Miscellaneous

Question 1

How do you assess nutrtion in a surgical patient?

Answer 1

History - weight loss and daily caloric intake

Examination
- Hands kolionykia and leukonychia
- Muscles - wasting and proximal myopathy
- Face - conjuntival pallor, angular stomatitis, glossitis
- Cachexia
- Ascites
- Peripheral oedema

Functional tests
- grip strength

Anthropometrics
BMI
Body composition with skin fold thickness

Bloods - albumin (not used in clinical assessment for nutrition but in risk) ,

MUST score - weight loss in the last 6 months, acute illness recently or unable to eat for the last 5 days, and BMI.

Question 2

What are the components of ERAS for colorectal operations?

Answer 2

Preoperative
- patient education & stoma site education
- Optimisation of medical comorbidities
- Mechanical bowel preparation and oral antibiotics
- Fasting from food 6 hours and clear liquids 2 hours

Intraoperative
- Thromboprophylaxis
- Antibiotics prophylaxis
- Normotheramia
- Fluid optimisation
- Minimally invasive approach
- Avoid drains
- Avoid NGT

Post operative
- ENteral nutrition beginning day 1
- High calorie supplements twice daily
- Multimodal analgesia
- Multimodal antiemetic regimen
- Early removal of catheter
- Early mobilisation with a structured approach

Benefits of ERAS is reduced morbidity, faster recovery and shorter length of stay

Successful ERAS programs
- multiple components, multidisciplinary, ongoing education, regualr audit, adequately resourced.

Question 3

What are the differentials for a retroperitoneal sarcoma?

Answer 3

Liposarcoma
Leiomyosarcoma
Pleomorphic undifferentiated sarcoma
Angiosarcoma
Desmoid tumour

Question 4

What are the most common types of sarcomas?

Answer 4

• GIST
• Liposarcoma
• Leiomyosarcoma
• Malignant peripheral nerve sheath tumours
• Desmoids
• Angiosarcoma
• Synovial sarcoma

Question 5

What additional feature is used in staging for sarcoma ther than TNM?

Answer 5

Grade (1,2,3) which is based on differentiation, mitotic rate, and tumour necrosis

Question 6

What is the MOA of steroids?

Answer 6

Steroids – decrease production of NF-kappa-beta -> decrease production of cytokines and decrease T cell activation -> decrease activation of prostaglandins

Question 7

What is the MOA of mycophenolate/azathioprine?

Answer 7

Mycophenolate – cytostatic medication -> purine antagonist that prevents DNA synthesis particularly affecting T and B cell proliferation

Question 8

What is the MOA of mTOR?

Answer 8

mTOR (everolimus) – inhibits T cell activation through blocking intra cellular signal transduction. Can be used in conjunction with calcineurin inhibitor to reduce nephrotoxicity. Poor wound healing.

Question 9

What is the MOA of calcineurin inhibitors?

Answer 9

Calcineurin inhibitors – inhibit the activation of IL2 which prevents T cell activation and proliferation. (cyclosporin and tacrolimus - nephrotoxin). b