Surgery

Question 1

PSA following prostatectomy?

Answer 1

Following a complete prostatectomy, the PSA level should be ‘undetectable’ which is defined usually as a value less than 0.2ng/ml.

If raised = urgent referral

Question 2

Colorectal cancer Treatment depending on site?
1. Caecal, ascending or proximal transverse colon
2. Distal transverse, descending colon
3. Sigmoid colon
4. Upper rectum
5. Low rectum
6. Anal verge

Answer 2

1. Right hemicolectomy
2. Left hemicolectomy
3. High anterior resection
4. Anterior resection (TME)
5. Anterior resection (Low TME)
6. Abdomino-perineal excision of rectum

Question 3

Abdominal wall hernias in children

1. Congenital Inguinal Hernia
2. Infantile umbilical Hernia

Answer 3

1. Indirect hernias resulting from a patent processus vaginalis
   Occur in around 1% of term babies. More common in premature babies and boys
   60% are right sided, 10% are bilaterally
   Should be surgically repaired soon after diagnosis as at risk of incarceration
2. Symmetrical bulge under the umbilicus
   More common in premature and Afro-Caribbean babies
   The vast majority resolve without intervention before the age of 4-5 years
   Complications are rare

Question 4

PAD management?

Answer 4

• As with any patient who has established cardiovascular disease, all patients should be taking a statin. Atorvastatin 80 mg is currently recommended. In 2010 NICE published guidance suggesting that clopidogrel should be used first-line in patients with peripheral arterial disease in preference to aspirin.
• Exercise Training
• Severe PAD or critical limb ischaemia may be treated by:

Endovascular revascularization
percutaenous transluminal angioplasty +/- stent placement
endovascular techniques are typically used for short segment stenosis (e.g. < 10 cm), aortic iliac disease and high-risk patients
surgical revascularization
surgical bypass with an autologous vein or prosthetic material

endarterectomy
open surgical techniques are typically used for long segment lesions (> 10 cm), multifocal lesions, lesions of the common femoral artery and purely infrapopliteal disease

• Amputation
• Drugs licensed for use in peripheral arterial disease (PAD) include:
  naftidrofuryl oxalate: vasodilator, sometimes used for patients with a poor quality of life
  cilostazol: phosphodiesterase III inhibitor with both antiplatelet and vasodilator effects - not recommended by NICE

Question 5

Fibroadenoma

Answer 5

• Common benign tumours of stromal/epithelial breast duct tissue.
• They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone). Often regress post-menopause.
• Features: Painless / Smooth / Round / Firm / Mobile / Usually < 3cm diameter
• Conservative mx but if > 3cm: for surgical referral

Question 6

Suspected SAH - investigation?

Answer 6

Non-contrast CT head is the first-line investigation of choice
acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system.

if CT head is done within 6 hours of symptom onset and is normal
new guidelines suggest not doing a lumbar puncture & consider an alternative diagnosis

If CT head is done more than 6 hours after symptom onset and is normal
do a lumber puncture (LP)
timing wise the LP should be performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown).
xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure).
as well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure
if the CT shows evidence of a SAH
referral to neurosurgery to be made as soon as SAH is confirmed

Question 7

SAH mx?

Answer 7

supportive:
bed rest
analgesia
venous thromboembolism prophylaxis
discontinuation of antithrombotics (reversal of anticoagulation if present)

vasospasm is prevented using a course of oral nimodipine

intracranial aneurysms are at risk of rebleeding and therefore require prompt intervention, preferably within 24 hours
most intracranial aneurysms are now treated with a coil by interventional neuroradiologists, but a minority require a craniotomy and clipping by a neurosurgeon

Question 8

SAH complications?

Answer 8

• re-bleeding
  happens in around 10% of cases and most common in the first 12 hours
  if rebleeding is suspected (e.g. sudden worsening of neurological symptoms) then a repeat CT should be arranged
  associated with a high mortality (up to 70%)
• hydrocephalus
  hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculoperitoneal shunt
• vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset
  ensure euvolaemia (normal blood volume)
  consider treatment with a vasopressor if symptoms persist
• hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH))
• seizures