Evidence Flashcards
What is the evidence for LARS?
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%
What evidence for POEM vs Heller vs PD
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)
What is the optimum management of Caustic ingestion?
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
In what circumstances can a T1b AC of the esophagus be managed by ESD?
ESMO guidelines 2016
SM1 - <500um invasion, L0,V0, G1/2, <20mm diameter)
Which trials are investigating the treatment of presurgery complete responders to CRT in AC oesophagus?
ESOstrate and SANO
What is the RCT evidence for a minimally invasive approach to oesophagectomy?
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
When might an endoscopic approach be appropriate for gastric cancers?
JGCA
- T1a non ulcerated, differentiated <2cm - EMR/ESD
- T1a with ulceration <3cm - ESD
What is the lymph node metastasis rate for T1b oesophageal tumours?
sm1 = 6% AC 27% SCC
sm2 = 23% AC 36% SCC
sm3 = 58% AC 55% SCC
When is a PET CT not useful for OG cancers?
-Obvious metastatic disease
-T1a Oesophageal cancer
-Gastric cancer unless suspecting occult metastatic disease
When should staging laparoscopy be undertaken for OG cancers
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)
When should splenic hilum dissection/splenectomy be undertaken in patients with gastric cancer?
With greater curve tumours where the lymph node positivity rate will be higher
BSG 2011
When should peritoneal washings be performed for gastric cancer?
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.
What is the evidence for minimally invasive approach for gastric cancer?
LOGICA trial 2020 - JCO
115 Lap vs 112 open
Similar results
Not clear where anastomosis performed
What is the evidence for D1 vs D2 resection?
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)
What is the recommended treatment for Type 3 achalasia
POEM (ASGE 2020)
What is the treatment of choice after a failed Heller myotomy?
Pneumatic dilatation (ASGE 2020, ISDE 2018)
What is the evidence for mesh placement in giant hiatal hernias?
Limited - but RCT by Watson 2020 (Ann Surg)
Suture vs Absorbable mesh vs Non-absorbable mesh
Similar recurrence rate, worse symptomatology with mesh
Tell me about the FLOT4 trial?
360 ECF/ECX vs 356 FLOT
Adenocarcinoma cT2/N+ Gastric/GOJ (50/50)
50% received Post op
FLOT OS 50months vs 35 months
Tell me about the CROSS trial?
NEJM 2012
178 CRT vs 188 Surgery GOJ (22%)/Oesophagus
T2+N+ 75% AdenoCa, 23% SCC
Median survival 49.4 vs 24.0mths
What is the evidence for ROBOTIC oesophagectomy?
RAMIE trial from china, Ann Surg 2022.
183RAMIE vs 179MIE
Roughly equivalent, RAMIE quicker
However - SCC, China, low rate of neoadjuvant (15%)
When should oesophagectomy be performed after neoadjuvant treatment?
3-6 weeks chemo
6-10 weeks CRT
What is the Hinchey classification of diverticulitis
1a) Pericolic inflammation
1b) Pericolic abscess
2a) Distant abscess amenable to drainage
2b) Complex abscess +/- fistula
3) Purulent peritonitis
4) Faecal peritonitis
What evidence is there for laparoscopic washout in diverticulitis?
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%
What are the relevant trials associated with treatment of diverticulitis?
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
What is the evidence for stent usage in large bowel obstruction secondary to cancer?
CREST trial
246 patients
Lower stoma rate with stent
Same 1 year survival, QoL, mortality
What is the evidence for treatment of infrainguinal occlusive disease (3) ?
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
What is the evidence for lap vs open for perforated peptic ulcer repair?
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
What medical treatment should patients with Barrett’s oesophagus receive?
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
What evidence is there for Bariatric surgery for T2DM
STAMPEDE trial
2017, NEJM
Bypass vs Sleeve vs BMT for DM
29 vs 23 vs 5% HbA1c ≤6 at 5 years with less meds
What is the evidence for lap vs open appendicectomy?
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
What guidelines can be used to guide management of GISTs?
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
What clinical practice guidelines are applicable to GORD?
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
What clinical practice guidelines are applicable to Achalasia?
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
What guidelines apply to groin hernia repair?
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
What guidelines apply to emergency groin hernia repair?
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
What is the evidence for use of SEMS for obstructing cancer?
The CREST trial (2019) - better short term outcomes and lower permanent stoma rate
What evidence is there for a laparoscopic approach to perforated peptic ulcer disease?
Meta-analysis of 8 RCTs by Cirocchi
Concluded less pain/wound infections, but similar major outcomes
What is the recommended first line treatment for C.Diff
Oral Vancomycin (NICE 2021)
Then PO Fidaxomicin
Then PO Vancomycin + IV Metro
What guidelines/evidence apply to management of appendicitis?
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
What are the guidelines for management of gallstones?
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
What guidelines management of gallstones in pregnancy?
WSES 2020
- Generally favour surgery as risk of miscarriage is less with surgery than NOM for AC
- Lap > Open, can do subtotal cholecystectomy
What guidelines for SSIs?
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
What guidelines are appropriate for SBO?
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
What guidelines apply for VTE?
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
What guidelines exist for management of perforated peptic ulcer?
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
What guidelines are used for diverticulitis management?
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
How should adrenal incidentalomas be managed?
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
What patients are suitable for day case surgery?
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
How should bile duct injuries be treated if detected intra-operatively?
WSES guidelines 2020
If no vascular injury
Minor BDIs (Strasberg A-D) –> direct repair +/- T-Tube +/- drain
Major BDIs –> Hepaticojejunostomy
If vascular injury –> CTA
What guidelines are available for incisional hernia repair?
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)
When should mesh be placed in an emergency hernia repair?
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
What is the evidence for minimisation of and treatment of parastomal hernia?
EHS 2018
- minimise aperture for stoma
- no preference of pararectus/through rectus
- use synthetic mesh when making elective colostomy
What is the evidence for neoadjuvant treatment of resectable colorectal Liver metastasis?
EPOC - FOLFOX + Surgery better than Surgery alone
NewEPOC- Cetuximab + FOLFOX worse than FOLFOX only
What is the evidence for adjuvant chemotherapy in pancreatic cancer?
ESPAC 1 5-FU > CRT/Surgery
ESPAC 3 GEM = 5-FU
ESPAC 4 GEM/CAP > GEM
ESPAC 5 NA > Surgery alone in borderline resectable
What guidelines direct treatment for acute pancreatitis?
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
What is the evidence for feeding in pancreatitis?
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
What evidence is there for SCPRT in rectal cancer?
Swedish trial (1997) SCPRT + Surgery > Surgery
Dutch Trial (2005) SCPRT + TME Surgery > TME Surgery
CR 07 (2006) SCPRT better than selective postopCRT
What evidence is there for LCCRT in rectal cancer?
EORTC/FFCD trials (2005) - LC-CRT>SCRT
What treatments do NICE recommend for rectal cancer?
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
What NA/A treatments do NICE recommend for colon cancer?
- preoperative FOLFOX for cT4
Adjuvant pStage 3 –> CAPOX 3/12 or FOLFOX 6/12
What treatments do NICE recommend for metastatic colorectal cancer?
- 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
What is the evidence for lap vs delayed cholecystectomy?
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
What guidelines are used for treatment of primary hyperparathyroidism?
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
What guidelines are used for the treatment of thyroid cancer?
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
What guidelines exist for treatment of soft tissue sarcoma?
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
What is the evidence for different types of haemorrhoid treatment?
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
What guidelines exist for the preoperative management of patients following oesophagectomy?
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
What guidelines are important for management of pancreatic cystic neoplasms?
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
What evidence exists for the prevention and repair of incisional hernias?
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
What evidence exists for the prevention and repair of incisional hernias?
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
What guidelines exist for the use of sedation?
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
What guidelines govern use of antibiotics and anticoagulants in endoscopy?
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)
What are the NICE guidelines for AAA?
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
What guidelines exist for Bariatric Surgery?
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
What RCTs for Bariatrics?
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
What are the appropriate guidelines for management of Phaeochromocytoma?
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
What management guidelines for appendiceal NETs?
ENETS 2016
No right hemi needed if <1cm, <3cmm mesoappendix, R0, not at base
Monitor with Chromogranin A
How are NETs graded?
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
What guidelines exist for screening for Gastric Cancer?
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
What is the evidence for lap vs open groin hernia repair?
Cochrane review 2003 - increased visceral injuries, longer, decreased pain
BJS Meta-analysis 2019 - 58 RCTs - decreased chronic pain/paraesthesia improved satisfaction
