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FRCS A > General Surgery > Flashcards

General Surgery Flashcards

1
Q

Ix for lymphoma

A

Bloods- FBC, UE, LFTs, Ca, Infectious mononucleosis, Hep B &C, HIV

US guided core biopsy/LN excision biopsy

If confirmed lymphoma - Ct C/A/P and PET CT

Haem MDT

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2
Q

Hodgkins Lymphoma

A

Defined by presence of Reed-Sternberg cells on biopsy

majority are classics (95%) (5% Noular lymphocytic - poor prognosis)

Subdivide into 4 subtypes
1- Nodular sclerosing
2- Lymphocyte rich
3-Lymphocyst deplete
4- Mixed cellularity

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3
Q

Staging of Hodgkins Lymphoma

A

Ann Arbor staging

Early Favourable 0 Stage 1 and 2A

Early unfavourable - Stage 2b with high ESR or >3 lymph node areas

Advanced - Stage 2B with extra nodal / large mediastinal mass stage 3/4

Stop smoking
Tx - combination of chemotherapy and radiotherapy - 90% with early disease and 80% with advanced disease achieve long-term remission

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4
Q

How to select patients for day surgery

A

Guildlines from British association of Day Surgery

1) Social Factors
2)Medical factors
3)Surgical factors
4) Post-operative factors

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5
Q

Indications for elective splenectomy

A

1) ITP - plus coated in autoantibodies - splenectomy if refractory or recurrent - 50-85% response rate (accessory spleen cause failure) - Good repose in young and immediate post-splenectomy thrombocytosis

2) Hereditary Spherocytosis - Required in moderate to severe causes - usually after 6yrs old

3 TTP - thrombosis in small vessels causing low plus - splenectomy if refectory to steroids and plasmaphereis

Less common - thalassaemia, sickle, PKD, Hodgkins, Feltys syndrome, splenic asbcess/cysts and sarcoidosis

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6
Q

Post splenectomy blood film

A

Howell jolly bodies - nuclear remnants
Pappenheimer bodies - iron inclusions
Target cells - immature RBC
Heinz bodies - denatured haemoglobin inclusions
Spur cells - deformed membranes
Leucocytosis - left shift
Thrombocytosis

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7
Q

Anatomical attachment software the spleen

A

Gastrosplenic ligaments - hilum of spleen to greater curve (short gastric)
Spleno-renal ligaments - hilum of spleen to anterior surface of left kidney (Containes splenic vessels and tail of pans
Splenocolic ligament
Splenophrenic ligament

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8
Q

Complications of splenectomy

A

Immediate - Bleeding

Early - pneumonia, gastric stasis, dilatation and necrosis, thromocystosis, pancreatic leak/fistula/pseudocyst, SMV thrombosis and abscess formation

Late - Overwhelming post- splenectomy infection (OPSI), splenosis, AV fistula, thromocystosis

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9
Q

OPSI

A

Uncommon (5% lifetime risk)
Typically occurs in first 2 yrs
80% mortality
Usually cause by Streptococcus Pneumonia / encapsulated bacteria

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10
Q

Splenectomy vaccinations

A

Usually 2 weeks before or prior to discharge:
Haemophilus influenza type 8, Men C + Men B + pneumococcal vacine

1 month post - Men ACWY + 2nd Men B

Yearly Flu vacine

Pneumococcal booster every 5 yrs

Long term Abe debated (lifelong or 2yrs) - Phenoxy-methyl-penicillin or erythromycin if pen allergic

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11
Q

Anatomy of the inguinal canal

A

4cm inferomedially running tunnel from deep to superficial ring
Anterior - External oblique + internal oblique (lateral 1/3)
Inferior - inguinal ligament
Posterior - conjoint tendon and transversals fascia
Roof - conjoint tendon

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12
Q

Sliding hernia

A

When a retroperitoneal organ protrudes with the peritoneal surface forming the hernia sac (5-8%)

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13
Q

Lap vs open inguinal hernia

A

NICE recommends for recurrent and bilateral primary and as an alternative for primary unilateral

Majority of meta-analysis show lower rate of chronic pain and fewer wound complications and reduced surgical site infections and earlier return to work.

European Hernia Society guidelines 2018 - personalised strategy

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14
Q

Risks of open hernia repair

A

1% recurrence (2.5% after Lap)
Chronic pain 10-40% (2% lap)
Wound complications - infection, bleeding, haematoma, serum

Injury to cord, ischaemic orchitis/testicular atrophy, injury to Vas, hydrocele

Risks of surge Generally

Mortality low approx 0.15%

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15
Q

Treatment of Chronic Pain post groin hernia

A

Simple analgesia - watch and wait
Referral to specialist in chronic pain
Systemic agents such as gabapentin, tricyclics SSRI
Nerve blocks
Chemical neurectomy -22% successful
Surgical neurectomy 71% successful - anterior or posterior approach.

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16
Q

Pilonidal sinus surgery

A

Lay open and secondary healing - lowest recurrence rate
Simple excision and closure - wound breakdown in approx 50%
Bascom 1 and 2
Karadakis
Both involve removal of pits/tracts with off midline incision and closure with flattening of natal cleft

Recurrence rate at least 10%

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17
Q

Loss of domain

A

No standard definition but usually over 20% of peritoneal contents are within hernial sac.
Great the volume the more difficult it is to close

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18
Q

Classification of incisional hernia

A

European Hernia Society 2009

Midline Zones (M1-5) and lateral Zones L1-4 Right to left)

Width (prognostic) W1 <4cm, W2 4-10cm W3 >10cm

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19
Q

Planning AWR

A

Can use Carbonyl Ratio - Sum of rectus width to defect ration
>2 can do Rives-Stoppa (retrorectus meshed midline closure - gold standard)

<2 or >10cm then consider other adjusts - Anterior component separation, Transversus Abdomens release, Pre-op botulinum/penumoperioteum

20
Q

Prophylactic mesh for midline closure

A

PRISMA trial - high risk patients. - 2 year recurrence rates slower with no significant increase in complications

21
Q

Mental Capacity Act

A

2005
Provides conditions under which people can be deemed to lack capacity to make decisions regarding their healthcare

Lack capacity when unable to understand, weight and use info provided to make an informed decision

22
Q

Gillick Competence

A

Under 16 and able to consent for their own medical treatment without parental permission or knowledge

Gillick vs West Norfolk and Wisbech Area Health Authority 1986

23
Q

CT Abdo/Pelvis vs colonosopy

A

6.9% cancer detection rate for unprepared CT Abdo/Pelvis vs 11% for colon

24
Q

Spegalian Hernia

A

Defect lateral to linea semilunares at or below the arcuate line

Often intra-parietal passing through the transverses and the internal oblique aponeuroses but staying below the intact aponeurosis of the external oblique

25
Q

Testicualr tumour markers

A

Important for diagnosis and staging - prognostic

Seminomas (1/3 Raised HCG) and non-seminomatous (60% AFP and HCG raised)

LDh is less specific and increased levels proportional to tumour volume

26
Q

Types of monopolar diathermy

A

Cutting - continuous waveform
Blend - mix of cutting and coat waveform
Spray (fulgurate) - pulsed waveform resulting in heating and necrosis + greater thermal spread)
Desiccate - coagulation with deep necrosis and greater thermal spread

27
Q

Warfarin around surgery

A

British Committee for standards in Haematology Guidlines
Stop 5 days prior
Doesn’t need bridging unless very high risk or recurrent VTE (previous DVT/PE on therapeutic anticoagulant (INR 3-5) <3months prior)

Check on day of surgery - proceed if INR <1.5

Restart day of surgery (4hrs post) or next day if afternoon case

Recheck INR day 2 post-op before 3rd dose.

Continue prophylactic LMWH until INR >2 for 2 days or for 5 days

28
Q

Rivaroxaban perioperative

A

Stop 48hrs prior to surgery unless Creat clearance <30ml/min then 72hrs

Restart 48hrs post if high bleeding risk

Bridge with prophylactic dose LWMH post until restarted if high risk of VTE

Can be reversed by Andexanet in emergency

29
Q

Clostridium Difficile

A

Gram +ve, anaerobic, spore forming bacillus

Present in 2-3% of healthy adultsProduces 2 toxins A - enterotoxin and B cytotoxin

Detected in lab by PCR, GDH EIA and toxin EIA

Severe causes - WCC >15, Acute raise in Creat >50, Temp >38.5, evidence of severe colitis, Latate >5

Tx - Mild (<3 stools) - Nil
Mild to moderate - oral metro
Severe oral vanc.

Recurrenct 20% - once replaced risk of subsequent is 50-60% - evidence for fidaxomicin

30
Q

Polycystic Kidney Disease

A

Autosomal dominant progressive systemic disease
Cyst formation in kidney, liver, aping and spleen
Half require renal replacement by age of 60

Bloods - FBC, UE, LFTs, Calcium, phosphate and PTH
US

Liver cysts can result in portal HTN, ascites, varies and malnutriation

Cerebral aneurysms occur in 10%

Renal stones in 20-30%

Genetic screening exists. - useful for -ve US patients wanting to be donors

31
Q

Need for nutritional support

A

Should be considered according to NICe in anyone malnutrished
BM<18.5
Unintentional weightless >10% in last 36months or BMI20 >5%
Risk of becoming malnourished - eaten little or nothing in last 5 days or next 5 days
Poor absorptive capacity or high nutrient losses/increased needs (catabolism)

32
Q

Radiation Enteritis

A

Small bowel disease secondary to radiation injury - Acute or Chronic
Chronic - typically 18mnths to 6yrs post

Radiation initially causes mucosal inflammation which can lead to progressive ischaemica causing fibrosis and impairing function

33
Q

GIST

A

Gastrointestinal stromal TUmours
Uncommon sarcoma derived from mesenchymal origin

Majority driven by KIT gene mutation and stain positive for CD117/CD34

Commonest site stomach 60-70%, SB 20-30% but rarely in oesophagus, mesentery, omens and colorectal.

EUS - hypoechoeic mass contiguous with muscular proprietary/mucosa

Most are PET Avid - used to stage, look for mets or response to imatinib

34
Q

Management of GIST

A

<2cm watch and wait
Larger tumours of symptomatic - resect
Cause use imatinib (Glivec) to downstage

Adjuvent Imatinib used for 3yrs in high risk of replies patients - Miettinen 2006 criteria (Size, location and mitotic rate)

If mets or unresectable - Imatinib 400mg OD incraed to 800mg OD - second Line is sunitinib

35
Q

Follow up for GIST

A

AUGIS 2009 Guidlines
Very low risk - Nil
Low risk CT at 3 months then clinical
Intermediate risk - CT at 3 months then 6monthly for 2 years then annually for 5yrs
High risk - 3months post surgery, then 3monthly for 2 yrs then 6monthly for 2yrs then annually

In patients with adjacent - 3months post surgery, then 6months for 2yrs then annually for 5yrs

36
Q

Drainage of liver abscess

A

Systemic review in 2014 favoured US guided drain over aspiration alone
Facilitates higher success rate and reduced time required to achieve clinic relief

37
Q

Amoebic liver abscess

A

Collection of pus in the liver in response to intestinal parasite
Entamoeba histolytica

Usually in endemic areas of the world

On imagining usually have poorly defined boundaries

Majority in right lobe - led lobe indicates advanced disease

Usually have antibodies detectable using ELISA

Tx - can aspirate if risk of rupture or uncertain - anchovy paste)
Metronidazole for abscess
Paromomycin for eradication of amoebiasis

38
Q

Appendix NET

A

Critical info from Histology
Size, location, depth of invasion, mesoappediceal, L/V invasion, Ki67 score, perforation and R status

See in clinic, ask about carcinoid symptoms.

Arranged CT C/A/P and Chromogranin A blood test, can consider urinary 5- HIAA (>25mg per day in carcinoid syndrome

Discuss at MDT

Can consider Idium 11 SPECT or PET with Gallium 68 labelled somatostatin analogues if suspicion of incomplete resection, residual disease or mets

Follow up
Post surgery - if no LN - No follow up
If LN then long term FU - 3,6,12month then yearly. Chromogranin A and possible MRI - no consensus

39
Q

Carcinoid crisis

A

Pre-op octreotide 100micrograms YDS for 2 weeks
Peri-op IV octreotide at 50-100 mic/hr
Post - slowly ceased over first week

40
Q

Surgical site infections Classification

A

US Centrers for Disease Control and Prevention CDC

Superficial, Deep or organ space

Degrees of contamination
1) Clean
2) Clean -contaminated
3)Contaminated - major breach of sterile technique/spillage. Open traumatic wounds older then 12-24hrs)
4) Dirty/infected

41
Q

Antibiotics to prevent SSI

A

Clean surgery with prosthesis or implant
Clean contaminated surgery
Contaminated surgery

42
Q

Trials in SSI

A

SUNRISE - Multicentre RCT using -ve pressure dressing - no difference at 30days
Falcon study - 2%alcoholic chlorhex vs iodine and triclosan coated sutures vs non-coated - Nil difference
Cheetah study - changing gloves and instruments prior to closure reduced SSI 18.9% vs 16%

43
Q

Splenic Cysts

A

Most cysts (80%) are secondary cysts - usually post trauma or infection.
20% are primary - epithelial or epidermoid cysts

Need to take aHx and evaluate symtpoms
MRI or CT can help evaluate further

Mangement - conservative, radiology or surgical

F/U every 6-12months depending on symptoms

44
Q

Retroperitoneal sarcomas

A

40-50% - liposarcoma
25-30% leiomyosarcoma

Less common - malignant peripheral nerve sheath tumours, fibrosarcomas, undifferentiated pleomorphic sarcomas

Ix - Contrast enhanced CT. MRI may be useful - Core needle biopsy to confirm histology

Mx - Surgery with -ve margins
Can consider neoadj radio to attempt down staging and adj to high grade tumours or positive margins. Limited role for chemo

F/U3-6monthly Clinical and CT for 2-3yrs then yearly. Looking for reoccurane

Mets - Liver and longs - depending on subtype
Leiomyosarcoma - lungs
liposarcomas -liver and intra-abdominal sites

45
Q

Parastomal hernia classification

A

European hernia society according to site - Ileostomy or colostomy
- Size -1-3 (largest_
Content - Type 1 - fat, 2,, small bowel, 3 colon

FRCS A (9 decks)

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