General Surgery Flashcards
Ix for lymphoma
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
Hodgkins Lymphoma
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
Staging of Hodgkins Lymphoma
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
How to select patients for day surgery
Guildlines from British association of Day Surgery
1) Social Factors
2)Medical factors
3)Surgical factors
4) Post-operative factors
Indications for elective splenectomy
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
Post splenectomy blood film
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
Anatomical attachment software the spleen
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
Complications of splenectomy
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
OPSI
Uncommon (5% lifetime risk)
Typically occurs in first 2 yrs
80% mortality
Usually cause by Streptococcus Pneumonia / encapsulated bacteria
Splenectomy vaccinations
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
Anatomy of the inguinal canal
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
Sliding hernia
When a retroperitoneal organ protrudes with the peritoneal surface forming the hernia sac (5-8%)
Lap vs open inguinal hernia
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
Risks of open hernia repair
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%
Treatment of Chronic Pain post groin hernia
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.
Pilonidal sinus surgery
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%
Loss of domain
No standard definition but usually over 20% of peritoneal contents are within hernial sac.
Great the volume the more difficult it is to close
Classification of incisional hernia
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
Planning AWR
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
Prophylactic mesh for midline closure
PRISMA trial - high risk patients. - 2 year recurrence rates slower with no significant increase in complications
Mental Capacity Act
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
Gillick Competence
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
CT Abdo/Pelvis vs colonosopy
6.9% cancer detection rate for unprepared CT Abdo/Pelvis vs 11% for colon
Spegalian Hernia
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
Testicualr tumour markers
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
Types of monopolar diathermy
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
Warfarin around surgery
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
Rivaroxaban perioperative
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
Clostridium Difficile
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
Polycystic Kidney Disease
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
Need for nutritional support
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)
Radiation Enteritis
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
GIST
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
Management of GIST
<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
Follow up for GIST
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
Drainage of liver abscess
Systemic review in 2014 favoured US guided drain over aspiration alone
Facilitates higher success rate and reduced time required to achieve clinic relief
Amoebic liver abscess
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
Appendix NET
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
Carcinoid crisis
Pre-op octreotide 100micrograms YDS for 2 weeks
Peri-op IV octreotide at 50-100 mic/hr
Post - slowly ceased over first week
Surgical site infections Classification
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
Antibiotics to prevent SSI
Clean surgery with prosthesis or implant
Clean contaminated surgery
Contaminated surgery
Trials in SSI
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%
Splenic Cysts
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
Retroperitoneal sarcomas
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
Parastomal hernia classification
European hernia society according to site - Ileostomy or colostomy
- Size -1-3 (largest_
Content - Type 1 - fat, 2,, small bowel, 3 colon
