Surgery (multiple) Flashcards
‘halo appearance’ on mammography?
breast cyst
Tamoxifen MoA
Selective oEstrogen Receptor Modulators (SERM)
oestrogen receptor antagonist and partial agonist.
mx of oestrogen receptor-positive breast cancer in premenopausal women
Tamoxifen adverse effects
menstrual disturbance:vaginal bleeding, amenorrhoea
hot flushes
venous thromboembolism
endometrial cancer
Adverse effects of aromatase inhibitors
(Anastrozole and letrozole)
osteoporosis (!!)
NICE recommends a DEXA scan when initiating
hot flushes
arthralgia, myalgia
insomnia
Fibroadenoma mx
nothing
if >3cm , surgically excise
Breast cyst
aspirated
if blood stained or persistently refill should be biopsied or excised
Main breast reconstruction options after cancer removal
latissimus dorsi myocutaneous flap and sub pectoral implants
Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps
Factors determining Mastectomy or wide local excision
M v WLE:
multifocal / solitary lesion
central / peripheral location
large lesion small breast / small lesion large breast
DCIS >4cm / DCIS <4cm
Patient choice
What determines prognosis following breast cancer surgery?
Nottingham Prognostic Index
Tumour Size x 0.2 + Lymph node score+Grade score
also vascular invasion and receptor status
How does axillary lymphadenopathy affect mx of breast cancer?
clinically palpable lymphadenopathy -> axillary node clearance at primary surgery
not clinically palpable –> pre-operative USS
USS negative -> sentinel node biopsy
Radiotherapy indication for breast ca
After wide local excision –> whole breast radiotherapy
(reduces recurrence risk by 2/3)
After mastectomy -> radiotherapy for T3-T4 tumours & those w 4 or more +ve axillary nodes
Hormonal/ biological therapy indications for breast ca
ER+ve (hormonal)
Tamoxifen - premenopausal
Aromatase inhb (anastrozole) - post-m
HER2 +ve (biological)
Trastuzumab (Herceptin)
[^^^ cannot be used in pts w heart disorders]
Chemotherapy indications for breast ca
- neo-adjuvent (before surgery) to downstage a primary lesion allowing breast conserving operation rather than mastectomy
- post adjacent depending on stage
- if axillary node disease - FEC-D is used
2ww breast ca referral criteria
REFER:
- >=30yrs & unexplained breast lump
- >=50yrs with unilateral nipple: discharge/ retraction/ other concerning changes
Consider:
- skin changes suggesting breast ca
- >=30yrs w unexplained lump in axilla
non-urgent referral if under 30 w/ unexplained breast lump
Breast cs RFs
-BRACA1/2 genes
-nulliparity (or 1st preg >30)
-early menarche, late menopause
-combined HRT
- COCP use
- P53 gene mutations
- obesity
-fhx of 1stdeg relative w breast ca when pre-menopause
- ionising radiation
- not breastfeeding
- past breast ca
- previous breast surgery
breast ca screening for who? how frequent?
women between 50-70 years
every 3 years
(after 70 still allowed, but make own appointments)
Types of breast ca & mist common?
Invasive ductal carcinoma.
(most common) (renamed ‘No Special Type (NST))
Invasive lobular carcinoma
Ductal carcinoma-in-situ (DCIS)
Lobular carcinoma-in-situ (LCIS)
Other rare types
Fat necrosis mx
Rare and may mimic breast cancer so further investigation is always warranted (imaging & core biopsy)
if fat necrosis - nothing
Cyclical mastalgia mx
supportive bra - firstline
conservative: simple oral/ topical analgesia
(flaxseed oil and evening primrose oil sometimes used but not recommended by NICE CKS)
if pain not responding to above in 3mos-> referral -> bromocriptine and danazol (hormonal agents)
Duct ectasia tx
troublesome nipple discharge may be treated by microdochectomy (if young) or total duct excision (if older)
Otherwise nothing as this is normal varient of breast involution
(don’t confuse w periductal mastitis - younger smokers -inflammation - tx w Abx)
Smoking is a RF for this too
Mastitis mx
typically associated with breastfeeding
1st line - continue breastfeeding.
Simple mx: analgesia, warm compresses
Treat if:
- systemically unwel
- nipple fissure present
- no improvement after 12-24 hours of effective milk removal
- culture indicates infection
1st line abx: oral flucloxacillin, 10-14 day
(most common cx = Staph aureus)
if develops into breast access -> I&D
Reporting of breast c investigations grade 1-5
1 - No abnormality
2 - Abnormality with benign features
3 - Indeterminate probably benign
4 - Indeterminate probably malignant
5 -Malignant
Paget’s dx v eczema of nipple
Paget - nipple primarily and only latterly spreads to the areolar (the opposite occurs in eczema)
Brain death testing involves
criteria to test
- deep coma, unknown aetiology
- reversible causes excluded
- no sedation
- normal electrolytes
Testing involves
- fixed pupils
- no corneal reflex
- no oculo-vestibular reflex (caloric test)
- no response to supraorbital pressure
- no cough to bronchial stimulation/ gagging to pharyngeal stimulation
- No rest effort observed when ventilator disconnected (for 5 mins to allow CO2 to build up)
2 experienced doctors on two separate occasions !!
(experienced in brain stem testing, 5 yrs post grad, one is consultant, not part of transplant team)
Brainstem compression (coning) / life threatening ICP mx
osmotherapy with hypertonic saline or manitol,
neurosurgical decompression -> decompressive craniotomy
ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan.
Cushing reflex
physiological nervous system response to raised ICP
Cushing triad of widened pulse pressure (increasing systolic, decreasing diastolic), bradycardia, and irregular respirations
constricted pupil causes
Bilaterally:
Opiates
Pontine lesions
Metabolic encephalopathy
Unilateral:
Sympathetic pathway disruption
dilated pupil causes
fixed pupil w sluggish/no response to light
- CN3 compression (uni-/bi-lateral)
- poor CNS perfusion (if bilateral)
cross reactive (RAPD)
- optic nerve injury
CT head within 1 hour of head injury
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 within 8 hours of head injury
loss of consciousness or amnesia since the injury with:
>= 65 years
hx of bleeding or clotting disorders including anticogulants
dangerous mechanism of injury
more than 30 minutes’ retrograde amnesia of events immediately before the head injury
If a patient is on warfarin & no other indications
conditions associated with berry aneurysms
hypertension,adult polycystic kidney disease, Ehlers-Danlos syndrome and coarctation of the aorta
berry aneurysms -> spontaneous SAH
SAH ix
non-contrast CT head
- acute blood = hyperdense/bright
- If w/in 6hrs & normal -> NO lumbar puncture
- If >6hrs & normal -> LP 12hrs post symptom onset
LP findings: xanthochromia, normal/ raised opening pressure
Once confirmed, find cause
- CT intracranial angiogram
+/- digital subtraction angiogram
subarachnoid haemorrhage mx
supportive
VTE prophylaxis
stop antithrombotics - reversal if needed
vasospasm prevented w oral nimodipine
prompt intervention needed due to risk of rebleeding of aneurysm
- w/in 24hrs: coil by interventional neuroradiologists / craniotomy & clipping
most common type of anal cancer?
SCC
(other: melanomas, lymphomas, and adenocarcinomas)
lymphatic spread of anal cancer?
anal margin tumours ->inguinal lymph nodes
more proximal -> pelvic lymph nodes.
anal ca RFs
HPV infection!! - esp for SCC ( HPV16 or HPV18 subtypes)
Anal intercourse
High sexual partners
Men sex men
Immunosuppressants
Woman w cervical ca or CIN
smoking
T stage system for anal cancer
(examination, including a digital rectal examination, anoscopic examination with biopsy, and palpation of the inguinal nodes)
TX - cannot be assessed
T0 - no evidence
Tis - carcinoma in situ
T1 - tumor 2cm or less
T2 - 2cm-5cm
T3 - more than 5cm
T4 - any size, invading adjacent organ (not incuding rectum/ sphincter muscle)
where are anal fissure usually found?
90% - posterior midline
if elsewhere, likely underlying cause, e.g. Chron’s
Anal fissure mx
<1wk
- soften stool (high fibre & fluid diet), bulk-forming laxatives 1st line –> 2nd: lactulose
- lubricants before defecation (petroleum jelly)
- topical anaesthetics
- analgesia
chronic (>6wks)
- continue above
- 1st line: topical GTN
- 2nd: if GTN not effective after 8wks -> surgery (shincerotomy) or botulinum toxin
colorectal cancer staging involves:
(all pts diagnosed w CRC should have:)
- carcinoembryonic antigen (CEA)
- CT of the chest, abdomen and pelvis
- colonoscopy or CT colonography
- tumours below the peritoneal reflection should have their mesorectum evaluated with MRI.
TNM (Tumour, Node, Metastasis) staging system to stage CRC from prognosis & tx
Indication for a FIT test
( Faecal Immunochemical Test (FIT) )
NHS bowel cancer screening programme (every 2yrs, 60-74)
& to guide referral for CRC:
-abdominal mass
-change in bowel habit
- iron-deficiency anaemia
- aged 40 and over with unexplained weight loss and abdominal pain
- aged under 50 with rectal bleeding and abdominal pain or weight loss,
- aged 50 and over with any of the following unexplained symptoms:
rectal bleeding
abdominal pain
weight loss, - aged 60 and over with anaemia even in the absence of iron deficiency
(abnormal results are offered a colonoscopy)
Diverticular disease tx
- increased fibre
- mild diverticulitis: Abx
- Peri colonic abscesses: surgical/ radiological drainage
- Recurrent episodes of acute diverticulitis requiring hospitalisation - surgical resection
- Hinchey stage IV perforations (generalised faecal peritonitis) - resection and usually a stoma, laparoscopic washout and drain insertion, potential HDU admission due to high risk post op complications
Dukes classification
extent of spread of colorectal cancer
a - confined to mucosal wall
b - invading bowel wall
c - lymph node met
d - distant met
Grading of internal haemorrhoids
(internal - above dentate line, usually painless)
1 - do not prolapse out of anal canal
2- prolapse on defection, reduce spontaneously
3 - manually reduced
5 - cannot be reduced
haemorrhoids mx
- soften stools: increase dietary fibre and fluid intake
- topical local anaesthetics and steroids
- outpatient treatments: rubber band ligation is superior to injection sclerotherapy
- surgery - large symptomatic haemorrhoids which do not respond to outpatient treatments
newer treatments: Doppler guided haemorrhoidal artery ligation, stapled haemorrhoidopexy
Acutely thrombosed external haemorrhoids
<72hrs - referral considered for excision
- otherwise conservative: stool softeners, ice packs, analgesia
Ischaemic colitis on x ray?
‘thumbprinting’ may be seen on abdominal x-ray due to mucosal oedema/haemorrhage
likely in in ‘watershed’ areas such as the splenic flexure
Volulus ix & mx
Abdo x ray
sigmoid volvulus: large bowel obstruction (large, dilated loop of colon, often with air-fluid levels) + coffee bean sign
caecal volvulus: small bowel obstruction may be seen
Management
sigmoid volvulus: rigid sigmoidoscopy with rectal tube insertion
caecal volvulus: management is usually operative. Right hemicolectomy is often needed
duodenal atresia age at px, ix and mx
Few hours after birth, RF- downs synd.
AXR shows double bubble sign, contrast study may confirm
Duodenoduodenostomy
Malrotation with volvulus age at px, ix and mx
3-7 days after birth
Upper GI contrast study- DJ flexure is more medially placed,
USS - abnormal orientation of SMA and SMV
Ladd’s procedure
Meconium ileus age at px, ix and mx
24-48 hours of life , RF- cystic fibrosis,
Air - fluid levels on AXR, sweat test to confirm cystic fibrosis
Surgical decompression, serosal damage may require segmental resection
Necrotising enterocolitis age at px, ix and mx
Usually second week of life
Dilated bowel loops on AXR, pneumatosis and portal venous air
Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
Rovsing’s sign:
more pain in RIF than LIF when palpating LIF
Boas sign?
cholecystitis- hyperaesthesia felt by the patient to light touch in the right lower scapular region or the right upper quadrant of the abdomen
what is a Richter hernia and complication
only the antimesenteric border of the bowel herniates through the fascial defect
can present with strangulation without symptoms of obstruction
Congenital inguinal hernia tx
Should be surgically repaired soon after diagnosis as at risk of incarceration
Infantile umbilical hernia tx
Symmetrical bulge under the umbilicus, rf: premature and Afro-Caribbean babies
The vast majority resolve without intervention before the age of 4-5 years
sudden full wound dehiscence mx
Coverage of the wound with saline impregnated gauze (on the ward)
IV broad-spectrum antibiotics
Analgesia
IV fluids
Arrangements made for a return to theatre
Ix appendicitis
thin, male patients - clinical
females - USS (free fluid)
In UK, don’t use CT scans
Appendicits mx
laparoscopic appendicectomy (can be open)
prophylactic intravenous antibiotics
hyperechoic mass on liver USS?
liver haemangioma- benign
Liver cell adenoma features
linked to COCP use
USS: mixed echocity & heterogeneous texture
leave it, if haemorrhage or symptoms -> removal
beware of cytadenoma (rare w malignant potential, solitary multiloculated lesions, surgical resection always)
most common extra intestinal manifestation of amoebiasis?
features & tx
Amoebic liver abscess (fever RUQ)
USS: fluid filled structure with poorly defined boundaries
Aspiration: odourless fluid which has an anchovy paste consistency
Tx: metronidazole
Hyatid cysts features & mx ?
Seen in echinococcosis infection -> parasitic infection caused by tapeworm
Px: abnormal LFTs & eosinophilia
USS: septa & hydatid sand / daughter cysts
Tx: sterilisation w mebedazole then surgical resection.
Fistula in ano tx
Lay open if low, no sphincter involvement or IBD
if complex, high or IBD insert seton
Adalimumab
Infliximab
Etanercept
Target & use?
TNF alpha inhibitor
Crohns disease
Rheumatoid disease
Bevacizumab
Anti VEGF (anti angiogenic)
Colorectal cancer
Renal
Glioblastoma
Trastuzumab
HER receptor
Breast cancer
Imatinib
Tyrosine kinase inhibitor
Gastrointestinal stromal tumours
Chronic myeloid leukaemia
Basiliximab
IL2 binding site
Renal transplants
Cetuximab
Epidermal growth factor inhibitor
EGF positive colorectal cancers
what is Cryptorchidism?
congenital undescended testis failed to reach the bottom of the scrotum by 3 months of age
surgical correction! -> 40x more likely to get testicular cancer (seminoma)
Cryptorchidism tx
Orchidopexy at 6- 18 mo
Intra-abdominal testis -evaluated laparoscopically and mobilised
After the age of 2 years - better to do orchidectomy due to degradation
Critera for malnourishment and at risk?
Patients identified as being malnourished
- BMI < 18.5 kg/m2
- unintentional weight loss of > 10% over 3-6months
- BMI < 20 kg/m2 and unintentional weight loss of > 5% over 3-6/12
AT RISK of malnutrition
- Eaten nothing or little > 5 days, who are likely to eat little for a further 5 days
- Poor absorptive capacity
- High nutrient losses
- High metabolism
complications of enteral feeding
diarrhoea
aspiration
metabolic: hyperglycaemia & refeeding syndrome
Borders & contents of the femoral canal
fem canal is at the medial aspect of femoral sheath
laterally - femoral vein
Medically - Lacunar ligament
Anteriorly - inguinal ligament
Posteriorly - pectineal ligament
Contents
Lymphatic vessels
Cloquet’s lymph node
significance- allows expansion of fem vein to allow for increased venous return. Potential space & site of fem hernias
Complications of a femoral hernia
Incarcination - herniated tissues cannot be reduced
Strangulation - Surgical emergency, ischemia due to comprised blood supply, tender & likely non-reducible & systemically unwell
Bowel obstruction - also emergency
Bowel ischemia
femoral hernia mx
Surgical repair is a necessity, given the risk of strangulation, laparoscopically or via a laparotomy (usually for emergencies)
Fluid resuscitation indication
> 15% total body area burns in adults (>10% children)
Parkland formula
For Fluid resuscitation in burns in the first 24hrs- Crystalloid only
Total fluid requirement in 24 hours =
4 ml x (total burn surface area (%)) x (body weight (kg))
50% given in first 8 hours
50% given in next 16 hours
burns fluid mx after first 24hrs
Colloid infusion is begun at a rate of 0.5 ml x(total burn surface area (%))x(body weight (kg))
–> albumin & FFP
Maintenance crystalloid (dextrose-saline) - rate of 1.5 ml x(burn area)x(body weight)
hiatus hernia ix & mx
(rolling or sliding)
ix - barium swallow (usually found incidentally on endoscopy -occurs first due to nature of symptoms.
Mx
- conservative mx: weight loss
- medical: PPI
surgical: most do not need surgery. Only in symptomating rolling(paraoesophagheal) hernias
normal diameter of small & large bowel
small = 35mm
large = 55mm
Inguinal hernia tx
treat medically fit patients even if they are asymptomatic
- mesh repair has lowest recurrence
- unilateral - open approach
- bilateral & recurrent - laparoscopic
hernia truss if not fit for surgery (cannot use this in femoral hernias due to high risk of strangulation)
if stagnated do not manually reduce!
lidocaine maximum safe dose?
3mg/kg
200mg (or 500mg if given in solutions containing adrenaline), which equates to 3mg/kg for a 66kg patient.
equivalent of 20ml of 1% solution or 10ml of 2% solution
Carotid endarterectomy can damage
hypoglossal nerve
Types of organ rejection
Hyperacute. This occurs immediately through presence of pre formed antigens (such as ABO incompatibility).
Acute. Occurs during the first 6 months and is usually T cell mediated. Usually tissue infiltrates and vascular lesions.
Chronic. Occurs after the first 6 months. Vascular changes predominate.
Familial adenomatous polyposis characteristics
APC gene, dominant
over 100 colonic adenomas
Cancer risk of 100%
mx: if at known risk do genetic testing as teen. Annual flexi sigmoidoscopy from 15yrs. If no polyps = 5 yearly colonoscopy from 20. Polyps found = resectional surgery
Peutz -Jeghers syndrome
Multiple benign intestinal hamartomas. Episodic obstruction and intussusception
Increased risk of colorectal, gastric, breast, ovarian, cervical, pancreatic & testicular ca.
Annual examination
Pan intestinal endoscopy every 2-3 years
HNPCC (Lynch syndrome)
Germline mutations of DNA mismatch repair genes
increased risk of colorectal. endometrial & gastric ca
Scanty colonic polyps may be present
Colonic tumours likely to be right sided and mucinous
colonoscopy every yr from age 25.
Small bowel obstructions
intial steps:
- NBM
- IV fluids
- nasogastric tube with free drainage
some patients settle with conservative management but otherwise will require surgery
Acute cholecystitis ix
ultrasound is the first-line investigation of choice
if the diagnosis remains unclear then cholescintigraphy (HIDA scan) may be used
Acute cholecystitis mx
intravenous antibiotics
early laparoscopic cholecystectomy, within 1 week of diagnosis
acute pancreatitis ix
serum lipase - more sensitive and specific, & longer half life
serum amylase
dx can be made without imaging if characteristic pain + amylase/lipase > 3 times normal level
early ultrasound imaging important for aetiology to determine mx
severe pancreatitis scoring?
Ranson score, Glasgow score and APACHE II.
P - PaO2 (< 7.9 kPa).
A - age (>55).
N - neutrophils (white cell count > 15x 109/L).
C - calcium (calcium < 2 mmol/L).
R - renal function (urea > 16 mmol/L).
E - enzymes (lactate dehydrogenase > 600 IU/L).
A - albumin (albumin < 32 g/L).
S - sugar (blood glucose > 10 mmol/L).
actual amylase level is not of prognostic value
Acute pancreatitis: causes
Gallstones
Ethanol
Trauma
Steroids
Mumps (other viruses include Coxsackie B)
Autoimmune (e.g. polyarteritis nodosa), Ascaris infection
Scorpion venom
Hypertriglyceridaemia, Hyperchylomicronaemia, Hypercalcaemia, Hypothermia
ERCP
Drugs (azathioprine, mesalazine*, didanosine, bendroflumethiazide, furosemide, pentamidine, steroids, sodium valproate)
Acute pancreatitis mx
fluid resuscitation - aggressive & early hydration w crystalloids
aim urine output >0.5mls/kg/hr
nutrition - NOT routinely nil by mouth unless vomitting lots, enteral nutrition should be offered w/in 72hrs
NO routine Abx
Boerhaave’s syndrome
dx
Diagnosis is CT contrast swallow.
Cholangiocarcinoma association
Primary sclerosing cholangitis & raised CA 19-9 levels
Chronic pancreatitis
causes
alcohol excess most common !!
idiopathic
genetic: cystic fibrosis, haemochromatosis
ductal obstruction: tumours, stones, structural abnormalities including pancreas divisum and annular pancreas
