Surgery Flashcards

Question

Haemorrhoids

Answer 1

Haemorrhoidal tissue is part of the normal anatomy which contributes to anal continence. These mucosal vascular cushions are found in the left lateral, right posterior and right anterior portions of the anal canal (3 o'clock, 7'o'clock and 11 o'clock respectively). Haemorrhoids are said to exist when they become enlarged, congested and symptomatic Clinical features painless rectal bleeding is the most common symptom pruritus pain: usually not significant unless piles are thrombosed soiling may occur with third or forth degree piles Types of haemorrhoids External originate below the dentate line prone to thrombosis, may be painful Internal originate above the dentate line do not generally cause pain Grading of internal haemorrhoids Grade I Do not prolapse out of the anal canal Grade II Prolapse on defecation but reduce spontaneously Grade III Can be manually reduced Grade IV Cannot be reduced Management soften stools: increase dietary fibre and fluid intake topical local anaesthetics and steroids may be used to help symptoms outpatient treatments: rubber band ligation is superior to injection sclerotherapy surgery is reserved for large symptomatic haemorrhoids which do not respond to outpatient treatments newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy Acutely thrombosed external haemorrhoids typically present with significant pain examination reveals a purplish, oedematous, tender subcutaneous perianal mass if patient presents within 72 hours then referral should be considered for excision. Otherwise patients can usually be managed with stool softeners, ice packs and analgesia. Symptoms usually settle within 10 days

Answer 2

Haemorrhoids Location: 3, 7, 11 o'clock position Internal or external Treatment: Conservative, Rubber band ligation, Haemorrhoidectomy Fissure in ano Location: midline 6 (posterior midline 90%) and 12 o'clock position. Distal to the dentate line Chronic fissure \> 6/52: triad: Ulcer, sentinel pile, enlarged anal papillae Proctitis Causes: Crohn's, ulcerative colitis, Clostridium difficile Ano rectal abscess E.coli, staph aureus Positions: Perianal, Ischiorectal, Pelvirectal, Intersphincteric Anal fistula Usually due to previous ano-rectal abscess Intersphincteric, transsphincteric, suprasphincteric, and extrasphincteric. Goodsalls rule determines location Rectal prolapse Associated with childbirth and rectal intussceception. May be internal or external Pruritus ani Systemic and local causes Anal neoplasm Squamous cell carcinoma commonest unlike adenocarcinoma in rectum Solitary rectal ulcer Associated with chronic straining and constipation. Histology shows mucosal thickening, lamina propria replaced with collagen and smooth muscle (fibromuscular obliteration)

Answer 3

TBI Basics primary brain injury may be focal (contusion/haematoma) or diffuse (diffuse axonal injury) diffuse axonal injury occurs as a result of mechanical shearing following deceleration, causing disruption and tearing of axons intra-cranial haematomas can be extradural, subdural or intracerebral, while contusions may occur adjacent to (coup) or contralateral (contre-coup) to the side of impact secondary brain injury occurs when cerebral oedema, ischaemia, infection, tonsillar or tentorial herniation exacerbates the original injury. The normal cerebral auto regulatory processes are disrupted following trauma rendering the brain more susceptible to blood flow changes and hypoxia the Cushings reflex (hypertension and bradycardia) often occurs late and is usually a pre terminal event Type of injury Notes Extradural (epidural) haematoma Bleeding into the space between the dura mater and the skull. Often results from acceleration-deceleration trauma or a blow to the side of the head. The majority of epidural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features features of raised intracranial pressure some patients may exhibit a lucid interval Subdural haematoma Bleeding into the outermost meningeal layer. Most commonly occur around the frontal and parietal lobes. Risk factors include old age, alcoholism and anticoagulation. Slower onset of symptoms than a epidural haematoma. There may be fluctuating confusion/consciousness Subarachnoid haemorrhage Classically causes a sudden occipital headache. Usually occurs spontaneously in the context of a ruptured cerebral aneurysm but may be seen in association with other injuries when a patient has sustained a traumatic brain injury

Answer 4

Head injury: NICE guidance on investigation NICE has strict and clear guidance regarding which adult patients are safe to discharge and which need further CT head imaging. The latter group are also divided into two further cohorts, those who require an immediate CT head and those requiring CT head within 8 hours of injury: CT head immediately GCS \< 13 on initial assessment GCS \< 15 at 2 hours post-injury suspected open or depressed skull fracture. any sign of basal skull fracture (haemotympanum, 'panda' eyes, cerebrospinal fluid leakage from the ear or nose, Battle's sign). post-traumatic seizure. focal neurological deficit. more than 1 episode of vomiting CT head scan within 8 hours of the head injury - for adults with any of the following risk factors who have experienced some loss of consciousness or amnesia since the injury: age 65 years or older any history of bleeding or clotting disorders dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle or a fall from a height of greater than 1 metre or 5 stairs) more than 30 minutes' retrograde amnesia of events immediately before the head injury If a patient is on warfarin who have sustained a head injury with no other indications for a CT head scan, perform a CT head scan within 8 hours of the injury.

Answer 5

Hearing Loss Hearing loss may be conductive or sensorineural. To determine which is present patients will often require a formal assessment with pure tone audiometry. In the clinical setting Webers and Rinnes tests may be helpful in categorising various types of hearing loss. Webers and Rinnes Tests In a normal patient, the Weber tuning fork sound is heard equally loud in both ears with no one ear hearing the sound louder than the other. A patient with symmetrical hearing loss will hear the Weber tuning fork sound equally well with diagnostic utility only in asymmetric (one-sided) hearing losses. In a patient with asymmetrical hearing loss, the Weber tuning fork sound is heard louder in one ear versus the other. This clinical finding should be confirmed by repeating the procedure and having the patient occlude one ear with a finger; the sound should be heard best in the occluded ear. Rinne Test Weber without lateralisation Weber lateralises to left Weber lateralises to right Both ears Air\>Bone Normal Sensorineural loss on right Sensorineural loss on left Left Bone \> Air Conductive loss on left Combined loss on left Right Bone\> Air Combined loss on right Conductive loss on right Both Bone \> Air Combined loss on right and conductive on left Combined loss on left and conductive on right

Answer 6

Inguinal hernia Inguinal hernias account for 75% of abdominal wall hernias. Around 95% of patients are male; men have around a 25% lifetime risk of developing an inguinal hernia. Features groin lump: disappears on pressure or when the patient lies down discomfort and ache: often worse with activity, severe pain is uncommon strangulation is rare Whilst traditional textbooks describe the anatomical differences between indirect (hernia through the inguinal canal) and direct hernias (through the posterior wall of the inguinal canal) this is of no relevance to the clinical management. Management the clinical consensus is currently to treat medically fit patients even if they are asymptomatic a hernia truss may be an option for patients not fit for surgery but probably has little role in other patients mesh repair is associated with the lowest recurrence rate The Department for Work and Pensions recommend that following an open repair patients return to non-manual work after 2-3 weeks and following laparoscopic repair after 1-2 weeks Complications early: bruising, wound infection late: chronic pain, recurrence

Answer 7

Lower urinary tract symptoms in men Lower urinary tract symptoms (LUTS) in men are very common and are present in the majority of men aged \> 50 years. They are most commonly secondary to benign prostatic hyperplasia but other causes should be considered including prostate cancer. It is useful to classify the symptoms into 3 broad groups. Voiding Storage Post-micturition Hesitancy Poor or intermittent stream Straining Incomplete emptying Terminal dribbling Urgency Frequency Nocturia Urinary incontinence Post-micturition dribbling Sensation of incomplete emptying Examination urinalysis: exclude infection, check for haematuria digital rectal examination: size and consistency of prostate a PSA test may be indicated, but the patient should be properly counselled first It is useful to get the patient to complete the following to guide management: urinary frequency-volume chart: distinguish between urinary frequency, polyuria, nocturia, and nocturnal polyuria. International Prostate Symptom Score (IPSS): assess the impact on the patient's life. This classifies the symptoms as mild, moderate or severe Management Predominately voiding symptoms conservative measures include: pelvic floor muscle training, bladder training, prudent fluid intake and containment products if 'moderate' or 'severe' symptoms offer an alpha-blocker if the prostate is enlarged and the patient is 'considered at high risk of progression' then a 5-alpha reductase inhibitor should be offered if the patient has an enlarged prostate and 'moderate' or 'severe' symptoms offer both an alpha-blocker and 5-alpha reductase inhibitor if there are mixed symptoms of voiding and storage not responding to an alpha blocker then a antimuscarinic (anticholinergic) drug may be added Predominately overactive bladder conservative measures include moderating fluid intake bladder retraining should be offered antimuscarinic drugs should be offered if symptoms persist. NICE recommend oxybutynin (immediate release), tolterodine (immediate release), or darifenacin (once daily preparation) mirabegron may be considered if first-line drugs fail Nocturia advise about moderating fluid intake at night furosemide 40mg in late afternoon may be considered desmopressin may also be helpful

Answer 8

Minor surgery Local anaesthetic (LA) Lidocaine is the most widely used LA. It has a rapid onset of action and anaesthesia lasts for around 1 hour. the maximum safe dose is 3mg/kg. The BNF states 200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient. This is the equivalent of 20ml of 1% solution or 10ml of 2% solution lidocaine is available pre-mixed with adrenaline. This increases the duration of action of lidocaine and reduces blood loss secondary to vasoconstriction. It must never be used near extremities due to the risk of ischaemia Suture material Non-absorbable Absorbable Silk Novafil Prolene Ethilon Vicryl Dexon PDS Non-absorbable sutures are normally removed after 7-14 days, depending on the location. Absorbable sutures normally disappear after 7-10 days. Removal times for non-absorbable sutures are shown below: Area Removal time (days) Face 3 - 5 Scalp, limbs, chest 7 - 10 Hand, foot, back 10 - 14

Answer 9

Penile cancer Penile cancer is a rare form of cancer that is usually a squamous cell carcinoma. Features penile lump penile ulceration Risk factors: Human immunodeficiency virus infection Human papillomavirus virus infection Genital warts Poor hygiene Phimosis Paraphimosis Balanitis Age \>50 Treatment: Radiotherapy Chemotherapy Surgery Prognosis: Approximately 50% at 5 years

Answer 10

Peripheral arterial disease management Peripheral arterial disease (PAD) is strongly linked to smoking. Patients who still smoke should be given help to quit smoking. Comorbidities should be treated, including hypertension diabetes mellitus obesity 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 has been shown to have significant benefits. NICE recommend a supervised exercise programme for all patients with peripheral arterial disease prior to other interventions. Severe PAD or critical limb ischaemia may be treated by: angioplasty stenting bypass surgery Amputation should be reserved for patients with critical limb ischaemia who are not suitable for other interventions such as angioplasty of bypass surgery. 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

Answer 11

Prostate cancer PSA testing Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate epithelial cells. It has become an important tumour marker but much controversy still exists regarding its usefulness as a screening tool. The NHS Prostate Cancer Risk Management Programme (PCRMP) has published updated guidelines in 2009 on how to handle requests for PSA testing in asymptomatic men. A recent European trial (ERSPC) showed a statistically significant reduction in the rate of death prostate cancer by 20% in men aged 55 to 69 years but this was associated with a high risk of over-diagnosis and over-treatment. Having reviewed this and other data the National Screening Committee have decided not to introduce a prostate cancer screening programme yet but rather allow men to make an informed choice. Age-adjusted upper limits for PSA were recommended by the PCRMP: Age PSA level (ng/ml) 50-59 years 3.0 60-69 years 4.0 \> 70 years 5.0 However, NICE Clinical Knowledge Summaries currently suggest a different cut-off: men aged 50-69 years should be referred if the PSA is \>= 3.0 ng/ml OR there is an abnormal DRE note this is a lower threshold than the PCRMP 60-69 years limits recommended above PSA levels may also be raised by\*: benign prostatic hyperplasia (BPH) prostatitis and urinary tract infection (NICE recommend to postpone the PSA test for at least 1 month after treatment) ejaculation (ideally not in the previous 48 hours) vigorous exercise (ideally not in the previous 48 hours) urinary retention instrumentation of the urinary tract Poor specificity and sensitivity around 33% of men with a PSA of 4-10 ng/ml will be found to have prostate cancer. With a PSA of 10-20 ng/ml this rises to 60% of men around 20% with prostate cancer have a normal PSA various methods are used to try and add greater meaning to a PSA level including age-adjusted upper limits and monitoring change in PSA level with time (PSA velocity or PSA doubling time) \*whether digital rectal examination actually causes a rise in PSA levels is a matter of debate Avoid performing a prostate specific antigen test within one month of prostatitis

Answer 12

Prostate cancer: investigation The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation. Complications of TRUS biopsy: sepsis: 1% of cases pain: lasting \>= 2 weeks in 15% and severe in 7% fever: 5% haematuria and rectal bleeding Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer. the results are reported using a 5‑point Likert scale If the Likert scale is \>=3 a multiparametric MRI-influenced prostate biopsy is offered If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy. Prostate cancer - more common in the Afro-Caribbean population Prostate cancer: features Prostate cancer is now the most common cancer in adult males in the UK and is the second most common cause of death due to cancer in men after lung cancer. Risk factors increasing age obesity Afro-Caribbean ethnicity family history: around 5-10% of cases have a strong family history Localised prostate cancer is often asymptomatic. This is partly because cancers tend to develop in the periphery of the prostate and hence don't cause obstructive symptoms early on. Possible features include: bladder outlet obstruction: hesitancy, urinary retention haematuria, haematospermia pain: back, perineal or testicular digital rectal examination: asymmetrical, hard, nodular enlargement with loss of median sulcus NICE advise that, as PSA levels may be increased, testing should not be done within at least: 6 weeks of a prostate biopsy 4 weeks following a proven urinary infection 1 week of digital rectal examination 48 hours of vigorous exercise 48 hours of ejaculation

Answer 13

The British Association of Urological Surgeons (BAUS) published guidelines in 2018 on the management of acute ureteric/renal colic. Initial management of renal colic Medication the BAUS recommend an NSAID as the analgesia of choice for renal colic whilst diclofenac has been traditionally used the increased risk of cardiovascular events with certain NSAIDs (e.g. diclofenac, ibuprofen) should be considered when prescribing the CKS guidelines suggest for patients who require admission: 'Administer a parenteral analgesic (such as intramuscular diclofenac) for rapid relief of severe pain' BAUS no longer endorse the use of alpha-adrenergic blockers to aid ureteric stone passage routinely. They do however acknowledge a recently published meta-analysis advocates the use of α-blockers for patients amenable to conservative management, with greatest benefit amongst those with larger stones Initial investigations urine dipstick and culture serum creatinine and electrolytes: check renal function FBC / CRP: look for associated infection calcium/urate: look for underlying causes also: clotting if percutaneous intervention planned and blood cultures if pyrexial or other signs of sepsis Imaging BAUS now recommend that non-contrast CT KUB should be performed on all patients, within 14 hours of admission if a patient has a fever, a solitary kidney or when the diagnosis is uncertain an immediate CT KUB should be performed. In the case of an uncertain diagnosis, this is to exclude other diagnoses such as ruptured abdominal aortic aneurysm CT KUB has a sensitivity of 97% for ureteric stones and a specificity of 95% ultrasound still has a role but given the wider availability of CT now and greater accurary it is no longer recommend first-line. The sensitivity of ultrasound for stones is around 45% and specificity is around 90% Management of renal stones Stones \< 5 mm will usually pass spontaneously. Lithotripsy and nephrolithotomy may be for severe cases. Most renal stones measuring less than 5mm in maximum diameter will typically pass within 4 weeks of symptom onset. More intensive and urgent treatment is indicated in the presence of ureteric obstruction, renal developmental abnormality such as horseshoe kidney and previous renal transplant. Ureteric obstruction due to stones together with infection is a surgical emergency and the system must be decompressed. Options include nephrostomy tube placement, insertion of ureteric catheters and ureteric stent placement. In the non-emergency setting, the preferred options for treatment of stone disease include extra corporeal shock wave lithotripsy, percutaneous nephrolithotomy, ureteroscopy, open surgery remains an option for selected cases. However, minimally invasive options are the most popular first-line treatment. Shockwave lithotripsy A shock wave is generated external to the patient, internally cavitation bubbles and mechanical stress lead to stone fragmentation. The passage of shock waves can result in the development of solid organ injury. Fragmentation of larger stones may result in the development of ureteric obstruction. The procedure is uncomfortable for patients and analgesia is required during the procedure and afterwards. Ureteroscopy A ureteroscope is passed retrograde through the ureter and into the renal pelvis. It is indicated in individuals (e.g. pregnant females) where lithotripsy is contraindicated and in complex stone disease. In most cases a stent is left in situ for 4 weeks after the procedure. Percutaneous nephrolithotomy In this procedure, access is gained to the renal collecting system. Once access is achieved, intra corporeal lithotripsy or stone fragmentation is performed and stone fragments removed. Therapeutic selection Disease Option Stone burden of less than 2cm in aggregate Lithotripsy Stone burden of less than 2cm in pregnant females Ureteroscopy Complex renal calculi and staghorn calculi Percutaneous nephrolithotomy Ureteric calculi less than 5mm Manage expectantly

Answer 14

Prevention of renal stones Calcium stones may be due to hypercalciuria, which is found in up to 5-10% of the general population. high fluid intake low animal protein, low salt diet (a low calcium diet has not been shown to be superior to a normocalcaemic diet) thiazides diuretics (increase distal tubular calcium resorption) Oxalate stones cholestyramine reduces urinary oxalate secretion pyridoxine reduces urinary oxalate secretion Uric acid stones allopurinol urinary alkalinization e.g. oral bicarbonate

Answer 15

Scrotal problems Epididymal cysts Epididymal cysts are the most common cause of scrotal swellings seen in primary care. Features separate from the body of the testicle found posterior to the testicle Associated conditions polycystic kidney disease cystic fibrosis von Hippel-Lindau syndrome Diagnosis may be confirmed by ultrasound. Management is usually supportive but surgical removal or sclerotherapy may be attempted for larger or symptomatic cysts. Hydrocele A hydrocele describes the accumulation of fluid within the tunica vaginalis. They can be divided into communicating and non-communicating: communicating: caused by patency of the processus vaginalis allowing peritoneal fluid to drain down into the scrotum. Communicating hydroceles are common in newborn males (clinically apparent in 5-10%) and usually resolve within the first few months of life non-communicating: caused by excessive fluid production within the tunica vaginalis Hydroceles may develop secondary to: epididymo-orchitis testicular torsion testicular tumours Features soft, non-tender swelling of the hemi-scrotum. Usually anterior to and below the testicle the swelling is confined to the scrotum, you can get 'above' the mass on examination transilluminates with a pen torch the testis may be difficult to palpate if the hydrocele is large Diagnosis may be clinical but ultrasound is required if there is any doubt about the diagnosis or if the underlying testis cannot be palpated. Management infantile hydroceles are generally repaired if they do not resolve spontaneously by the age of 1-2 years in adults a conservative approach may be taken depending on the severity of the presentation. Further investigation (e.g. ultrasound) is usually warranted however to exclude any underlying cause such as a tumour Varicocele A varicocele is an abnormal enlargement of the testicular veins. They are usually asymptomatic but may be important as they are associated with infertility. Varicoceles are much more common on the left side (\> 80%). Features: classically described as a 'bag of worms' subfertility Diagnosis ultrasound with Doppler studies Management usually conservative occasionally surgery is required if the patient is troubled by pain. There is ongoing debate regarding the effectiveness of surgery to treat infertility For each of the following scenarios please select the most likely diagnosis

Answer 16

A subarachnoid haemorrhage (SAH) is an intracranial haemorrhage that is defined as the presence of blood within the subarachnoid space, i.e. deep to the subarachnoid layer of the meninges. The most common cause of SAH is head injury and this is called traumatic SAH . In the absence of trauma, SAH is termed spontaneous SAH . The rest of this note focuses on spontaneous SAH. Causes of spontaneous SAH include: Intracranial aneurysm\* (saccular ‘berry’ aneurysms): this accounts for around 85% of cases. Conditions associated with berry aneurysms include adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta Arteriovenous malformation Pituitary apoplexy Arterial dissection Mycotic (infective) aneurysms Perimesencephalic (an idiopathic venous bleed) Classical presenting features include: Headache: typically sudden-onset (‘thunderclap’ or ‘baseball bat’), severe (‘worst of my life’) and occipital Nausea and vomiting Meningism (photophobia, neck stiffness) Coma Seizures Sudden death ECG changes including ST elevation may be seen Confirmation of SAH: Computed tomography (CT) head Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system. CT is negative for SAH (no blood seen) in 7% of cases. Lumbar puncture (LP) Used to confirm SAH if CT is negative. LP is 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 Referral to neurosurgery to be made as soon as SAH is confirmed After spontaneous SAH is confirmed, the aim of investigation is to identify a causative pathology that needs urgent treatment: CT intracranial angiogram (to identify a vascular lesion e.g. aneurysm or AVM) +/- digital subtraction angiogram (catheter angiogram) Treatment The treatment in spontaneous SAH is in accordance with the causative pathology 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 Until the aneurysm is treated, the patient should be kept on strict bed rest, well-controlled blood pressure and should avoid straining in order to prevent a re-bleed of the aneurysm Vasospasm is prevented using a 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) and treated with hypervolaemia, induced-hypertension and haemodilution\*\* Hydrocephalus is temporarily treated with an external ventricular drain (CSF diverted into a bag at the bedside) or, if required, a long-term ventriculo-peritoneal shunt Complications of aneurysmal SAH: Re-bleeding (in around 30%) Vasospasm (also termed delayed cerebral ischaemia), typically 7-14 days after onset Hyponatraemia (most typically due to syndrome inappropriate anti-diuretic hormone (SIADH)) Seizures Hydrocephalus Death Important predictive factors in SAH: conscious level on admission age amount of blood visible on CT head Coiling of the aneurysm by an interventional radiologist is the most likely management option from the list. This is based on the patient's relatively stable state at this point. Craniotomy and clipping of the aneurysm might be appropriate if the patient was showing more evidence of raised intracranial pressure, such as haemodynamic instability or change in GCS. Whether or not the aneurysm is coiled or clipped, the priority is to prevent further bleeding, so mechanically occluding the aneurysm is important, preferably within the first 24 hours. Therefore, the other options are not likely to be the correct, definitive, management of the patient's condition. Tranexamic acid has been used in some studies to aim to prevent early rebleeds in patients with subarachnoid haemorrhage (SAH), but this is not standard practice and is not definitive management of the situation. Studies into therapeutic cooling of patients after SAH are limited, and it is not recognised as a standard part of management. Supportive therapies may be important to manage the patient's condition, but outright conservative management would not be appropriate for this patient due to the risk of rebleeding, and the very poor prognosis this would carry. If subarachnoid haemorrhage is suspected but the CT head is normal, a lumbar puncture is required to confirm or exclude this diagnosis Importance: 76

Answer 17

Basics twist of the spermatic cord resulting in testicular ischaemia and necrosis. most common in males aged between 10 and 30 (peak incidence 13-15 years) Features pain is usually severe and of sudden onset the pain may be referred to the lower abdomen nausea and vomiting may be present on examination, there is usually a swollen, tender testis retracted upwards. The skin may be reddened cremasteric reflex is lost elevation of the testis does not ease the pain (Prehn's sign) Management treatment is with urgent surgical exploration if a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral.

Answer 18

A low anterior resection would be the most preferable surgery for the patient in this scenario. The important information to consider when answering this question is the position of the tumour, the grading and whether it is operable. The fact that this patients tumour is rectal means that there are only two surgical procedures in the list of possible answers that could be right; abdominoperineal resection and low anterior resection. Left hemicolectomy and total colectomy are used to surgically treat colonic diseases, including malignancies. Furthermore, Hartmann's procedure is no longer used as frequently as in the past, and is now largely reserved for emergency colorectal surgery and terminally ill patients. Due to this, these options are inappropriate responses to this question. Both abdominoperineal resections and low anterior resections are used to treat rectal malignancy. However, abdominoperineal resections, which involve the removal of the anus, rectum and section of sigmoid colon, are used for tumours located in the distal one third of the rectum. Given that the patient in this question has a mid-rectal tumour, this surgical procedure would be inappropriate. Low anterior resection is the operation of choice for this patient and patients whose malignancy lies in the upper two thirds of their rectum. This surgery involves resection of the area of malignancy, followed by anastomosis. To attempt to reduce complication rates, a defunctioning ileostomy can be created, which results in the majority of bowel matter bypassing the newly formed anastomosis. Colorectal cancer treatment Patients diagnosed as having colorectal cancer should be completely staged using CT of the chest/ abdomen and pelvis. Their entire colon should have been evaluated with colonoscopy or CT colonography. Patients whose tumours lie below the peritoneal reflection should have their mesorectum evaluated with MRI. Once their staging is complete patients should be discussed within a dedicated colorectal MDT meeting and a treatment plan formulated. Treatment of colonic cancer Cancer of the colon is nearly always treated with surgery. Stents, surgical bypass and diversion stomas may all be used as palliative adjuncts. Resectional surgery is the only option for cure in patients with colon cancer. The procedure is tailored to the patient and the tumour location. The lymphatic drainage of the colon follows the arterial supply and therefore most resections are tailored around the resection of particular lymphatic chains (e.g. ileo-colic pedicle for right sided tumours). Some patients may have confounding factors that will govern the choice of procedure, for example a tumour in a patient from a HNPCC family may be better served with a panproctocolectomy rather than segmental resection. Following resection the decision has to be made regarding restoration of continuity. For an anastomosis to heal the key technical factors include; adequate blood supply, mucosal apposition and no tissue tension. Surrounding sepsis, unstable patients and inexperienced surgeons may compromise these key principles and in such circumstances it may be safer to construct an end stoma rather than attempting an anastomosis. When a colonic cancer presents with an obstructing lesion; the options are to either stent it or resect. In modern practice it is unusual to simply defunction a colonic tumour with a proximal loop stoma. This differs from the situation in the rectum (see below). Following resection patients with risk factors for disease recurrence are usually offered chemotherapy, a combination of 5FU and oxaliplatin is common. Treatment of rectal cancer The management of rectal cancer is slightly different to that of colonic cancer. This reflects the rectum's anatomical location and the challenges posed as a result. Tumours located in the rectum can be surgically resected with either an anterior resection or an abdomino-perineal excision of rectum (APER). The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the exam is that involvement of the sphincter complex or very low tumours require APER. In the rectum a 2cm distal clearance margin is required and this may also impact on the procedure chosen. In addition to excision of the rectal tube an integral part of the procedure is a meticulous dissection of the mesorectal fat and lymph nodes (total mesorectal excision/ TME). In rectal cancer surgery involvement of the cirumferential resection margin carries a high risk of disease recurrence. Because the rectum is an extraperitoneal structure (until you remove it that is!) it is possible to irradiate it, something which cannot be offered for colonic tumours. This has a major impact in rectal cancer treatment and many patients will be offered neoadjuvent radiotherapy (both long and short course) prior to resectional surgery. Patients with T1 and 2 /N0 disease on imaging do not require irradiation and should proceed straight to surgery. Patients with T4 disease will typically have long course chemo radiotherapy. Those with T3 , N0 tumours may be offered short course radiotherapy prior to surgery. Patients presenting with large bowel obstruction from rectal cancer should not undergo resectional surgery without staging as primary treatment (very different from colonic cancer). This is because rectal surgery is more technically demanding, the anastomotic leak rate is higher and the danger of a positive resection margin in an unstaged patient is high. Therefore patients with obstructing rectal cancer should have a defunctioning loop colostomy.

Answer 19

Summary of procedures The operations for cancer are segmental resections based on blood supply and lymphatic drainage. Site of cancer Type of resection Anastomosis Caecal, ascending or proximal transverse colon Right hemicolectomy Ileo-colic Distal transverse, descending colon Left hemicolectomy Colo-colon Sigmoid colon High anterior resection Colo-rectal Upper rectum Anterior resection (TME) Colo-rectal Low rectum Anterior resection (Low TME) Colo-rectal (+/- Defunctioning stoma) Anal verge Abdomino-perineal excision of rectum None In the emergency setting where the bowel has perforated the risk of an anastomosis is much greater, particularly when the anastomosis is colon-colon. In this situation an end colostomy is often safer and can be reversed later. When resection of the sigmoid colon is performed and an end colostomy is fashioned the operation is referred to as a Hartmans procedure. Whilst left sided resections are more risky, ileo-colic anastomoses are relatively safe even in the emergency setting and do not need to be defunctioned. References A review of the diagnosis and management of colorectal cancer and a summary of the UK National Institute of Clinical Excellence guidelines is provided in: Poston G, et al . Diagnosis and management of colorectal cancer:summary of NICE guidance. BMJ 2011: 343: d 6751. A Hartmann's procedure would be the most preferable surgery for the patient in this scenario. The important pieces of information to consider when answering this question are the urgency of the operation and the location of the malignancy. This patient has presented to hospital as an emergency perforation, resulting from his malignancy. Therefore, the surgery for this patient needs to be appropriate for an emergency situation. Under routine circumstances, this patient would receive surgery that would consist of resection of the relevant section of bowel and then anastomosis of the two ends. However, in emergency situations anastomosis is not a preferable surgical option. Hartmann's procedure involves resection of the relevant portion of bowel and formation of an end colostomy/ileostomy. In the future patients can undergo a reversal of Hartmann's procedure, whereby the end colostomy is closed following the formation of a colorectal anastomosis, restoring continuity of the bowels. This makes it the ideal surgical procedure for emergency situations. Furthermore, this operation involves resection of the sigmoid colon, where this patients tumour is located. Abdominoperineal resections and low anterior resections are used to treat rectal malignancies, and are therefore inappropriate responses to this question. A total colectomy is not required in this patient, as it is only the sigmoid colon that is affected, meaning removal of the entire colon is an out of proportion response to the problem. A left hemicolectomy, could at first glance, appear a correct answer. However, the emergency of the patients situation dictates that anastomosis formation is not advisable, meaning a Hartmann's procedure is more appropriate, and the correct answer for this scenario.

Answer 20

Male sterilisation - vasectomy failure rate: 1 per 2,000 - male sterilisation is a more effective method of contraception than female sterilisation simple operation, can be done under LA (some GA), go home after a couple of hours doesn't work immediately semen analysis needs to be performed twice following a vasectomy before a man can have unprotected sex (usually at 16 and 20 weeks) complications: bruising, haematoma, infection, sperm granuloma, chronic testicular pain (affects between 5-30% men) the success rate of vasectomy reversal is up to 55%, if done within 10 years, and approximately 25% after more than 10 years

Answer 21

VTEs can cause severe morbidity and mortality, but they are preventable. Current NICE guidelines (updated for 2018) outline recommendations for assessment and management of patients at risk of VTE in hospital. Risk factors All patients admitted to hospital should be individually assessed to identify risk factors for VTE development and bleeding risk. For medical and surgical patients the recommended risk proforma is the department of healths VTE risk assessment tool. The following inpatients would be deemed at increased risk of developing a VTE: Medical patients: significant reduction in mobility for 3 days or more (or anticipated to have significantly reduced mobility) Surgical/trauma patients: hip/knee replacement hip fracture general anaesthetic and a surgical duration of over 90 minutes surgery of the pelvis or lower limb with a general anaesthetic and a surgical duration of over 60 minutes acute surgical admission with an inflammatory/intra-abdominal condition surgery with a significant reduction in mobility General risk factors: active cancer/chemotherapy aged over 60 known blood clotting disorder (e.g. thrombophilia) BMI over 35 dehydration one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions) critical care admission use of hormone replacement therapy (HRT) use of the combined oral contraceptive pill varicose veins pregnant or less than 6 weeks post-partum After a patients VTE risk has been assessed, this should be compared to their risk of bleeding to decide whether VTE prophylaxis should be offered. If indicated VTE prophylaxis should be started as soon as possible. Types of VTE prophylaxis Mechanical: Correctly fitted anti-embolism (aka compression) stockings (thigh or knee height) An Intermittent pneumatic compression device Pharmacological: Fondaparinux sodium (SC injection) Low molecular weight heparin (LMWH) - e.g. enoxaparin (brand name = Clexane) Unfractionated heparin (UFH) - used in patients with chronic kidney disease Management In general, all medical patients deemed at risk of VTE after individual assessment are started on pharmacological VTE prophylaxis. This is providing the risk of VTE outweighs the risk of bleeding (this is often a clinical judgement) and there are no contraindications. Those at very high risk may be offered anti-embolic stockings alongside the pharmacological methods. For surgical patients at low risk of VTE first-line treatment is anti-embolism stockings. If a patient is at high risk these stockings are used in conjunction with pharmacological prophylaxis. Advice for patients Pre-surgical interventions: Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4 weeks before surgery. Post-surgical interventions: Try to mobilise patients as soon as possible after surgery Ensure the patient is hydrated Post procedure prophylaxis For certain surgical procedures (hip and knee replacements) pharmacological VTE prophylaxis is recommended for all patients to reduce the risk of a VTE developing post-surgery. NICE make the following recommendations: Procedure Prophylaxis Elective hip LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days or LMWH for 28 days combined with anti-embolism stockings until discharge or Rivaroxaban Elective knee Aspirin (75 or 150 mg) for 14 days or LMWH for 14 days combined with anti-embolism stockings until discharge or Rivaroxaban Fragility fractures of the pelvis, hip and proximal femur LMWH or fondaparinux 'Continue until the person no longer has significantly reduced mobility relative to their normal or anticipated mobility'