple line reinforcement and 36fr bougie
- RYGB - preferred if GORD, similar weight loss to SG
- OAGB -?more short term weight loss

74
Q

What RCTs for Bariatrics?

A

By-Band-Sleeve - not reported

STAMPEDE 2017- RYGB/SG > BMT at treating T2DM

YOMEGA 2019 - RYGB = OAGB at 2 years (nb long term, bile reflux)

SLEEVEPASS/SM-BOSS 2021 - RYGB > SG weight loss/HTN but not T2DM

75
Q

What are the appropriate guidelines for management of Phaeochromocytoma?

A

European Society Clinical Practice Guidelines

Supine plasma metanephrines or 24 hr urinary fractionated metanephrines for diagnosis
Give 7-14days of Alpha blocker (phenoxybenzamine -irreversisble or doxazosin)
Then betablockade (labetolol)

Monitor resected with annual metanephrines
Open >6cm invasive tumours

76
Q

What management guidelines for appendiceal NETs?

A

ENETS 2016

No right hemi needed if <1cm, <3cmm mesoappendix, R0, not at base
Monitor with Chromogranin A

77
Q

How are NETs graded?

A

WHO 2010 classification

G1 NET - Ki ≤2%, MR <2/10
G2 NET - KI 3-20%, MR 2-20/10
G3 NET - KI >20, MR >20

78
Q

What guidelines exist for screening for Gastric Cancer?

A

BSG guidelines 2019
- Eradicate H.Pylori if Gastric atrophy or GIM/dysplasia
- Patients with GA/GIM should have regular screening endoscopy + photography with HR-Image enhanced endoscopy, every 3 years if extensive (antrum + Body)
- Biopsies taken at mucosal sites in Sydney protocol areas (antrum, incisor, lesser/greater curve)
- LGD –> repeat and extensive sampling if non visible + repeat 1 year
- HGD –> repeat and extensive sampling if non visible + repeat 6 months + MDT
- Visible LGD/HGD –> EMR if ≤10mm or ESD if ≥10mm
- R0 resection is curative for:
–LGD/HGD
–intramucosal adenocarcinoma
–up to T1bSM1 <3cm unless poorly differentiated
- Resect all adenomas, biopsy intervening mucosa
- Resect hyperplastic >1cm or symptomatic

79
Q

What is the evidence for lap vs open groin hernia repair?

A

Cochrane review 2003 - increased visceral injuries, longer, decreased pain
BJS Meta-analysis 2019 - 58 RCTs - decreased chronic pain/paraesthesia improved satisfaction

FRCS General Section 1/2 (13 decks)

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