Surgery (non-ortho) Flashcards

Question

What is the investigation of choice to look for renal scarring in a child with vesicoureteric reflux? ``` Abdominal x-ray Ultrasound DMSA CT KUB Micturating cystourethrogram ```

Answer 1

DMSA Vesicoureteric reflux (VUR) is the abnormal backflow of urine from the bladder into the ureter and kidney. It is relatively common abnormality of the urinary tract in children and predisposes to urinary tract infection (UTI), being found in around 30% of children who present with a UTI. As around 35% of children develop renal scarring it is important to investigate for VUR in children following a UTI Pathophysiology of VUR ureters are displaced laterally, entering the bladder in a more perpendicular fashion than at an angle therefore shortened intramural course of ureter vesicoureteric junction cannot therefore function adequately The table below summarises the grading of VUR {Grade} I Reflux into the ureter only, no dilatation II Reflux into the renal pelvis on micturition, no dilatation III Mild/moderate dilatation of the ureter, renal pelvis and calyces IV Dilation of the renal pelvis and calyces with moderate ureteral tortuosity V Gross dilatation of the ureter, pelvis and calyces with ureteral tortuosity Investigation VUR is normally diagnosed following a micturating cystourethrogram a DMSA scan may also be performed to look for renal scarring

Answer 2

Takayasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches Females> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase Takayasu's arteritis is a large vessel vasculitis. It typically causes occlusion of the aorta and questions commonly refer to an absent limb pulse. It is more common in females and Asian people Associations renal artery stenosis Management steroids

Answer 3

Sub arachnoid haemorrhage A sudden collapse and loss of consciousness is most likely to be due to a sub arachnoid haemorrhage. The other potential causes in the list usually occur as a sequel to a traumatic event, which has not occurred here. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 4

Intraventricular haemorrhage Neonatal deterioration in premature babies is not infrequently due to intra ventricular haemorrhage. In extreme prematurity the prognosis can be very poor. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 5

Chronic sub dural haematoma The injuries that are responsible for chronic sub dural haematomas are usually fairly trivial and forgotten by the patient and their families. The onset of symptoms can be insidious with vague symptomatology and confusion predominating. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 6

Most cases will settle with conservative management with NG decompression and appropriate support. Laparotomy should be undertaken in patients who progress despite conservative management or in whom compelling indications for surgery exist (eg free air). Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 7

Infection with diphtheria classically causes a systemic illness that lasts several days. The tonsils or pharynx can be covered in a thick grey membrane which bleeds on attempted removal. There is often quite marked cervical adenopathy and some individuals can have a bulls neck appearance. Death can occur through airway compromise, which is why the often described attempted removal of the pseudomembrane so beloved of examiners, is, in practice rather a foolish thing to attempt in a young child! Acute tonsillitis Characterised by pharyngitis, fever, malaise and lymphadenopathy. Over half of all cases are bacterial with Streptococcus pyogenes the most common organism The tonsils are typically oedematous and yellow or white pustules may be present Infectious mononucleosis may mimic the condition. Treatment with penicillin type antibiotics is indicated for bacterial tonsillitis. Bacterial tonsillitis may result in local abscess formation (quinsy)

Answer 8

Insertion of intracranial bolt monitor This patient may well develop raised ICP over the next few days and Intracranial pressure monitoring will help with management. Head injury management- NICE Guidelines Summary of guidelines All patients should be assessed within 15 minutes on arrival to A&E Document all 3 components of the GCS If GCS <8 or = to 8, consider stabilising the airway Treat pain with low dose IV opiates (if safe) Full spine immobilisation until assessment if: - GCS < 15 - neck pain/tenderness - paraesthesia extremities - focal neurological deficit - suspected c-spine injury If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if: - Intubated - GCS <13 - Normal x-ray but continued concerns regarding c-spine injury - Any focal neurology - A CT head scan is being performed - Initial plain films are abnormal ``` Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy ``` ``` Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak ``` Observations 1/2 hourly GCS until 15

Answer 9

Parietotemporal craniotomy This man needs urgent decompression and extradural haematoma is the most likely event, from a lacerated middle meningeal artery. The debate as to whether Burr Holes or craniotomy is the best option continues. Most neurosurgeons would perform a craniotomy. However, rural units and those units without neurosurgical kit facing this emergency may resort to Burr Holes. Head injury management- NICE Guidelines Summary of guidelines All patients should be assessed within 15 minutes on arrival to A&E Document all 3 components of the GCS If GCS <8 or = to 8, consider stabilising the airway Treat pain with low dose IV opiates (if safe) Full spine immobilisation until assessment if: - GCS < 15 - neck pain/tenderness - paraesthesia extremities - focal neurological deficit - suspected c-spine injury If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if: - Intubated - GCS <13 - Normal x-ray but continued concerns regarding c-spine injury - Any focal neurology - A CT head scan is being performed - Initial plain films are abnormal ``` Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy ``` ``` Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak ``` Observations 1/2 hourly GCS until 15

Answer 10

Intravenous mannitol This women has raised ICP and mannitol will help reduce this in the acute phase. Head injury management- NICE Guidelines Summary of guidelines All patients should be assessed within 15 minutes on arrival to A&E Document all 3 components of the GCS If GCS <8 or = to 8, consider stabilising the airway Treat pain with low dose IV opiates (if safe) Full spine immobilisation until assessment if: - GCS < 15 - neck pain/tenderness - paraesthesia extremities - focal neurological deficit - suspected c-spine injury If a c-spine injury is suspected a 3 view c-spine x-ray is indicated. CT c-spine is preferred if: - Intubated - GCS <13 - Normal x-ray but continued concerns regarding c-spine injury - Any focal neurology - A CT head scan is being performed - Initial plain films are abnormal ``` Immediate CT head (within 1 hour) if: GCS < 13 on admission GCS < 15 2 hours after admission Suspected open or depressed skull fracture Suspected skull base fracture (panda eyes, Battle's sign, CSF from nose/ear, bleeding ear) Focal neurology Vomiting > 1 episode Post traumatic seizure Coagulopathy ``` ``` Contact neurosurgeon if: Persistent GCS < 8 or = 8 Unexplained confusion > 4h Reduced GCS after admission Progressive neurological signs Incomplete recovery post seizure Penetrating injury Cerebrospinal fluid leak ``` Observations 1/2 hourly GCS until 15

Answer 11

Retinal and cerebellar haemangiomas are key features of Von Hippel-Lindau syndrome. Retinal haemangiomas are bilateral in 25% of patients and may lead to vitreous haemorrhage on Hippel-Lindau (VHL) syndrome is an autosomal dominant condition predisposing to neoplasia. It is due to an abnormality in the VHL gene located on short arm of chromosome 3 Features cerebellar haemangiomas retinal haemangiomas: vitreous haemorrhage renal cysts (premalignant) phaeochromocytoma extra-renal cysts: epididymal, pancreatic, hepatic endolymphatic sac tumours

Answer 12

Milroy's disease Milroy's disease is present from birth and is due to failure of the lymphatic vessels to develop. Note that Meige's disease develops AFTER birth. Lymphoedema Due to impaired lymphatic drainage in the presence of normal capillary function. Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening. Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis. Causes of lymphoedema Primary Congenital < 1 year: sporadic, Milroy's disease Onset 1-35 years: sporadic, Meige's disease > 35 years: Tarda Secondary Bacterial/fungal/parasitic infection (filariasis) Lymphatic malignancy Radiotherapy to lymph nodes Surgical resection of lymph nodes DVT Thrombophlebitis Indications for surgery Marked disability or deformity from limb swelling Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure Lymphocutaneous fistulae and megalymphatics Procedures Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third. Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure. Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Answer 13

Locally advanced bladder carcinoma Always consider a malignancy in an older adult with new lymphoedema in a limb, especially if the swelling is greater proximally than distally. If malignancy is excluded consider the diagnosis of lymphoedema tarda. Lymphoedema Due to impaired lymphatic drainage in the presence of normal capillary function. Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening. Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis. Causes of lymphoedema Primary Congenital < 1 year: sporadic, Milroy's disease Onset 1-35 years: sporadic, Meige's disease > 35 years: Tarda Secondary Bacterial/fungal/parasitic infection (filariasis) Lymphatic malignancy Radiotherapy to lymph nodes Surgical resection of lymph nodes DVT Thrombophlebitis Indications for surgery Marked disability or deformity from limb swelling Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure Lymphocutaneous fistulae and megalymphatics Procedures Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third. Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure. Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Answer 14

Filariasis Filariasis is caused by the nematode Wuchereria bancrofti, which is mainly spread by mosquito. The oedema can be gross leading to elephantitis. Treatment is with diethylcarbamazine. Lymphoedema Due to impaired lymphatic drainage in the presence of normal capillary function. Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening. Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis. Causes of lymphoedema Primary Congenital < 1 year: sporadic, Milroy's disease Onset 1-35 years: sporadic, Meige's disease > 35 years: Tarda Secondary Bacterial/fungal/parasitic infection (filariasis) Lymphatic malignancy Radiotherapy to lymph nodes Surgical resection of lymph nodes DVT Thrombophlebitis Indications for surgery Marked disability or deformity from limb swelling Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure Lymphocutaneous fistulae and megalymphatics Procedures Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third. Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure. Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Answer 15

Adductor canal compression syndrome most commonly presents in young males and is an important differential diagnosis in men presenting with symptoms of acute limb ischaemia on exertion. It is caused by compression of the femoral artery by the musculotendinous band from adductor magnus muscle. The treatment consists of the division of the abnormal band and restoration of the arterial circulation. Popliteal fossa entrapment is the main differential diagnosis, however the pulse disappears when the knee is fully extended. Adductor canal Also called Hunter's or subsartorial canal Immediately distal to the apex of the femoral triangle, lying in the middle third of the thigh. Canal terminates at the adductor hiatus. Borders Contents Laterally Vastus medialis muscle Saphenous nerve Posteriorly Adductor longus, adductor magnus Superficial femoral artery Roof Sartorius Superficial femoral vein

Answer 16

Basal skull fracture Bruising over the mastoid process of the temporal bone is battle's sign caused by a basal skull fracture Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.

Answer 17

Acute sub dural haematoma Sub dural haematomas are the commonest intracranial mass lesions resulting from trauma. They are classified as acute, sub acute or chronic according to tempo of onset. Acute sub dural haematomas will present within 72 hours of the original injury and have hyperdense, crescent shaped appearances on CT scanning. Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.

Answer 18

Diffuse axonal injury The baby is likely to be a victim of shaken baby syndrome. This may result in diffuse axonal injury causing extensive lesions in the white matter. Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children.

Answer 19

Angioplasty Short occlusions are generally reasonable candidates for primary attempts at angioplasty. ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 20

Femoro-distal bypass graft using PTFE with Miller Cuff This man needs a bypass operation. Using PTFE alone will not give a good result as sub intimal hyperplasia will give poor outcome early. Using a vein cuff (Miller cuff) at the end of a PTFE graft will improve the situation. ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 21

Above knee amputation A femoro-distal bypass graft would carry a high risk of failure and risk of peri-operative myocardial infarct. This lady would be well suited to primary amputation. ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 22

Drugs commonly implicated in parotid gland enlargement include: Thiouracil, isoprenaline, phenylbutazone, high oestrogen dose contraceptive pills. Parotid gland clinical Benign neoplasms Up to 80% of all salivary gland tumours occur in the parotid gland and up to 80% of these are benign. There is no consistent correlation between the rate of growth and the malignant potential of the lesion. However, benign tumours should not invade structures such as the facial nerve. With the exception of Warthins tumours, they are commoner in women than men. The median age of developing a lesion is in the 5th decade of life. Benign tumour types Benign pleomorphic adenoma or benign mixed tumor Most common parotid neoplasm (80%) Proliferation of epithelial and myoepithelial cells of the ducts and an increase in stromal components Slow growing, lobular, and not well encapsulated Recurrence rate of 1-5% with appropriate excision (parotidectomy) Recurrence possibly secondary to capsular disruption during surgery Malignant degeneration occurring in 2-10% of adenomas observed for long periods, with carcinoma ex-pleomorphic adenoma occurring most frequently as adenocarcinoma Warthin tumor (papillary cystadenoma lymphoma or adenolymphoma) Second most common benign parotid tumor (5%) Most common bilateral benign neoplasm of the parotid Marked male as compared to female predominance Occurs later in life (sixth and seventh decades) Presents as a lymphocytic infiltrate and cystic epithelial proliferation May represent heterotopic salivary gland epithelial tissue trapped within intraparotid lymph nodes Incidence of bilaterality and multicentricity of 10% Malignant transformation rare (almost unheard of) Monomorphic adenoma Account for less than 5% of tumours Slow growing Consist of only one morphological cell type (hence term mono) Include; basal cell adenoma, canalicular adenoma, oncocytoma, myoepitheliomas Haemangioma Should be considered in the differential of a parotid mass in a child Accounts for 90% of parotid tumours in children less than 1 year of age Hypervascular on imaging Spontaneous regression may occur and malignant transformation is almost unheard of Malignant salivary gland tumours Mucoepidermoid carcinoma 30% of all parotid malignancies Usually low potential for local invasiveness and metastasis (depends mainly on grade) Adenoid cystic carcinoma Unpredictable growth pattern Tendency for perineural spread Nerve growth may display skip lesions resulting in incomplete excision Distant metastasis more common (visceral rather than nodal spread) 5 year survival 35% Mixed tumours Often a malignancy occurring in a previously benign parotid lesion Acinic cell carcinoma Intermediate grade malignancy May show perineural invasion Low potential for distant metastasis 5 year survival 80% Adenocarcinoma Develops from secretory portion of gland Risk of regional nodal and distant metastasis 5 year survival depends upon stage at presentation, may be up to 75% with small lesions with no nodal involvement Lymphoma Large rubbery lesion, may occur in association with Warthins tumours Diagnosis should be based on regional nodal biopsy rather than parotid resection Treatment is with chemotherapy (and radiotherapy) Diagnostic evaluation Plain x-rays may be used to exclude calculi Sialography may be used to delineate ductal anatomy FNAC is used in most cases Superficial parotidectomy may be either diagnostic of therapeutic depending upon the nature of the lesion Where malignancy is suspected the primary approach should be definitive resection rather than excisional biopsy CT/ MRI may be used in cases of malignancy for staging primary disease Treatment For nearly all lesions this consists of surgical resection, for benign disease this will usually consist of a superficial parotidectomy. For malignant disease a radical or extended radical parotidectomy is performed. The facial nerve is included in the resection if involved. The need for neck dissection is determined by the potential for nodal involvement. Other parotid disorders HIV infection Lymphoepithelial cysts associated with HIV occur almost exclusively in the parotid Typically presents as bilateral, multicystic, symmetrical swelling Risk of malignant transformation is low and management usually conservative Sjogren syndrome Autoimmune disorder characterised by parotid enlargement, xerostomia and keratoconjunctivitis sicca 90% of cases occur in females Second most common connective tissue disorder Bilateral, non tender enlargement of the gland is usual Histologically, the usual findings are of a lymphocytic infiltrate in acinar units and epimyoepithelial islands surrounded by lymphoid stroma Treatment is supportive There is an increased risk of subsequent lymphoma Sarcoid Parotid involvement occurs in 6% of patients with sarcoid Bilateral in most cases Gland is not tender Xerostomia may occur Management of isolated parotid disease is usually conservative

Answer 23

Between 5 and 10 days after surgery Haemorrhage in the first 6 hours after surgery is termed reactionary haemorrhage. Feeding does not increase the risk and may actually lower the risks of infection developing. Secondary haemorrhage after tonsillectomy Haemorrhage is a feared complication following tonsillectomy. Primary, or reactionary haemorrhage most commonly occurs in the first 6-8 hours following surgery. It is managed by immediate return to theatre. Secondary haemorrhage occurs between 5 and 10 days after surgery, it is often associated with a wound infection. Treatment is usually with admission and antibiotics. Severe bleeding may require surgery. Secondary haemorrhage occurs in 3% of all tonsillectomies.

Answer 24

Re-assess in 6 months Undescended testes are not uncommon in young children. They may be present in 4% of term infants, but only in 1.3% children at 3 months of age. In this scenario the testis is retractile and can be managed expectantly. Cryptorchidism A congenital undescended testis is one that has failed to reach the bottom of the scrotum by 3 months of age. At birth up to 5% of boys will have an undescended testis, post natal descent occurs in most and by 3 months the incidence of cryptorchidism falls to 1-2%. In the vast majority of cases the cause of the maldescent is unknown. A proportion may be associated with other congenital defects including: ``` Patent processus vaginalis Abnormal epididymis Cerebral palsy Mental retardation Wilms tumour Abdominal wall defects (e.g. gastroschisis, prune belly syndrome) ``` Differential diagnosis These include retractile testes and, in the case of absent bilateral testes the possibility of intersex conditions. A retractile testis can be brought into the scrotum by the clinician and when released remains in the scrotum. If the examining clinician notes the testis to return rapidly into the inguinal canal when released then surgery is probably indicated. Reasons for correction of cryptorchidism Reduce risk of infertility Allows the testes to be examined for testicular cancer Avoid testicular torsion Cosmetic appearance Males with undescended testis are 40 times as likely to develop testicular cancer (seminoma) as males without undescended testis The location of the undescended testis affects the relative risk of testicular cancer (50% intra-abdominal testes) Treatment Orchidopexy at 6- 18 months of age. The operation usually consists of inguinal exploration, mobilisation of the testis and implantation into a dartos pouch. Intra-abdominal testis should be evaluated laparoscopically and mobilised. Whether this is a single stage or two stage procedure depends upon the exact location. After the age of 2 years in untreated individuals the Sertoli cells will degrade and those presenting late in teenage years may be better served by orchidectomy than to try and salvage a non functioning testis with an increased risk of malignancy.

Answer 25

1 in 6000 Risk of haematoma (requiring removal) in adults attending accident and emergency units following head injury. - Concussion, no skull fracture Orientated 1 in 6000 - Concussion, no skull fracture Not orientated 1 in 120 - Skull fracture Orientated 1 in 32 - Skull fracture Not orientated 1 in 4

Answer 26

Boas' sign refers to hyperaesthesia of the tip of the right scapula and is seen classically in association with acute cholecystitis. A number of eponymous abdominal signs are noted. These include: Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

Answer 27

These are features of anal cancer. Anal cancers arise from the cutaneous epithelium and are therefore typically squamous cell. They are usually sensitive to chemoradiotherapy. Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. In the table below we give some typical bleeding scenarios together with physical examination findings and causation. - Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) - Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. - Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. - Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. - Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Investigation All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline. Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory. In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed. In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test. Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia. In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease. Special tests In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common. Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy. Management - Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. - Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). - Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 28

A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture. Lower genitourinary tract trauma Most bladder injuries occur due to blunt trauma 85% associated with pelvic fractures Easily overlooked during assessment in trauma Up to 10% of male pelvic fractures are associated with urethral or bladder injuries ``` Urethral injury Mainly in males Blood at the meatus (50% cases) There are 2 types: i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult) ``` - Investigation: ascending urethrogram - Management: suprapubic catheter (surgical placement, not percutaneously) External genitalia injuries (i.e., the penis and the scrotum) Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation Bladder injury rupture is intra or extraperitoneal presents with haematuria or suprapubic pain history of pelvic fracture and inability to void: always suspect bladder or urethral injury inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury investigation- IVU or cystogram management: laparotomy if intraperitoneal, conservative if extraperitoneal

Answer 29

A combination of sepsis and jaundice generally favors a diagnosis of cholangitis. Conditions such as empyema may cause sepsis but not marked jaundice, the same is also true of the other differentials listed. Gallstones Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo. The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal. Investigation In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option. Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy Acute cholecystitis Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome) Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2) Gallbladder abscess Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present Imaging with USS +/- CT Scanning Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile In unfit patients percutaneous drainage may be considered ``` Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP ``` Gallstone ileus Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent) Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with. Acalculous cholecystitis Patients with inter current illness (e.g. diabetes, organ failure) Patient of systemically unwell Gallbladder inflammation in absence of stones High fever If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy Treatment Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy. During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously. ``` Risks of ERCP Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5% ```

Answer 30

In most cases the treatment of choice for acute cholecystitis is an acute cholecystectomy performed early in the illness. Delayed surgery particularly around 5- 7 days after presentation is much more technically challenging and is often best deferred. In most cases the procedure can be performed laparoscopically, even when acute inflammation is present. Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo. The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal. Investigation In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option. Specific gallstone and gallbladder related disease Disease Features Management Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy Acute cholecystitis Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome) Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2) Gallbladder abscess Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present Imaging with USS +/- CT Scanning Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile In unfit patients percutaneous drainage may be considered Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP Gallstone ileus Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent) Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with. Acalculous cholecystitis Patients with inter current illness (e.g. diabetes, organ failure) Patient of systemically unwell Gallbladder inflammation in absence of stones High fever If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy Treatment Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy. During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously. ``` Risks of ERCP(1) Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5% ```

Answer 31

Thyroid lymphoma (Non Hodgkin's B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto's thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option. Thyroiditis Sub acute thyroiditis Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism ``` Features Hyperthyroidism Painful goitre Raised ESR Globally reduced uptake on iodine-131 scan ``` Management Usually self-limiting - most patients do not require treatment Thyroid pain may respond to aspirin or other NSAIDs In more severe cases steroids are used, particularly if hypothyroidism develops Hashimotos thyroiditis Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines. Features Goitre and either euthyroid or mild hypothyroidism Progressive hypothyroidism (and associated symptoms) Management During the hyperthyroid phase of illness beta blockers may manage symptoms As hypothyroidism develops patients may require thyroxine

Answer 32

This is a typical scenario for medullary carcinoma in which a phaeochromocytoma may also be present. It may be inherited in an autosomal dominant fashion and affected family members may be offered prophylactic thyroidectomy. Thyroid disease Patients may present with a number of different manifestations of thyroid disease. They can be broadly sub classified according to whether they are euthyroid or have clinical signs of thyroid dysfunction. In addition it needs to be established whether they have a mass or not. Assessment History Examination including USS If a nodule is identified then it should be sampled ideally via an image guided fine needle aspiration Radionucleotide scanning is of limited use ``` Thyroid Tumours Papillary carcinoma Follicular carcinoma Anaplastic carcinoma Medullary carcinoma Lymphoma's ``` Multinodular goitre One of the most common reasons for presentation Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured. In those with compressive symptoms surgery is required and the best operation is a total thyroidectomy. Sub total resections were practised in the past and simply result in recurrent disease that requires a difficult revisional resection. Endocrine dysfunction In general these patients are managed by physicians initially. Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women). Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine. Complications following surgery Anatomical such as recurrent laryngeal nerve damage. Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory compromise owing to laryngeal oedema. Damage to the parathyroid glands resulting in hypocalcaemia.

Answer 33

Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy. Large multinodular goitre Surgery for pressure symptoms. Total thyroidectomy is treatment of choice Toxic nodule Hemithyroidectomy Follicular lesion (THY 3f) Hemithyroidectomy to establish diagnosis Papillary thyroid cancer Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required) Follicular thyroid cancer Total thyroidectomy (usually completion as already had hemithyroidectomy) Anaplastic thyroid cancer Palliative radiotherapy Medullary thyroid cancer Total thyroidectomy (screen for other MEN tumours) Lymphoma of the thyroid Consider core biopsy Persistent refilling cysts Hemithyroidectomy Graves disease with significant eye signs Total thyroidectomy Graves disease without significant eye signs Patient choice radioiodine Vs surgery

Answer 34

The passage of bloody diarrhoea together with mucus and a short history makes this a likely first presentation of inflammatory bowel disease. A rectal malignancy in a 22 year old would be a very unlikely event. The history is too short to be consistent with solitary rectal ulcer. Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Investigation All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline. Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory. In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed. In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test. Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia. In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease. Special tests In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common. Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy. Management Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 35

Any advanced right iliac fossa pathology can result in a positive Rovsings sign. However, in retrocaecal appendicitis, it may be absent and this fact can contribute to a delayed diagnosis if undue weight is placed on the presence of the sign in making the diagnosis. Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

Answer 36

The key point in the history is the preceding flu like illness and absence of abdominal signs. These make mesenteric adenitis the most likely diagnosis. The patient should have a period of active observation, if this were to represent early appendicitis, then the clinical picture may change and this would be detected with serial examination. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea ``` Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 37

In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used. Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Now seldom used Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open) Lanz Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Gable Rooftop incision Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Answer 38

The timing of the pain and the fact that it is mid cycle makes Mittelschmerz the most likely cause. When follicular cysts rupture, there is sometimes associated bleeding of small volume. The cyst contents and blood if present can be very irritant and pain can sometimes mimic appendicitis or pelvic inflammatory disease. However, normal inflammatory markers makes the former less likely and unless the 14 year old was sexually active, PID is also relatively rare in this group. Crohns disease and pelvic abscesses would typically present with a more protracted history and raised inflammatory markers and fever. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 39

A pelvic fracture and lower abdominal peritonism should raise suspicions of bladder rupture (especially as this man cannot pass urine). Lower genitourinary tract trauma Most bladder injuries occur due to blunt trauma 85% associated with pelvic fractures Easily overlooked during assessment in trauma Up to 10% of male pelvic fractures are associated with urethral or bladder injuries ``` Urethral injury Mainly in males Blood at the meatus (50% cases) There are 2 types: i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult) ``` - Investigation: ascending urethrogram - Management: suprapubic catheter (surgical placement, not percutaneously) External genitalia injuries (i.e., the penis and the scrotum) Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation Bladder injury rupture is intra or extraperitoneal presents with haematuria or suprapubic pain history of pelvic fracture and inability to void: always suspect bladder or urethral injury inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury investigation- IVU or cystogram management: laparotomy if intraperitoneal, conservative if extraperitoneal

Answer 40

Once the bowel has been disconnected, a degree of inflammation is commonly seen in the quiescent bowel. This is typically referred to as diversion colitis. Dysplasia is not usually seen in this context as a Hartmanns procedure is not usually a treatment modality used for IBD (which is the main risk factor for dysplasia). Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. - Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) - Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. - Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. - Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. - Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Investigation All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline. Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory. In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed. In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test. Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia. In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease. Special tests In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common. Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy. Management Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 41

Murphy's sign Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

Answer 42

Nocturnal diarrhea and incontinence is a key feature in the history and is strongly suggestive of a diagnosis of IBD. More benign IBS presentations seldom have nocturnal events or a short history. Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. - Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) - Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. - Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. - Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. - Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Investigation All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline. Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory. In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed. In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test. Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia. In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease. Special tests In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common. Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy. Management Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 43

A Rutherford Morrison incision is the traditional approach for a renal transplant and provides extra peritoneal access to the iliac vessels. Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Now seldom used Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open) Lanz Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Gable Rooftop incision Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Answer 44

The vast majority of small adrenal lesions are incidental, benign and non functioning adenomas. Apart from minimal workup, no further investigation is needed. Of note, if there are concerns about malignancy, the only surgical option is adrenalectomy. Adrenal lesions- Incidental Incidentaloma of the adrenal glands have become increasingly common as CT scanning of the abdomen is widely undertaken. Prevalences range from 1.5-9% in autopsy studies. Overall, 75% will be non functioning adenomas. However, a thorough diagnostic work up is required to exclude a more significant lesion. Investigation Morning and midnight plasma cortisol measurements Dexamethasone suppression test 24 hour urinary cortisol excretion 24 hour urinary excretion of catecholamines Serum potassium, aldosterone and renin levels Management The risk of malignancy is related to the size of the lesion and 25% of all masses greater than 4cm will be malignant. Such lesions should usually be excised. Where a lesion is a suspected metastatic deposit a biopsy may be considered.

Answer 45

Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected. Spigelian hernias are very rare in children, liposarcomas are not smooth swellings. An appendix mass will usually produce systemic illness. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea ``` Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 46

A McEvedy incision is traditionally used to approach incarcerated femoral hernias. The disadvantage of the Lothessien approach is that it weakens the inguinal canal and predisposes to inguinal hernia formation. The other incisions would not usually address femoral hernias. Given the features of bowel obstruction, a low approach would be inappropriate. Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Now seldom used Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open) Lanz Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Gable Rooftop incision Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Answer 47

Total thyroidectomy Sub total thyroidectomy is no longer routinely undertaken in this group. Large multinodular goitre Surgery for pressure symptoms. Total thyroidectomy is treatment of choice Toxic nodule Hemithyroidectomy Follicular lesion (THY 3f) Hemithyroidectomy to establish diagnosis Papillary thyroid cancer Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required) Follicular thyroid cancer Total thyroidectomy (usually completion as already had hemithyroidectomy) Anaplastic thyroid cancer Palliative radiotherapy Medullary thyroid cancer Total thyroidectomy (screen for other MEN tumours) Lymphoma of the thyroid Consider core biopsy Persistent refilling cysts Hemithyroidectomy Graves disease with significant eye signs Total thyroidectomy Graves disease without significant eye signs Patient choice radioiodine Vs surgery

Answer 48

Laparoscopic appendicectomy The most likely diagnosis is appendicitis. The negative vaginal examination (and therefore by definition the absence of cervical excitation) makes pelvic inflammatory disease unlikely. Given the raised inflammatory markers, the correct course of action is to proceed with surgery. In females, there are considerable advantages of undertaking this laparoscopically as it allows evaluation of the pelvic viscera. Imaging with USS is unlikely to alter management as it has a false negative rate and given the context of the clinical findings, surgery is likely to occur in any case. Whilst a CT scan would allow for an accurate pre-operative diagnosis, it carries a significant radiation dose, and again, is unlikely to alter management. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 49

Grey Turner: Rovsings sign- appendicitis Boas sign -cholecystitis Murphys sign- cholecystitis Cullens sign- pancreatitis (other intraabdominal haemorrhage) Grey-Turners sign- pancreatitis (or other retroperitoneal haemorrhage)

Answer 50

Painful rectal bleeding is typically seen with fissure in ano (most will be posterior). The initial history is often short (as in this case). A fistula is more likely to present with discharge than just blood. Haemorrhoidal disease bleeding is usually painless. Although thrombosed haemorrhoids may be painful, they typically occur in patients with a longer history. Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. In the table below we give some typical bleeding scenarios together with physical examination findings and causation. Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 51

Perform operative cholecystectomy The timeframe of 10 days makes attempts at proceeding with surgery hazardous even in experienced hands. However, the patient is unwell and this will not settle without some form of intervention. If only the fundus can be seen, then it may be difficult to even proceed with a sub total cholecystectomy. Therefore, a cholecystostomy can be performed and this will usually allow the situation to settle. Definitive surgery can then be undertaken in more favourable circumstances. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier)

Answer 52

This scenario should raise suspicion for Meckels as these may contain ectopic gastric mucosa which may secrete acid with subsequent bleeding and ulceration. The iron deficiency anaemia is makes a Meckels more likely than IBD. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 53

This is the classic description of acalculous cholecystitis and its commonest in patients with type 2 diabetes. If you answered it incorrectly, ensure that you were not caught out by the acute calculous cholecystitis as this is a common exam mistake if options are mis read in a rush. Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo. The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal. Investigation In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option. Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy Acute cholecystitis Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome) Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2) Gallbladder abscess Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present Imaging with USS +/- CT Scanning Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile In unfit patients percutaneous drainage may be considered ``` Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP ``` Gallstone ileus Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent) Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with. Acalculous cholecystitis Patients with inter current illness (e.g. diabetes, organ failure) Patient of systemically unwell Gallbladder inflammation in absence of stones High fever If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy Treatment Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy. During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously. ``` Risks of ERCP(1) Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5% ```

Answer 54

Solitary rectal ulcers are associated with chronic constipation and straining. It will need to be biopsied to exclude malignancy (the histological appearances are characteristic). Diagnostic work up should include endoscopy and probably defecating proctogram and ano-rectal manometry studies. Rectal bleeding is a common cause for patients to be referred to the surgical clinic. In the clinical history it is useful to try and localise the anatomical source of the blood. Bright red blood is usually of rectal anal canal origin, whilst dark red blood is more suggestive of a proximally sited bleeding source. Blood which has entered the GI tract from a gastro-duodenal source will typically resemble malaena due to the effects of the digestive enzymes on the blood itself. Fissure in ano Bright red rectal bleeding Painful bleeding that occurs post defecation in small volumes. Usually antecedent features of constipation Muco-epithelial defect usually in the midline posteriorly (anterior fissures more likely to be due to underlying disease) Haemorroids Bright red rectal bleeding Post defecation bleeding noted both on toilet paper and drips into pan. May be alteration of bowel habit and history of straining. No blood mixed with stool. No local pain. Normal colon and rectum. Proctoscopy may show internal haemorrhoids. Internal haemorrhoids are usually impalpable. Crohns disease Bright red or mixed blood Bleeding that is accompanied by other symptoms such as altered bowel habit, malaise, history of fissures (especially anterior) and abscesses. Perineal inspection may show fissures or fistulae. Proctoscopy may demonstrate indurated mucosa and possibly strictures. Skip lesions may be noted at colonoscopy. Ulcerative colitis Bright red bleeding often mixed with stool Diarrhoea, weight loss, nocturnal incontinence, passage of mucous PR. Proctitis is the most marked finding. Peri anal disease is usually absent. Colonoscopy will show continuous mucosal lesion. Rectal cancer Bright red blood mixed volumes Alteration of bowel habit. Tenesmus may be present. Symptoms of metastatic disease. Usually obvious mucosal abnormality. Lesion may be fixed or mobile depending upon disease extent. Surrounding mucosa often normal, although polyps may be present. Investigation All patients presenting with rectal bleeding require digital rectal examination and procto-sigmoidoscopy as a minimal baseline. Remember that haemorrhoids are typically impalpable and to attribute bleeding to these in the absence of accurate internal inspection is unsatisfactory. In young patients with no other concerning features in the history a carefully performed sigmoidoscopy that demonstrates clear haemorrhoidal disease may be sufficient. If clear views cannot be obtained then patients require bowel preparation with an enema and a flexible sigmoidscopy performed. In those presenting with features of altered bowel habit or suspicion of inflammatory bowel disease a colonoscopy is the best test. Patients with excessive pain who are suspected of having a fissure may require an examination under general or local anaesthesia. In young patients with external stigmata of fissure and a compatible history it is acceptable to treat medically and defer internal examination until the fissure is healed. If the fissure fails to heal then internal examination becomes necessary along the lines suggested above to exclude internal disease. Special tests In patients with a malignancy of the rectum the staging investigations comprise an MRI of the rectum to identify circumferential resection margin compromise and to identify mesorectal nodal disease. In addition to this CT scanning of the chest abdomen and pelvis is necessary to stage for more distant disease. Some centres will still stage the mesorectum with endo rectal ultrasound but this is becoming far less common. Patients with fissure in ano who are being considered for surgical sphincterotomy and are females who have an obstetric history should probably have ano rectal manometry testing performed together with endo anal ultrasound. As this service is not universally available it is not mandatory but in the absence of such information there are continence issues that may arise following sphincterotomy. Management Fissure in ano GTN ointment 0.2% or diltiazem cream applied topically is the usual first line treatment. Botulinum toxin for those who fail to respond. Internal sphincterotomy for those who fail with botox, can be considered earlier in males. Haemorroids Lifestyle advice, for small internal haemorrhoids can consider injection sclerotherapy or rubber band ligation. For external haemorrhoids consider haemorrhoidectomy. Modern options include HALO procedure and stapled haemorrhoidectomy. Inflammatory bowel disease Medical management- although surgery may be needed for fistulating Crohns (setons). Rectal cancer Anterior resection or abdomino-perineal excision of the colon and rectum. Total mesorectal excision is now standard of care. Most resections below the peritoneal reflection will require defunctioning ileostomy. Most patients will require preoperative radiotherapy.

Answer 55

Follicular carcinomas may metastasise haematogenously (often to bone) where they may give rise to pathological fractures as in this case. Multinodular goitre One of the most common reasons for presentation Provided the patient is euthyroid and asymptomatic and no discrete nodules are seen, they can be reassured. In those with compressive symptoms surgery is required and the best operation is a total thyroidectomy. Sub total resections were practised in the past and simply result in recurrent disease that requires a difficult revisional resection. Endocrine dysfunction In general these patients are managed by physicians initially. Surgery may be offered alongside radio iodine for patients with Graves disease that fails with medical management or in patients who would prefer not to be irradiated (e.g. pregnant women). Patients with hypothyroidism do not generally get offered a thyroidectomy. Sometimes people inadvertently get offered resections during the early phase of Hashimotos thyroiditis, however, with time the toxic phase passes and patients can simply be managed with thyroxine. Complications following surgery Anatomical such as recurrent laryngeal nerve damage. Bleeding. Owing to the confined space haematoma's may rapidly lead to respiratory compromise owing to laryngeal oedema. Damage to the parathyroid glands resulting in hypocalcaemia.

Answer 56

Abdominal and pelvic USS The history of blood stained discharge and tenderness makes an ectopic pregnancy a strong possibility, a USS should be performed and a pregnancy test undertaken. If the beta HCG is high then an intra uterine pregnancy should be found. If it is not, then an ectopic pregnancy is likely and surgery should be considered. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 57

Patients with gallstone pancreatitis should undergo early cholecystectomy. Enteral feeding helps minimise gut bacterial translocation and should be given to most patients with pancreatitis. Many studies have evaluated the role of octreotide in reducing pancreatic secretions and shown no benefit The use of antibiotics in pancreatitis is controversial. However, a recent Cochrane review has presented reasonable evidence in favor of administration of imipenem to prevent infection in established necrosis. Management of Acute Pancreatitis in the UK Diagnosis Traditionally hyperamylasaemia has been utilised with amylase being elevated three times the normal range. However, amylase may give both false positive and negative results. Serum lipase is both more sensitive and specific than serum amylase. It also has a longer half life. Serum amylase levels do not correlate with disease severity. ``` Differential causes of hyperamylasaemia Acute pancreatitis Pancreatic pseudocyst Mesenteric infarct Perforated viscus Acute cholecystitis Diabetic ketoacidosis ``` Assessment of severity Glasgow, Ranson scoring systems and APACHE II Biochemical scoring e.g. using CRP Features that may predict a severe attack within 48 hours of admission to hospital ``` Initial assessment Clinical impression of severity Body mass index >30 Pleural effusion APACHE score >8 ``` ``` 24 hours after admission Clinical impression of severity APACHE II >8 Glasgow score of 3 or more Persisting multiple organ failure CRP>150 ``` ``` 48 hours after admission Glasgow Score of >3 CRP >150 Persisting or progressive organ failure Table adapted from UK guidelines for management of acute pancreatitis. GUT 2005, 54 suppl III ``` Management Nutrition There is reasonable evidence to suggest that the use of enteral nutrition does not worsen the outcome in pancreatitis Most trials to date were underpowered to demonstrate a conclusive benefit. The rationale behind feeding is that it helps to prevent bacterial translocation from the gut, thereby contributing to the development of infected pancreatic necrosis. Use of antibiotic therapy Many UK surgeons administer antibiotics to patients with acute pancreatitis. However, there is very little evidence to support this practice. A recent Cochrane review highlights the potential benefits of administering Imipenem to patients with established pancreatic necrosis in the hope of averting the progression to infection. There are concerns that the administration of antibiotics in mild attacks of pancreatitis will not affect outcome and may contribute to antibiotic resistance and increase the risks of antibiotic associated diarrhoea. Surgery Patients with acute pancreatitis due to gallstones should undergo early cholecystectomy. Patients with obstructed biliary system due to stones should undergo early ERCP. Patients with extensive necrosis where infection is suspected should usually undergo FNA for culture. Patients with infected necrosis should undergo either radiological drainage or surgical necrosectomy. The choice of procedure depends upon local expertise.

Answer 58

The history of weight loss and intermittent diarrhea makes inflammatory bowel disease the most likely diagnosis. Conditions such as appendicitis and infections have a much shorter history. Although Meckels can bleed and cause inflammation, they seldom cause marked weight loss. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 59

First time renal tranplants and typically implanted in the left or right iliac fossae. The vessels are usually joined to the external iliac artery and vein as these are the most easily accessible. The Rutherford Morrison incision provides access to the external iliac vessels. A number of different organ and tissue transplants are now available. In many cases an allograft is performed, where an organ is transplanted from one individual to another. Allografts will elicit an immune response and this is one of the main reasons for organ rejection. Graft rejection occurs because allografts have allelic differences at genes that code immunohistocompatability complex genes. The main antigens that give rise to rejection are: ABO blood group Human leucocyte antigens (HLA) Minor histocompatability antigens ABO Matching ABO incompatibility will result in early organ rejection (hyperacute) because of pre existing antibodies to other groups. Group O donors can give organs to any type of ABO recipient whereas group AB donor can only donate to AB recipient. HLA System The four most important HLA alleles are: HLA A HLA B HLA C HLA DR An ideal organ match would be one in which all 8 alleles are matched (remember 2 from each parent, four each = 8 alleles). Modern immunosuppressive regimes help to manage the potential rejection due to HLA mismatching. However, the greater the number of mismatches the worse the long term outcome will be. T lymphocytes will recognise antigens bound to HLA molecules and will then become activated. Clonal expansion then occurs with a response directed against that antigen. Types of organ rejection Hyperacute. This occurs immediately through presence of pre formed antibodies (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. Hyperacute Renal transplants at greatest risk and liver transplants at least risk. Although ABO incompatibility and HLA Class I incompatible transplants will all fare worse in long term. Acute All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Chronic Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants. Surgical overview-Renal transplantation A brief overview of the steps involved in renal transplantation is given. Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Exclusion criteria include; active malignancy, old age (due to limited organ availability). Patients are medically optimised. Donor kidneys, these may be taken from live related donors and close family, members may have less HLA mismatch than members of the general population. Laparoscopic donor nephrectomy further minimises the operative morbidity for the donor. Other organs are typically taken from brain dead or dying patients who have a cardiac arrest and in whom resuscitation is futile. The key event is to minimise the warm ischaemic time in the donor phase. The kidney once removed is usually prepared on the bench in theatre by the transplant surgeon immediately prior to implantation and factors such as accessory renal arteries and vessel length are assessed and managed. For first time recipients the operation is performed under general anaesthesia. A Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. The vein and artery are anastamosed to the iliacs and the clamps removed. The ureter is then implanted into the bladder and a stent is usually placed to maintain patency. The wounds are then closed and the patient recovered from surgery. In the immediate phase a common problem encountered in cadaveric kidneys is acute tubular necrosis and this tends to resolve. Graft survival times from cadaveric donors are typically of the order of 9 years and monozygotic twin transplant (live donor) may survive as long as 25 years.

Answer 60

5 alpha reductase inhibitors have a more favorable side effect profile than α blockers. Alpha blockers have a faster onset of action (but lower reduction of complications from BPH) than 5 α reductase inhibitors. Benign prostatic hyperplasia occurs via an increase in the epithelial and stromal cell numbers in the peri-urethral zone of the prostate. BPH is very common and 90% of men aged over 80 will have at least microscopic evidence of benign prostatic hyperplasia. The causes of BPH are still not well understood, but the importance of androgens remains appreciated even if the exact role by which they induce BPH is elusive. Presentation The vast majority of men will present with lower urinary tract symptoms. These will typically be: ``` Poor flow Nocturia Hesitancy Incomplete and double voiding Terminal dribbling Urgency Incontinence ``` Investigation Digital rectal examination to assess prostatic size and morphology. Urine dipstick for infections and haematuria. Uroflowmetry (a flow rate of >15ml/second helps to exclude BOO) Bladder pressure studies may help identify detrusor failure and whilst may not form part of first line investigations should be included in those with atypical symptoms and prior to redo surgery. Bladder scanning to demonstrate residual volumes. USS if high pressure chronic retention. Management Lifestyle changes such as stopping smoking and altering fluid intake may help those with mild symptoms. Medical therapy includes alpha blockers and 5 α reductase inhibitors. The former work quickly on receptor zones located at the bladder neck. Cardiovascular side effects are well documented. The latter work on testosterone metabolising enzymes. Although they have a slower onset of action, the 5 α reductase inhibitors may prevent acute urinary retention. Surgical therapy includes transurethral resection of the prostate and is the treatment of choice in those with severe symptoms and those who fail to respond to medical therapy. More tailored bladder neck incision procedures may be considered in those with small prostates. Retrograde ejaculation may occur following surgery. The change in the type of irrigation solutions used has helped to minimise the TURP syndrome of electrolyte disturbances.

Answer 61

No further action needed Colocutaneous fistulae may occur as a result of anastomotic leakage following loop colostomy reversal. In the absence of abdominal signs a laparotomy is not necessarily required. Signs of wound sepsis may require antibiotics. Because there is not any distal obstruction (note normal pre-operative gastrograffin enema) these fistulae will usually close spontaneously. A fistula is defined as an abnormal connection between two epithelial surfaces. There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally. In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn's. As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae. The four types of fistulae are: Enterocutaneous These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis. Suspect if there is excess fluid in the drain. Enteroenteric or Enterocolic This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease. Enterovaginal Aetiology as above. Enterovesicular This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Management Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 62

Total parenteral nutrition and octreotide This man has a high output and anatomically high fistula. Drying up the fistula with octreotide will not suffice, his nutrition is compromised and TPN will help. A fistula is defined as an abnormal connection between two epithelial surfaces. There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally. In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn's. As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae. The four types of fistulae are: Enterocutaneous These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis. Suspect if there is excess fluid in the drain. Enteroenteric or Enterocolic This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease. Enterovaginal Aetiology as above. Enterovesicular This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Management Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 63

No further action needed When the bile duct is closed over a T Tube the latex in the T tube encourages tract fibrosis. This actually encourages a fistula to develop. The result is that when the tube is removed any bile which leaks will usually drain through the tract. Provided that there are no residual stones in the duct the fistula will slowly close. Persistent high volume drainage may be managed with ERCP and sphincterotomy. A fistula is defined as an abnormal connection between two epithelial surfaces. There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally. In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn's. As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae. The four types of fistulae are: Enterocutaneous These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis. Suspect if there is excess fluid in the drain. Enteroenteric or Enterocolic This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease. Enterovaginal Aetiology as above. Enterovesicular This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Management Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 64

This lady has thyrotoxicosis (low TSH) and a hot solitary nodule indicating a toxic adenoma. Thyroid cancer rarely causes thyrotoxicosis or hot nodules. ``` Causes of hyperthyroidism include: Diffuse toxic goitre (Graves Disease) Toxic nodular goitre Toxic nodule Rare causes ``` Graves disease Graves disease is characterised by a diffuse vascular goitre that appears at the same time as the clinical manifestations of hyperthyroidism. It is commonest in younger females and may be associated with eye signs. Thyrotoxic symptoms will predominate. Up to 50% of patients will have a familial history of autoimmune disorders. The glandular hypertrophy and hyperplasia occur as a result of the thyroid stimulating effects of the TSH receptor antibodies. Toxic nodular goitre In this disorder the goitre is present for a long period of time prior to the development of clinical symptoms. In most goitres the nodules are inactive and in some cases it is the internodular tissue that is responsible for the hyperthyroidism. Toxic nodule Overactive, autonomously functioning nodule. It may occur as part of generalised nodularity or be a true toxic adenoma. The TSH levels are usually low as the autonomously functioning thyroid tissue will exert a negative feedback effect. ``` Lethargy Tachycardia Emotionally labile Agitation Heat intolerance Hot, moist palms Weight loss Exopthalmos Excessive appetite Thyroid goitre and bruit Palpitations Lid lag/retraction ``` Diagnosis The most sensitive test for diagnosing hyperthyroidism is plasma T3 (which is raised). Note in hypothyroidism the plasma T4 and TSH are the most sensitive tests. A TSH level of <0.5U/L suggests hyperthyroidism. TSH receptor antibodies may be tested for in the diagnosis of Graves. Treatment First line treatment for Graves disease is usually medical and the block and replace regime is the favored option. Carbimazole is administered at higher doses and thyroxine is administered orally. Patient are maintained on this regime for between 6 and 12 months. Attempts are then made to wean off medication. Where relapse then occurs the options are between ongoing medical therapy, radioiodine or surgery.

Answer 65

Epididymo-orchitis Epididymo-orchitis: acute pain and swelling after urological intervention. To differentiate from testicular torsion there is usually pyrexia and positive urine dipstick. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 66

Testicular torsion Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. There is usually severe pain and the patient will often not tolerate the testis being touched. Urgent scrotal exploration is indicated. It is associated with a high investment of the the tunica vaginalis with horizontal testicular lie, or when the epididymis and testis are separated by a mesorchium, in which case the twist occurs at that point. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 67

Orchitis Orchitis may be associated with mumps viral infections. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 68

Ketamine does not affect healing. All the other situations in the list carry a strong association with poor healing and risk of dehisence Abdominal wound dehiscence This is a significant problem facing all surgeons who undertake abdominal surgery on a regular basis. Traditionally, it is said to occur when all layers of an abdominal mass closure fail and the viscera protrude externally (associated with 30% mortality). It can be subdivided into superficial, in which the skin wound alone fails and complete, implying failure of all layers. Factors which increase the risk are: * Malnutrition * Vitamin deficiencies * Jaundice * Steroid use * Major wound contamination (e.g. faecal peritonitis) * Poor surgical technique (Mass closure technique is the preferred method-Jenkins Rule) When sudden full dehiscence occurs the management is as follows: * Analgesia * Intravenous fluids * Intravenous broad spectrum antibiotics * Coverage of the wound with saline impregnated gauze (on the ward) * Arrangements made for a return to theatre Surgical strategy Correct the underlying cause (e.g. TPN or NG feed if malnourished) Determine the most appropriate strategy for managing the wound Options Resuturing of the wound This may be an option if the wound edges are healthy and there is enough tissue for sufficient coverage. Deep tension sutures are traditionally used for this purpose. Application of a wound manager This is a clear dressing with removable front. Particularly suitable when some granulation tissue is present over the viscera or where there is a high output bowel fistula present in the dehisced wound. Application of a 'Bogota bag' This is a clear plastic bag that is cut and sutured to the wound edges and is only a temporary measure to be adopted when the wound cannot be closed and will necessitate a return to theatre for definitive management. Application of a VAC dressing system These can be safely used BUT ONLY if the correct layer is interposed between the suction device and the bowel. Failure to adhere to this absolute rule will almost invariably result in the development of multiple bowel fistulae and create an extremely difficult management problem.

Answer 69

Laxative abuse This may occur as a result of laxative abuse and consists of lipofuschin laden marcophages that appear brown. World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days Acute Diarrhoea Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever Antibiotic therapy More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Constipation causing overflow A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Chronic Diarrhoea Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia Coeliac disease In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: Thyrotoxicosis Laxative abuse Appendicitis with pelvic abscess or pelvic appendix Radiation enteritis Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose

Answer 70

Ischaemic colitis The IMA is commonly ligated during an AAA repair and this may then render the left colon relatively ischaemic, thereby causing mesenteric colitis. Treatment is supportive and most cases will settle with conservative management. World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days Acute Diarrhoea Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever Antibiotic therapy More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Constipation causing overflow A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Chronic Diarrhoea Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia Coeliac disease In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: Thyrotoxicosis Laxative abuse Appendicitis with pelvic abscess or pelvic appendix Radiation enteritis Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose

Answer 71

Campylobacter jejuni infection Severe abdominal pain tends to favour Campylobacter infection. World Health Organisation definitions Diarrhoea: > 3 loose or watery stool per day Acute diarrhoea < 14 days Chronic diarrhoea > 14 days Acute Diarrhoea Gastroenteritis May be accompanied by abdominal pain or nausea/vomiting Diverticulitis Classically causes left lower quadrant pain, diarrhoea and fever Antibiotic therapy More common with broad spectrum antibiotics Clostridium difficile is also seen with antibiotic use Constipation causing overflow A history of alternating diarrhoea and constipation may be given May lead to faecal incontinence in the elderly Chronic Diarrhoea Irritable bowel syndrome Extremely common. The most consistent features are abdominal pain, bloating and change in bowel habit. Patients may be divided into those with diarrhoea predominant IBS and those with constipation predominant IBS. Features such as lethargy, nausea, backache and bladder symptoms may also be present Ulcerative colitis Bloody diarrhoea may be seen. Crampy abdominal pain and weight loss are also common. Faecal urgency and tenesmus may occur Crohn's disease Crampy abdominal pains and diarrhoea. Bloody diarrhoea less common than in ulcerative colitis. Other features include malabsorption, mouth ulcers perianal disease and intestinal obstruction Colorectal cancer Symptoms depend on the site of the lesion but include diarrhoea, rectal bleeding, anaemia and constitutional symptoms e.g. Weight loss and anorexia Coeliac disease In children may present with failure to thrive, diarrhoea and abdominal distension In adults lethargy, anaemia, diarrhoea and weight loss are seen. Other autoimmune conditions may coexist Other conditions associated with diarrhoea include: Thyrotoxicosis Laxative abuse Appendicitis with pelvic abscess or pelvic appendix Radiation enteritis Diagnosis Stool culture Abdominal and digital rectal examination Consider colonoscopy (radiological studies unhelpful) Thyroid function tests, serum calcium, anti endomysial antibodies, glucose

Answer 72

Mesenteric cysts may be associated with intra abdominal catastrophes where these occur they are typically either intestinal volvulus or intestinal infarction. They seldom cause intussusception. Cystic fibrosis may lead to the formation of meconium ileus equivalent and plugs may occasionally serve as the lead points for an intussusception. Intussusception typically presents with colicky abdominal pain and vomiting. The telescoping of the bowel produces mucosal ischaemia and bleeding may occur resulting in the passage of "red current jelly" stools. Recognised causes include lumenal pathologies such as polyps, lymphadenopathy and diseases such as cystic fibrosis. Idiopathic intussceception of the ileocaecal valve and terminal ileum is the most common variant and typically affects young children and toddlers. The diagnosis is usually made by abdominal ultrasound investigation. The decision as to the optimal treatment is dictated by the patients physiological status and abdominal signs. In general, children who are unstable with localising peritoneal signs should undergo laparotomy, as should those in whom attempted radiological reduction has failed. In relatively well children without localising signs attempted pneumatic reduction under fluroscopic guidance is the usual treatment.

Answer 73

MAG 3 Renogram Because it is excreted by renal tubular cells a MAG 3 renogram provides excellent imaging of renal function and is often used in investigating failing transplants. ``` DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system. ``` Diethylene-triamine-penta-acetic acid (DTPA) This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR. MAG 3 renogram Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired). ``` Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated ``` Intra venous urography This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used. PET/CT This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.

Answer 74

DMSA scan Although MAG 3 renograms may provide some information relating to the structural integrity of the kidney, many still consider a DMSA scan to be the gold standard for the detection of renal scarring (which is the main concern in PUJ obstruction and infections). ``` DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system. ``` Diethylene-triamine-penta-acetic acid (DTPA) This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR. MAG 3 renogram Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired). ``` Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated ``` Intra venous urography This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used. PET/CT This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.

Answer 75

MAG 3 Renogram In patients with long standing PUJ obstruction and renal scarring the main diagnostic question is whether the individual has sufficient renal function to consider a pyeloplasty or whether a primary nephrectomy is preferable. Since the CT has demonstrated scarring there is no use in obtaining a DMSA scan. Of the investigations listed both a DTPA and MAG 3 renogram will allow assessment of renal function. However, MAG 3 is superior in the assessment of renal function in damaged kidneys (as it is subjected to tubular secretion). ``` DMSA scan Dimercaptosuccinic acid (DMSA) scintigraphy DMSA localises to the renal cortex with little accumulation in the renal papilla and medulla. It is useful for the identification of cortical defects and ectopic or aberrant kidneys. It does not provide useful information on the ureter of collecting system. ``` Diethylene-triamine-penta-acetic acid (DTPA) This is primarily a glomerular filtration agent. It is most useful for the assessment of renal function. Because it is filtered at the level of the glomerulus it provides useful information about the GFR. Image quality may be degraded in patients with chronic renal impairment and derangement of GFR. MAG 3 renogram Mercaptoacetyle triglycine is an is extensively protein bound and is primarily secreted by tubular cells rather than filtered at the glomerulus. This makes it the agent of choice for imaging the kidneys of patients with existing renal impairment (where GFR is impaired). ``` Micturating cystourethrogram (MCUG scan) This scan provides information relating to bladder reflux and is obtained by filling the bladder with contrast media (via a catheter) and asking the child to void. Images are taken during this phase and the degree of reflux can be calculated ``` Intra venous urography This examination is conducted by the administration of intravenous iodinated contrast media. The agent is filtered by the kidneys and excreted and may provide evidence of renal stones or other structural lesions. A rough approximation of renal function may be obtained using the technique. But it is not primarily a technique to be used for this purpose. With the advent of widespread non contrast CT scan protocols for the detection of urinary tract calculi it is now rarely used. PET/CT This may be used to evaluate structurally indeterminate lesions in the staging of malignancy.

Answer 76

``` Tuberous sclerosis Tuberous sclerosis (TS) is a genetic condition of autosomal dominant inheritance. Like neurofibromatosis, the majority of features seen in TS are neuro-cutaneous ``` Cutaneous features depigmented 'ash-leaf' spots which fluoresce under UV light roughened patches of skin over lumbar spine (Shagreen patches) adenoma sebaceum: butterfly distribution over nose fibromata beneath nails (subungual fibromata) café-au-lait spots* may be seen Neurological features developmental delay epilepsy (infantile spasms or partial) intellectual impairment Also retinal hamartomas: dense white areas on retina (phakomata) rhabdomyomas of the heart gliomatous changes can occur in the brain lesions polycystic kidneys, renal angiomyolipomata *these of course are more commonly associated with neurofibromatosis. However a 1998 study of 106 children with TS found café-au-lait spots in 28% of patients

Answer 77

Suspected penile fractures should be surgically explored and the injury repaired. Penile fractures are a rare type of urological trauma that may be encountered. The injury is usually in the proximal part of the penile shaft and may involve the urethra. A classically history of a snapping sensation followed by immediate pain is usually given by the patient (usually during vigorous intercourse). On examination there is usually a tense haematoma and blood may be seen at the meatus if the urethra is injured. When there is a a strong suspicion of the diagnosis the correct management is surgical and a circumferential incision made immediately inferior to the glans. The skin and superficial tissues are stripped back and the penile shaft inspected. Injuries are usually sutured and the urethra repaired over a catheter.

Answer 78

Phosphaturia causes cloudy urine not red urine Causes of haematuria Trauma Injury to renal tract Renal trauma commonly due to blunt injury (others penetrating injuries) Ureter trauma rare: iatrogenic Bladder trauma: due to RTA or pelvic fractures Infection Remember TB Malignancy Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare bladder tumours Prostate cancer Penile cancers: SCC Renal disease Glomerulonephritis Stones Microscopic haematuria common Structural abnormalities Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland Cystic renal lesions e.g. polycystic kidney disease Vascular malformations Renal vein thrombosis due to renal cell carcinoma Coagulopathy Causes bleeding of underlying lesions Drugs Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy Interstitial nephritis: penicillin, sulphonamides, and NSAIDs Anticoagulants Benign Exercise Gynaecological Endometriosis: flank pain, dysuria, and haematuria that is cyclical Iatrogenic Catheterisation Radiotherapy; cystitis, severe haemorrhage, bladder necrosis Pseudohaematuria For example following consumption of beetroot

Answer 79

Cyclophosphamide is metabolised into a toxic metabolite acrolein. The effects may be attenuated by administration of large volumes of intravenous fluids and mesna (which neutralises the metabolite). The condition may be managed initially by bladder catheterisation and irrigation. Causes of haematuria Trauma Injury to renal tract Renal trauma commonly due to blunt injury (others penetrating injuries) Ureter trauma rare: iatrogenic Bladder trauma: due to RTA or pelvic fractures Infection Remember TB Malignancy Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare bladder tumours Prostate cancer Penile cancers: SCC Renal disease Glomerulonephritis Stones Microscopic haematuria common Structural abnormalities Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland Cystic renal lesions e.g. polycystic kidney disease Vascular malformations Renal vein thrombosis due to renal cell carcinoma Coagulopathy Causes bleeding of underlying lesions Drugs Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy Interstitial nephritis: penicillin, sulphonamides, and NSAIDs Anticoagulants Benign Exercise Gynaecological Endometriosis: flank pain, dysuria, and haematuria that is cyclical Iatrogenic Catheterisation Radiotherapy; cystitis, severe haemorrhage, bladder necrosis Pseudohaematuria For example following consumption of beetroot

Answer 80

In a Hartmans procedure the sigmoid colon is removed and an end colostomy is fashioned. The bowel remains in continuity and no absorptive ability is lost. An ileo-colic bypass leaves a redundant loop of small bowel in continuity, where the contents will stagnate and bacterial overgrowth will occur. Therefore this is recognised cause of malabsorption Malabsorption is characterised by diarrhoea, steatorrhoea and weight loss. Causes may be broadly divided into intestinal (e.g. villous atrophy), pancreatic (deficiency of pancreatic enzyme production or secretion) and biliary (deficiency of bile-salts needed for emulsification of fats) ``` Intestinal causes of malabsorption coeliac disease Crohn's disease tropical sprue Whipple's disease Giardiasis brush border enzyme deficiencies (e.g. lactase insufficiency) ``` Pancreatic causes of malabsorption chronic pancreatitis cystic fibrosis pancreatic cancer Biliary causes of malabsorption biliary obstruction primary biliary cirrhosis Other causes bacterial overgrowth (e.g. systemic sclerosis, diverticulae, blind loop) short bowel syndrome lymphoma

Answer 81

Sub total colectomy In patients with fulminant UC a sub total colectomy is the safest treatment option. The rectum will be left in situ as resection of the rectum in these acutely unwell patients carries an extremely high risk of complications. Surgery for inflammatory bowel disease Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract. Ulcerative colitis Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids. Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula. Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory. Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy. Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling. Crohns disease Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation and strictures. Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis). Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence. Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended. Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections. Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Answer 82

Proctectomy Severe rectal Crohns that has developed complications such as haemorrhage and multiple fistulae is usually best managed with proctectomy. Although a diverting stoma may reduce the risk of local sepsis it is unlikely to reduce the bleeding. She is keen to conserve a rectum, however, an ileoanal pouch in this setting is unwise. Surgery for inflammatory bowel disease Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract. Ulcerative colitis Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids. Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula. Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory. Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy. Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling. Crohns disease Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation and strictures. Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis). Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence. Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended. Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections. Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Answer 83

Panproctocolectomy and ileoanal pouch In patients with UC where medical management is not successful, surgical resection may offer a chance of cure. Those patients wishing to avoid a permanent stoma may be considered for an ileoanal pouch. However, this procedure is only offered in the elective setting. Surgery for inflammatory bowel disease Patients with inflammatory bowel disease (UC and Crohns) frequently present in surgical practice. Ulcerative colitis may be cured by surgical resection (Proctocolectomy), this is not the case in Crohns disease which may recur and affect other areas of the gastrointestinal tract. Ulcerative colitis Elective indications for surgery include disease that is requiring maximal therapy, or prolonged courses of steroids. Longstanding UC is associated with a risk of malignant transformation. Dysplastic transformation of the colonic epithelium with associated mass lesions is an absolute indication for a proctocolectomy. Emergency presentations of poorly controlled colitis that fails to respond to medical therapy should usually be managed with a sub total colectomy. Excision of the rectum is a procedure with a higher morbidity and is not generally performed in the emergency setting. An end ileostomy is usually created and the rectum either stapled off and left in situ, or, if the bowel is very oedematous, may be brought to the surface as a mucous fistula. Patients with IBD have a high incidence of DVT and appropriate thromboprophylaxis is mandatory. Restorative options in UC include an ileoanal pouch. This procedure can only be performed whilst the rectum is in situ and cannot usually be undertaken as a delayed procedure following proctectomy. Ileoanal pouch complications include, anastomotic dehiscence, pouchitis and poor physiological function with seepage and soiling. Crohns disease Surgical resection of Crohns disease does not equate with cure, but may produce substantial symptomatic improvement. Indications for surgery include complications such as fistulae, abscess formation and strictures. Extensive small bowel resections may result in short bowel syndrome and localised stricturoplasty may allow preservation of intestinal length. Staging of Crohns will usually involve colonoscopy and a small bowel study (e.g. MRI enteroclysis). Complex perianal fistulae are best managed with long term draining seton sutures, complex attempts at fistula closure e.g. advancement flaps, may be complicated by non healing and fistula recurrence. Severe perianal and / or rectal Crohns may require proctectomy. Ileoanal pouch reconstruction in Crohns carries a high risk of fistula formation and pouch failure and is not recommended. Terminal ileal Crohns remains the commonest disease site and these patients may be treated with limited ileocaecal resections. Terminal ileal Crohns may affect enterohepatic bile salt recycling and increase the risk of gallstones.

Answer 84

Pseudomyxoma peritonei Pseudomyxoma is classically associated with mucin production and the appendix is the commonest source. Pseudomyxoma peritoneii- Curative treatment is peritonectomy (Sugarbaker procedure) and heated intra peritoneal chemotherapy. Pseudomyxoma Peritonei Rare mucinous tumour Most commonly arising from the appendix (other abdominal viscera are also recognised as primary sites) Incidence of 1-2/1,000,000 per year The disease is characterised by the accumulation of large amounts of mucinous material in the abdominal cavity Treatment Is usually surgical and consists of cytoreductive surgery (and often peritonectomy c.f Sugarbaker procedure) combined with intra peritoneal chemotherapy with mitomycin C. Survival is related to the quality of primary treatment and in Sugarbakers own centre 5 year survival rates of 75% have been quoted. Patients with disseminated intraperitoneal malignancy from another source fare far worse. In selected patients a second look laparotomy is advocated and some practice this routinely.

Answer 85

Retroperitoneal fibrosis Retroperitoneal fibrosis is an uncommon condition and its aetiology is poorly understood. In a significant proportion the ureters are displaced medially. In most retroperitoneal malignancies they are displaced laterally. Hypertension is another common finding. A CT scan will often show a para-aortic mass

Answer 86

Metastatic adenocarcinoma of the pancreas Although not specific CA 19-9 in the context of this history is highly suggestive of pancreatic cancer over the other scenarios.

Answer 87

The Hurthle cell subtype have a worse prognosis. Thyroid malignancy Papillary carcinoma Commonest sub-type Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma Follicular carcinoma Are less common than papillary lesions Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy Anaplastic carcinoma Less common and tend to occur in elderly females Disease is usually advanced at presentation and often only palliative decompression and radiotherapy can be offered. Medullary carcinoma These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin. The serum calcitonin may be elevated which is of use when monitoring for recurrence. They may be familial and occur as part of the MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived primarily from thyroid cells they are not responsive to radioiodine. Lymphoma These respond well to radiotherapy Radical surgery is unnecessary once the disease has been diagnosed on biopsy material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Answer 88

Hyperacute graft rejection is due to pre-existent antibodies to HLA antigens and is therefore IgG mediated Renal transplant:HLA typing and graft failure The human leucocyte antigen (HLA) system is the name given to the major histocompatibility complex (MHC) in humans. It is coded for on chromosome 6. Some basic points on the HLA system Class 1 antigens include A, B and C. Class 2 antigens include DP,DQ and DR When HLA matching for a renal transplant the relative importance of the HLA antigens are as follows DR > B > A Graft survival 1 year = 90%, 10 years = 60% for cadaveric transplants 1 year = 95%, 10 years = 70% for living-donor transplants ``` Post-op problems ATN of graft Vascular thrombosis Urine leakage UTI ``` Hyperacute acute rejection Due to antibodies against donor HLA type 1 antigens Rarely seen due to HLA matching Acute graft failure (< 6 months) Usually due to mismatched HLA Other causes include cytomegalovirus infection Management: give steroids, if resistant use monoclonal antibodies Causes of chronic graft failure (> 6 months) Chronic allograft nephropathy Ureteric obstruction Recurrence of original renal disease (MCGN > IgA > FSGS)

Answer 89

A McKeown procedure is a total oesophagectomy Bariatric surgery Obesity is a major health problem in the Western world. Surgical solutions to the problem have evolved dramatically over the past few years. Randomised controlled trials have shown that dramatic weight loss can be achieved following surgical interventions compared with standard medical therapy. The weight loss process is also more durable following surgery than with non surgical interventions. Case selection BMI >/= 40 kg/m2 or between 35-40 kg/m2 and other significant disease (for example, type 2 diabetes, hypertension) that could be improved with weight loss. Pre-requisites to surgery (NICE UK Guidelines) All non-surgical measures have failed to achieve or maintain adequate clinically beneficial weight loss for at least 6 months. Will receive intensive specialist management They are generally fit for anaesthesia and surgery They commit to the need for long-term follow-up First-line option for adults with a BMI > 40 kg/m2 in whom surgical intervention is considered appropriate; consider orlistat if there is a long waiting list. Surgical options Adjustable gastric band Laparoscopic placement of adjustable band around proximal stomach. Contains an adjustable filling port Effective method for lifestyle control Reversible Takes longer to achieve target weight Complications such as band erosion (rare), slippage or loss of efficacy may require re-intervention Gastric bypass Combines changes to reservoir size with malabsorptive procedure for more enduring weight loss. Technically more challenging Risks related to anastomoses (2% leak rate) Irreversible Up to 50% may become B12 deficient Sleeve gastrectomy Resection of stomach using stapling devices Less popular now as initial promising results not sustained

Answer 90

Thyrotoxicosis The diagnosis is thyrotoxicosis. An elevated T4 and a low TSH should indicate this diagnosis. Remember atrial fibrillation and its complications i.e acute ischaemic limbs can be precipitated by hyperthyroid disorders.

Answer 91

Hashimotos thyroiditis Hashimotos usually presents in women aged between 30- 50 years. They are normally associated with a goitre. To differentiate from hypothyroidism, the antithyroid peroxidase antibodies will be elevated.

Answer 92

Sick euthyroid syndrome Sick euthyroid syndrome is most commonly seen in chronically ill patients or those with starvation. The thyroid function tests are often low and the patient clinically euthyroid.

Answer 93

A patients should have their Rockall score calculated following endoscopy for upper GI haemorrhage ``` Mnemonic for Rockall score ABCDE A: Age B: Blood pressure drop (Shock) C: Co-morbidity D: Diagnosis E: Evidence of bleeding ``` Rockall Score Applies to upper gastrointestinal bleeding Score <3 = Good prognosis (mortality approx. 2%) Score >8= High mortality (Mortality approx. 40%) ``` Upper gastrointestinal bleeding Patients may present with the following: Haematemesis and/ or malaena Epigastric discomfort Sudden collapse ``` The extent to which these will occur will depend upon the source. Mortality is higher in patients presenting with haematemesis than malaena alone. Oesophageal bleeding Oesophagitis Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms. Cancer Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed. Mallory Weiss Tear Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously. Varices Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed. Gastric Bleeding Gastric cancer May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage. Dieulafoy Lesion Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically. Diffuse erosive gastritis Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise. Gastric ulcer Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis. Duodenum Most common cause of major haemorrhage is a posteriorly sited duodenal ulcer. However, ulcers at any site in the duodenum may present with haematemesis, malaena and epigastric discomfort. The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Peri ampullary tumours may bleed but these are rare. In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality. Management Admission to hospital careful monitoring, cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum) Patients with on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood Early control of airway is vital (e.g. Drowsy patient with liver failure) Patients with suspected varices should receive terlipressin prior to endoscopy Ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it. The endoscopy department is a potentially dangerous place for unstable patients and it may be safer to perform the endoscopy in theatre with an anaesthetist present. Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengaksten- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS. Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor. Mallory Weiss tears will typically resolve spontaneously Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate. Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy Bleeding ulcers that cannot be controlled endoscopically may require laparotomy and ulcer underruning Indications for surgery Patients > 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension Surgery Duodenal ulcer Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis. ``` For gastric ulcer Under-running of the bleeding site Partial gastrectomy-antral ulcer Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery) Total gastrectomy if bleeding persists ``` Summary of Acute Upper GI bleeding recommendations: The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy. The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata of recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention. Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.

Answer 94

Necrosis Construction of a stoma may be complicated by several factors. Necrosis may occur because of technical errors in mesenteric division, excessive tension or failure to construct a fascial defect of adequate size to permit safe passage of the mesentery and the bowel. Ileostomy Ileostomies are generally fashioned in the right iliac fossa in a triangle between the anterior superior iliac spine, symphysis pubis and umbilicus. They should lie one-third of the distance between the umbilicus and anterior superior iliac spine. A 2cm skin incision is made and dissection continued through the rectus muscle. A cruciate incision should be made, and generally dilated to admit two fingers. The ileum is brought through the incisions and should generally be spouted to a final length of 2.5cm. Ileostomies that are too short may cause problems with appliance fixation and those which are too long may cause problems with tension and subsequent ulceration or prolapse. Complications following ileostomy construction include dermatitis (most common), bowel obstruction (usually adhesional) and prolapse. Ileostomy output is roughly in the range of 5-10ml/Kg/ 24 hours. Output in excess of 20ml/Kg/24 hours usually requires supplementary intravenous fluids. Excessive fluid losses are generally managed by administration of oral loperamide (up to 4mg QDS) to try and slow the output. Foods containing gelatine may also thicken output. Early high output is not uncommon and most patients (50%) will respond to conservative management.

Answer 95

Image guided fine needle aspiration of the axillary nodes Where axillary nodal involvement is suspected from the outset it is important to establish whether this is the case prior to surgery. This is because, if axillary metastatic disease is present then the correct management would be an axillary node clearance and this is irrespective of the surgical plans for the breast primary. In the case of breast cancer, image guided FNAC is acceptable as it is accurate and if carcinoma cells are identified at FNA then axillary node clearance can be performed. If FNAC is negative then a sentinel node biopsy should accompany excision of the primary tumour. Where the axilla is clinically clear on palpation and imaging then a sentinel lymph node biopsy should accompany excision of the primary tumour. Management of the axilla- breast cancer Lymph node stage Accurate staging of the axilla is an essential component of breast cancer management. Involvement of the axillary nodes has an adverse effect on prognosis with 10 year survival reduced from 75% to 25%[1]. Involvement of level 3 nodes carries the worst prognosis[2]. Historically, management of the axilla ranged from limited level 1 axillary node excision through to full level 3 axillary nodal clearances. Attempts to mimimise the morbidity of axillary node clearance led to targeted operations including axillary nodal sampling and sentinel lymph node biopsy. The focus on sentinel lymph node biopsy has led to more detailed pathological analysis of excised lymph nodes (e.g. using immunohistochemistry). This has led to increasing focus on the develop of axillary nodal micrometastasis. The presence of micrometastasis and its impact on survival is debated. In some studies it seems to confer an increased risk of locoregional recurrence [3] and a reduction of disease free survival [4], whilst in others it shows no overall impact[5]. It is important to distinguish between micrometastasis and isolated tumour cells, as the latter do not have an adverse impact on prognosis[6]. The need for definitive treatment of the axilla in women with positive sentinel nodes was addressed by the ASCOG Z0011trial. In this trial women were randomised to either undergo axillary node clearance or observation, groups were adjusted for other prognostic factors and treatments. The investigators found no survival benefit in routinely undertaking axillary node clearance where axillary nodal disease was limited in its extent. Regardless of the options in women with a low risk axilla, those individuals who have overt evidence of axillary nodal involvement either through positive SLNB or preoperative USS and FNA, should still receive axillary clearance as a standard of care.

Answer 96

Upper GI contrast study Bilious vomiting in neonates is a surgical emergency and is intestinal malrotation and volvulus until otherwise proven. It is investigated with an upper GI contrast study. Contrast should be seen to exit the stomach and the location of the DJ flexure is noted (it lies to the left of the midline). If this is not the case, or the study is inconclusive, a laparotomy is performed. ``` Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management ``` Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 97

Roux-en-Y portojejunostomy This child has biliary atresia. The aim is to avoid liver transplantation (however, most will come to transplant in time). Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) ``` Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management ``` Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 98

Rectal biopsy Delayed passage of meconium is suggestive of Hirschsprung's disease and the investigation of choice is full thickness suction rectal biopsy. If Hirschprungs is confirmed, then the correct treatment is laparotomy and stoma formation. At between 9 and 12 months of age, definitive surgery (usually resection and primary anastomosis) is performed. ``` Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management ``` Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 99

Carcinoma of the oesophagus A short history of progressive dysphagia in a middle aged man who has a background history of reflux is strongly suggestive of malignancy. Long standing reflux symptoms may be suggestive of a increased risk of developing Barretts oesophagus. Note that not all patients with Barretts transformation alone are symptomatic. Dysphagia Causes of dysphagia ``` Extrinsic Mediastinal masses Cervical spondylosis Oesophageal wall Achalasia Diffuse oesophageal spasm Hypertensive lower oesophageal sphincter ``` ``` Intrinsic Tumours Strictures Oesophageal web Schatzki rings ``` Neurological CVA Parkinson's disease Multiple Sclerosis Brainstem pathology Myasthenia Gravis Investigation All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.

Answer 100

Achalasia Patients with dysphagia will usually undergo an upper GI endoscopy as a first line investigation. Where this investigation is normal, the next stage is to perform studies assessing oesophageal motility. These comprise fluroscopic barium swallows and oesophageal manometry and pH studies. Lack of sphincter relaxation suggests achalasia (pressures are usually high). Dysphagia Causes of dysphagia ``` Extrinsic Mediastinal masses Cervical spondylosis Oesophageal wall Achalasia Diffuse oesophageal spasm Hypertensive lower oesophageal sphincter ``` ``` Intrinsic Tumours Strictures Oesophageal web Schatzki rings ``` Neurological CVA Parkinson's disease Multiple Sclerosis Brainstem pathology Myasthenia Gravis Investigation All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.

Answer 101

Benign oesophageal stricture Children with tracheo-oesophageal fistulas will commonly develop oesophageal strictures following repair. These may require regular dilations throughout childhood. Dysphagia Causes of dysphagia ``` Extrinsic Mediastinal masses Cervical spondylosis Oesophageal wall Achalasia Diffuse oesophageal spasm Hypertensive lower oesophageal sphincter ``` ``` Intrinsic Tumours Strictures Oesophageal web Schatzki rings ``` Neurological CVA Parkinson's disease Multiple Sclerosis Brainstem pathology Myasthenia Gravis Investigation All patients require an upper GI endoscopy unless there are compelling reasons for this not to be performed. Motility disorders may be best appreciated by undertaking fluoroscopic swallowing studies. A full blood count should be performed. Ambulatory oesophageal pH and manometry studies will be required to evaluate conditions such as achalasia and patients with GORD being considered for fundoplication surgery.

Answer 102

Fibroadenoma Fibroadenomas account for 60% of discrete breast lesions in the 18-25 year age group. They are mobile lesions. Core biopsy should be performed in lesions measuring more than 4cm in diameter. Fibroadenoma Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group, fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome. Breast cysts Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a "halo appearance" on mammography. Ultrasound will confirm the fluid filled nature of the cyst. Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone. Duct ectasia As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.

Answer 103

Duct ectasia Duct ectasia is a common alteration in the breast that occurs with aging. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of cheese like discharge may occur. Fibroadenoma Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group, fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome. Breast cysts Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a "halo appearance" on mammography. Ultrasound will confirm the fluid filled nature of the cyst. Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone. Duct ectasia As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.

Answer 104

Breast cyst Lesions such as breast cysts compress the underlying fat and produce a radiolucent area (halo sign). If symptomatic, these cysts should be aspirated. Fibroadenoma Under the age of 25 years the breast is usually classified as undergoing development. Lobular units are being formed and a dense stroma is formed within the breast tissue. This may result in the development of fibroadenomas. As a group, fibroadenomas account for 13% of all palpable breast lesions. However, in women aged 18-25 they constitute up to 60% of all palpable breast lesions. The are classified as juvenile, common and giant. The former occur in early adolescence and the latter are characterised by a size greater than 4cm. In young females with small fibroadenomas (less than 3cm on imaging) a policy of watchful waiting without biopsy may be adopted. A size of greater than 4cm attracts a recommendation for core biopsy to exclude a phyllodes tumour. The natural history of fibroadenomas is that 10% will increase in size, 30% regress and the remainder stay the same. This does not apply during pregnancy and lactation when they may increase in size substantially and subsequently sequester milk. Some women may wish to have their fibroadenomas excised, they can usually be shelled out through a circumareolar incision. Smaller lesions may be removed using a mammotome. Breast cysts Palpable cysts constitute 15% of all breast lumps. They occur most frequently in perimenopausal females and are caused by distended and involuted lobules. They may be readily apparent on clinical examination as soft, fluctuant swellings. It is important to exclude the presence of an underlying mass lesion. On imaging they will usually show a "halo appearance" on mammography. Ultrasound will confirm the fluid filled nature of the cyst. Symptomatic cysts may be aspirated and following aspiration the breast re-examined to ensure that the lump has gone. Duct ectasia As women progress through the menopause the breast ducts shorten and dilate. In some women this may cause a cheese like nipple discharge and slit like retraction of the nipple. No specific treatment is required.

Answer 105

Obstructed incisional hernia In this scenario the most likely diagnosis would be obstructed incisional hernia. The tender swelling coupled with symptoms of obstruction point to this diagnosis. Prompt surgical exploration is warranted. Loop colostomy reversals are at high risk of this complication as the operative site is at increased risk of the development of post operative wound infections. Acute incisional hernia Any surgical procedure involving entry into a cavity containing viscera may be complicated by post operative hernia The abdomen is the commonest site The deep layer of the wound has usually broken down, allowing internal viscera to protrude through Management is dictated by the patients clinical status and the timing of the hernia in relation to recent surgery Bowel obstruction or tenderness at the hernia site both mandate early surgical intervention to reduce the risk of bowel necrosis Mature incisional hernias with a wide neck, and no symptoms, may be either left or listed for elective repair Risk factors for the development of post operative incisional hernias include; post operative wound infections, long term steroid use, obesity and chronic cough

Answer 106

Nodal status is the single most important prognostic factor in breast cancer. Nodal status is important because it serves as a marker of tumour metastatic potential. This translates to survival advantages of up to 40% at five years. Both grade and size are of secondary importance as they both less concerning in the absence of nodal involvement. Breast cancer Commoner in the older age group Invasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS). There are associated carcinomas of special type e.g. Tubular that may carry better prognosis. The pathological assessment involves assessment of the tumour and lymph nodes, sentinel lymph node biopsy is often used to minimise the morbidity of an axillary dissection. Treatment, typically this is either wide local excision or mastectomy. There are many sub types of both of these that fall outside of the MRCS. Some key rules to bear in mind. Whatever operation is contemplated the final cosmetic outcome does have a bearing. A woman with small breasts and a large tumour will tend to fare better with mastectomy, even if clear pathological and clinical margins can be obtained. Conversely a women with larger breasts may be able to undergo breast conserving surgery even with a relatively large primary lesion (NB tumours >4cm used to attract recommendation for mastectomy). For screen detected and impalpable tumour image guidance will be necessary. Reconstruction is always an option following any resectional procedure. However, its exact type must be tailored to age and co-morbidities of the patient. The main operations in common use include latissimus dorsi myocutaneous flap and sub pectoral implants. Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps. Surgical options Mastectomy vs Wide local excision Mastectomy: Multifocal tumour, Central tumour, Large lesion in small breast, DCIS >4cm Wide Local Excision: Solitary lesion, Peripheral tumour, Small lesion in large breast, DCIS <4cm Central lesions may be managed using breast conserving surgery where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast conserving surgery Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years . Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below). Score Lymph nodes involved Grade 1 0 1 2 1-3 2 3 >3 3 Prognosis ``` Score Percentage 5 year survival 2.0 to 2.4 93% 2.5 to 3.4 85% 3.5 to 5.4 70% >5.4 50% ```

Answer 107

Loop ileostomy Colonic resections with an anastomosis below the peritoneal reflection may have an anastomotic leak rate (both clinical and radiological) of up to 15%. Therefore most surgeons will defunction such an anastomosis to reduce the clinical severity of an anastomotic leak. A loop ileostomy will achieve this end point and is relatively easy to reverse. Types of stomas Gastrostomy Gastric decompression or fixation Feeding Epigastrium Loop jejunostomy Seldom used as very high output May be used following emergency laparotomy with planned early closure Any location according to need Percutaneous jejunostomy Usually performed for feeding purposes and site in the proximal bowel Usually left upper quadrant Loop ileostomy Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon (if ileocaecal valve competent) Usually right iliac fossa End ilestomy Usually following complete excision of colon or where ileo-colic anastomosis is not planned May be used to defunction colon, but reversal is more difficult Usually right iliac fossa End colostomy Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable Either left or right iliac fossa Loop colostomy To defunction a distal segment of colon Since both lumens are present the distal lumen acts as a vent May be located in any region of the abdomen, depending upon colonic segment used Caecostomy Stoma of last resort where loop colostomy is not possible Right iliac fossa Mucous fistula To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable May be located in any region of the abdomen according to clinical need

Answer 108

End ileostomy Following a sub total colectomy the immediate surgical options include an end ileostomy or ileorectal anastomosis. In the emergency setting an ileorectal anastomosis would be unsafe. Types of stomas Gastrostomy Gastric decompression or fixation Feeding Epigastrium Loop jejunostomy Seldom used as very high output May be used following emergency laparotomy with planned early closure Any location according to need Percutaneous jejunostomy Usually performed for feeding purposes and site in the proximal bowel Usually left upper quadrant Loop ileostomy Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon (if ileocaecal valve competent) Usually right iliac fossa End ilestomy Usually following complete excision of colon or where ileo-colic anastomosis is not planned May be used to defunction colon, but reversal is more difficult Usually right iliac fossa End colostomy Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable Either left or right iliac fossa Loop colostomy To defunction a distal segment of colon Since both lumens are present the distal lumen acts as a vent May be located in any region of the abdomen, depending upon colonic segment used Caecostomy Stoma of last resort where loop colostomy is not possible Right iliac fossa Mucous fistula To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable May be located in any region of the abdomen according to clinical need

Answer 109

Loop colostomy Large bowel obstruction resulting from carcinoma should be resected, stented or defunctioned. The first two options typically apply to tumours above the peritoneal reflection. Lower tumours should be defunctioned with a loop colostomy and then formal staging undertaken prior to definitive surgery. An emergency attempted rectal resection carries a high risk of involvement of the circumferential resection margin and is not recommended. Abdominal stomas Stomas may be sited during a range of abdominal procedures and involve bringing the lumen or visceral contents onto the skin. In most cases this applies to the bowel. However, other organs or their contents may be diverted in case of need. With bowel stomas the type method of construction and to a lesser extent the site will be determined by the contents of the bowel. In practice, small bowel stomas should be spouted so that their irritant contents are not in contact with the skin. Colonic stomas do not need to be spouted as their contents are less irritant. In the ideal situation the site of the stoma should be marked with the patient prior to surgery. Stoma siting is important as it will ultimately influence the ability of the patient to manage their stoma and also reduce the risk of leakage. Leakage of stoma contents and subsequent maceration of the surrounding skin can rapidly progress into a spiraling loss of control of stoma contents. Types of stomas Gastrostomy Gastric decompression or fixation Feeding Epigastrium Loop jejunostomy Seldom used as very high output May be used following emergency laparotomy with planned early closure Any location according to need Percutaneous jejunostomy Usually performed for feeding purposes and site in the proximal bowel Usually left upper quadrant Loop ileostomy Defunctioning of colon e.g. following rectal cancer surgery Does not decompress colon (if ileocaecal valve competent) Usually right iliac fossa End ilestomy Usually following complete excision of colon or where ileo-colic anastomosis is not planned May be used to defunction colon, but reversal is more difficult Usually right iliac fossa End colostomy Where a colon is diverted or resected and anastomosis is not primarily achievable or desirable Either left or right iliac fossa Loop colostomy To defunction a distal segment of colon Since both lumens are present the distal lumen acts as a vent May be located in any region of the abdomen, depending upon colonic segment used Caecostomy Stoma of last resort where loop colostomy is not possible Right iliac fossa Mucous fistula To decompress a distal segment of bowel following colonic division or resection Where closure of a distal resection margin is not safe or achievable May be located in any region of the abdomen according to clinical need

Answer 110

Percutaneous nephrostomy An obstructed, infected system is an indication for urgent decompression. This may be achieved by ureteroscopy or nephrostomy. In addition to this the patient should also receive broad spectrum, intravenous antibiotics. Management of renal stones Urolithiasis will affect up to 15% of the worldwide population. The development of sudden onset loin to groin pain which is colicky in nature is a classic feature in the history. It is nearly always associated with haematuria that is either micro or macroscopic. Where the diagnosis is suspected the most sensitive and specific diagnostic test is helical, non contrast, computerised tomographic (CT) scanning. Management 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. Shock wave 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 - 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 111

Extra corporeal shock wave lithotripsy Stones with a total volume of less than 2cm can be considered for lithotripsy. If it is impacted in the upper ureter then some may consider a ureteroscopy. Management of renal stones Urolithiasis will affect up to 15% of the worldwide population. The development of sudden onset loin to groin pain which is colicky in nature is a classic feature in the history. It is nearly always associated with haematuria that is either micro or macroscopic. Where the diagnosis is suspected the most sensitive and specific diagnostic test is helical, non contrast, computerised tomographic (CT) scanning. Management 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. Shock wave 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 - 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 112

Percutaneous nephrolithotomy Large, proximal stones are generally best managed with a percutaneous nephrolithotomy. The use of lithotripsy has low clearance rates. Where stones remain after the initial procedure a repeat percutaneous nephrolithotomy is generally preferred over follow up lithotripsy. Management of renal stones Urolithiasis will affect up to 15% of the worldwide population. The development of sudden onset loin to groin pain which is colicky in nature is a classic feature in the history. It is nearly always associated with haematuria that is either micro or macroscopic. Where the diagnosis is suspected the most sensitive and specific diagnostic test is helical, non contrast, computerised tomographic (CT) scanning. Management 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. Shock wave 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 - 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 113

Choledochoduodenostomy A patient with long standing common bile duct stones is at risk of developing duct fibrosis and ductal disproportion. This can result in impaired biliary drainage. Not only may further stones be formed in the bile that is present, but because of the ductal disproportion the tendency will be for the stones to accumulate (rather than pass spontaneously, as would usually be the case post ERCP and sphincterotomy). A biliary bypass procedure is the standard method dealing with this and a choledochoduodenstomy is one procedure that can be used. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) A gallbladder may develop a thickened wall in chronic cholecystitis, microscopically Roikitansky-Aschoff Sinuses may be seen

Answer 114

Acute laparoscopic cholecystectomy This is an ideal case for an acute cholecystectomy, provided that surgery can be undertaken promptly. After 48 -72 hours the patient should receive parenteral antibiotics and delayed cholecystectomy performed. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) A gallbladder may develop a thickened wall in chronic cholecystitis, microscopically Roikitansky-Aschoff Sinuses may be seen

Answer 115

Elective cholecystectomy and intra operative cholangiogram The easiest option is to perform an intraoperative cholangiogram. It is unlikely to reveal any stones. If is does then either laparoscopic bile duct exploration or urgent ERCP can be performed. An MRCP pre op is an alternative strategy. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) A gallbladder may develop a thickened wall in chronic cholecystitis, microscopically Roikitansky-Aschoff Sinuses may be seen

Answer 116

Topical diltiazem Initial therapy should be with pharmacological agents to relax the sphincter and facilitate healing. This is particularly true in females presenting for the first time. Fissure in ano: Painful, bright red rectal bleeding Stool softeners, topical diltiazem or GTN, botulinum toxin, Sphincterotomy Haemorroids: Painless, bright red rectal bleeding occurs following defecation and bleeds onto the toilet paper and into the toilet pan Stool softeners, avoid straining, surgery (see below) Fistula in ano: May initially present with an abscess and then persisting discharge onto the perineum, separate from the anus Lay open if low, no sphincter involvement or IBD, if complex, high or IBD insert seton and consider other options (see below) Peri anal abscess: Peri anal swelling and surrounding erythema Incision and drainage, leave the cavity open to heal by secondary intention Pruritus ani: Peri anal itching, occasional mild bleeding (if severe skin damage) Avoid scented products, use wet wipes rather than tissue, avoidance of scratching, ensure no underlying faecal incontinence Overview of surgical therapies Haemorroidal disease The treatment of haemorroids is usually conservative. Acutely thrombosed haemorroids may be extremely painful. Treatment of this acute condition is usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases managed with this approach will settle over the next 5-7 days. After this period there may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may necessitate haemorroidectomy. Patients with more chronic symptoms are managed according to the stage of their disease, small mild internal haemorroids causing little symptoms are best managed conservatively. More marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal may benefit from stapled haemorroidopexy. This procedure excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but settles over 6-12 months) and recurrence. The procedure does not address skin tags and therefore this procedure is unsuitable if this is the dominant symptom. Large haemorroids with a substantial external component may be best managed with a Milligan Morgan style conventional haemorroidectomy. In this procedure three haemorroidal cushions are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may result in anal stenosis. The procedure is quite painful and most surgeons prescribe metronidazole post operatively as it decreases post operative pain. Fissure in ano Probably the most efficient and definitive treatment for fissure in ano is lateral internal sphincterotomy. The treatment is permanent and nearly all patients will recover. Up to 30% will develop incontinence to flatus. There are justifiable concerns about using this procedure in females as pregnancy and pelvic floor damage together with a sphincterotomy may result in faecal incontinence. The usual first line therapy is relaxation of the internal sphincter with either GTN or diltiazem (the latter being better tolerated) applied topically for 6 weeks. Treatment failures with topical therapy will usually go on to have treatment with botulinum toxin. This leads to more permanent changes in the sphincter and this may facilitate healing. Typical fissures usually present in the posterior midline, multiple or unusually located fissures should prompt a search for an underlying cause such as inflammatory bowel disease or internal prolapse. Refractory cases where the above treatments have failed may be considered for advancement flaps. Fistula in ano The most effective treatment for fistula is laying it open (fistulotomy). When the fistula is below the sphincter and uncomplicated, this is a reasonable option. Sphincter involvement and complex underlying disease should be assessed both surgically and ideally with imaging (either MRI or endoanal USS). Surgery is then usually staged, in the first instance a draining seton suture may be inserted. This avoids the development of recurrent sepsis and may allow resolution. In patients with Crohns disease the seton should be left in situ long term and the patient managed medically, as in these cases attempts at complex surgical repair nearly always fail. Fistulas not associated with IBD may be managed by advancement flaps, instillation of plugs and glue is generally unsuccessful. A newer technique of ligation of intersphincteric tract (LIFT procedure) is reported to have good results in selected centres.

Answer 117

Haemorroidectomy Prolapsed haemorroids are best managed surgically if symptomatic. Note that phenol injections are usually only used for minor internal haemorroids. Where used low concentration phenol in oil is used, the phenolic solution above is used to ablate the nail bed in toe nail surgery! Fissure in ano: Painful, bright red rectal bleeding Stool softeners, topical diltiazem or GTN, botulinum toxin, Sphincterotomy Haemorroids: Painless, bright red rectal bleeding occurs following defecation and bleeds onto the toilet paper and into the toilet pan Stool softeners, avoid straining, surgery (see below) Fistula in ano: May initially present with an abscess and then persisting discharge onto the perineum, separate from the anus Lay open if low, no sphincter involvement or IBD, if complex, high or IBD insert seton and consider other options (see below) Peri anal abscess: Peri anal swelling and surrounding erythema Incision and drainage, leave the cavity open to heal by secondary intention Pruritus ani: Peri anal itching, occasional mild bleeding (if severe skin damage) Avoid scented products, use wet wipes rather than tissue, avoidance of scratching, ensure no underlying faecal incontinence Overview of surgical therapies Haemorroidal disease The treatment of haemorroids is usually conservative. Acutely thrombosed haemorroids may be extremely painful. Treatment of this acute condition is usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases managed with this approach will settle over the next 5-7 days. After this period there may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may necessitate haemorroidectomy. Patients with more chronic symptoms are managed according to the stage of their disease, small mild internal haemorroids causing little symptoms are best managed conservatively. More marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal may benefit from stapled haemorroidopexy. This procedure excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but settles over 6-12 months) and recurrence. The procedure does not address skin tags and therefore this procedure is unsuitable if this is the dominant symptom. Large haemorroids with a substantial external component may be best managed with a Milligan Morgan style conventional haemorroidectomy. In this procedure three haemorroidal cushions are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may result in anal stenosis. The procedure is quite painful and most surgeons prescribe metronidazole post operatively as it decreases post operative pain. Fissure in ano Probably the most efficient and definitive treatment for fissure in ano is lateral internal sphincterotomy. The treatment is permanent and nearly all patients will recover. Up to 30% will develop incontinence to flatus. There are justifiable concerns about using this procedure in females as pregnancy and pelvic floor damage together with a sphincterotomy may result in faecal incontinence. The usual first line therapy is relaxation of the internal sphincter with either GTN or diltiazem (the latter being better tolerated) applied topically for 6 weeks. Treatment failures with topical therapy will usually go on to have treatment with botulinum toxin. This leads to more permanent changes in the sphincter and this may facilitate healing. Typical fissures usually present in the posterior midline, multiple or unusually located fissures should prompt a search for an underlying cause such as inflammatory bowel disease or internal prolapse. Refractory cases where the above treatments have failed may be considered for advancement flaps. Fistula in ano The most effective treatment for fistula is laying it open (fistulotomy). When the fistula is below the sphincter and uncomplicated, this is a reasonable option. Sphincter involvement and complex underlying disease should be assessed both surgically and ideally with imaging (either MRI or endoanal USS). Surgery is then usually staged, in the first instance a draining seton suture may be inserted. This avoids the development of recurrent sepsis and may allow resolution. In patients with Crohns disease the seton should be left in situ long term and the patient managed medically, as in these cases attempts at complex surgical repair nearly always fail. Fistulas not associated with IBD may be managed by advancement flaps, instillation of plugs and glue is generally unsuccessful. A newer technique of ligation of intersphincteric tract (LIFT procedure) is reported to have good results in selected centres.

Answer 118

Incision and drainage Abscesses require incision and drainage as a first line treatment. Fissure in ano: Painful, bright red rectal bleeding Stool softeners, topical diltiazem or GTN, botulinum toxin, Sphincterotomy Haemorroids: Painless, bright red rectal bleeding occurs following defecation and bleeds onto the toilet paper and into the toilet pan Stool softeners, avoid straining, surgery (see below) Fistula in ano: May initially present with an abscess and then persisting discharge onto the perineum, separate from the anus Lay open if low, no sphincter involvement or IBD, if complex, high or IBD insert seton and consider other options (see below) Peri anal abscess: Peri anal swelling and surrounding erythema Incision and drainage, leave the cavity open to heal by secondary intention Pruritus ani: Peri anal itching, occasional mild bleeding (if severe skin damage) Avoid scented products, use wet wipes rather than tissue, avoidance of scratching, ensure no underlying faecal incontinence Overview of surgical therapies Haemorroidal disease The treatment of haemorroids is usually conservative. Acutely thrombosed haemorroids may be extremely painful. Treatment of this acute condition is usually conservative and consists of stool softeners, ice compressions and topical GTN or diltiazem to reduce sphincter spasm. Most cases managed with this approach will settle over the next 5-7 days. After this period there may be residual skin tags that merit surgical excision or indeed residual haemorroidal disease that may necessitate haemorroidectomy. Patients with more chronic symptoms are managed according to the stage of their disease, small mild internal haemorroids causing little symptoms are best managed conservatively. More marked symptoms of bleeding and occasional prolapse, where the haemorroidal complex is largely internal may benefit from stapled haemorroidopexy. This procedure excises rectal tissue above the dentate line and disrupts the haemorroidal blood supply. At the same time the excisional component of the procedure means that the haemorroids are less prone to prolapse. Adverse effects of this procedure include urgency, which can affect up to 40% of patients (but settles over 6-12 months) and recurrence. The procedure does not address skin tags and therefore this procedure is unsuitable if this is the dominant symptom. Large haemorroids with a substantial external component may be best managed with a Milligan Morgan style conventional haemorroidectomy. In this procedure three haemorroidal cushions are excised, together with their vascular pedicle. Excision of excessive volumes of tissue may result in anal stenosis. The procedure is quite painful and most surgeons prescribe metronidazole post operatively as it decreases post operative pain. Fissure in ano Probably the most efficient and definitive treatment for fissure in ano is lateral internal sphincterotomy. The treatment is permanent and nearly all patients will recover. Up to 30% will develop incontinence to flatus. There are justifiable concerns about using this procedure in females as pregnancy and pelvic floor damage together with a sphincterotomy may result in faecal incontinence. The usual first line therapy is relaxation of the internal sphincter with either GTN or diltiazem (the latter being better tolerated) applied topically for 6 weeks. Treatment failures with topical therapy will usually go on to have treatment with botulinum toxin. This leads to more permanent changes in the sphincter and this may facilitate healing. Typical fissures usually present in the posterior midline, multiple or unusually located fissures should prompt a search for an underlying cause such as inflammatory bowel disease or internal prolapse. Refractory cases where the above treatments have failed may be considered for advancement flaps. Fistula in ano The most effective treatment for fistula is laying it open (fistulotomy). When the fistula is below the sphincter and uncomplicated, this is a reasonable option. Sphincter involvement and complex underlying disease should be assessed both surgically and ideally with imaging (either MRI or endoanal USS). Surgery is then usually staged, in the first instance a draining seton suture may be inserted. This avoids the development of recurrent sepsis and may allow resolution. In patients with Crohns disease the seton should be left in situ long term and the patient managed medically, as in these cases attempts at complex surgical repair nearly always fail. Fistulas not associated with IBD may be managed by advancement flaps, instillation of plugs and glue is generally unsuccessful. A newer technique of ligation of intersphincteric tract (LIFT procedure) is reported to have good results in selected centres.

Answer 119

Image guided core biopsy All discrete breast lumps, including those that seem benign, should have a confirmed histological diagnosis. In this case, a core biopsy has not yet been performed. This may yield a diagnosis that is concordant with imaging findings. In which case, this concludes the investigative process (if benign). If it remains unclear, excision biopsy will be needed. Fibroadenoma Develop from a whole lobule Mobile, firm breast lumps 12% of all breast masses Over a 2 year period up to 30% will get smaller No increase in risk of malignancy If >3cm surgical excision is usual, Phyllodes tumours should be widely excised (mastectomy if the lesion is large) Breast cyst 7% of all Western females will present with a breast cyst Usually presents as a smooth discrete lump (may be fluctuant) Small increased risk of breast cancer (especially if younger) Cysts should be aspirated, those which are blood stained or persistently refill should be biopsied or excised Sclerosing adenosis, (radial scars and complex sclerosing lesions) Usually presents as a breast lump or breast pain Causes mammographic changes which may mimic carcinoma Cause distortion of the distal lobular unit, without hyperplasia (complex lesions will show hyperplasia) Considered a disorder of involution, no increase in malignancy risk Lesions should be biopsied, excision is not mandatory Epithelial hyperplasia Variable clinical presentation ranging from generalised lumpiness through to discrete lump Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present Atypical features and family history of breast cancer confers greatly increased risk of malignancy If no atypical features then conservative, those with atypical features require either close monitoring or surgical resection Fat necrosis Up to 40% cases usually have a traumatic aetiology Physical features usually mimic carcinoma Mass may increase in size initially Imaging and core biopsy ``` Duct papilloma Usually present with nipple discharge Large papillomas may present with a mass The discharge usually originates from a single duct No increase risk of malignancy Microdochectomy ```

Answer 120

Snare polypectomy Polyps on long stalks are best managed by snare excision. It is important to retrieve the polyp for histology. Colonic Polyps May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP greater than 100 polyps are typically present. The risk of malignancy in association with adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may produce mucous and if very large, electrolyte disturbances may occur. Follow up of colonic polyps - Low risk 1 or 2 adenomas less than 1cm No follow up or re-colonoscopy at 5 years - Moderate risk 3 or 4 small adenomas or 1 adenoma greater than 1cm Re-scope at 3 years - High risk More than 5 small adenomas or more than 3 with 1 of them greater than 1cm Re scope at 1 year Segmental resection or complete colectomy should be considered when: 1. Incomplete excision of malignant polyp 2. Malignant sessile polyp 3. Malignant pedunculated polyp with submucosal invasion 4. Polyps with poorly differentiated carcinoma 5. Familial polyposis coli - Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy - Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy. Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Answer 121

Repeat endoscopy at 1 year She is at high risk of malignancy and should be closely followed up. Fulguration of polyps without histology is unhelpful. Colonic Polyps May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP greater than 100 polyps are typically present. The risk of malignancy in association with adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may produce mucous and if very large, electrolyte disturbances may occur. Follow up of colonic polyps - Low risk 1 or 2 adenomas less than 1cm No follow up or re-colonoscopy at 5 years - Moderate risk 3 or 4 small adenomas or 1 adenoma greater than 1cm Re-scope at 3 years - High risk More than 5 small adenomas or more than 3 with 1 of them greater than 1cm Re scope at 1 year Segmental resection or complete colectomy should be considered when: 1. Incomplete excision of malignant polyp 2. Malignant sessile polyp 3. Malignant pedunculated polyp with submucosal invasion 4. Polyps with poorly differentiated carcinoma 5. Familial polyposis coli - Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy - Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy. Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Answer 122

Segmental colonic resection Management of right sided colonic polyps such as this is controversial. There is a high liklihood that this lesion will harbor an focus on invasive malignancy (which should generally be managed with resection). This is further suggested by the background history of anaemia. It is for this reason that resection over right sided colonic endoscopic mucosal resection is chosen. Polypectomy of flat broad lesions in the right colon is difficult and where concern arises a right hemicolectomy is probably the safest option. Colonic Polyps May occur in isolation, or greater numbers as part of the polyposis syndromes. In FAP greater than 100 polyps are typically present. The risk of malignancy in association with adenomas is related to size, and is the order of 10% in a 1cm adenoma. Isolated adenomas seldom give risk of symptoms (unless large and distal). Distally sited villous lesions may produce mucous and if very large, electrolyte disturbances may occur. Follow up of colonic polyps - Low risk 1 or 2 adenomas less than 1cm No follow up or re-colonoscopy at 5 years - Moderate risk 3 or 4 small adenomas or 1 adenoma greater than 1cm Re-scope at 3 years - High risk More than 5 small adenomas or more than 3 with 1 of them greater than 1cm Re scope at 1 year Segmental resection or complete colectomy should be considered when: 1. Incomplete excision of malignant polyp 2. Malignant sessile polyp 3. Malignant pedunculated polyp with submucosal invasion 4. Polyps with poorly differentiated carcinoma 5. Familial polyposis coli - Screening from teenager up to 40 years by 2 yearly sigmoidoscopy/colonoscopy - Panproctocolectomy and Ileostomy or Restorative Panproctocolectomy. Rectal polypoidal lesions may be amenable to trans anal endoscopic microsurgery.

Answer 123

Extended right hemicolectomy Carcinoma of the splenic flexure requires extended right hemicolectomy. Or a left hemicolectomy. The ileocolic anastomosis has a lower leak rate, particularly when the bowel is obstructed. 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. 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 resection. The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the MRCS 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 invovlement 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, 2 and 3 /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. 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. Summary of procedures The operations for cancer are segmental resections based on blood supply and lymphatic drainage. These commonly performed procedures are core knowledge for the MRCS and should be understood. Site of cancer // Type of resection // Anastomosis // Risk of leak - Right colon Right hemicolectomy Ileo-colic Low <5% - Transverse Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Left hemicolectomy Colo-colon 2-5% - Left colon Left hemicolectomy Colo-colon 2-5% - Sigmoid colon High anterior resection Colo-rectal 5% - Upper rectum Anterior resection (TME) Colo-rectal 5% - Low rectum Anterior resection (Low TME) Colo-rectal (+/- Defunctioning stoma) 10% - Anal verge Abdomino-perineal excision of colon and rectum None n/a 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.

Answer 124

Loop colostomy This patient should be defunctioned, definitive surgery should wait until staging is completed. A loop ileostomy will not satisfactorily decompress an acutely obstructed colon. Low rectal cancers that are obstructed should not usually be primarily resected. The obstructed colon that would be used for anastomosis would carry a high risk of anastomotic dehisence. In addition, as this is an emergency presentation, staging may not be completed, an attempted resection may therefore compromise the circumferential resection margin, with an associated risk of local recurrence. 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. 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 resection. The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the MRCS 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 invovlement 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, 2 and 3 /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. 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. Summary of procedures The operations for cancer are segmental resections based on blood supply and lymphatic drainage. These commonly performed procedures are core knowledge for the MRCS and should be understood. Site of cancer // Type of resection // Anastomosis // Risk of leak - Right colon Right hemicolectomy Ileo-colic Low <5% - Transverse Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Left hemicolectomy Colo-colon 2-5% - Left colon Left hemicolectomy Colo-colon 2-5% - Sigmoid colon High anterior resection Colo-rectal 5% - Upper rectum Anterior resection (TME) Colo-rectal 5% - Low rectum Anterior resection (Low TME) Colo-rectal (+/- Defunctioning stoma) 10% - Anal verge Abdomino-perineal excision of colon and rectum None n/a 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.

Answer 125

Anterior resection with covering loop ileostomy Low rectal cancer is usually treated with a low anterior resection. Contraindications to this include involvement of the sphincters (unlikely here) and poor sphincter function that would lead to unsatisfactory function post resection. Most colorectal surgeons defunction resections below the peritoneal reflection as they have an intrinsically high risk of anastomotic leak. A loop ileostomy provides a safe an satisfactory method of defunctioning these patients. A contrast enema should be performed prior to stoma reversal. 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. 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 resection. The technical aspects governing the choice between these two procedures can be complex to appreciate and the main point to appreciate for the MRCS 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 invovlement 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, 2 and 3 /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. 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. Summary of procedures The operations for cancer are segmental resections based on blood supply and lymphatic drainage. These commonly performed procedures are core knowledge for the MRCS and should be understood. Site of cancer // Type of resection // Anastomosis // Risk of leak - Right colon Right hemicolectomy Ileo-colic Low <5% - Transverse Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Extended right hemicolectomy Ileo-colic Low <5% - Splenic flexure Left hemicolectomy Colo-colon 2-5% - Left colon Left hemicolectomy Colo-colon 2-5% - Sigmoid colon High anterior resection Colo-rectal 5% - Upper rectum Anterior resection (TME) Colo-rectal 5% - Low rectum Anterior resection (Low TME) Colo-rectal (+/- Defunctioning stoma) 10% - Anal verge Abdomino-perineal excision of colon and rectum None n/a 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.

Answer 126

A pelvic fracture and highly displaced prostate should indicate a diagnosis of membranous urethral rupture. Lower genitourinary tract trauma Most bladder injuries occur due to blunt trauma 85% associated with pelvic fractures Easily overlooked during assessment in trauma Up to 10% of male pelvic fractures are associated with urethral or bladder injuries Types of injury ``` Urethral injury Mainly in males Blood at the meatus (50% cases) There are 2 types: i.Bulbar rupture - most common - straddle type injury e.g. bicycles - triad signs: urinary retention, perineal haematoma, blood at the meatus ii. Membranous rupture - can be extra or intraperitoneal - commonly due to pelvic fracture - Penile or perineal oedema/ hematoma - PR: prostate displaced upwards (beware co-existing retroperitoneal haematomas as they may make examination difficult) ``` - Investigation: ascending urethrogram - Management: suprapubic catheter (surgical placement, not percutaneously) External genitalia injuries (i.e., the penis and the scrotum) Secondary to injuries caused by penetration, blunt trauma, continence- or sexual pleasure-enhancing devices, and mutilation Bladder injury rupture is intra or extraperitoneal presents with haematuria or suprapubic pain history of pelvic fracture and inability to void: always suspect bladder or urethral injury inability to retrieve all fluid used to irrigate the bladder through a Foley catheter indicates bladder injury investigation- IVU or cystogram management: laparotomy if intraperitoneal, conservative if extraperitoneal

Answer 127

Thyroid lymphoma (Non Hodgkin's B cell lymphoma) is rare. It should be considered in patients with a background of Hashimoto's thyroiditis and a rapid growth in size of the thyroid gland. Diagnosis can be made with core needle biopsy; however an incisional biopsy may be needed. Radiotherapy is the main treatment option. Thyroiditis ``` Sub acute thyroiditis Subacute thyroiditis (also known as De Quervain's thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism ``` ``` Features Hyperthyroidism Painful goitre Raised ESR Globally reduced uptake on iodine-131 scan ``` Management Usually self-limiting - most patients do not require treatment Thyroid pain may respond to aspirin or other NSAIDs In more severe cases steroids are used, particularly if hypothyroidism develops Hashimotos thyroiditis Hashimotos thyroiditis is an immunological disorder in which lymphocytes become sensitised to thyroidal antigens. The three most important antibodies include; thyroglobulin, TPO and TSH-R. During the early phase of Hashimotos the the thyroglobulin antibody is markedly elevated and then declines. Features Goitre and either euthyroid or mild hypothyroidism Progressive hypothyroidism (and associated symptoms) Management During the hyperthyroid phase of illness beta blockers may manage symptoms As hypothyroidism develops patients may require thyroxine

Answer 128

Ligation of patent processus vaginalis via inguinal approach In children, a hydrocele is most commonly due to a persistent processus vaginalis. The swelling is intermittent and in most cases that are diagnosed in infancy the hydrocele resolves. Cases that persist beyond two years of age are best managed surgically and the surgical approach is usually made via the inguinal canal where the patent processus is identified and ligated. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 129

Testicular exploration within 6 hours Testicular torsion: Severe pain which can be spontaneous or precipitated by minor trauma. The patient may have noticed pain previously. Surgical intervention is needed as soon as possible to prevent the risk of loss of the testis. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 130

Jaboulay procedure via scrotal approach Adult hydroceles are less commonly due to the persistence of embryonic remnants and therefore can be managed via a scrotal approach. Both the Lords and Jaboulay procedures are reasonable options. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 131

Resection of the ipsilateral thyroid lobe Persist refilling cysts may be associated with a well differentiated tumour and should be removed by lobectomy. Large multinodular goitre Surgery for pressure symptoms. Total thyroidectomy is treatment of choice Toxic nodule Hemithyroidectomy Follicular lesion (THY 3f) Hemithyroidectomy to establish diagnosis Papillary thyroid cancer Total thyroidectomy and central compartment nodal dissection (extended lymphadenectomy as required) Follicular thyroid cancer Total thyroidectomy (usually completion as already had hemithyroidectomy) Anaplastic thyroid cancer Palliative radiotherapy Medullary thyroid cancer Total thyroidectomy (screen for other MEN tumours) Lymphoma of the thyroid Consider core biopsy Persistent refilling cysts Hemithyroidectomy Graves disease with significant eye signs Total thyroidectomy Graves disease without significant eye signs Patient choice radioiodine Vs surgery

Answer 132

Iatrogenic perforations of the oesophagus may be managed non operatively. This usually involves a nil by mouth regime, tube thoracostomy may be needed. Total parenteral nutrition is the safest option. Insertion of NG feeding tubes and PEG tubes may complicate the process or allow feed to enter the perforation site. Nutrition options in surgical patients Oral intake Easiest option May be supplemented by calorie rich dietary supplements May contra indicated following certain procedures Naso gastric feeding Usually administered via fine bore naso gastric feeding tube Complications relate to aspiration of feed or misplaced tube May be safe to use in patients with impaired swallow Often contra indicated following head injury due to risks associated with tube insertion Naso jejunal feeding Avoids problems of feed pooling in stomach (and risk of aspiration) Insertion of feeding tube more technically complicated (easiest if done intra operatively) Safe to use following oesophagogastric surgery Feeding jejunostomy Surgically sited feeding tube May be used for long term feeding Low risk of aspiration and thus safe for long term feeding following upper GI surgery Main risks are those of tube displacement and peritubal leakage immediately following insertion, which carries a risk of peritonitis Percutaneous endoscopic gastrostomy Combined endoscopic and percutaneous tube insertion May not be technically possible in those patients who cannot undergo successful endoscopy Risks include aspiration and leakage at the insertion site Total parenteral nutrition The definitive option in those patients in whom enteral feeding is contra indicated Individualised prescribing and monitoring needed Should be administered via a central vein as it is strongly phlebitic Long term use is associated with fatty liver and deranged LFT's

Answer 133

Pancreatoduodenectomy Localised carcinoma of the pancreas is treated with a pancreatoduodenectomy, the eponymous name for this is a Whipples procedure. Newer variants of the procedure include pylorus preservation. Adjuvent chemotherapy is often used. Pancreatic cancer Adenocarcinoma Risk factors: Smoking, diabetes, adenoma, familial adenomatous polyposis Mainly occur in the head of the pancreas (70%) Spread locally and metastasizes to the liver Carcinoma of the pancreas should be differentiated from other periampullary tumours with better prognosis Clinical features Weight loss Painless jaundice Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late feature) Pancreatitis Trousseau's sign: migratory superficial thrombophlebitis Investigations USS: May miss small lesions CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed PET/CT for those with operable disease on CT alone ERCP/ MRI for bile duct assessment Staging laparoscopy to exclude peritoneal disease Management Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques include pylorus preservation and SMA/ SMV resection Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable Usually adjuvent chemotherapy for resectable disease ERCP and stent for jaundice and palliation Surgical bypass may be needed for duodenal obstruction

Answer 134

Endoscopic biliary stent Jaundice associated with pancreatic cancer is best managed with a stent. These are usually inserted at the time of ERCP. Consideration here should be given to the use of a metallic stent (which is contra indicated where resection is contemplated). Pancreatic cancer Adenocarcinoma Risk factors: Smoking, diabetes, adenoma, familial adenomatous polyposis Mainly occur in the head of the pancreas (70%) Spread locally and metastasizes to the liver Carcinoma of the pancreas should be differentiated from other periampullary tumours with better prognosis Clinical features Weight loss Painless jaundice Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late feature) Pancreatitis Trousseau's sign: migratory superficial thrombophlebitis Investigations USS: May miss small lesions CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed PET/CT for those with operable disease on CT alone ERCP/ MRI for bile duct assessment Staging laparoscopy to exclude peritoneal disease Management Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques include pylorus preservation and SMA/ SMV resection Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable Usually adjuvent chemotherapy for resectable disease ERCP and stent for jaundice and palliation Surgical bypass may be needed for duodenal obstruction

Answer 135

Gastrojejunostomy Gastric outlet obstruction from pancreatic cancer is best managed with a surgical bypass procedure or a duodenal stent (if the disease is not resectable or curable). Pancreatic cancer Adenocarcinoma Risk factors: Smoking, diabetes, adenoma, familial adenomatous polyposis Mainly occur in the head of the pancreas (70%) Spread locally and metastasizes to the liver Carcinoma of the pancreas should be differentiated from other periampullary tumours with better prognosis Clinical features Weight loss Painless jaundice Epigastric discomfort (pain usually due to invasion of the coeliac plexus is a late feature) Pancreatitis Trousseau's sign: migratory superficial thrombophlebitis Investigations USS: May miss small lesions CT Scanning (pancreatic protocol). If unresectable on CT then no further staging needed PET/CT for those with operable disease on CT alone ERCP/ MRI for bile duct assessment Staging laparoscopy to exclude peritoneal disease Management Head of pancreas: Whipple's resection (SE dumping and ulcers). Newer techniques include pylorus preservation and SMA/ SMV resection Carcinoma body and tail: poor prognosis, distal pancreatectomy, if operable Usually adjuvent chemotherapy for resectable disease ERCP and stent for jaundice and palliation Surgical bypass may be needed for duodenal obstruction

Answer 136

Percutaneous transhepatic cholangiogram Cancer of the pancreatic head will cause obstructive jaundice and intrahepatic duct dilatation. When an ERCP has failed the most appropriate option is to attempt a PTC. This procedure is always preceded by an ultrasound (which presumably this patient has already had or they would not be undergoing an ERCP). Prior to performing the PTC it is important to stage the disease and establish resectability or not. This is because the PTC drains frequently dislodge and fall out. It is usually desirable to pass a stent at the time of doing the PTC to mitigate the effects of this problem. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 137

ERCP In this scenario it must be assumed that the bile duct has been damaged. In most cases an ERCP is the most appropriate investigation. This can also allow the passage of a stent if this is deemed to be safe and sensible. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 138

CT scan There are two main differential diagnoses here. One is pancreatitis, repeated trauma to the ampulla and duct (if partially cannulated) is a major risk factor for pancreatitis. The second is the possibility that the duodenum has been perforated. ERCP is performed using a side viewing endoscope, the manipulation of which can be technically challenging for the inexperienced operator in a patient with abnormal anatomy. A CT scan is the best investigation to distinguish between these two differential diagnoses. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 139

In young children, laparotomy is performed via transverse supra umbilical incision. Access via midline incisions is very poor and they should not be used. Midline incision Commonest approach to the abdomen Structures divided: linea alba, transversalis fascia, extraperitoneal fat, peritoneum (avoid falciform ligament above the umbilicus) Bladder can be accessed via an extraperitoneal approach through the space of Retzius Paramedian incision Parallel to the midline (about 3-4cm) Structures divided/retracted: anterior rectus sheath, rectus (retracted), posterior rectus sheath, transversalis fascia, extraperitoneal fat, peritoneum Incision is closed in layers Battle Similar location to paramedian but rectus displaced medially (and thus denervated) Now seldom used Kocher's Incision under right subcostal margin e.g. Cholecystectomy (open) Lanz Incision in right iliac fossa e.g. Appendicectomy Gridiron Oblique incision centered over McBurneys point- usually appendicectomy (less cosmetically acceptable than Lanz Gable Rooftop incision Pfannenstiel's Transverse supra pubic, primarily used to access pelvic organs McEvedy's Groin incision e.g. Emergency repair strangulated femoral hernia Rutherford Morrison Extraperitoneal approach to left or right lower quadrants. Gives excellent access to iliac vessels and is the approach of choice for first time renal transplantation.

Answer 140

False : When discovered during incision and drainage of peri anal abscess; should always be probed to locate the internal opening Probing fistulae during acute sepsis is associated with a high complication rate and should not be undertaken routinely. Fistulas A fistula is defined as an abnormal connection between two epithelial surfaces. There are many types ranging from Branchial fistulae in the neck to entero-cutaneous fistulae abdominally. In general surgical practice the abdominal cavity generates the majority and most of these arise from diverticular disease and Crohn's. As a general rule all fistulae will resolve spontaneously as long as there is no distal obstruction. This is particularly true of intestinal fistulae. The four types of fistulae are: Enterocutaneous These link the intestine to the skin. They may be high (>500ml) or low output (<250ml) depending upon source. Duodenal /jejunal fistulae will tend to produce high volume, electrolyte rich secretions which can lead to severe excoriation of the skin. Colo-cutaneous fistulae will tend to leak faeculent material. Both fistulae may result from the spontaneous rupture of an abscess cavity onto the skin (such as following perianal abscess drainage) or may occur as a result of iatrogenic input. In some cases it may even be surgically desirable e.g. mucous fistula following sub total colectomy for colitis. Suspect if there is excess fluid in the drain. Enteroenteric or Enterocolic This is a fistula that involves the large or small intestine. They may originate in a similar manner to enterocutaneous fistulae. A particular problem with this fistula type is that bacterial overgrowth may precipitate malabsorption syndromes. This may be particularly serious in inflammatory bowel disease. Enterovaginal Aetiology as above. Enterovesicular This type of fistula goes to the bladder. These fistulas may result in frequent urinary tract infections, or the passage of gas from the urethra during urination. Management Some rules relating to fistula management: They will heal provided there is no underlying inflammatory bowel disease and no distal obstruction, so conservative measures may be the best option Where there is skin involvement, protect the overlying skin, often using a well fitted stoma bag- skin damage is difficult to treat A high output fistula may be rendered more easily managed by the use of octreotide, this will tend to reduce the volume of pancreatic secretions. Nutritional complications are common especially with high fistula (e.g. high jejunal or duodenal) these may necessitate the use of TPN to provide nutritional support together with the concomitant use of octreotide to reduce volume and protect skin. When managing perianal fistulae surgeons should avoid probing the fistula where acute inflammation is present, this almost always worsens outcomes. When perianal fistulae occur secondary to Crohn's disease the best management option is often to drain acute sepsis and maintain that drainage through the judicious use of setons whilst medical management is implemented. Always attempt to delineate the fistula anatomy, for abscesses and fistulae that have an intra abdominal source the use of barium and CT studies should show a track. For perianal fistulae surgeons should recall Goodsall's rule in relation to internal and external openings.

Answer 141

Reassure and discharge This is likely to be simple duct ectasia and U1 (normal USS) coupled with normal examination would favor discharge from clinic. Mammography is generally unhelpful in this age group ``` Causes of nipple discharge Physiological During breast feeding Galactorrhoea Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated Hyperprolactinaemia Commonest type of pituitary tumour Microadenomas <1cm in diameter Macroadenomas >1cm in diameter Pressure on optic chiasm may cause bitemporal hemianopia Mammary duct ectasia Dilatation breast ducts. Most common in menopausal women Discharge typically thick and green in colour Most common in smokers Carcinoma Often blood stained May be underlying mass or axillary lymphadenopathy Intraductal papilloma Commoner in younger patients May cause blood stained discharge There is usually no palpable lump ``` Assessment of patients Examine breast and determine whether there is mass lesion present All mass lesions should undergo Triple assessment. Reporting of investigations Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below: ``` 1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant ``` Management of non malignant nipple discharge Exclude endocrine disease Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

Answer 142

Total duct excision This woman has troublesome duct ectasia and total duct excision is warranted. ``` Causes of nipple discharge Physiological During breast feeding Galactorrhoea Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated Hyperprolactinaemia Commonest type of pituitary tumour Microadenomas <1cm in diameter Macroadenomas >1cm in diameter Pressure on optic chiasm may cause bitemporal hemianopia Mammary duct ectasia Dilatation breast ducts. Most common in menopausal women Discharge typically thick and green in colour Most common in smokers Carcinoma Often blood stained May be underlying mass or axillary lymphadenopathy Intraductal papilloma Commoner in younger patients May cause blood stained discharge There is usually no palpable lump ``` Assessment of patients Examine breast and determine whether there is mass lesion present All mass lesions should undergo Triple assessment. Reporting of investigations Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below: ``` 1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant ``` Management of non malignant nipple discharge Exclude endocrine disease Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

Answer 143

Microdochectomy Although this is likely to be benign disease, her age coupled with an episode of blood stained discharge would attract a recommendation for microdochectomy. She may have an intraductal papilloma. But the concern would be DCIS. ``` Causes of nipple discharge Physiological During breast feeding Galactorrhoea Commonest cause may be response to emotional events, drugs such as histamine receptor antagonists are also implicated Hyperprolactinaemia Commonest type of pituitary tumour Microadenomas <1cm in diameter Macroadenomas >1cm in diameter Pressure on optic chiasm may cause bitemporal hemianopia Mammary duct ectasia Dilatation breast ducts. Most common in menopausal women Discharge typically thick and green in colour Most common in smokers Carcinoma Often blood stained May be underlying mass or axillary lymphadenopathy Intraductal papilloma Commoner in younger patients May cause blood stained discharge There is usually no palpable lump ``` Assessment of patients Examine breast and determine whether there is mass lesion present All mass lesions should undergo Triple assessment. Reporting of investigations Where a mass lesion is suspected or investigations are requested these are prefixed using a system that denotes the investigation type e.g. M for mammography, followed by a numerical code as shown below: ``` 1 No abnormality 2 Abnormality with benign features 3 Indeterminate probably benign 4 Indeterminate probably malignant 5 Malignant ``` Management of non malignant nipple discharge Exclude endocrine disease Nipple cytology unhelpful Smoking cessation advice for duct ectasia For duct ectasia with severe symptoms, total duct excision may be warranted.

Answer 144

Hydrocele This is a secondary hydrocele which occurs in patients aged 20-40 years. It develops rapidly and there may not be a tense swelling. The underlying testis is NOT palpated therefore indicating a hydrocele. Causes include trauma, infection and tumour. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 145

Epididymal cyst The testis is palpated therefore this differentiates it from a hydrocele. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 146

Haematocele Acute haematocele: tense, tender and non transilluminating mass post trauma. A chronic haematoma causes a blood clot to surround the testis. The blood clot hardens and contracts causing a hard mass which may be indistinguishable from a tumour. Therefore the testis will need surgical exploration. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 147

Orchidectomy via a scrotal approach At one time bilateral orchidectomy was performed routinely when prostate cancer was diagnosed (sometimes under the same anaesthetic). A combination of modern agents (GnRH analogues) and better consent processes have made this almost obsolete. Where required a scrotal approach should be used. Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: Seminoma Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions) Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen. Non seminomatous germ cell tumours (42%) (Teratoma, Yolk sac tumour, Choriocarcinoma, Mixed germ cell tumours (10%)) Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful Heterogenous texture with occasional ectopic tissue such as hair ``` Risk factors for testicular cancer Cryptorchidism Infertility Family history Klinefelter's syndrome Mumps orchitis ``` Features A painless lump is the most common presenting symptom Pain may also be present in a minority of men Other possible features include hydrocele, gynaecomastia Diagnosis Ultrasound is first-line CT scanning of the chest/ abdomen and pelvis is used for staging Tumour markers (see above) should be measured Management Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection. Prognosis is generally excellent 5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I Benign disease Epididymo-orchitis Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection. Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections. Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug. Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis. Testicular torsion 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) Pain is usually severe and of sudden onset. Cremasteric reflex is lost and elevation of the testis does not ease the pain. Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral. Hydrocele Presents as a mass that transilluminates, usually possible to "get above" it on examination. In younger men it should be investigated with USS to exclude tumour. In children it may occur as a result of a patent processus vaginalis. Treatment in adults is with a Lords or Jabouley procedure. Treatment in children is with trans inguinal ligation of PPV.

Answer 148

Orchidectomy via an inguinal approach Oncological orchidectomy is routinely performed via an inguinal approach to avoid contamination of another lymphatic field. Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: Seminoma Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions) Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen. Non seminomatous germ cell tumours (42%) (Teratoma, Yolk sac tumour, Choriocarcinoma, Mixed germ cell tumours (10%)) Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful Heterogenous texture with occasional ectopic tissue such as hair ``` Risk factors for testicular cancer Cryptorchidism Infertility Family history Klinefelter's syndrome Mumps orchitis ``` Features A painless lump is the most common presenting symptom Pain may also be present in a minority of men Other possible features include hydrocele, gynaecomastia Diagnosis Ultrasound is first-line CT scanning of the chest/ abdomen and pelvis is used for staging Tumour markers (see above) should be measured Management Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection. Prognosis is generally excellent 5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I Benign disease Epididymo-orchitis Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection. Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections. Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug. Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis. Testicular torsion 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) Pain is usually severe and of sudden onset. Cremasteric reflex is lost and elevation of the testis does not ease the pain. Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral. Hydrocele Presents as a mass that transilluminates, usually possible to "get above" it on examination. In younger men it should be investigated with USS to exclude tumour. In children it may occur as a result of a patent processus vaginalis. Treatment in adults is with a Lords or Jabouley procedure. Treatment in children is with trans inguinal ligation of PPV.

Answer 149

Division of patent processus vaginalis via an inguinal approach Ligation of the patent processus vaginalis is performed via an inguinal approach. There is no indication for scrotal surgery for hydrocele in young children. Testicular cancer is the most common malignancy in men aged 20-30 years. Around 95% of cases of testicular cancer are germ-cell tumours. Germ cell tumours may essentially be divided into: Seminoma Commonest subtype (50%) Average age at diagnosis = 40 Even advanced disease associated with 5 year survival of 73% AFP usually normal HCG elevated in 10% seminomas Lactate dehydrogenase; elevated in 10-20% seminomas (but also in many other conditions) Sheet like lobular patterns of cells with substantial fibrous component. Fibrous septa contain lymphocytic inclusions and granulomas may be seen. Non seminomatous germ cell tumours (42%) (Teratoma, Yolk sac tumour, Choriocarcinoma, Mixed germ cell tumours (10%)) Younger age at presentation =20-30 years Advanced disease carries worse prognosis (48% at 5 years) Retroperitoneal lymph node dissection may be needed for residual disease after chemotherapy AFP elevated in up to 70% of cases HCG elevated in up to 40% of cases Other markers rarely helpful Heterogenous texture with occasional ectopic tissue such as hair ``` Risk factors for testicular cancer Cryptorchidism Infertility Family history Klinefelter's syndrome Mumps orchitis ``` Features A painless lump is the most common presenting symptom Pain may also be present in a minority of men Other possible features include hydrocele, gynaecomastia Diagnosis Ultrasound is first-line CT scanning of the chest/ abdomen and pelvis is used for staging Tumour markers (see above) should be measured Management Orchidectomy (Inguinal approach) Chemotherapy and radiotherapy may be given depending on staging Abdominal lesions >1cm following chemotherapy may require retroperitoneal lymph node dissection. Prognosis is generally excellent 5 year survival for seminomas is around 95% if Stage I 5 year survival for teratomas is around 85% if Stage I Benign disease Epididymo-orchitis Acute epididymitis is an acute inflammation of the epididymis, often involving the testis and usually caused by bacterial infection. Infection spreads from the urethra or bladder. In men <35 years, gonorrhoea or chlamydia are the usual infections. Amiodarone is a recognised non infective cause of epididymitis, which resolves on stopping the drug. Tenderness is usually confined to the epididymis, which may facilitate differentiating it from torsion where pain usually affects the entire testis. Testicular torsion 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) Pain is usually severe and of sudden onset. Cremasteric reflex is lost and elevation of the testis does not ease the pain. Treatment is with surgical exploration. If a torted testis is identified then both testis should be fixed as the condition of bell clapper testis is often bilateral. Hydrocele Presents as a mass that transilluminates, usually possible to "get above" it on examination. In younger men it should be investigated with USS to exclude tumour. In children it may occur as a result of a patent processus vaginalis. Treatment in adults is with a Lords or Jabouley procedure. Treatment in children is with trans inguinal ligation of PPV.

Answer 150

Splenectomy Hilar injuries usually mandate splenectomy. The main risk with conservative management here is that he will rebleed and with hilar injuries this can be dramatic. Splenic trauma The spleen is one of the more commonly injured intra abdominal organs In most cases the spleen can be conserved. The management is dictated by the associated injuries, haemodynamic status and extent of direct splenic injury. ``` Management of splenic trauma Conservative Small subcapsular haematoma Minimal intra abdominal blood No hilar disruption Laparotomy with conservation Increased amounts of intraabdominal blood Moderate haemodynamic compromise Tears or lacerations affecting <50% Resection Hilar injuries Major haemorrhage Major associated injuries ``` Splenectomy Technique Trauma GA Long midline incision If time permits insert a self retaining retractor (e.g. Balfour/ omnitract) Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the anaesthetist to 'catch up' Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal lacerations will usually require splenectomy. Divide the short gastric vessels and ligate them. Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double ligation and serve as a safety net if your assistant does not release the clamp smoothly. Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed. Wash out the abdomen and place a tube drain to the splenic bed. Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter of personal choice. Post operatively the patient will require prophylactic penicillin V and pneumococcal vaccine. Elective Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction. Complications Haemorrhage (may be early and either from short gastrics or splenic hilar vessels Pancreatic fistula (from iatrogenic damage to pancreatic tail) Thrombocytosis: prophylactic aspirin Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis

Answer 151

Splenic conservation As minimum damage, attempt conservation Splenic trauma The spleen is one of the more commonly injured intra abdominal organs In most cases the spleen can be conserved. The management is dictated by the associated injuries, haemodynamic status and extent of direct splenic injury. ``` Management of splenic trauma Conservative Small subcapsular haematoma Minimal intra abdominal blood No hilar disruption Laparotomy with conservation Increased amounts of intraabdominal blood Moderate haemodynamic compromise Tears or lacerations affecting <50% Resection Hilar injuries Major haemorrhage Major associated injuries ``` Splenectomy Technique Trauma GA Long midline incision If time permits insert a self retaining retractor (e.g. Balfour/ omnitract) Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the anaesthetist to 'catch up' Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal lacerations will usually require splenectomy. Divide the short gastric vessels and ligate them. Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double ligation and serve as a safety net if your assistant does not release the clamp smoothly. Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed. Wash out the abdomen and place a tube drain to the splenic bed. Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter of personal choice. Post operatively the patient will require prophylactic penicillin V and pneumococcal vaccine. Elective Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction. Complications Haemorrhage (may be early and either from short gastrics or splenic hilar vessels Pancreatic fistula (from iatrogenic damage to pancreatic tail) Thrombocytosis: prophylactic aspirin Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis

Answer 152

Ultrasound scan This will demonstrate any overt splenic injury. A CT scan carries a significant dose of radiation. In the absence of haemodynamic instability or other major associated injuries the use of USS to exclude intraabdominal free fluid (blood) would seem safe when coupled with active observation. An USS will also show splenic haematomas. Splenic trauma The spleen is one of the more commonly injured intra abdominal organs In most cases the spleen can be conserved. The management is dictated by the associated injuries, haemodynamic status and extent of direct splenic injury. ``` Management of splenic trauma Conservative Small subcapsular haematoma Minimal intra abdominal blood No hilar disruption Laparotomy with conservation Increased amounts of intraabdominal blood Moderate haemodynamic compromise Tears or lacerations affecting <50% Resection Hilar injuries Major haemorrhage Major associated injuries ``` Splenectomy Technique Trauma GA Long midline incision If time permits insert a self retaining retractor (e.g. Balfour/ omnitract) Large amount of free blood is usually present. Pack all 4 quadrants of the abdomen. Allow the anaesthetist to 'catch up' Remove the packs and assess the viability of the spleen. Hilar injuries and extensive parenchymal lacerations will usually require splenectomy. Divide the short gastric vessels and ligate them. Clamp the splenic artery and vein. Two clamps on the patient side are better and allow for double ligation and serve as a safety net if your assistant does not release the clamp smoothly. Be careful not to damage the tail of the pancreas, if you do then this will need to be formally removed and the pancreatic duct closed. Wash out the abdomen and place a tube drain to the splenic bed. Some surgeons implant a portion of spleen into the omentum, whether you decide to do this is a matter of personal choice. Post operatively the patient will require prophylactic penicillin V and pneumococcal vaccine. Elective Elective splenectomy is a very different operation from that performed in the emergency setting. The spleen is often large (sometimes massive). Most cases can be performed laparoscopically. The spleen will often be macerated inside a specimen bag to facilitate extraction. Complications Haemorrhage (may be early and either from short gastrics or splenic hilar vessels Pancreatic fistula (from iatrogenic damage to pancreatic tail) Thrombocytosis: prophylactic aspirin Encapsulated bacteria infection e.g. Strep. pneumoniae, Haemophilus influenzae and Neisseria meningitidis

Answer 153

Perform a laparotomy and under-running of the ulcer The decision as to how best to manage patients with re-bleeding is difficult. Whilst it is tempting to offer repeat endoscopy, this intervention is best used on those with small ulcers. Large posteriorly sited duodenal ulcers are at high risk for re-bleeding and the timeframe of this event suggests that primary endoscopic haemostasis was inadequate. Surgery thus represents the safest way forward. Upper gastrointestinal bleeding Patients may present with the following: Haematemesis and/ or malaena Epigastric discomfort Sudden collapse The extent to which these will occur will depend upon the source. Mortality is higher in patients presenting with haematemesis than malaena alone. Oesophageal bleeding Cause Presenting features Oesophagitis Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms. Cancer Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed. Mallory Weiss Tear Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously. Varices Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed. Gastric Bleeding Cause Presenting features Gastric cancer May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage. Dieulafoy Lesion Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically. Diffuse erosive gastritis Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise. Gastric ulcer Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis. Duodenum Most common cause of major haemorrhage is a posteriorly sited duodenal ulcer. However, ulcers at any site in the duodenum may present with haematemesis, malaena and epigastric discomfort. The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Peri ampullary tumours may bleed but these are rare. In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality. Management Admission to hospital careful monitoring, cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum) Patients with on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood Early control of airway is vital (e.g. Drowsy patient with liver failure) Patients with suspected varices should receive terlipressin prior to endoscopy Ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it. The endoscopy department is a potentially dangerous place for unstable patients and it may be safer to perform the endoscopy in theatre with an anaesthetist present. Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengaksten- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS. Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor. Mallory Weiss tears will typically resolve spontaneously Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate. Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy Bleeding ulcers that cannot be controlled endoscopically may require laparotomy and ulcer underruning Indications for surgery Patients > 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension Surgery Duodenal ulcer Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis. ``` For gastric ulcer Under-running of the bleeding site Partial gastrectomy-antral ulcer Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery) Total gastrectomy if bleeding persists ``` Summary of Acute Upper GI bleeding recommendations: The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy. The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata of recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention. Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge.

Answer 154

Acute rejection The features described are those of worsening graft function and acute rejection. The fact that there is a 10 day delay goes against hyperacute rejection. Cold ischaemic times are a major factor for delayed graft function. However, even 26 hours is not incompatible with graft survival. Complications following renal transplant Renal transplantation is widely practised. The commonest technical related complications are related to the ureteric anastomosis. The warm ischaemic time is also of considerable importance and graft survival is directly related to this. Long warm ischaemic times increase the risk of acute tubular necrosis which may occur in all types of renal transplanation and provided other insults are minimised, will usually recover. Organ rejection may occur at any phase following the transplantation process. Immunological complications Types of organ rejection Hyperacute. This occurs immediately through presence of pre formed antibody (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. Hyperacute Renal transplants are most susceptible to this process. Risk factors include major HLA mismatch and ABO incompatibility. The rejection occurs almost immediately and the macroscopic features may become manifest following completion of the vascular anastomosis and removal of clamps. The kidney becomes mottled, dusky and the vessels will thrombose. The only treatment is removal of the graft, if left in situ it will result in abscess formation. Acute All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Most cases can be managed medically. Chronic Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants. Technical complications - Renal artery thrombosis Sudden complete loss of urine output Immediate surgery may salvage the graft, delays beyond 30 minutes are associated with a high rate of graft loss - Renal artery stenosis Uncontrolled hypertension, allograft dysfunction and oedema Angioplasty is the treatment of choice - Renal vein thrombosis Pain and swelling over the graft site, haematuria and oliguria The graft is usually lost - Urine leaks Diminished urine output, rising creatinine, fever and abdominal pain USS shows perigraft collection, necrosis of ureter tip is the commonest cause and the anastomosis may need revision - Lymphocele Common complication (occurs in 15%), may present as a mass, if large may compress ureter May be drained with percutaneous technique and sclerotherapy, or intraperitoneal drainage

Answer 155

Bladder occlusion The most likely explanation for this event is a blocked catheter. This may be the result of blood clot from the ureteric anastomosis. Bladder irrigation will usually resolve the problem. Complications following renal transplant Renal transplantation is widely practised. The commonest technical related complications are related to the ureteric anastomosis. The warm ischaemic time is also of considerable importance and graft survival is directly related to this. Long warm ischaemic times increase the risk of acute tubular necrosis which may occur in all types of renal transplanation and provided other insults are minimised, will usually recover. Organ rejection may occur at any phase following the transplantation process. Immunological complications Types of organ rejection Hyperacute. This occurs immediately through presence of pre formed antibody (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. Hyperacute Renal transplants are most susceptible to this process. Risk factors include major HLA mismatch and ABO incompatibility. The rejection occurs almost immediately and the macroscopic features may become manifest following completion of the vascular anastomosis and removal of clamps. The kidney becomes mottled, dusky and the vessels will thrombose. The only treatment is removal of the graft, if left in situ it will result in abscess formation. Acute All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Most cases can be managed medically. Chronic Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants. Technical complications - Renal artery thrombosis Sudden complete loss of urine output Immediate surgery may salvage the graft, delays beyond 30 minutes are associated with a high rate of graft loss - Renal artery stenosis Uncontrolled hypertension, allograft dysfunction and oedema Angioplasty is the treatment of choice - Renal vein thrombosis Pain and swelling over the graft site, haematuria and oliguria The graft is usually lost - Urine leaks Diminished urine output, rising creatinine, fever and abdominal pain USS shows perigraft collection, necrosis of ureter tip is the commonest cause and the anastomosis may need revision - Lymphocele Common complication (occurs in 15%), may present as a mass, if large may compress ureter May be drained with percutaneous technique and sclerotherapy, or intraperitoneal drainage

Answer 156

Renal artery thrombosis Right sided live donor transplants are extremely rare. This is because the vena cava precludes mobilisation of the right renal artery. The short right renal artery that is produced therefore presents a major challenge. The sudden cessation of urine output in this context is highly suggestive of an acute thrombosis. Delay in thrombectomy beyond 1 hour almost inevitably results in graft loss. Complications following renal transplant Renal transplantation is widely practised. The commonest technical related complications are related to the ureteric anastomosis. The warm ischaemic time is also of considerable importance and graft survival is directly related to this. Long warm ischaemic times increase the risk of acute tubular necrosis which may occur in all types of renal transplanation and provided other insults are minimised, will usually recover. Organ rejection may occur at any phase following the transplantation process. Immunological complications Types of organ rejection Hyperacute. This occurs immediately through presence of pre formed antibody (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. Hyperacute Renal transplants are most susceptible to this process. Risk factors include major HLA mismatch and ABO incompatibility. The rejection occurs almost immediately and the macroscopic features may become manifest following completion of the vascular anastomosis and removal of clamps. The kidney becomes mottled, dusky and the vessels will thrombose. The only treatment is removal of the graft, if left in situ it will result in abscess formation. Acute All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Most cases can be managed medically. Chronic Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants. Technical complications - Renal artery thrombosis Sudden complete loss of urine output Immediate surgery may salvage the graft, delays beyond 30 minutes are associated with a high rate of graft loss - Renal artery stenosis Uncontrolled hypertension, allograft dysfunction and oedema Angioplasty is the treatment of choice - Renal vein thrombosis Pain and swelling over the graft site, haematuria and oliguria The graft is usually lost - Urine leaks Diminished urine output, rising creatinine, fever and abdominal pain USS shows perigraft collection, necrosis of ureter tip is the commonest cause and the anastomosis may need revision - Lymphocele Common complication (occurs in 15%), may present as a mass, if large may compress ureter May be drained with percutaneous technique and sclerotherapy, or intraperitoneal drainage

Answer 157

Oesophageal rupture Spontaneous rupture of the oesophagus may occur following an episode of vomiting. The subsequent mediastinitis can produce severe sepsis and death if not treated promptly. Adequate drainage of sepsis and early surgery are the cornerstones of management. Mallory-Weiss Tear Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms. Hiatus hernia of gastric cardia Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis. Oesophageal rupture Complete disruption of the oesophageal wall in absence of pre-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1). Squamous cell carcinoma of the oesophagus History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms. Adenocarcinoma of the oesophagus Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus. Peptic stricture Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy Dysmotility disorder May have dysphagia that is episodic and non progressive. Retrosternal pain may accompany the episodes. Diagnosis Most of the differential diagnoses listed above can be accurately categorised by upper GI endoscopy (usually most patients). Where this fails to demonstrate a mechanical stricture the use of pH and manometry studies together with radiological contrast swallows will facilitate the diagnosis.

Answer 158

Squamous cell carcinoma The risk of squamous cell carcinoma of the oesophagus is increased in people with achalasia. The condition often presents late and has a poor prognosis. Mallory-Weiss Tear Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms. Hiatus hernia of gastric cardia Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis. Oesophageal rupture Complete disruption of the oesophageal wall in absence of pre-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1). Squamous cell carcinoma of the oesophagus History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms. Adenocarcinoma of the oesophagus Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus. Peptic stricture Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy Dysmotility disorder May have dysphagia that is episodic and non progressive. Retrosternal pain may accompany the episodes. Diagnosis Most of the differential diagnoses listed above can be accurately categorised by upper GI endoscopy (usually most patients). Where this fails to demonstrate a mechanical stricture the use of pH and manometry studies together with radiological contrast swallows will facilitate the diagnosis.

Answer 159

Pharyngeal pouch Pharyngeal pouches occur when a defect occurs in killians dehiscence. Difficulty in intubation is a well recognised consequence and care must be taken to take the correct track during OGD to avoid perforation. Most cases are now treated with endoscopic stapling. Mallory-Weiss Tear Usually history of antecedent vomiting. This is then followed by the vomiting of a small amount of blood. There is usually little in the way of systemic disturbance or prior symptoms. Hiatus hernia of gastric cardia Often longstanding history of dyspepsia, patients are often overweight. Uncomplicated hiatus hernias should not be associated with dysphagia or haematemesis. Oesophageal rupture Complete disruption of the oesophageal wall in absence of pre-existing pathology. Left postero-lateral oesophageal is commonest site (2-3cm from OG junction). Suspect in patients with severe chest pain without cardiac diagnosis and signs suggestive of pneumonia without convincing history, where there is history of vomiting. Erect CXR shows infiltrate or effusion in 90% of cases(1). Squamous cell carcinoma of the oesophagus History of progressive dysphagia. Often signs of weight loss. Usually little or no history of previous GORD type symptoms. Adenocarcinoma of the oesophagus Progressive dysphagia, may have previous symptoms of GORD or Barretts oesophagus. Peptic stricture Longer history of dysphagia, often not progressive. Usually symptoms of GORD. Often lack systemic features seen with malignancy Dysmotility disorder May have dysphagia that is episodic and non progressive. Retrosternal pain may accompany the episodes. Diagnosis Most of the differential diagnoses listed above can be accurately categorised by upper GI endoscopy (usually most patients). Where this fails to demonstrate a mechanical stricture the use of pH and manometry studies together with radiological contrast swallows will facilitate the diagnosis.

Answer 160

Intestinal malrotation The combination of scaphoid abdomen and bilious vomiting is highly suggestive of intestinal malrotation and volvulus. An urgent upper GI contrast study and ultrasound is required. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 161

Hypertrophy of the pyloric sphincter A history of projective vomiting and weight loss is a common story suggestive of pyloric stenosis. The vomit is often not bile stained. Diagnosis is further suggested by hypochloraemic metabolic alkalosis and a palpable tumour on test feeding. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 162

Congenital diaphragmatic hernia Displaced apex beat and decreased air entry are suggestive of diaphragmatic hernia. The abdomen may well be scaphoid in some cases. The underlying lung may be hypoplastic and this correlates directly with prognosis. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 163

Intraventricular haemorrhage Acute neurological deterioration in premature neonates is usually due to intraventricular haemorrhage. Diagnosis is made by cranial ultrasound. Development of hydrocephalus may necessitate surgery. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 164

Acute sub dural bleed The time frame of deterioration of an acute sub dural bleed would fit with this scenario. They are highly lethal and not uncommon injuries. As the bleed enlarges, lateralising signs may be seen and eventually coning and death will occur. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 165

Sub arachnoid haemorrhage The absence of trauma here makes an acute sub dural and extra dural bleed unlikely. Chronic sub dural bleeds would usually cause a more gradual deterioration than is seen here. The absence of any skull fracture also makes an underlying intra cranial bleed less likely. Sudden onset headaches, together with sudden deterioration in neurological function are typical of a sub arachnoid haemorrhage. Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Intracerebral haematoma Usually hyperdense lesions on CT scanning. Arise in areas of traumatic contusion with fuse to become a haematoma. Areas of clot and fresh blood may co-exist on the same CT scan (Swirl sign). Large haematomas and those associated with mass effect should be evacuated. Subarachnoid haemorrhage 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 Intraventricular haemorrhage Haemorrhage that occurs into the ventricular system of the brain. It is relatively rare in adult surgical practice and when it does occur, it is typically associated with severe head injuries. In premature neonates it may occur spontaneously. The blood may clot and occlude CSF flow, hydrocephalus may result. In neonatal practice the vast majority of IVH occur in the first 72 hours after birth, the aetiology is not well understood and it is suggested to occur as a result of birth trauma combined with cellular hypoxia, together with the delicate neonatal CNS.

Answer 166

Inflammatory carcinoma Inflammatory breast cancers have an aggressive nature. Dissemination occurs early and is more resistant to adjuvent treatments than other types of breast cancer. Often occurs in pregnancy or lactation. Breast cancer Commoner in the older age group Invasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS). There are associated carcinomas of special type e.g. Tubular that may carry better prognosis. The pathological assessment involves assessment of the tumour and lymph nodes, sentinel lymph node biopsy is often used to minimise the morbidity of an axillary dissection. Treatment, typically this is either wide local excision or mastectomy. There are many sub types of both of these that fall outside of the MRCS. Some key rules to bear in mind. Whatever operation is contemplated the final cosmetic outcome does have a bearing. A woman with small breasts and a large tumour will tend to fare better with mastectomy, even if clear pathological and clinical margins can be obtained. Conversely a women with larger breasts may be able to undergo breast conserving surgery even with a relatively large primary lesion (NB tumours >4cm used to attract recommendation for mastectomy). For screen detected and impalpable tumour image guidance will be necessary. Reconstruction is always an option following any resectional procedure. However, its exact type must be tailored to age and co-morbidities of the patient. The main operations in common use include latissimus dorsi myocutaneous flap and sub pectoral implants. Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast conserving surgery Image sourced from Wikipedia Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years [1]. Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below). Score Lymph nodes involved Grade 1 0 1 2 1-3 2 3 >3 3 Prognosis ``` Score Percentage 5 year survival 2.0 to 2.4 93% 2.5 to 3.4 85% 3.5 to 5.4 70% >5.4 50% ```

Answer 167

Invasive ductal carcinoma A post menopausal woman is more likely to have a ductal carcinoma and they tend to occur at a single focus within the breast. Breast cancer Commoner in the older age group Invasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS). There are associated carcinomas of special type e.g. Tubular that may carry better prognosis. The pathological assessment involves assessment of the tumour and lymph nodes, sentinel lymph node biopsy is often used to minimise the morbidity of an axillary dissection. Treatment, typically this is either wide local excision or mastectomy. There are many sub types of both of these that fall outside of the MRCS. Some key rules to bear in mind. Whatever operation is contemplated the final cosmetic outcome does have a bearing. A woman with small breasts and a large tumour will tend to fare better with mastectomy, even if clear pathological and clinical margins can be obtained. Conversely a women with larger breasts may be able to undergo breast conserving surgery even with a relatively large primary lesion (NB tumours >4cm used to attract recommendation for mastectomy). For screen detected and impalpable tumour image guidance will be necessary. Reconstruction is always an option following any resectional procedure. However, its exact type must be tailored to age and co-morbidities of the patient. The main operations in common use include latissimus dorsi myocutaneous flap and sub pectoral implants. Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast conserving surgery Image sourced from Wikipedia Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years [1]. Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below). Score Lymph nodes involved Grade 1 0 1 2 1-3 2 3 >3 3 Prognosis ``` Score Percentage 5 year survival 2.0 to 2.4 93% 2.5 to 3.4 85% 3.5 to 5.4 70% >5.4 50% ```

Answer 168

Invasive lobular carcinoma This is likely to be an invasive lobular carcinoma, mainly due to the multifocal lesions and the history of previous breast cancer in the opposite breast. Breast cancer Commoner in the older age group Invasive ductal carcinomas are the most common type. Some may arise as a result of ductal carcinoma in situ (DCIS). There are associated carcinomas of special type e.g. Tubular that may carry better prognosis. The pathological assessment involves assessment of the tumour and lymph nodes, sentinel lymph node biopsy is often used to minimise the morbidity of an axillary dissection. Treatment, typically this is either wide local excision or mastectomy. There are many sub types of both of these that fall outside of the MRCS. Some key rules to bear in mind. Whatever operation is contemplated the final cosmetic outcome does have a bearing. A woman with small breasts and a large tumour will tend to fare better with mastectomy, even if clear pathological and clinical margins can be obtained. Conversely a women with larger breasts may be able to undergo breast conserving surgery even with a relatively large primary lesion (NB tumours >4cm used to attract recommendation for mastectomy). For screen detected and impalpable tumour image guidance will be necessary. Reconstruction is always an option following any resectional procedure. However, its exact type must be tailored to age and co-morbidities of the patient. The main operations in common use include latissimus dorsi myocutaneous flap and sub pectoral implants. Women wishing to avoid a prosthesis may be offered TRAM or DIEP flaps. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts A compelling indication for mastectomy, a larger tumour that would be unsuitable for breast conserving surgery Image sourced from Wikipedia Whatever surgical option is chosen the aim should be to have a local recurrence rate of 5% or less at 5 years [1]. Nottingham Prognostic Index The Nottingham Prognostic Index can be used to give an indication of survival. In this system the tumour size is weighted less heavily than other major prognostic parameters. Calculation of NPI Tumour Size x 0.2 + Lymph node score(From table below)+Grade score(From table below). Score Lymph nodes involved Grade 1 0 1 2 1-3 2 3 >3 3 Prognosis ``` Score Percentage 5 year survival 2.0 to 2.4 93% 2.5 to 3.4 85% 3.5 to 5.4 70% >5.4 50% ```

Answer 169

Insertion of self expanding metallic stent Ideally, the distant disease should be managed first and then the primary lesion addressed. A self expanding stent is likely to achieve this and avoids a stoma. Large bowel obstruction Colonic obstruction remains a common surgical problem. It is most commonly due to malignancy (60%) and diverticular disease (20%). Volvulus affecting the colon accounts for 5% of cases. Acute colonic pseudo-obstruction remains a potential differential diagnosis in all cases. Intussusception affecting the colon (most often due to tumours in the adult population) remains a rare but recognised cause. The typical patient will present with gradual onset of progressive abdominal distension, colicky abdominal pain and either obstipation or absolute constipation. On examination abdominal distension is present, the presence of caecal tenderness (assuming no overt evidence of peritonitis) is a useful sign to elicit. A digital rectal examination and rigid sigmoidoscopy should be performed. A plain abdominal x-ray is the usual first line test and; the caecal diameter and ileocaecal valve competency should be assessed on this film. Imaging modalities Debate long surrounds the use of CT versus gastrograffin enemas. The latter investigation has always been the traditional method of determining whether a structural lesion is indeed present. However, in the UK the use of this technique has declined and in most units a CT scan will be offered as the first line investigation by the majority of radiologists (and is advocated by the ACPGBI). In most cases this will provide sufficient detail to allow operative planning, and since malignancy accounts for most presentations may also stage the disease. In the event that the radiologist cannot provide a clear statement of lesion site, the surgeon should have no hesitation in requesting a contrast enema. Surgical options The decision as to when to operate or not is determined firstly by the patients physiological status. Unstable patients require resuscitation prior to surgery and admission to a critical care unit for invasive monitoring and potential inotropic support may be needed. In patients who are otherwise stable the decision then rests on the radiological and clinical findings. As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery. Right sided and transverse lesions Right sided lesions producing large bowel obstruction should generally be treated by right hemicolectomy or its extended variant if the lesion lies in the distal transverse colon or splenic flexure. In these cases an ileocolic anastomosis may be easily constructed and even in the emergency setting has a low risk of anastomotic leak. Left sided lesions The options here lie between sub total colectomy and anastomosis, left hemicolectomy with on table lavage and primary anastomosis, left hemicolectomy and end colostomy formation and finally colonic stent insertion. The usefulness of colonic stents was the subject of a Cochrane review in 2011. The authors concluded that on the basis of the data that they reviewed, there was no benefit from the use of colonic stents over conventional surgical resection with a tendency to better outcomes seen in the surgical group (1). A more recently conducted meta analysis met with the same conclusion (2). However, the recently concluded CREST trial has suggested that self expanding metallic stents can improve outcomes and avoids a stoma. Rectosigmoid lesions Lesions below the peritoneal reflection that are causing obstruction should generally be treated with a loop colostomy. Primary resection of unstaged rectal cancer would most likely carry a high CRM positivity rate and cannot be condoned. Where the lesion occupies the distal sigmoid colon the usual practice would be to perform a high anterior resection. The decision surrounding restoration of intestinal continuity would lie with the operating surgeon.

Answer 170

Loop colostomy of the sigmoid colon Rectal cancers should not be primarily resected prior to definitive staging and a tumour of this nature is likely to have circumferential margin involvement. Whilst a sigmoid and transverse loop colostomy would both provide an equal relief of obstruction the former procedure has the added benefit of making a subsequent resection safer, since a transverse colostomy would have to be taken down and closed during the course of subsequent surgery. Large bowel obstruction Colonic obstruction remains a common surgical problem. It is most commonly due to malignancy (60%) and diverticular disease (20%). Volvulus affecting the colon accounts for 5% of cases. Acute colonic pseudo-obstruction remains a potential differential diagnosis in all cases. Intussusception affecting the colon (most often due to tumours in the adult population) remains a rare but recognised cause. The typical patient will present with gradual onset of progressive abdominal distension, colicky abdominal pain and either obstipation or absolute constipation. On examination abdominal distension is present, the presence of caecal tenderness (assuming no overt evidence of peritonitis) is a useful sign to elicit. A digital rectal examination and rigid sigmoidoscopy should be performed. A plain abdominal x-ray is the usual first line test and; the caecal diameter and ileocaecal valve competency should be assessed on this film. Imaging modalities Debate long surrounds the use of CT versus gastrograffin enemas. The latter investigation has always been the traditional method of determining whether a structural lesion is indeed present. However, in the UK the use of this technique has declined and in most units a CT scan will be offered as the first line investigation by the majority of radiologists (and is advocated by the ACPGBI). In most cases this will provide sufficient detail to allow operative planning, and since malignancy accounts for most presentations may also stage the disease. In the event that the radiologist cannot provide a clear statement of lesion site, the surgeon should have no hesitation in requesting a contrast enema. Surgical options The decision as to when to operate or not is determined firstly by the patients physiological status. Unstable patients require resuscitation prior to surgery and admission to a critical care unit for invasive monitoring and potential inotropic support may be needed. In patients who are otherwise stable the decision then rests on the radiological and clinical findings. As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery. Right sided and transverse lesions Right sided lesions producing large bowel obstruction should generally be treated by right hemicolectomy or its extended variant if the lesion lies in the distal transverse colon or splenic flexure. In these cases an ileocolic anastomosis may be easily constructed and even in the emergency setting has a low risk of anastomotic leak. Left sided lesions The options here lie between sub total colectomy and anastomosis, left hemicolectomy with on table lavage and primary anastomosis, left hemicolectomy and end colostomy formation and finally colonic stent insertion. The usefulness of colonic stents was the subject of a Cochrane review in 2011. The authors concluded that on the basis of the data that they reviewed, there was no benefit from the use of colonic stents over conventional surgical resection with a tendency to better outcomes seen in the surgical group (1). A more recently conducted meta analysis met with the same conclusion (2). However, the recently concluded CREST trial has suggested that self expanding metallic stents can improve outcomes and avoids a stoma. Rectosigmoid lesions Lesions below the peritoneal reflection that are causing obstruction should generally be treated with a loop colostomy. Primary resection of unstaged rectal cancer would most likely carry a high CRM positivity rate and cannot be condoned. Where the lesion occupies the distal sigmoid colon the usual practice would be to perform a high anterior resection. The decision surrounding restoration of intestinal continuity would lie with the operating surgeon.

Answer 171

Right hemicolectomy This lesion should be amenable to standard right hemicolectomy. Extending the resection to take the middle colic vessels and distal transverse colon is unlikely to provide additional oncological benefit. Large bowel obstruction Colonic obstruction remains a common surgical problem. It is most commonly due to malignancy (60%) and diverticular disease (20%). Volvulus affecting the colon accounts for 5% of cases. Acute colonic pseudo-obstruction remains a potential differential diagnosis in all cases. Intussusception affecting the colon (most often due to tumours in the adult population) remains a rare but recognised cause. The typical patient will present with gradual onset of progressive abdominal distension, colicky abdominal pain and either obstipation or absolute constipation. On examination abdominal distension is present, the presence of caecal tenderness (assuming no overt evidence of peritonitis) is a useful sign to elicit. A digital rectal examination and rigid sigmoidoscopy should be performed. A plain abdominal x-ray is the usual first line test and; the caecal diameter and ileocaecal valve competency should be assessed on this film. Imaging modalities Debate long surrounds the use of CT versus gastrograffin enemas. The latter investigation has always been the traditional method of determining whether a structural lesion is indeed present. However, in the UK the use of this technique has declined and in most units a CT scan will be offered as the first line investigation by the majority of radiologists (and is advocated by the ACPGBI). In most cases this will provide sufficient detail to allow operative planning, and since malignancy accounts for most presentations may also stage the disease. In the event that the radiologist cannot provide a clear statement of lesion site, the surgeon should have no hesitation in requesting a contrast enema. Surgical options The decision as to when to operate or not is determined firstly by the patients physiological status. Unstable patients require resuscitation prior to surgery and admission to a critical care unit for invasive monitoring and potential inotropic support may be needed. In patients who are otherwise stable the decision then rests on the radiological and clinical findings. As a general rule the old adage that the sun should not rise and set on unrelieved large bowel obstruction still holds true. A caecal diameter of 12cm or more in the presence of complete obstruction with a competent ileocaecal valve and caecal tenderness is a sign of impending perforation and a relative indication for prompt surgery. Right sided and transverse lesions Right sided lesions producing large bowel obstruction should generally be treated by right hemicolectomy or its extended variant if the lesion lies in the distal transverse colon or splenic flexure. In these cases an ileocolic anastomosis may be easily constructed and even in the emergency setting has a low risk of anastomotic leak. Left sided lesions The options here lie between sub total colectomy and anastomosis, left hemicolectomy with on table lavage and primary anastomosis, left hemicolectomy and end colostomy formation and finally colonic stent insertion. The usefulness of colonic stents was the subject of a Cochrane review in 2011. The authors concluded that on the basis of the data that they reviewed, there was no benefit from the use of colonic stents over conventional surgical resection with a tendency to better outcomes seen in the surgical group (1). A more recently conducted meta analysis met with the same conclusion (2). However, the recently concluded CREST trial has suggested that self expanding metallic stents can improve outcomes and avoids a stoma. Rectosigmoid lesions Lesions below the peritoneal reflection that are causing obstruction should generally be treated with a loop colostomy. Primary resection of unstaged rectal cancer would most likely carry a high CRM positivity rate and cannot be condoned. Where the lesion occupies the distal sigmoid colon the usual practice would be to perform a high anterior resection. The decision surrounding restoration of intestinal continuity would lie with the operating surgeon.

Answer 172

Lymphangiosarcoma is a rare condition arising as a result of chronic oedema. It is an aggressive malignancy. Lymphoedema Due to impaired lymphatic drainage in the presence of normal capillary function. Lymphoedema causes the accumulation of protein rich fluid, subdermal fibrosis and dermal thickening. Characteristically fluid is confined to the epifascial space (skin and subcutaneous tissues); muscle compartments are free of oedema. It involves the foot, unlike other forms of oedema. There may be a 'buffalo hump' on the dorsum of the foot and the skin cannot be pinched due to subcutaneous fibrosis. Causes of lymphoedema Primary Congenital < 1 year: sporadic, Milroy's disease Onset 1-35 years: sporadic, Meige's disease > 35 years: Tarda Secondary Bacterial/fungal/parasitic infection (filariasis) Lymphatic malignancy Radiotherapy to lymph nodes Surgical resection of lymph nodes DVT Thrombophlebitis Indications for surgery Marked disability or deformity from limb swelling Lymphoedema caused by proximal lymphatic obstruction with patent distal lymphatics suitable for a lymphatic drainage procedure Lymphocutaneous fistulae and megalymphatics Procedures Homans operation Reduction procedure with preservation of overlying skin (which must be in good condition). Skin flaps are raised and the underlying tissue excised. Limb circumference typically reduced by a third. Charles operation All skin and subcutaneous tissue around the calf are excised down to the deep fascia. Split skin grafts are placed over the site. May be performed if overlying skin is not in good condition. Larger reduction in size than with Homans procedure. Lymphovenous anastamosis Identifiable lymphatics are anastomosed to sub dermal venules. Usually indicated in 2% of patients with proximal lymphatic obstruction and normal distal lymphatics.

Answer 173

Renal artery stenosis Renal artery stenosis typically occurs over several months and will usually result in the development of hypertension. Most cases can be assessed using duplex scanning and managed with angioplasty. Complications of renal transplantation A number of complications may occur following renal transplantation. A critical aspect of post operative care is evaluation of graft function. Post operatively, urine output is the most readily available, and easily measured, indicator of graft function. If an individual was relatively anuric pre-transplant and has a good urine output following surgery then this is more useful than it would be in someone who had a higher volume diuresis prior to transplantation. Recipients can be divided into three main groups following renal transplantation, with regard to their graft function: Immediate graft function; brisk diuresis and falling serum creatinine Slow graft function; modest urine output and slowly falling creatinine levels Delayed graft function; defined as need for dialysis post transplant Decreased urine output following surgery can be the result of hypovolvaemia or a blocked catheter (commonest causes). Other important causes include rejection, or a vascular complication. Vascular complications These may involve the donor vessels, those of the recipient or both. Renal artery thrombosis usually occurs early post transplant, but is uncommon with an incidence of less than 1%. It typically results in graft loss. It usually occurs as a result of a technical problem such a vessel torsion or sub intimal flaps. The usual presenting feature is a sudden cessation of urine output. When suspected, the occlusion is usually well demonstrated with duplex scanning. Ideally immediate surgical re-exploration should occur. Sadly, the graft has usually been lost by this stage and will require graft nephrectomy. Renal vein thrombosis is not as common as arterial graft thrombosis and the usual presenting features include discomfort at the graft site and swelling of the graft associated with loss of urine output. Again, duplex scanning is indicated. Unfortunately, this complication is also associated with a high incidence of graft loss. Over a longer time frame (typically months) some individuals will develop renal artery stenosis. These individuals will typically develop hypertension and over time graft function will decline as hypertensive nephropathy occurs. It is usually demonstrated by duplex scanning and is usually amenable to endovascular intervention. Urological complications Urinary tract complications manifesting as leakage or obstruction are common complications following renal transplantation and occur in up to 10% of patients. The main underlying cause is the relatively poor blood supply to the transplanted ureter. Patients typically present relatively early in the first 5 weeks following transplantation with pain and swelling at the graft site. Imaging with USS is often the initial test. Therapeutic options include surgical re-implantation of the ureter for large leaks and stent insertion and nephrostomy placement for smaller leaks. Lymphocele These do not generally occur until 2 weeks or longer after surgery. They are, however, relatively common and may be seen in up to 18% of patients. Symptoms usually occur as a result of mass effect with compression of adjacent structures. These include the vessels supplying both the graft, with deterioration in graft function, the ureter, with alteration in urine output and the recipients lower limb vessels, with development of leg swelling. Creation of a laparoscopic or open peritoneal window is a favored treatment. Rejection Four types of graft rejection are recognised; hyperacute, accelerated acute, acute and chronic. Type of rejection Key features Hyperacute Occurs within minutes of clamp release Due to pre formed antibodies Immediate loss of graft occurs Accelerated acute Occurs in first few days following surgery Involved both cellular and antibody mediated injury Pre-sensitisation of the donor is a common cause Acute Traditionally the most common type of rejection Seen days to weeks after surgery Predominantly a cell mediated process mediated by lymphocytes Organ biopsy demonstrates cellular infiltrates and graft cell apoptosis Chronic Increasingly common problem Typically; graft atrophy and atherosclerosis are seen. Fibrosis often occurs as a late event

Answer 174

Renal artery thrombosis Sudden loss of urine output is most commonly due to a blocked catheter. However, if this is excluded (and is not included in the options) the most worrisome cause is arterial thrombosis. This will often be a delayed diagnosis and the rate of graft loss is high. Complications of renal transplantation A number of complications may occur following renal transplantation. A critical aspect of post operative care is evaluation of graft function. Post operatively, urine output is the most readily available, and easily measured, indicator of graft function. If an individual was relatively anuric pre-transplant and has a good urine output following surgery then this is more useful than it would be in someone who had a higher volume diuresis prior to transplantation. Recipients can be divided into three main groups following renal transplantation, with regard to their graft function: Immediate graft function; brisk diuresis and falling serum creatinine Slow graft function; modest urine output and slowly falling creatinine levels Delayed graft function; defined as need for dialysis post transplant Decreased urine output following surgery can be the result of hypovolvaemia or a blocked catheter (commonest causes). Other important causes include rejection, or a vascular complication. Vascular complications These may involve the donor vessels, those of the recipient or both. Renal artery thrombosis usually occurs early post transplant, but is uncommon with an incidence of less than 1%. It typically results in graft loss. It usually occurs as a result of a technical problem such a vessel torsion or sub intimal flaps. The usual presenting feature is a sudden cessation of urine output. When suspected, the occlusion is usually well demonstrated with duplex scanning. Ideally immediate surgical re-exploration should occur. Sadly, the graft has usually been lost by this stage and will require graft nephrectomy. Renal vein thrombosis is not as common as arterial graft thrombosis and the usual presenting features include discomfort at the graft site and swelling of the graft associated with loss of urine output. Again, duplex scanning is indicated. Unfortunately, this complication is also associated with a high incidence of graft loss. Over a longer time frame (typically months) some individuals will develop renal artery stenosis. These individuals will typically develop hypertension and over time graft function will decline as hypertensive nephropathy occurs. It is usually demonstrated by duplex scanning and is usually amenable to endovascular intervention. Urological complications Urinary tract complications manifesting as leakage or obstruction are common complications following renal transplantation and occur in up to 10% of patients. The main underlying cause is the relatively poor blood supply to the transplanted ureter. Patients typically present relatively early in the first 5 weeks following transplantation with pain and swelling at the graft site. Imaging with USS is often the initial test. Therapeutic options include surgical re-implantation of the ureter for large leaks and stent insertion and nephrostomy placement for smaller leaks. Lymphocele These do not generally occur until 2 weeks or longer after surgery. They are, however, relatively common and may be seen in up to 18% of patients. Symptoms usually occur as a result of mass effect with compression of adjacent structures. These include the vessels supplying both the graft, with deterioration in graft function, the ureter, with alteration in urine output and the recipients lower limb vessels, with development of leg swelling. Creation of a laparoscopic or open peritoneal window is a favored treatment. Rejection Four types of graft rejection are recognised; hyperacute, accelerated acute, acute and chronic. Type of rejection Key features Hyperacute Occurs within minutes of clamp release Due to pre formed antibodies Immediate loss of graft occurs Accelerated acute Occurs in first few days following surgery Involved both cellular and antibody mediated injury Pre-sensitisation of the donor is a common cause Acute Traditionally the most common type of rejection Seen days to weeks after surgery Predominantly a cell mediated process mediated by lymphocytes Organ biopsy demonstrates cellular infiltrates and graft cell apoptosis Chronic Increasingly common problem Typically; graft atrophy and atherosclerosis are seen. Fibrosis often occurs as a late event

Answer 175

Lymphocele Swelling over the graft site is often due to a lymphocele and this is further suggested by the normal renal function. They cause symptoms through mass effect and limb swelling may occur. Treatment is often surgical. Complications of renal transplantation A number of complications may occur following renal transplantation. A critical aspect of post operative care is evaluation of graft function. Post operatively, urine output is the most readily available, and easily measured, indicator of graft function. If an individual was relatively anuric pre-transplant and has a good urine output following surgery then this is more useful than it would be in someone who had a higher volume diuresis prior to transplantation. Recipients can be divided into three main groups following renal transplantation, with regard to their graft function: Immediate graft function; brisk diuresis and falling serum creatinine Slow graft function; modest urine output and slowly falling creatinine levels Delayed graft function; defined as need for dialysis post transplant Decreased urine output following surgery can be the result of hypovolvaemia or a blocked catheter (commonest causes). Other important causes include rejection, or a vascular complication. Vascular complications These may involve the donor vessels, those of the recipient or both. Renal artery thrombosis usually occurs early post transplant, but is uncommon with an incidence of less than 1%. It typically results in graft loss. It usually occurs as a result of a technical problem such a vessel torsion or sub intimal flaps. The usual presenting feature is a sudden cessation of urine output. When suspected, the occlusion is usually well demonstrated with duplex scanning. Ideally immediate surgical re-exploration should occur. Sadly, the graft has usually been lost by this stage and will require graft nephrectomy. Renal vein thrombosis is not as common as arterial graft thrombosis and the usual presenting features include discomfort at the graft site and swelling of the graft associated with loss of urine output. Again, duplex scanning is indicated. Unfortunately, this complication is also associated with a high incidence of graft loss. Over a longer time frame (typically months) some individuals will develop renal artery stenosis. These individuals will typically develop hypertension and over time graft function will decline as hypertensive nephropathy occurs. It is usually demonstrated by duplex scanning and is usually amenable to endovascular intervention. Urological complications Urinary tract complications manifesting as leakage or obstruction are common complications following renal transplantation and occur in up to 10% of patients. The main underlying cause is the relatively poor blood supply to the transplanted ureter. Patients typically present relatively early in the first 5 weeks following transplantation with pain and swelling at the graft site. Imaging with USS is often the initial test. Therapeutic options include surgical re-implantation of the ureter for large leaks and stent insertion and nephrostomy placement for smaller leaks. Lymphocele These do not generally occur until 2 weeks or longer after surgery. They are, however, relatively common and may be seen in up to 18% of patients. Symptoms usually occur as a result of mass effect with compression of adjacent structures. These include the vessels supplying both the graft, with deterioration in graft function, the ureter, with alteration in urine output and the recipients lower limb vessels, with development of leg swelling. Creation of a laparoscopic or open peritoneal window is a favored treatment. Rejection Four types of graft rejection are recognised; hyperacute, accelerated acute, acute and chronic. Type of rejection Key features Hyperacute Occurs within minutes of clamp release Due to pre formed antibodies Immediate loss of graft occurs Accelerated acute Occurs in first few days following surgery Involved both cellular and antibody mediated injury Pre-sensitisation of the donor is a common cause Acute Traditionally the most common type of rejection Seen days to weeks after surgery Predominantly a cell mediated process mediated by lymphocytes Organ biopsy demonstrates cellular infiltrates and graft cell apoptosis Chronic Increasingly common problem Typically; graft atrophy and atherosclerosis are seen. Fibrosis often occurs as a late event

Answer 176

Such marked weight loss should arouse suspicion of cancer. She is most likely to have a longstanding stricture associated with oesophagitis and Barretts oesophagus. This may progress to carcinoma which will tend to occur in association with worsening dysphagia and weight loss. Oesophageal cancer Incidence is increasing In most cases in the Western world this increase is accounted for by a rise in the number of cases of adenocarcinoma. In the UK adenocarcinomas account for 65% of cases. Barretts oesophagus is a major risk factor for most cases of oesophageal adenocarcinoma. In other regions of the world squamous cancer is more common and is linked to smoking, alcohol intake, diets rich in nitrosamines and achalasia. Surveillance of Barretts is important, as it imparts a 30 fold increase in cancer risk and if invasive malignancy is diagnosed early then survival may approach 85% at 5 years. Diagnosis Upper GI endoscopy is the first line test Contrast swallow may be of benefit in classifying benign motility disorders but has no place in the assessment of tumours Staging is initially undertaken with CT scanning of the chest, abdomen and pelvis. If overt metastatic disease is identified using this modality then further complex imaging is unnecessary If CT does not show metastatic disease, then local stage may be more accurately assessed by use of endoscopic ultrasound. Staging laparoscopy is performed to detect occult peritoneal disease. PET CT is performed in those with negative laparoscopy. Thoracoscopy is not routinely performed. Treatment Operable disease is best managed by surgical resection. The most standard procedure is an Ivor- Lewis type oesophagectomy. This procedure involves the mobilisation of the stomach and division of the oesophageal hiatus. The abdomen is closed and a right sided thoracotomy performed. The stomach is brought into the chest and the oesophagus mobilised further. An intrathoracic oesophagogastric anastomosis is constructed. Alternative surgical strategies include a transhiatal resection (for distal lesions), a left thoraco-abdominal resection (difficult access due to thoracic aorta) and a total oesophagectomy (McKeown) with a cervical oesophagogastric anastomosis. The biggest surgical challenge is that of anastomotic leak, with an intrathoracic anastomosis this will result in mediastinitis. With high mortality. The McKeown technique has an intrinsically lower systemic insult in the event of anastomotic leakage. In addition to surgical resection many patients will be treated with adjuvant chemotherapy.

Answer 177

Arrange a hormonal assay The vast majority of small adrenal lesions are incidental, benign and non functioning adenomas. Apart from minimal workup, no further investigation is needed. Of note, if there are concerns about malignancy, the only surgical option is adrenalectomy. Adrenal lesions- Incidental Incidentaloma of the adrenal glands have become increasingly common as CT scanning of the abdomen is widely undertaken. Prevalences range from 1.5-9% in autopsy studies. Overall, 75% will be non functioning adenomas. However, a thorough diagnostic work up is required to exclude a more significant lesion. Investigation Morning and midnight plasma cortisol measurements Dexamethasone suppression test 24 hour urinary cortisol excretion 24 hour urinary excretion of catecholamines Serum potassium, aldosterone and renin levels Management The risk of malignancy is related to the size of the lesion and 25% of all masses greater than 4cm will be malignant. Such lesions should usually be excised. Where a lesion is a suspected metastatic deposit a biopsy may be considered.

Answer 178

Carcinoma of the head of the pancreas Carcinoma of the pancreas (Courvoisiers law!). The development of jaundice in association with a smooth right upper quadrant mass is typical of distal biliary obstruction secondary to pancreatic malignancy. A bile duct stricture would not present in this way, all the other choices are related to gallstones and Fitz Hugh Curtis syndrome is a complication of pelvic inflammatory disease. Courvoisiers Law: Obstructive jaundice in the presence of a palpable gallbladder is unlikely to be due to stones. This is due to the fibrotic effect that stones have on the gallbladder. Like all these laws there are numerous exceptions and many cases will not present in the typical manner. Bile duct injury Inadvertent bile duct injury during laparoscopic surgery should be referred to a specialist hepatobiliary surgeon. Outcomes are far worse when repair is undertaken by a non specialist surgeon in a district hospital. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 179

Mirizzi syndrome In Mirizzi syndrome the gallstone becomes impacted in Hartmans pouch. Episodes of recurrent inflammation occur and this causes compression of the bile duct. In severe cases this then progresses to fistulation. Surgery is extremely difficult as Calots triangle is often completely obliterated and the risks of causing injury to the CBD are high. Courvoisiers Law: Obstructive jaundice in the presence of a palpable gallbladder is unlikely to be due to stones. This is due to the fibrotic effect that stones have on the gallbladder. Like all these laws there are numerous exceptions and many cases will not present in the typical manner. Bile duct injury Inadvertent bile duct injury during laparoscopic surgery should be referred to a specialist hepatobiliary surgeon. Outcomes are far worse when repair is undertaken by a non specialist surgeon in a district hospital. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 180

Peri hilar lymphadenopathy Unfortunately metastatic disease is the most likely event. Peri hilar lymphadenopathy would be a common culprit. Courvoisiers Law: Obstructive jaundice in the presence of a palpable gallbladder is unlikely to be due to stones. This is due to the fibrotic effect that stones have on the gallbladder. Like all these laws there are numerous exceptions and many cases will not present in the typical manner. Bile duct injury Inadvertent bile duct injury during laparoscopic surgery should be referred to a specialist hepatobiliary surgeon. Outcomes are far worse when repair is undertaken by a non specialist surgeon in a district hospital. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcots triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice offers rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) Diagnosis An ultrasound of the liver and biliary tree is the most commonly used first line test. This will establish bile duct calibre, often ascertain the presence of gallstones, may visualise pancreatic masses and other lesions. The most important clinical question is essentially the extent of biliary dilatation and its distribution. Where pancreatic neoplasia is suspected, the next test should be a pancreatic protocol CT scan. With liver tumours and cholangiocarcinoma an MRI/ MRCP is often the preferred option. PET scans may be used to stage a number of malignancies but do not routinely form part of first line testing. Where MRCP fails to give adequate information an ERCP may be necessary. In many cases this may form part of patient management. It is however, invasive and certainly not without risk and highly operator dependent. Management Clearly this will depend to an extent upon the underlying cause but relief of jaundice is important, even if surgery forms part of the planned treatment. Patients with unrelieved jaundice have a much higher incidence of septic complications, bleeding and death. Screen for and address any clotting irregularities In patients with malignancy a stent will need to be inserted. These come in two main types; metal and plastic. Plastic stents are cheap and easy to replace and should be used if any surgical intervention (e.g. Whipples) is planned. However, they are prone to displacement and blockage. Metal stents are much more expensive and may compromise a surgical resection. However, they are far less prone to displacement and to a lesser extent blockage than their plastic counterparts. If malignancy is in bile duct/ pancreatic head and stenting has been attempted and has failed, then an alternative strategy is to drain the biliary system percutaneously via a transhepatic route. It may also be possible to insert a stent in this way. One of the main problems with temporary PTC's is their propensity to displacement, which may result in a bile leak. In patients who have a bile duct injury surgery will be required to repair the defect. If the bile duct has been inadvertently excised then a hepatico-jejunostomy will need to be created (difficult!) If gallstones are the culprit, then these may be removed by ERCP and a cholecystectomy performed. Where there is doubt about the efficacy of the ERCP an operative cholangiogram should be performed and bile duct exploration undertaken where stones remain. When the bile duct has been formally opened the options are between closure over a T tube, a choledochoduodenostomy or choledochojejunostomy. Patients with cholangitis should receive high dose broad spectrum antibiotics via the intravenous route. Biliary decompression should follow soon afterwards, instrumenting the bile duct of these patients will often provoke a septic episode (but should be done anyway).

Answer 181

Seborrhoeic keratosis Seborrhoeic keratosis may have a number of appearances. However, the scaly, thick, greasy surface with scattered keratin plugs makes this the most likely diagnosis. Benign skin diseases Seborrhoeic keratosis Most commonly arise in patients over the age of 50 years, often idiopathic Equal sex incidence and prevalence Usually multiple lesions over face and trunk Flat, raised, filiform and pedunculated subtypes are recognised Variable colours and surface may have greasy scale overlying it Treatment options consist of leaving alone or simple shave excision Melanocytic naevi Congenital melanocytic naevi Typically appear at, or soon after, birth Usually greater than 1cm diameter Increased risk of malignant transformation (increased risk greatest for large lesions) Junctional melanocytic naevi Circular macules May have heterogeneous colour even within same lesion Most naevi of the palms, soles and mucous membranes are of this type Compound naevi Domed pigmented nodules up to 1cm in diameter Arise from junctional naevi, usually have uniform colour and are smooth Spitz naevus Usually develop over a few months in children May be pink or red in colour, most common on face and legs May grow up to 1cm and growth can be rapid, this usually results in excision Atypical naevus syndrome Atypical melanocytic naevi that may be autosomally dominantly inherited Some individuals are at increased risk of melanoma (usually have mutations of CDKN2A gene) Many people with atypical naevus syndrome AND a parent sibling with melanoma will develop melanoma Epidermoid cysts Common and affect face and trunk They have a central punctum, they may contain small quantities of sebum The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar cyst) Dermatofibroma Solitary dermal nodules Usually affect extremities of young adults Lesions feel larger than they appear visually Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues ``` Painful skin lesions Eccrine spiradenoma Neuroma Glomus tumour Leimyoma Angiolipoma Neurofibroma (rarely painful) and dermatofibroma (rarely painful) ```

Answer 182

Pilar cyst Pilar cysts may contain foul smelling cheesy material and are surrounded by the outer part of a hair follicle. Because of their histological appearances they are more correctly termed pilar cysts than sebaceous cysts. Benign skin diseases Seborrhoeic keratosis Most commonly arise in patients over the age of 50 years, often idiopathic Equal sex incidence and prevalence Usually multiple lesions over face and trunk Flat, raised, filiform and pedunculated subtypes are recognised Variable colours and surface may have greasy scale overlying it Treatment options consist of leaving alone or simple shave excision Melanocytic naevi Congenital melanocytic naevi Typically appear at, or soon after, birth Usually greater than 1cm diameter Increased risk of malignant transformation (increased risk greatest for large lesions) Junctional melanocytic naevi Circular macules May have heterogeneous colour even within same lesion Most naevi of the palms, soles and mucous membranes are of this type Compound naevi Domed pigmented nodules up to 1cm in diameter Arise from junctional naevi, usually have uniform colour and are smooth Spitz naevus Usually develop over a few months in children May be pink or red in colour, most common on face and legs May grow up to 1cm and growth can be rapid, this usually results in excision Atypical naevus syndrome Atypical melanocytic naevi that may be autosomally dominantly inherited Some individuals are at increased risk of melanoma (usually have mutations of CDKN2A gene) Many people with atypical naevus syndrome AND a parent sibling with melanoma will develop melanoma Epidermoid cysts Common and affect face and trunk They have a central punctum, they may contain small quantities of sebum The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar cyst) Dermatofibroma Solitary dermal nodules Usually affect extremities of young adults Lesions feel larger than they appear visually Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues ``` Painful skin lesions Eccrine spiradenoma Neuroma Glomus tumour Leimyoma Angiolipoma Neurofibroma (rarely painful) and dermatofibroma (rarely painful) ```

Answer 183

Dermatofibroma Dermatofibromas may be pigmented and are often larger than they appear. They frequently occur at sites of previous trauma. Benign skin diseases Seborrhoeic keratosis Most commonly arise in patients over the age of 50 years, often idiopathic Equal sex incidence and prevalence Usually multiple lesions over face and trunk Flat, raised, filiform and pedunculated subtypes are recognised Variable colours and surface may have greasy scale overlying it Treatment options consist of leaving alone or simple shave excision Melanocytic naevi Congenital melanocytic naevi Typically appear at, or soon after, birth Usually greater than 1cm diameter Increased risk of malignant transformation (increased risk greatest for large lesions) Junctional melanocytic naevi Circular macules May have heterogeneous colour even within same lesion Most naevi of the palms, soles and mucous membranes are of this type Compound naevi Domed pigmented nodules up to 1cm in diameter Arise from junctional naevi, usually have uniform colour and are smooth Spitz naevus Usually develop over a few months in children May be pink or red in colour, most common on face and legs May grow up to 1cm and growth can be rapid, this usually results in excision Atypical naevus syndrome Atypical melanocytic naevi that may be autosomally dominantly inherited Some individuals are at increased risk of melanoma (usually have mutations of CDKN2A gene) Many people with atypical naevus syndrome AND a parent sibling with melanoma will develop melanoma Epidermoid cysts Common and affect face and trunk They have a central punctum, they may contain small quantities of sebum The cyst lining is either normal epidermis (epidermoid cyst) or outer root sheath of hair follicle (pilar cyst) Dermatofibroma Solitary dermal nodules Usually affect extremities of young adults Lesions feel larger than they appear visually Histologically they consist of proliferating fibroblasts merging with sparsely cellular dermal tissues ``` Painful skin lesions Eccrine spiradenoma Neuroma Glomus tumour Leimyoma Angiolipoma Neurofibroma (rarely painful) and dermatofibroma (rarely painful) ```

Answer 184

Orchidectomy via inguinal approach The patient is likely to have a teratoma which has metastasized to the supraclavicular nodes. There is suspicion of spread to the para-aortic nodes due to the abdominal pain. He will need orchidectomy and combination chemotherapy. There is no role for orchidectomy via scrotal approach in malignancy. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 185

No treatment needed This is an epididymal cyst, the testis is palpated therefore this differentiates it from a hydrocele. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 186

Testicular exploration within 6 hours Acute haematocele: tense, tender and non transilluminating mass. The testis will need surgical exploration to evacuate the blood and repair any damage. Inguinal hernia If inguinoscrotal swelling; cannot "get above it" on examination Cough impulse may be present May be reducible Testicular tumours Often discrete testicular nodule (may have associated hydrocele) Symptoms of metastatic disease may be present USS scrotum and serum AFP and β HCG required Acute epididymo-orchitis Often history of dysuria and urethral discharge Swelling may be tender and eased by elevating testis Most cases due to Chlamydia Infections with other gram negative organisms may be associated with underlying structural abnormality Epididymal cysts Single or multiple cysts May contain clear or opalescent fluid (spermatoceles) Usually occur over 40 years of age Painless Lie above and behind testis It is usually possible to "get above the lump" on examination Hydrocele Non painful, soft fluctuant swelling Often possible to "get above it" on examination Usually contain clear fluid Will often transilluminate May be presenting feature of testicular cancer in young men Testicular torsion Severe, sudden onset testicular pain Risk factors include abnormal testicular lie Typically affects adolescents and young males On examination testis is tender and pain not eased by elevation Urgent surgery is indicated, the contra lateral testis should also be fixed Varicocele Varicosities of the pampiniform plexus Typically occur on left (because testicular vein drains into renal vein) May be presenting feature of renal cell carcinoma Affected testis may be smaller and bilateral varicoceles may affect fertility Management Testicular malignancy is always treated with orchidectomy via an inguinal approach. This allows high ligation of the testicular vessels and avoids exposure of another lymphatic field to the tumour. Torsion is commonest in young teenagers and the history in older children can be difficult to elicit. Intermittent torsion is a recognised problem. The treatment is prompt surgical exploration and testicular fixation. This can be achieved using sutures or by placement of the testis in a Dartos pouch. Varicoceles are usually managed conservatively. If there are concerns about testicular function of infertility then surgery or radiological management can be considered. Epididymal cysts can be excised using a scrotal approach Hydroceles are managed differently in children where the underlying pathology is a patent processus vaginalis and therefore an inguinal approach is used in children so that the processus can be ligated. In adults a scrotal approach is preferred and the hydrocele sac excised or plicated.

Answer 187

Mesenteric cysts are often smooth. Imaging with ultrasound and CT is usually sufficient. Although rare, they most often occur in young children (up to 30% present before the age of 15). Many are asymptomatic and discovered incidentally. Acute presentations are recognised and may occur following cyst torsion, infarction or rupture. Most cysts will be surgically resected. Spigelian hernias are very rare in children, liposarcomas are not smooth swellings. An appendix mass will usually produce systemic illness. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 188

Laparoscopic appendicectomy The most likely diagnosis is appendicitis. The negative vaginal examination (and therefore by definition the absence of cervical excitation) makes pelvic inflammatory disease unlikely. Given the raised inflammatory markers, the correct course of action is to proceed with surgery. In females, there are considerable advantages of undertaking this laparoscopically as it allows evaluation of the pelvic viscera. Imaging with USS is unlikely to alter management as it has a false negative rate and given the context of the clinical findings, surgery is likely to occur in any case. Whilst a CT scan would allow for an accurate pre-operative diagnosis, it carries a significant radiation dose, and again, is unlikely to alter management. ``` Appendicitis Pain radiating to right iliac fossa Anorexia (very common) Short history Diarrhoea and profuse vomiting rare ``` Crohn's disease Often long history Signs of malnutrition Change in bowel habit, especially diarrhoea Mesenteric adenitis Mainly affects children Causes include Adenoviruses, Epstein Barr Virus, beta-haemolytic Streptococcus, Staphylococcus spp., Escherichia coli, Streptococcus viridans and Yersinia spp. Patients have a higher temperature than those with appendicitis If laparotomy is performed, enlarged mesenteric lymph nodes will be present Diverticulitis Both left and right sided disease may present with right iliac fossa pain Clinical history may be similar, although some change in bowel habit is usual When suspected, a CT scan may help in refining the diagnosis Meckel's diverticulitis A Meckel's diverticulum is a congenital abnormality that is present in about 2% of the population Typically 2 feet proximal to the ileocaecal valve May be lined by ectopic gastric mucosal tissue and produce bleeding Perforated peptic ulcer This usually produces upper quadrant pain but pain may be lower Perforations typically have a sharp sudden onset of pain in the history Incarcerated right inguinal or femoral hernia Usually only right iliac fossa pain if right sided or bowel obstruction. Bowel perforation secondary to caecal or colon carcinoma Seldom localised to right iliac fossa, although complete large bowel obstruction with caecal distension may cause pain prior to perforation. Gynaecological causes Pelvic inflammatory disease/salpingitis/pelvic abscess/Ectopic pregnancy/Ovarian torsion/Threatened or complete abortion/Mittelschmerz Urological causes Ureteric colic/UTI/Testicular torsion Other causes TB/Typhoid/Herpes Zoster/AAA/Situs inversus

Answer 189

Congenital heart disease Cyanotic: TGA most common at birth, Fallot's most common overall Acyanotic: VSD most common cause It is important to be aware of common congenital cardiac abnormalities. The main differentiating factor is whether the patient is cyanotic or acyanotic. In the neonate, TGA is the most common condition presenting with profound cyanosis. The other options are causes of acyanotic congenital heart disease Congenital heart disease ``` Acyanotic - most common causes Ventricular septal defects (VSD) - most common, accounts for 30% Atrial septal defect (ASD) Patent ductus arteriosus (PDA) Coarctation of the aorta Aortic valve stenosis ``` VSDs are more common than ASDs. However, in adult patients ASDs are the more common new diagnosis as they generally present later. ``` Cyanotic - most common causes Tetralogy of Fallot Transposition of the great arteries (TGA) Tricuspid atresia Pulmonary valve stenosis ```

Answer 190

Wide local excision and sentinel lymph node biopsy A small peripheral lesion such as this would usually be suitable for breast conserving surgery. Since imaging and clinical examination is not suspicious for axillary disease, a sentinel lymph node biopsy should be performed. Breast cancer management Surgery is performed in most patients suffering from breast cancer. Chemotherapy may be used to downstage tumours and allow breast conserving surgery. Hormonal therapy may also be used for the same purposes. Radiotherapy is given to all patients who have undergone breast conserving surgery. Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or as a staged procedure at a later date. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts Axillary disease As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy. Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance. Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.

Answer 191

Wide local excision and axillary node clearance Although the primary lesion is small enough for breast conserving surgery, the presence of overt axillary lymph node metastasis will attract a recommendation for axillary node clearance. Breast cancer management Surgery is performed in most patients suffering from breast cancer. Chemotherapy may be used to downstage tumours and allow breast conserving surgery. Hormonal therapy may also be used for the same purposes. Radiotherapy is given to all patients who have undergone breast conserving surgery. Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or as a staged procedure at a later date. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts Axillary disease As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy. Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance. Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.

Answer 192

Simple mastectomy and axillary node clearance A combination of established axillary disease and multifocal invasive lesions attracts an indication for mastectomy and axillary clearance. A radical mastectomy is less frequently indicated in modern surgical practice, disease that is locally advanced is often best downstaged using medical therapy, rather than embarking on the operations for breast cancer that were first popularised over 100 years ago. Breast cancer management Surgery is performed in most patients suffering from breast cancer. Chemotherapy may be used to downstage tumours and allow breast conserving surgery. Hormonal therapy may also be used for the same purposes. Radiotherapy is given to all patients who have undergone breast conserving surgery. Patients who have undergone mastectomy may be offered a reconstructive procedure either in conjunction with their primary resection or as a staged procedure at a later date. Surgical options Mastectomy vs Wide local excision ``` Mastectomy Wide Local Excision Multifocal tumour Solitary lesion Central tumour Peripheral tumour Large lesion in small breast Small lesion in large breast DCIS >4cm DCIS <4cm Patient Choice Patient choice ``` Central lesions may be managed using breast conserving surgery, where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts Axillary disease As a minimum, all patients with invasive breast cancer should have their axilla staged. In those who do not have overt evidence of axillary nodal involvement this can be undertaken using sentinel lymph node biopsy. Patients with a positive sentinel lymph node biopsy or who have imaging and cytological or histological evidence of axillary nodal metastasis should undergo axillary node clearance. Axillary node clearance is associated with the development of lymphoedema, increased risk of cellulitis and frozen shoulder.

Answer 193

Endoscopic mucosal resection EMR is an reasonable option for small areas of malignancy occurring on a background of Barretts change. Segmental resections of the oesophagus are not practised and the only resectional strategy in this scenario would be an Ivor- Lewis type resection. The morbidity such a strategy in T1 disease is probably not justified. Oesophageal cancer - treatment Treatments for SCC's and adenocarcinomas of the oesophagus differ. This is primarily due to the positive outcomes that are observed when localised SCC's (particularly of the proximal oesophagus are treated with radical chemoradiotherapy (obviating the need for surgery). Only those patients whose staging investigations are negative for metastatic disease should be considered for surgery. Surgical options Endoscopic mucosal resection Treatment for early localised adenocarcinoma of the distal oesophagus. Survival mirrors that of surgical resection for Tis and T1 disease Transhiatal oeosphagectomy Most commonly used for junctional (type II) (1) tumours where limited thoracic oesophageal resection is required. Less morbidity than two field oesophagectomy Ivor Lewis oesophagectomy Two stage approach for middle and distal tumours. Very commonly performed, intrathoracic anastomosis will result in mediastinitis in event of anastomotic leak. Lower incidence of recurrent laryngeal nerve injury McKeown oesophagectomy Three field approach, may be useful for proximal tumours. Anastomotic leakage is less serious. Higher incidence of recurrent laryngeal nerve injury Neoadjuvent and adjuvent treatment Neoadjuvent radiotherapy alone prior to resection confers little benefit and is not routinely performed (2) Preoperative chemotherapy is associated with a survival advantage (OE02 trial) Peri operative (pre and post operative) chemotherapy confers a survival advantage in junctional tumours Post operative chemotherapy is not generally recommended following oesophageal resections outside clinical trials Palliation strategies Combination chemotherapy improves quality of life and survival in non operable disease (3) Trastuzumab may improve survival in patients with HER 2 positive tumours Oesophageal intubation with self expanding metal stents is the treatment of choice in patients with occluding tumours >2cm from the cricopharyngeus Covered metal stents are useful in cases of malignant fistulas Laser therapy and argon plasma coagulation may be useful as therapies for tumour overgrowth and bleeding Photodynamic therapy and ethanol injections confer little benefit and should not be routinely used

Answer 194

Insertion of expanding metallic stent Distant disease in patients with oesophageal cancer is a contra indication to a resectional strategy and downstaging with chemotherapy is not routinely undertaken in this age group as the results are poor. An expanding stent will provide rapid and durable palliation. Oesophageal cancer - treatment Treatments for SCC's and adenocarcinomas of the oesophagus differ. This is primarily due to the positive outcomes that are observed when localised SCC's (particularly of the proximal oesophagus are treated with radical chemoradiotherapy (obviating the need for surgery). Only those patients whose staging investigations are negative for metastatic disease should be considered for surgery. Surgical options Endoscopic mucosal resection Treatment for early localised adenocarcinoma of the distal oesophagus. Survival mirrors that of surgical resection for Tis and T1 disease Transhiatal oeosphagectomy Most commonly used for junctional (type II) (1) tumours where limited thoracic oesophageal resection is required. Less morbidity than two field oesophagectomy Ivor Lewis oesophagectomy Two stage approach for middle and distal tumours. Very commonly performed, intrathoracic anastomosis will result in mediastinitis in event of anastomotic leak. Lower incidence of recurrent laryngeal nerve injury McKeown oesophagectomy Three field approach, may be useful for proximal tumours. Anastomotic leakage is less serious. Higher incidence of recurrent laryngeal nerve injury Neoadjuvent and adjuvent treatment Neoadjuvent radiotherapy alone prior to resection confers little benefit and is not routinely performed (2) Preoperative chemotherapy is associated with a survival advantage (OE02 trial) Peri operative (pre and post operative) chemotherapy confers a survival advantage in junctional tumours Post operative chemotherapy is not generally recommended following oesophageal resections outside clinical trials Palliation strategies Combination chemotherapy improves quality of life and survival in non operable disease (3) Trastuzumab may improve survival in patients with HER 2 positive tumours Oesophageal intubation with self expanding metal stents is the treatment of choice in patients with occluding tumours >2cm from the cricopharyngeus Covered metal stents are useful in cases of malignant fistulas Laser therapy and argon plasma coagulation may be useful as therapies for tumour overgrowth and bleeding Photodynamic therapy and ethanol injections confer little benefit and should not be routinely used

Answer 195

Chemo-radiotherapy SCC of the oesophagus is treated with chemo-radiotherapy in the first instance. Oesophageal cancer - treatment Treatments for SCC's and adenocarcinomas of the oesophagus differ. This is primarily due to the positive outcomes that are observed when localised SCC's (particularly of the proximal oesophagus are treated with radical chemoradiotherapy (obviating the need for surgery). Only those patients whose staging investigations are negative for metastatic disease should be considered for surgery. Surgical options Endoscopic mucosal resection Treatment for early localised adenocarcinoma of the distal oesophagus. Survival mirrors that of surgical resection for Tis and T1 disease Transhiatal oeosphagectomy Most commonly used for junctional (type II) (1) tumours where limited thoracic oesophageal resection is required. Less morbidity than two field oesophagectomy Ivor Lewis oesophagectomy Two stage approach for middle and distal tumours. Very commonly performed, intrathoracic anastomosis will result in mediastinitis in event of anastomotic leak. Lower incidence of recurrent laryngeal nerve injury McKeown oesophagectomy Three field approach, may be useful for proximal tumours. Anastomotic leakage is less serious. Higher incidence of recurrent laryngeal nerve injury Neoadjuvent and adjuvent treatment Neoadjuvent radiotherapy alone prior to resection confers little benefit and is not routinely performed (2) Preoperative chemotherapy is associated with a survival advantage (OE02 trial) Peri operative (pre and post operative) chemotherapy confers a survival advantage in junctional tumours Post operative chemotherapy is not generally recommended following oesophageal resections outside clinical trials Palliation strategies Combination chemotherapy improves quality of life and survival in non operable disease (3) Trastuzumab may improve survival in patients with HER 2 positive tumours Oesophageal intubation with self expanding metal stents is the treatment of choice in patients with occluding tumours >2cm from the cricopharyngeus Covered metal stents are useful in cases of malignant fistulas Laser therapy and argon plasma coagulation may be useful as therapies for tumour overgrowth and bleeding Photodynamic therapy and ethanol injections confer little benefit and should not be routinely used

Answer 196

Elevated thyroglobulin levels raises suspicion of recurrence. Thyroid malignancy Papillary carcinoma Commonest sub-type Accurately diagnosed on fine needle aspiration cytology Histologically, they may demonstrate psammoma bodies (areas of calcification) and so called 'orphan Annie' nuclei They typically metastasise via the lymphatics and thus laterally located apparently ectopic thyroid tissue is usually a metastasis from a well differentiated papillary carcinoma Follicular carcinoma Are less common than papillary lesions Like papillary tumours, they may present as a discrete nodule. Although they appear to be well encapsulated macroscopically there is invasion on microscopic evaluation Lymph node metastases are uncommon and these tumours tend to spread haematogenously. This translates into a higher mortality rate Follicular lesions cannot be accurately diagnosed on fine needle aspiration cytology and thus all follicular FNA's (THY 3f) will require at least a hemi thyroidectomy Anaplastic carcinoma Less common and tend to occur in elderly females Disease is usually advanced at presentation and often only palliative decompression and radiotherapy can be offered. Medullary carcinoma These are tumours of the parafollicular cells ( C Cells) and are of neural crest origin. The serum calcitonin may be elevated which is of use when monitoring for recurrence. They may be familial and occur as part of the MEN -2A disease spectrum. Spread may be either lymphatic or haematogenous and as these tumours are not derived primarily from thyroid cells they are not responsive to radioiodine. Lymphoma These respond well to radiotherapy Radical surgery is unnecessary once the disease has been diagnosed on biopsy material. Such biopsy material is not generated by an FNA and thus a core biopsy has to be obtained (with care!).

Answer 197

Liver function testing is part of the core diagnostic work up of biliary colic and surgical planning cannot proceed until this (and the diameter of the CBD on USS) are known. Gallstones Up to 24% of women and 12% of men may have gallstones. Of these up to 30% may develop local infection and cholecystitis. In patients subjected to surgery 12% will have stones contained within the common bile duct. The majority of gallstones are of a mixed composition (50%) with pure cholesterol stones accounting for 20% of cases. The aetiology of CBD stones differs in the world, in the West most CBD stones are the result of migration. In the East a far higher proportion arise in the CBD de novo. The classical symptoms are of colicky right upper quadrant pain that occurs post prandially. The symptoms are usually worst following a fatty meal when cholecystokinin levels are highest and gallbladder contraction is maximal. Investigation In almost all suspected cases the standard diagnostic work up consists of abdominal ultrasound and liver function tests. Of patients who have stones within the bile duct, 60% will have at least one abnormal result on LFT's. Ultrasound is an important test, but is operator dependent and therefore may occasionally need to be repeated if a negative result is at odds with the clinical picture. Where stones are suspected in the bile duct, the options lie between magnetic resonance cholangiography and intraoperative imaging. The choice between these two options is determined by the skills and experience of the surgeon. The advantages of intra operative imaging are less useful in making therapeutic decisions if the operator is unhappy about proceeding the bile duct exploration, and in such circumstances pre operative MRCP is probably a better option. Specific gallstone and gallbladder related disease Disease Features Management Biliary colic Colicky abdominal pain, worse post prandially, worse after fatty foods If imaging shows gallstones and history compatible then laparoscopic cholecystectomy Acute cholecystitis Right upper quadrant pain Fever Murphys sign on examination Occasionally mildly deranged LFT's (especially if Mirizzi syndrome) Imaging (USS) and cholecystectomy (ideally within 48 hours of presentation) (2) Gallbladder abscess Usually prodromal illness and right upper quadrant pain Swinging pyrexia Patient may be systemically unwell Generalised peritonism not present Imaging with USS +/- CT Scanning Ideally surgery, sub total cholecystectomy may be needed if Calots triangle is hostile In unfit patients percutaneous drainage may be considered Cholangitis Patient severely septic and unwell Jaundice Right upper quadrant pain Fluid resuscitation Broad spectrum intravenous antibiotics Correct any coagulopathy Early ERCP Gallstone ileus Patients may have a history of previous cholecystitis and known gallstones Small bowel obstruction (may be intermittent) Laparotomy and removal of gallstone from small bowel, the enterotomy must be made proximal to the site of obstruction and not at the site of obstruction. The fistula between the gallbladder and duodenum should not be interfered with. Acalculous cholecystitis Patients with inter current illness (e.g. diabetes, organ failure) Patient of systemically unwell Gallbladder inflammation in absence of stones High fever If patient fit then cholecystectomy, if unfit then percutaneous cholecystostomy Treatment Patients with asymptomatic gallstones rarely develop symptoms related to them (less than 2% per year) and may therefore be managed expectantly. In almost all cases of symptomatic gallstones the treatment of choice is cholecystectomy performed via the laparoscopic route. In the very frail patient there is sometimes a role for selective use of ultrasound guided cholecystostomy. During the course of the procedure some surgeons will routinely perform either intra operative cholangiography or laparoscopic USS to either confirm anatomy or to exclude CBD stones. The latter may be more easily achieved by use of laparoscopic ultrasound. If stones are found then the options lie between early ERCP in the day or so following surgery or immediate surgical exploration of the bile duct. When performed via the trans cystic route this adds little in the way of morbidity and certainly results in faster recovery. Where transcystic exploration fails the alternative strategy is that of formal choledochotomy. The exploration of a small duct is challenging and ducts of less than 8mm should not be explored. Small stones that measure less than 5mm may be safely left and most will pass spontaneously. ``` Risks of ERCP(1) Bleeding 0.9% (rises to 1.5% if sphincterotomy performed) Duodenal perforation 0.4% Cholangitis 1.1% Pancreatitis 1.5% ```

Answer 198

Place a drain laparoscopically and administer parenteral antibiotics Attempt conservative management for appendix mass without peritonitis. Dissection of appendix masses can be associated with a considerable degree of morbidity, the gains of formally dissecting them over simple drainage and antibiotics are minimal. This was initially described as the Ochsner-Sherren regime and was based on the teachings of Albert Ochsner of Chicago and James Sherren of the London hospital. Appendicitis History Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is mid gut structure) radiating to the right iliac fossa due to localised parietal peritoneal inflammation. Vomit once or twice but marked and persistent vomiting is unusual. Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation and some loose stools. A pelvic abscess may also cause diarrhoea. Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are more typical of conditions like mesenteric adenitis. Anorexia is very common. It is very unusual for patients with appendicitis to be hungry. Examination Generalised peritonitis if perforation has occurred or localised peritonism. Retrocaecal appendicitis may have relatively few signs. Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness with a pelvic appendix. Diagnosis Typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy. Urine analysis may show mild leucocytosis but no nitrites. Ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion. Ultrasound examination may show evidence of luminal obstruction and thickening of the appendiceal wall as shown below Image sourced from Wikipedia Treatment Appendicectomy which can be performed via either an open or laparoscopic approach. Administration of metronidazole reduces wound infection rates. Patients with perforated appendicitis require copious abdominal lavage. Patients without peritonitis who have an appendix mass should receive broad spectrum antibiotics and consideration given to performing an interval appendicectomy. Be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.

Answer 199

Saphenous varix The history of varicose veins should indicate a more likely diagnosis of a varix. The varix can enlarge during coughing/sneezing. A blue discolouration may be noted. ``` Groin masses are common and include: Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!) ``` In the history, features relating to systemic illness and tempo of onset will often give a clue as to the most likely underlying diagnosis. Groin lumps- some key questions Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma) Scrotal lumps - some key questions Is the lump entirely intra scrotal Does it transilluminate (?hydrocele) Is there a cough impulse (?hernia) In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most convenient next investigation.

Answer 200

Lymphadenitis The red streaks are along the line of the lymphatics, indicating infection of the lymphatic vessels. Lymphadenitis is infection of the local lymph nodes. ``` Groin masses are common and include: Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!) ``` In the history, features relating to systemic illness and tempo of onset will often give a clue as to the most likely underlying diagnosis. Groin lumps- some key questions Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma) Scrotal lumps - some key questions Is the lump entirely intra scrotal Does it transilluminate (?hydrocele) Is there a cough impulse (?hernia) In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most convenient next investigation.

Answer 201

False femoral artery aneurysm False aneurysms may occur following arterial trauma in IVDU. They may have associated blood borne virus infections and should undergo duplex scanning prior to surgery. False aneurysms do not contain all layers of the arterial wall. ``` Groin masses are common and include: Herniae Lipomas Lymph nodes Undescended testis Femoral aneurysm Saphena varix (more a swelling than a mass!) ``` In the history, features relating to systemic illness and tempo of onset will often give a clue as to the most likely underlying diagnosis. Groin lumps- some key questions Is there a cough impulse Is it pulsatile AND is it expansile (to distinguish between false and true aneurysm) Are both testes intra scrotal Any lesions in the legs such as malignancy or infections (?lymph nodes) Examine the ano rectum as anal cancer may metastasise to the groin Is the lump soft, small and very superficial (?lipoma) Scrotal lumps - some key questions Is the lump entirely intra scrotal Does it transilluminate (?hydrocele) Is there a cough impulse (?hernia) In most cases a diagnosis can be made clinically. Where it is not clear an ultrasound scan is often the most convenient next investigation.

Answer 202

Clot embolus The development of mural or atrial appendage thrombi may occur following a myocardial infarct and co-existing atrial fibrillation may contribute to the formation. They tend to present with classical features of an embolic event. Embolus Sudden onset Depending upon level of occlusion; limb may show typical features of pain, loss of pulses and pallor. Sensory perceptive changes may also be present Thrombosis Usually known disease and prodromal symptoms e.g. claudication Disruption to flow may be incomplete If background disease process present then collaterals may be present and picture less dramatic Vasospasm May be due to Raynauds and affect extremities Symptoms are often temperature related Discolouration of the hands may occur (pale, dark, red) Symptoms improve during pregnancy (hyperdynamic circulation) Steal syndromes Occur secondary to arteriovenous fistula, or partial arterial occlusions (e.g. cervical rib) Pain and diminished pulses distal to fistula are seen ``` Vasculitis Vessel diameter and vasculitis classification Aorta and branches Takayasu's arteritis Buergers disease Giant cell arteritis Large and medium sized arteries Buergers disease Giant cell arteritis Polyarteritis nodosa Medium sized muscular arteries Polyarteritis nodosa Wegeners granulomatosis Small muscular arteries Wegeners granulomatosis Rheumatoid vasculitis ``` Specific conditions Takyasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches Females> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase Buergers disease Segmental thrombotic occlusions of the small and medium sized lower limb vessels Commonest in young male smokers Proximal pulses usually present, but pedal pulses are lost An acuter hypercellular occlusive thrombus is often present Tortuous corkscrew shaped collateral vessels may be seen on angiography Giant cell arteritis Systemic granulomatous arteritis that usually affects large and medium sized vessels Females > Males Temporal arteritis is commonest type Granulomatous lesions may be seen on biopsy (although up to 50% are normal) Polyarteritis nodosa Systemic necrotising vasculitis affecting small and medium sized muscular arteries Most common in populations with high prevalence of hepatitis B Renal disease is seen in 70% cases Angiography may show saccular or fusiform aneurysms and arterial stenoses Wegeners granulomatosis Predominantly affects small and medium sized arteries Systemic necrotising granulomatous vasculitis Cutaneous vascular lesions may be seen (ulceration, nodules and purpura) Sinus imaging may show mucosal thickening and air fluid levels

Answer 203

Direct arterial injury Both vasospasm and arterial injury may complicate supracondylar fractures and are seen in 1% of all cases. Vasospasm is usually transient and more likely when the injury is minor and reduced early. Severely displaced injuries and those with more advanced signs are usually associated with direct arterial injury. Embolus Sudden onset Depending upon level of occlusion; limb may show typical features of pain, loss of pulses and pallor. Sensory perceptive changes may also be present Thrombosis Usually known disease and prodromal symptoms e.g. claudication Disruption to flow may be incomplete If background disease process present then collaterals may be present and picture less dramatic Vasospasm May be due to Raynauds and affect extremities Symptoms are often temperature related Discolouration of the hands may occur (pale, dark, red) Symptoms improve during pregnancy (hyperdynamic circulation) Steal syndromes Occur secondary to arteriovenous fistula, or partial arterial occlusions (e.g. cervical rib) Pain and diminished pulses distal to fistula are seen ``` Vasculitis Vessel diameter and vasculitis classification Aorta and branches Takayasu's arteritis Buergers disease Giant cell arteritis Large and medium sized arteries Buergers disease Giant cell arteritis Polyarteritis nodosa Medium sized muscular arteries Polyarteritis nodosa Wegeners granulomatosis Small muscular arteries Wegeners granulomatosis Rheumatoid vasculitis ``` Specific conditions Takyasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches Females> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase Buergers disease Segmental thrombotic occlusions of the small and medium sized lower limb vessels Commonest in young male smokers Proximal pulses usually present, but pedal pulses are lost An acuter hypercellular occlusive thrombus is often present Tortuous corkscrew shaped collateral vessels may be seen on angiography Giant cell arteritis Systemic granulomatous arteritis that usually affects large and medium sized vessels Females > Males Temporal arteritis is commonest type Granulomatous lesions may be seen on biopsy (although up to 50% are normal) Polyarteritis nodosa Systemic necrotising vasculitis affecting small and medium sized muscular arteries Most common in populations with high prevalence of hepatitis B Renal disease is seen in 70% cases Angiography may show saccular or fusiform aneurysms and arterial stenoses Wegeners granulomatosis Predominantly affects small and medium sized arteries Systemic necrotising granulomatous vasculitis Cutaneous vascular lesions may be seen (ulceration, nodules and purpura) Sinus imaging may show mucosal thickening and air fluid levels

Answer 204

Vasculitis This is likely to represent Buergers disease. It is commonest in young males who smoke heavily. Embolus Sudden onset Depending upon level of occlusion; limb may show typical features of pain, loss of pulses and pallor. Sensory perceptive changes may also be present Thrombosis Usually known disease and prodromal symptoms e.g. claudication Disruption to flow may be incomplete If background disease process present then collaterals may be present and picture less dramatic Vasospasm May be due to Raynauds and affect extremities Symptoms are often temperature related Discolouration of the hands may occur (pale, dark, red) Symptoms improve during pregnancy (hyperdynamic circulation) Steal syndromes Occur secondary to arteriovenous fistula, or partial arterial occlusions (e.g. cervical rib) Pain and diminished pulses distal to fistula are seen ``` Vasculitis Vessel diameter and vasculitis classification Aorta and branches Takayasu's arteritis Buergers disease Giant cell arteritis Large and medium sized arteries Buergers disease Giant cell arteritis Polyarteritis nodosa Medium sized muscular arteries Polyarteritis nodosa Wegeners granulomatosis Small muscular arteries Wegeners granulomatosis Rheumatoid vasculitis ``` Specific conditions Takyasu's arteritis Inflammatory, obliterative arteritis affecting aorta and branches Females> Males Symptoms may include upper limb claudication Clinical findings include diminished or absent pulses ESR often affected during the acute phase Buergers disease Segmental thrombotic occlusions of the small and medium sized lower limb vessels Commonest in young male smokers Proximal pulses usually present, but pedal pulses are lost An acuter hypercellular occlusive thrombus is often present Tortuous corkscrew shaped collateral vessels may be seen on angiography Giant cell arteritis Systemic granulomatous arteritis that usually affects large and medium sized vessels Females > Males Temporal arteritis is commonest type Granulomatous lesions may be seen on biopsy (although up to 50% are normal) Polyarteritis nodosa Systemic necrotising vasculitis affecting small and medium sized muscular arteries Most common in populations with high prevalence of hepatitis B Renal disease is seen in 70% cases Angiography may show saccular or fusiform aneurysms and arterial stenoses Wegeners granulomatosis Predominantly affects small and medium sized arteries Systemic necrotising granulomatous vasculitis Cutaneous vascular lesions may be seen (ulceration, nodules and purpura) Sinus imaging may show mucosal thickening and air fluid levels

Answer 205

Renal adenocarcinoma Renal adenocarcinoma is the most common variant and is associated with polycythaemia. Causes of haematuria Trauma Injury to renal tract Renal trauma commonly due to blunt injury (others penetrating injuries) Ureter trauma rare: iatrogenic Bladder trauma: due to RTA or pelvic fractures Infection Remember TB Malignancy Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare bladder tumours Prostate cancer Penile cancers: SCC Renal disease Glomerulonephritis Stones Microscopic haematuria common Structural abnormalities Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland Cystic renal lesions e.g. polycystic kidney disease Vascular malformations Renal vein thrombosis due to renal cell carcinoma Coagulopathy Causes bleeding of underlying lesions Drugs Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy Interstitial nephritis: penicillin, sulphonamides, and NSAIDs Anticoagulants Benign Exercise Gynaecological Endometriosis: flank pain, dysuria, and haematuria that is cyclical Iatrogenic Catheterisation Radiotherapy; cystitis, severe haemorrhage, bladder necrosis Pseudohaematuria For example following consumption of beetroot

Answer 206

Transitional cell carcinoma These arise from urothelium and necessitate a nephroureterectomy. Causes of haematuria Trauma Injury to renal tract Renal trauma commonly due to blunt injury (others penetrating injuries) Ureter trauma rare: iatrogenic Bladder trauma: due to RTA or pelvic fractures Infection Remember TB Malignancy Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare bladder tumours Prostate cancer Penile cancers: SCC Renal disease Glomerulonephritis Stones Microscopic haematuria common Structural abnormalities Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland Cystic renal lesions e.g. polycystic kidney disease Vascular malformations Renal vein thrombosis due to renal cell carcinoma Coagulopathy Causes bleeding of underlying lesions Drugs Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy Interstitial nephritis: penicillin, sulphonamides, and NSAIDs Anticoagulants Benign Exercise Gynaecological Endometriosis: flank pain, dysuria, and haematuria that is cyclical Iatrogenic Catheterisation Radiotherapy; cystitis, severe haemorrhage, bladder necrosis Pseudohaematuria For example following consumption of beetroot

Answer 207

Nephroblastoma Wilms tumours (nephroblastoma) usually present in the first 4 years of life and may cause lung metastases. Causes of haematuria Trauma Injury to renal tract Renal trauma commonly due to blunt injury (others penetrating injuries) Ureter trauma rare: iatrogenic Bladder trauma: due to RTA or pelvic fractures Infection Remember TB Malignancy Renal cell carcinoma (remember paraneoplastic syndromes): painful or painless Urothelial malignancies: 90% are transitional cell carcinoma, can occur anywhere along the urinary tract. Painless haematuria. Squamous cell carcinoma and adenocarcinoma: rare bladder tumours Prostate cancer Penile cancers: SCC Renal disease Glomerulonephritis Stones Microscopic haematuria common Structural abnormalities Benign prostatic hyperplasia (BPH) causes haematuria due to hypervascularity of the prostate gland Cystic renal lesions e.g. polycystic kidney disease Vascular malformations Renal vein thrombosis due to renal cell carcinoma Coagulopathy Causes bleeding of underlying lesions Drugs Cause tubular necrosis or interstitial nephritis: aminoglycosides, chemotherapy Interstitial nephritis: penicillin, sulphonamides, and NSAIDs Anticoagulants Benign Exercise Gynaecological Endometriosis: flank pain, dysuria, and haematuria that is cyclical Iatrogenic Catheterisation Radiotherapy; cystitis, severe haemorrhage, bladder necrosis Pseudohaematuria For example following consumption of beetroot

Answer 208

They are contained within the peritoneal sac and therefore do not have the fluid losses seen in gastroschisis. True malrotation is unusual and minor variants may not result in a requirement for surgery. Gastroschisis: Isolated abnormality, bowel lies outside abdominal wall through defect located to right of umbilicus. Exomphalos: Liver and gut remain covered with membranous sac connected to umbilical cord. It is associated with other developmental defects. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 209

Unilateral inferior laryngeal nerve injury This patient has diplophonia which causes a gargling sound. This is associated with dysphagia. This can also be caused by a vagus nerve lesion, but the recurrent laryngeal nerve is more at risk of damage. Voice production There are 2 main nerves involved: Superior laryngeal nerve (SLN) Innervates the cricothyroid muscle Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve Innervates intrinsic larynx muscles a. Opening vocal folds (as in breathing, coughing) b. Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing

Answer 210

Superior laryngeal nerve injury SLN lesions cause difficulty in voice pitch. Voice production There are 2 main nerves involved: Superior laryngeal nerve (SLN) Innervates the cricothyroid muscle Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve Innervates intrinsic larynx muscles a. Opening vocal folds (as in breathing, coughing) b. Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing

Answer 211

Bilateral inferior laryngeal nerves injuries This patient has aphonia due to bilateral damage to the recurrent laryngeal nerve. Voice production There are 2 main nerves involved: Superior laryngeal nerve (SLN) Innervates the cricothyroid muscle Since the cricothyroid muscle is involved in adjusting the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in: a. Abnormalities in pitch b. Inability to sing with smooth change to each higher note (glissando or pitch glide) Recurrent laryngeal nerve (RLN)/Inferior laryngeal nerve Innervates intrinsic larynx muscles a. Opening vocal folds (as in breathing, coughing) b. Closing vocal folds for vocal fold vibration during voice use c. Closing vocal folds during swallowing

Answer 212

Ethmoid sinus cancer Nasopharyngeal cancer is strongly associated with wood work. Most cases require an occupational exposure of greater than 10 years and are adenocarcinomas on histology. Most cases are ethmoidal in origin (Hadfield E. Ann R Coll Surg Engl. 1970 June; 46(6): 301319) Diseases of nose and sinuses Benign Tumours Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management. Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy. Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively. Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence. Malignant disease Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure). Adenoid cystic carcinoma usually originate in the smaller salivary glands. The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%. Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities. Maxillary sinusitis Common symptoms include post nasal discharge, pain, headache and toothache. Imaging may show a fluid level in the antrum. Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis Usually presents with frontal headache, nasal obstruction and altered sense of smell. Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.

Answer 213

Nasal polyps The combination of nasal polyps and atopy is well described. Some cases will respond favourably to systemic steroids and avoid surgery. Diseases of nose and sinuses Benign Tumours Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management. Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy. Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively. Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence. Malignant disease Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure). Adenoid cystic carcinoma usually originate in the smaller salivary glands. The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%. Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities. Maxillary sinusitis Common symptoms include post nasal discharge, pain, headache and toothache. Imaging may show a fluid level in the antrum. Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis Usually presents with frontal headache, nasal obstruction and altered sense of smell. Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.

Answer 214

Ethmoidal sinusitis Ethmoidal sinusitis may spread to the periorbital tissues resulting in periorbital cellulitis. The superomedial distribution makes a maxillary sinusitis less likely. Diseases of nose and sinuses Benign Tumours Simple papillomas may be an incidental finding or present with obstructive symptoms. Excision under general anaesthesia is sufficient management. Transitional cell papillomas may be more extensive and produce obstructive symptoms. Erosion of local structures is a recognised complication. These lesions may rarely undergo malignant transformation and therefore careful and complete excision is required, some cases may require partial or total maxillectomy. Pleomorphic adenomas of the maxillary sinuses are reported but are extremely rare, their symptoms typically include nasal obstruction and pain if the sinus is obstructed. Treatment is by complete surgical excision, the diagnosis is not infrequently made post operatively. Benign osteomas may develop in the paranasal sinuses, the frontal sinus is the most frequent location of such lesions. Symptoms include; pain, rhinorrhoea and anosmia. Most osteomas may be observed if asymptomatic, sphenoid osteomas should be resected soon after diagnosis as enlargement may compromise visual fields. Many sinus osteomas can now be resected endoscopically, complete surgical resection is required. Nasal polyps are benign lesions of the ethmoid sinus mucosa. Many patients may also have asthma, cystic fibrosis and a sensitivity to aspirin. Symptoms include watery rhinorrhoea, infection and anosmia. The polyps are usually a semi transparent grey mass. They are rare in childhood. Treatment is either with systemic steroids or surgical resection. The latter should be combined with antral washout. Low dose, nasal, steroid drops may reduce the risk of recurrence. Malignant disease Malignancies encountered in the nose and paranasal sinuses include; adenoid cystic carcinoma, squamous cell carcinoma and adenocarcinoma. Adenocarcinoma of the paranasal sinuses and nasopharynx is strongly linked to exposure to hard wood dust (after >10 years exposure). Adenoid cystic carcinoma usually originate in the smaller salivary glands. The majority of cancers (50%) arise from the lateral nasal wall, a smaller number (33%) arise from the maxillary antrum, ethmoid and sphenoid cancers comprise only 7%. Signs of malignancy on clinical examination include loose teeth, cranial nerve palsies and lymphadenopathy. Nasopharyngeal cancers are most common in individuals presenting from China and Asia and are linked to viral infection with Epstein Barr Virus. Radiotherapy and chemotherapy are the most commonly used modalities. Maxillary sinusitis Common symptoms include post nasal discharge, pain, headache and toothache. Imaging may show a fluid level in the antrum. Common organisms include Haemophilus influenzae or Streptococcus pneumoniae. Treatment with antral lavage may facilitate diagnosis and relieve symptoms. Antimicrobial therapy has to be continued for long periods. Antrostomy may be needed. Frontoethmoidal sinusitis Usually presents with frontal headache, nasal obstruction and altered sense of smell. Inflammation may progress to involve periorbital tissues. Ocular symptoms may occur and secondary CNS involvement brought about by infection entering via emissary veins. CT scanning is the imaging modality of choice. Early cases may be managed with antibiotics. More severe cases usually require surgical drainage.

Answer 215

Nimodipine is a calcium channel blocker. It reduces cerebral vasospasm and improves outcomes. It is administered to most cases of sub arachnoid haemorrhage. Sub arachnoid haemorrhage Spontaneous intracranial haemorrhage Most commonly sub arachnoid haemorrhage. It is due to intra cranial aneurysm in 85% cases. Approximately 10% of cases will have normal angiography and the cause will remain unclear. Patients with inherited connective tissue disorders are at higher risk although most cases are sporadic. >95% cases will have headache (often thunderclap) >15% will have coma Investigation CT scan for all (although as CSF blood clears the sensitivity declines) Lumbar puncture if CT normal (very unlikely if normal) CT angiogram to look for aneurysms. Management Supportive treatment, optimising BP (not too high if untreated aneurysm) and ventilation if needed. Nimodipine reduces cerebral vasospasm and reduces poor outcomes. Untreated patients most likely to rebleed in first 2 weeks. Patients developing hydrocephalus will need a V-P shunt (external ventricular drain acutely). Electrolytes require careful monitoring and hyponatraemia is common. Treatment of aneurysm >80% aneuryms arise from the anterior circulation Craniotomy and clipping of aneurysm is standard treatment, alternatively suitable lesions may be coiled using an endovascular approach. Where both options are suitable data suggests that outcomes are better with coiling than surgery.

Answer 216

Oesophagectomy Some may argue for local therapy. However, in young patients who are otherwise fit, multifocal disease such as this should probably be resected. Treatment of oesophageal cancer In general resections are not offered to those patients with distant metastasis, and usually not to those with N2 disease. Local nodal involvement is not in itself a contra indication to resection. Surgical resection is the mainstay of treatment. Neoadjuvent chemotherapy is given in most cases prior to surgery. In situ disease may be managed by endoscopic mucosal resection, although this is still debated. In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably. More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus. Patients with unresectable disease may derive benefit from local ablative procedures, palliative chemotherapy or stent insertion. Operative details of Ivor- Lewis procedure Combined laparotomy and right thoracotomy Indication Lower and middle third oesophageal tumours Preparation Staging with a combination of CT chest abdomen and pelvis- if no metastatic disease detected then patients will undergo a staging laparoscopy to detect peritoneal disease. If both these modalities are negative then patients will finally undergo a PET CT scan to detect occult metastatic disease. Only in those whom no evidence of advanced disease is detected will proceed to resection. Patients receive a GA, double lumen endotracheal tube to allow for lung deflation, CVP and arterial monitoring. Procedure A rooftop incision is made to access the stomach and duodenum. Laparotomy To mobilize the stomach The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach. Then the short gastric vessels are ligated and detached from the greater curvature from the spleen. The lesser omentum is incised, preserving the right gastric artery. The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying. The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy. Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis Through 5th intercostal space Dissection performed 10cm above the tumour This may involve transection of the azygos vein. The oesophagus is then removed with the stomach creating a gastric tube. An anastomosis is created. The chest is closed with underwater seal drainage and tube drains to the abdominal cavity. Post operatively Patients will typically recover in ITU initially. A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery. Post operatively these patients are at relatively high risk of developing complications: * Atelectasis- due to the effects of thoracotomy and lung collapse * Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge. * Delayed gastric emptying (may be avoided by performing a pyloroplasty).

Answer 217

Insertion of oesophageal stent Although he may be palliated with chemotherapy a stent will produce the quickest clinical response. Metastatic disease is usually a contra indication to oesophageal resection Treatment of oesophageal cancer In general resections are not offered to those patients with distant metastasis, and usually not to those with N2 disease. Local nodal involvement is not in itself a contra indication to resection. Surgical resection is the mainstay of treatment. Neoadjuvent chemotherapy is given in most cases prior to surgery. In situ disease may be managed by endoscopic mucosal resection, although this is still debated. In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably. More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus. Patients with unresectable disease may derive benefit from local ablative procedures, palliative chemotherapy or stent insertion. Operative details of Ivor- Lewis procedure Combined laparotomy and right thoracotomy Indication Lower and middle third oesophageal tumours Preparation Staging with a combination of CT chest abdomen and pelvis- if no metastatic disease detected then patients will undergo a staging laparoscopy to detect peritoneal disease. If both these modalities are negative then patients will finally undergo a PET CT scan to detect occult metastatic disease. Only in those whom no evidence of advanced disease is detected will proceed to resection. Patients receive a GA, double lumen endotracheal tube to allow for lung deflation, CVP and arterial monitoring. Procedure A rooftop incision is made to access the stomach and duodenum. Laparotomy To mobilize the stomach The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach. Then the short gastric vessels are ligated and detached from the greater curvature from the spleen. The lesser omentum is incised, preserving the right gastric artery. The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying. The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy. Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis Through 5th intercostal space Dissection performed 10cm above the tumour This may involve transection of the azygos vein. The oesophagus is then removed with the stomach creating a gastric tube. An anastomosis is created. The chest is closed with underwater seal drainage and tube drains to the abdominal cavity. Post operatively Patients will typically recover in ITU initially. A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery. Post operatively these patients are at relatively high risk of developing complications: * Atelectasis- due to the effects of thoracotomy and lung collapse * Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge. * Delayed gastric emptying (may be avoided by performing a pyloroplasty).

Answer 218

Endoscopic sub mucosal dissection As she is elderly and the disease localised EMR is an appropriate first line step. The technique involves raising the mucosa containing the lesion and then using an endoscopic snare to remove it. This technique is therefore minimally invasive. However, it is only suitable for early superficial lesions. Deeper invasion would carry a high risk of recurrence Treatment of oesophageal cancer In general resections are not offered to those patients with distant metastasis, and usually not to those with N2 disease. Local nodal involvement is not in itself a contra indication to resection. Surgical resection is the mainstay of treatment. Neoadjuvent chemotherapy is given in most cases prior to surgery. In situ disease may be managed by endoscopic mucosal resection, although this is still debated. In patients with lower third lesions an Ivor - Lewis type procedure is most commonly performed. Very distal tumours may be suitable to a transhiatal procedure. Which is an attractive option as the penetration of two visceral cavities required for an Ivor- Lewis type procedure increases the morbidity considerably. More proximal lesions will require a total oesphagectomy (Mckeown type) with anastomosis to the cervical oesophagus. Patients with unresectable disease may derive benefit from local ablative procedures, palliative chemotherapy or stent insertion. Operative details of Ivor- Lewis procedure Combined laparotomy and right thoracotomy Indication Lower and middle third oesophageal tumours Preparation Staging with a combination of CT chest abdomen and pelvis- if no metastatic disease detected then patients will undergo a staging laparoscopy to detect peritoneal disease. If both these modalities are negative then patients will finally undergo a PET CT scan to detect occult metastatic disease. Only in those whom no evidence of advanced disease is detected will proceed to resection. Patients receive a GA, double lumen endotracheal tube to allow for lung deflation, CVP and arterial monitoring. Procedure A rooftop incision is made to access the stomach and duodenum. Laparotomy To mobilize the stomach The greater omentum is incised away from its attachment to the right gastroepiploic vessels along the greater curvature of the stomach. Then the short gastric vessels are ligated and detached from the greater curvature from the spleen. The lesser omentum is incised, preserving the right gastric artery. The retroperitoneal attachments of the duodenum in its second and third portions are incised, allowing the pylorus to reach the oesophageal hiatus. Some surgeons perform a pyloroplasty at this point to facilitate gastric emptying. The left gastric vessels are then ligated, avoiding any injury to the common hepatic or splenic arteries. Care must be taken to avoid inadvertently devascularising the liver owing to variations in anatomy. Right Thoracotomy Oesophageal resection and oesophagogastric anastomosis Through 5th intercostal space Dissection performed 10cm above the tumour This may involve transection of the azygos vein. The oesophagus is then removed with the stomach creating a gastric tube. An anastomosis is created. The chest is closed with underwater seal drainage and tube drains to the abdominal cavity. Post operatively Patients will typically recover in ITU initially. A nasogastric tube will have been inserted intraoperatively and must remain in place during the early phases of recovery. Post operatively these patients are at relatively high risk of developing complications: * Atelectasis- due to the effects of thoracotomy and lung collapse * Anastomotic leakage. The risk is relatively high owing to the presence of a relatively devascularised stomach. Often the only blood supply is from the gastroepiploic artery as all others will have been divided. If a leak does occur then many will attempt to manage conservatively with prolonged nasogastric tube drainage and TPN. The reality is that up to 50% of patients developing an anastomotic leak will not survive to discharge. * Delayed gastric emptying (may be avoided by performing a pyloroplasty).

Answer 219

Oesophageal atresia Diagnosis is confirmed when an nasogastric tube fails to reach the stomach. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 220

Oesophageal atresia This child has VACTERL, which is a combination of Vertebral, Ano-rectal, Cardiac, Tracheo-oesophageal, Renal and Radial limb anomalies. Half of babies with oesophageal atresia will have VACTERL. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 221

Mesenteric adenitis. Mesenteric adenitis may complicate upper respiratory tract infection and clinical exclusion of appendicitis can be difficult. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 222

Angioplasty Short segment disease and good run off with tissue loss is a compelling indication for angioplasty. He should receive aspirin and a statin if not already taking them. Peripheral vascular disease ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 223

Conservative management with medical therapy and exercise Structured exercise programmes combined with medical therapy will improve many patients. Should his symptoms worsen or fail to improve then imaging with duplex scanning would be required. Peripheral vascular disease ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 224

Primary amputation Poor runoff and sepsis would equate to poor outcome with attempted bypass surgery. Peripheral vascular disease ``` Indications for surgery to revascularise the lower limb Intermittent claudication Critical ischaemia Ulceration Gangrene ``` Intermittent claudication that is not disabling may provide a relative indication, whilst the other complaints are often absolute indications depending upon the frailty of the patient. Assessment Clinical examination Ankle brachial pressure index measurement Duplex arterial ultrasound Angiography (standard, CT or MRI): usually performed only if intervention being considered. Angioplasty In order for angioplasty to be undertaken successfully the artery has to be accessible. The lesion relatively short and reasonable distal vessel runoff. Longer lesions may be amenable to sub-intimal angioplasty. Surgery Surgery will be undertaken where attempts at angioplasty have either failed or are unsuitable. Bypass essentially involves bypassing the affected arterial segment by utilising a graft to run from above the disease to below the disease. As with angioplasty good runoff improves the outcome. Some key concepts with bypass surgery Superficial femoral artery occlusion to the above knee popliteal In the ideal scenario, vein (either in situ or reversed LSV) would the used as a conduit. However, prosthetic material has reasonable 5 year patency rates and some would advocate using this in preference to vein so that vein can be used for other procedures in the future. In general terms either technique is usually associated with an excellent outcome (if run off satisfactory). Procedure Artery dissected out, IV heparin 3,000 units given and then the vessels are cross clamped Longitudinal arteriotomy Graft cut to size and tunneled to arteriotomy sites Anastomosis to femoral artery usually with 5/0 'double ended' Prolene suture Distal anastomosis usually using 6/0 'double ended' Prolene Distal disease Femoro-distal bypass surgery takes longer to perform, is more technically challenging and has higher failure rates. In elderly diabetic patients with poor runoff a primary amputation may well be a safer and more effective option. There is no point in embarking on this type of surgery in patients who are wheelchair bound. In femorodistal bypasses vein gives superior outcomes to PTFE. Rules Vein mapping 1st to see whether there is suitable vein (the preferred conduit). Sub intimal hyperplasia occurs early when PTFE is used for the distal anastomosis and will lead to early graft occlusion and failure. Essential operative procedure as for above knee fem-pop. If there is insufficient vein for the entire conduit then vein can be attached to the end of the PTFE graft and then used for the distal anastomosis. This type of 'vein boot' is technically referred to as a Miller Cuff and is associated with better patency rates than PTFE alone. Remember the more distal the arterial anastomosis the lower the success rate.

Answer 225

Profuse vomiting and diarrhoea are rare in early appendicitis Whilst patients may vomit once or twice, profuse vomiting is unusual, and would fit more with gastroenteritis or an ileus. A trace of protein is not an uncommon occurrence in acute appendicitis. A free lying pelvic appendix may result in localised bladder irritation, with inflammation occurring as a secondary phenomena. This latter feature may result in patients being incorrectly diagnosed as having a urinary tract infection. A urine dipstick test is useful in differentiating between the two conditions. Appendicitis History Peri umbilical abdominal pain (visceral stretching of appendix lumen and appendix is mid gut structure) radiating to the right iliac fossa due to localised parietal peritoneal inflammation. Vomit once or twice but marked and persistent vomiting is unusual. Diarrhoea is rare. However, pelvic appendicitis may cause localised rectal irritation and some loose stools. A pelvic abscess may also cause diarrhoea. Mild pyrexia is common - temperature is usually 37.5 -38oC. Higher temperatures are more typical of conditions like mesenteric adenitis. Anorexia is very common. It is very unusual for patients with appendicitis to be hungry. Examination Generalised peritonitis if perforation has occurred or localised peritonism. Retrocaecal appendicitis may have relatively few signs. Digital rectal examination may reveal boggy sensation if pelvic abscess is present, or even tenderness with a pelvic appendix. Diagnosis Typically raised inflammatory markers coupled with compatible history and examination findings should be enough to justify appendicectomy. Urine analysis may show mild leucocytosis but no nitrites. Ultrasound is useful in females where pelvic organ pathology is suspected. Although it is not always possible to visualise the appendix on ultrasound, the presence of free fluid (always pathological in males) should raise suspicion. Ultrasound examination may show evidence of luminal obstruction and thickening of the appendiceal wall Treatment Appendicectomy which can be performed via either an open or laparoscopic approach. Administration of metronidazole reduces wound infection rates. Patients with perforated appendicitis require copious abdominal lavage. Patients without peritonitis who have an appendix mass should receive broad spectrum antibiotics and consideration given to performing an interval appendicectomy. Be wary in the older patients who may have either an underlying caecal malignancy or perforated sigmoid diverticular disease.

Answer 226

Sutured repair of the hernial defect using nylon and placement of a prolene mesh posterior to the cord structures Laparoscopic repair- bilateral and recurrent cases During an inguinal hernia repair in males the cord structures will always lie anterior to the mesh. In the conventional open repairs the cord structures are mobilised and the mesh placed behind them, with a slit made to allow passage of the cord structures through the deep inguinal ring. Placement of the mesh over the cord structures results in chronic pain and usually a higher risk of recurrence. Laparoscopic inguinal hernia repair is the procedure of choice for bilateral inguinal hernias. ``` Types of surgery include: Onlay mesh repair (Lichtenstein style) Inguinal herniorrhaphy Shouldice repair Darn repair Laparoscopic mesh repair ``` Open mesh repair and laparoscopic repair are the two main procedures in mainstream use. The Shouldice repair is a useful procedure in cases where a mesh repair would be associated with increased risk of infection, e.g. repair of case with strangulated bowel, as it avoids the use of mesh. It is, however, far more technically challenging to perform. Inguinal hernias occur when the abdominal viscera protrude through the anterior abdominal wall into the inguinal canal. They may be classified as being either direct or indirect. The distinction between these two rests on their relation to Hesselbach's triangle. Boundaries of Hesselbach's Triangle Medial: Rectus abdominis Lateral: Inferior epigastric vessels Inferior: Inguinal ligament Hernias occurring within the triangle tend to be direct and those outside - indirect. Diagnosis Most cases are diagnosed clinically, a reducible swelling may be located at the level of the inguinal canal. Large hernia's may extend down into the male scrotum, these will not trans-illuminate and it is not possible to "get above" the swelling. Cases that are unclear on examination, but suspected from the history, may be further investigated using ultrasound or by performing a herniogram. Treatment Hernias associated with few symptoms may be managed conservatively. Symptomatic hernias or those which are at risk of developing complications are usually treated surgically. First time hernias may be treated by performing an open inguinal hernia repair; the inguinal canal is opened, the hernia reduced and the defect repaired. A prosthetic mesh may be placed posterior to the cord structures to re-enforce the repair and reduce the risk of recurrence. Recurrent hernias and those which are bilateral are generally managed with a laparoscopic approach. This may be via an intra or extra peritoneal route. As in open surgery a mesh is deployed. However, it will typically lie posterior to the deep ring. Inguinal hernia in children Inguinal hernias in children are almost always of an indirect type and therefore are usually dealt with by herniotomy, rather than herniorraphy. Neonatal hernias especially in those children born prematurely are at highest risk of strangulation and should be repaired urgently. Other hernias may be repaired on an elective basis.

Answer 227

Hirschsprungs disease Hirschsprung's disease is an absence of ganglion cells in the neural plexus of the intestinal wall. It is more common in boys than girls. The delayed passage of meconium together with distension of abdomen is the usual clinical presentation. A plain abdominal x ray will demonstrate dilated loops of bowel with fluid levels and a barium enema can be helpful when it demonstrates a cone with dilated ganglionic proximal colon and the distal aganglionic bowel failing to distend. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 228

Necrotising enterocolitis Necrotising enterocolitis is more common in premature infants. Mesenteric ischemia causes bacterial invasion of the mucosa leading to sepsis. Terminal ileum, caecum and the distal colon are commonly affected. The abdomen is distended and tense, and the infant passes blood and mucus per rectum. X -Ray of the abdomen shows distended loops of intestine and gas bubbles may be seen in the bowel wall. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 229

Meconium ileus One in 5,000 newborns will have a distal small bowel obstruction secondary to abnormal bulky and viscid meconium. Ninety percent of these infants will have cystic fibrosis and the abnormal meconium is the result of deficient intestinal secretions. This condition presents during the first days of life with gross abdominal distension and bilious vomiting. x Ray of the abdomen shows distended coils of bowel and typical mottled ground glass appearance. Fluid levels are scarce as the meconium is viscid. Pyloric stenosis M>F 5-10% Family history in parents Projectile non bile stained vomiting at 4-6 weeks of life Diagnosis is made by test feed or USS Treatment: Ramstedt pyloromyotomy (open or laparoscopic) Acute appendicitis Uncommon under 3 years When occurs may present atypically Mesenteric adenitis Central abdominal pain and URTI Conservative management Intussusception Telescoping bowel Proximal to or at the level of, ileocaecal valve 6-9 months age Colicky pain, diarrhoea and vomiting, sausage shaped mass, red jelly stool. Treatment: reduction with air insufflation Malrotation High caecum at the midline Feature in exomphalos, congenital diaphragmatic hernia, intrinsic duodenal atresia May be complicated by development of volvulus, infant with volvulus may have bile stained vomiting Diagnosis is made by upper GI contrast study and USS Treatment is by laparotomy, if volvulus is present (or at high risk of occurring then a ladds procedure is performed Hirschsprung's disease Absence of ganglion cells from myenteric and submucosal plexuses Occurs in 1/5000 births Full thickness rectal biopsy for diagnosis Delayed passage of meconium and abdominal distension Treatment is with rectal washouts initially, thereafter an anorectal pull through procedure Oesophageal atresia Associated with tracheo-oesophageal fistula and polyhydramnios May present with choking and cyanotic spells following aspiration VACTERL associations Meconium ileus Usually delayed passage of meconium and abdominal distension Majority have cystic fibrosis X-Rays may not show a fluid level as the meconium is viscid (depends upon feeding), PR contrast studies may dislodge meconium plugs and be therapeutic Infants who do not respond to PR contrast and NG N-acetyl cysteine will require surgery to remove the plugs Biliary atresia Jaundice > 14 days Increased conjugated bilirubin Urgent Kasai procedure Necrotising enterocolitis Prematurity is the main risk factor Early features include abdominal distension and passage of bloody stools X-Rays may show pneumatosis intestinalis and evidence of free air Increased risk when empirical antibiotics are given to infants beyond 5 days Treatment is with total gut rest and TPN, babies with perforations will require laparotomy

Answer 230

Senna contains glycosides. It passes unchanged into the colon where bacteria hydrolyse the glycosidic bond, releasing the anthracene derivatives. These stimulate the myenteric plexus. Laxatives Bulk forming laxatives Bran Psyllium Methylcellulose ``` Osmotic laxatives Magnesium sulphate Magnesium citrate Sodium phosphate Sodium sulphate Potassium sodium tatrate Polyethylene glycol ``` ``` Stimulant laxatives Docusates Bisacodyl Sodium picosulphate Senna Ricinoleic acid ```

Answer 231

Cavernous sinus syndrome is most commonly caused by cavernous sinus tumours. In this case, the nasopharyngeal malignancy has locally invaded the left cavernous sinus. Diagnosis is based on signs of pain, opthalmoplegia, proptosis, trigeminal nerve lesion (opthalmic branch) and Horner's syndrome. Cavernous sinus The cavernous sinuses are paired and are situated on the body of the sphenoid bone. It runs from the superior orbital fissure to the petrous temporal bone. Relations Medial Lateral Pituitary fossa Sphenoid sinus Temporal lobe Contents Lateral wall components (from top to bottom:) Oculomotor nerve Trochlear nerve Ophthalmic nerve Maxillary nerve Contents of the sinus (from medial to lateral:) Internal carotid artery (and sympathetic plexus) Abducens nerve Blood supply Ophthalmic vein, superficial cortical veins, basilar plexus of veins posteriorly. Drains into the internal jugular vein via: the superior and inferior petrosal sinuses

Answer 232

Bile salt reabsorption occurs at the ileum. Therefore cholesterol gallstones form as a result of ileal resection. Gallstones Typically history of biliary colic or episodes of chlolecystitis. Obstructive type history and test results. Usually small calibre gallstones which can pass through the cystic duct. In Mirizzi syndrome the stone may compress the bile duct directly- one of the rare times that cholecystitis may present with jaundice Cholangitis Usually obstructive and will have Charcot's triad of symptoms (pain, fever, jaundice) Ascending infection of the bile ducts usually by E. coli and by definition occurring in a pool of stagnant bile. Pancreatic cancer Typically painless jaundice with palpable gallbladder (Courvoisier's Law) Direct occlusion of distal bile duct or pancreatic duct by tumour. Sometimes nodal disease at the portal hepatis may be the culprit in which case the bile duct may be of normal calibre. TPN (total parenteral nutrition) associated jaundice Usually follows long term use and is usually painless with non obstructive features Often due to hepatic dysfunction and fatty liver which may occur with long term TPN usage. Bile duct injury Depending upon the type of injury may be of sudden or gradual onset and is usually of obstructive type Often due to a difficult laparoscopic cholecystectomy when anatomy in Calots triangle is not appreciated. In the worst scenario the bile duct is excised and jaundice develops rapidly post operatively. More insidious is that of bile duct stenosis which may be caused by clips or diathermy injury. Cholangiocarcinoma Gradual onset obstructive pattern Direct occlusion by disease and also extrinsic compression by nodal disease at the porta hepatis. Septic surgical patient Usually hepatic features Combination of impaired biliary excretion and drugs such as ciprofloxacin which may cause cholestasis. Metastatic disease Mixed hepatic and post hepatic Combination of liver synthetic failure (late) and extrinsic compression by nodal disease and anatomical compression of intra hepatic structures (earlier) A gallbladder may develop a thickened wall in chronic cholecystitis, microscopically Roikitansky-Aschoff Sinuses may be seen

Answer 233

Excision biopsy Lesion bearing normal dermal appendages and regular borders are likely to be a benign pigmented naevi. Therefore diagnostic and not radical excision is indicated. Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management. Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Basal Cell Carcinoma Most common form of skin cancer. Commonly occur on sun exposed sites apart from the ear. Sub types include nodular, morphoeic, superficial and pigmented. Typically slow growing with low metastatic potential. Standard surgical excision, topical chemotherapy and radiotherapy are all successful. As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned. Squamous Cell Carcinoma Again related to sun exposure. May arise in pre - existing solar keratoses. May metastasize if left. Immunosupression (e.g. following transplant), increases risk. Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required. ``` Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation ``` Treatment Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below): Margins of excision-Related to Breslow thickness Lesions 0-1mm thick 1cm Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick 3cm Marsden J et al. Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256. Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied. Kaposi Sarcoma Tumour of vascular and lymphatic endothelium. Purple cutaneous nodules. Associated with immuno supression. Classical form affects elderly males and is slow growing. Immunosupression form is much more aggressive and tends to affect those with HIV related disease. Non malignant skin disease Dermatitis Herpetiformis Chronic itchy clusters of blisters. Linked to underlying gluten enteropathy (coeliac disease). ``` Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes. ``` ``` Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma. ``` Acanthosis nigricans Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.

Answer 234

Punch biopsy Punch biopsies are a useful option for obtaining a full thickness tissues sample with minimal tissue disruption. In this situation the other differential would be AIN or VIN and punch biopsies would be useful in distinguishing these. Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management. Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Basal Cell Carcinoma Most common form of skin cancer. Commonly occur on sun exposed sites apart from the ear. Sub types include nodular, morphoeic, superficial and pigmented. Typically slow growing with low metastatic potential. Standard surgical excision, topical chemotherapy and radiotherapy are all successful. As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned. Squamous Cell Carcinoma Again related to sun exposure. May arise in pre - existing solar keratoses. May metastasize if left. Immunosupression (e.g. following transplant), increases risk. Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required. ``` Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation ``` Treatment Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below): Margins of excision-Related to Breslow thickness Lesions 0-1mm thick 1cm Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick 3cm Marsden J et al. Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256. Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied. Kaposi Sarcoma Tumour of vascular and lymphatic endothelium. Purple cutaneous nodules. Associated with immuno supression. Classical form affects elderly males and is slow growing. Immunosupression form is much more aggressive and tends to affect those with HIV related disease. Non malignant skin disease Dermatitis Herpetiformis Chronic itchy clusters of blisters. Linked to underlying gluten enteropathy (coeliac disease). ``` Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes. ``` ``` Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma. ``` Acanthosis nigricans Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.

Answer 235

Excision with 0.5 cm margin A small lesion such as this is adequately treated by local excision. The British Association of Dermatology guidelines suggest that excision of conventional BCC (<2cm) with margins of 3-5mm have locoregional control rates of 85%. Morpoeic lesions have higher local recurrence rates. Skin lesions may be referred for surgical assessment, but more commonly will come via a dermatologist for definitive surgical management. Skin malignancies include basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Basal Cell Carcinoma Most common form of skin cancer. Commonly occur on sun exposed sites apart from the ear. Sub types include nodular, morphoeic, superficial and pigmented. Typically slow growing with low metastatic potential. Standard surgical excision, topical chemotherapy and radiotherapy are all successful. As a minimum a diagnostic punch biopsy should be taken if treatment other than standard surgical excision is planned. Squamous Cell Carcinoma Again related to sun exposure. May arise in pre - existing solar keratoses. May metastasize if left. Immunosupression (e.g. following transplant), increases risk. Wide local excision is the treatment of choice and where a diagnostic excision biopsy has demonstrated SCC, repeat surgery to gain adequate margins may be required. ``` Malignant Melanoma The main diagnostic features (major criteria): Change in size Change in shape Change in colour Secondary features (minor criteria) Diameter >6mm Inflammation Oozing or bleeding Altered sensation ``` Treatment Suspicious lesions should undergo excision biopsy. The lesion should be removed in completely as incision biopsy can make subsequent histopathological assessment difficult. Once the diagnosis is confirmed the pathology report should be reviewed to determine whether further re-excision of margins is required (see below): Margins of excision-Related to Breslow thickness Lesions 0-1mm thick 1cm Lesions 1-2mm thick 1- 2cm (Depending upon site and pathological features) Lesions 2-4mm thick 2-3 cm (Depending upon site and pathological features) Lesions >4 mm thick 3cm Marsden J et al. Revised UK guidelines for management of Melanoma. Br J Dermatol 2010 163:238-256. Further treatments such as sentinel lymph node mapping, isolated limb perfusion and block dissection of regional lymph node groups should be selectively applied. Kaposi Sarcoma Tumour of vascular and lymphatic endothelium. Purple cutaneous nodules. Associated with immuno supression. Classical form affects elderly males and is slow growing. Immunosupression form is much more aggressive and tends to affect those with HIV related disease. Non malignant skin disease Dermatitis Herpetiformis Chronic itchy clusters of blisters. Linked to underlying gluten enteropathy (coeliac disease). ``` Dermatofibroma Benign lesion. Firm elevated nodules. Usually history of trauma. Lesion consists of histiocytes, blood vessels and fibrotic changes. ``` ``` Pyogenic granuloma Overgrowth of blood vessels. Red nodules. Usually follow trauma. May mimic amelanotic melanoma. ``` Acanthosis nigricans Brown to black, poorly defined, velvety hyperpigmentation of the skin. Usually found in body folds such as the posterior and lateral folds of the neck, the axilla, groin, umbilicus, forehead, and other areas. The most common cause of acanthosis nigricans is insulin resistance, which leads to increased circulating insulin levels. Insulin spillover into the skin results in its abnormal increase in growth (hyperplasia of the skin). In the context of a malignant disease, acanthosis nigricans is a paraneoplastic syndrome and is then commonly referred to as acanthosis nigricans maligna. Involvement of mucous membranes is rare and suggests a coexisting malignant condition.

Answer 236

Le fort fracture 3 affecting maxilla The flattened appearance of the face is a classical description of the dish/pan face associated with Le fort fracture 2 or 3 of the maxilla. Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children. Interpretation of pupillary findings in head injuries Pupil size Light response Interpretation Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial herniation Bilaterally dilated Sluggish or fixed Poor CNS perfusion Bilateral 3rd nerve palsy Unilaterally dilated or equal Cross reactive (Marcus - Gunn) Optic nerve injury Bilaterally constricted May be difficult to assess Opiates Pontine lesions Metabolic encephalopathy Unilaterally constricted Preserved Sympathetic pathway disruption

Answer 237

Extradural haematoma The middle meningeal artery is prone to damage when the temporal side of the head is hit. Note that there may NOT be any initial LOC or lucid interval. Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children. Interpretation of pupillary findings in head injuries Pupil size Light response Interpretation Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial herniation Bilaterally dilated Sluggish or fixed Poor CNS perfusion Bilateral 3rd nerve palsy Unilaterally dilated or equal Cross reactive (Marcus - Gunn) Optic nerve injury Bilaterally constricted May be difficult to assess Opiates Pontine lesions Metabolic encephalopathy Unilaterally constricted Preserved Sympathetic pathway disruption

Answer 238

Subdural haematoma Subdural haematomas can have a history over weeks/months. It is common in alcoholics due to cerebral atrophy causing increased stretching of veins. Head injury Patients who suffer head injuries should be managed according to ATLS principles and extra cranial injuries should be managed alongside cranial trauma. Inadequate cardiac output will compromise CNS perfusion irrespective of the nature of the cranial injury. Types of traumatic brain injury Extradural 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 extradural haematomas occur in the temporal region where skull fractures cause a rupture of the middle meningeal artery. Features 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. May be either acute or chronic. Risk factors include old age and alcoholism. Slower onset of symptoms than a extradural haematoma. Subarachnoid haemorrhage 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. Pathophysiology 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 Management Where there is life threatening rising ICP such as in extra dural haematoma and whilst theatre is prepared or transfer arranged use of IV mannitol/ frusemide may be required. Diffuse cerebral oedema may require decompressive craniotomy Exploratory Burr Holes have little management in modern practice except where scanning may be unavailable and to thus facilitate creation of formal craniotomy flap Depressed skull fractures that are open require formal surgical reduction and debridement, closed injuries may be managed non operatively if there is minimal displacement. ICP monitoring is appropriate in those who have GCS 3-8 and normal CT scan. ICP monitoring is mandatory in those who have GCS 3-8 and abnormal CT scan. Hyponatraemia is most likely to be due to syndrome of inappropriate ADH secretion. Minimum of cerebral perfusion pressure of 70mmHg in adults. Minimum cerebral perfusion pressure of between 40 and 70 mmHg in children. Interpretation of pupillary findings in head injuries Pupil size Light response Interpretation Unilaterally dilated Sluggish or fixed 3rd nerve compression secondary to tentorial herniation Bilaterally dilated Sluggish or fixed Poor CNS perfusion Bilateral 3rd nerve palsy Unilaterally dilated or equal Cross reactive (Marcus - Gunn) Optic nerve injury Bilaterally constricted May be difficult to assess Opiates Pontine lesions Metabolic encephalopathy Unilaterally constricted Preserved Sympathetic pathway disruption

Answer 239

On biopsy will typically show neo intimal hyperplasia of donor arterioles. - FALSE These changes are more often seen in the chronic setting. Thrombosis is more commonly seen in the hyperacute phase. Organ Transplant A number of different organ and tissue transplants are now available. In many cases an allograft is performed, where an organ is transplanted from one individual to another. Allografts will elicit an immune response and this is one of the main reasons for organ rejection. Graft rejection occurs because allografts have allelic differences at genes that code immunohistocompatability complex genes. The main antigens that give rise to rejection are: ABO blood group Human leucocyte antigens (HLA) Minor histocompatability antigens ABO Matching ABO incompatibility will result in early organ rejection (hyperacute) because of pre existing antibodies to other groups. Group O donors can give organs to any type of ABO recipient whereas group AB donor can only donate to AB recipient. HLA System The four most important HLA alleles are: HLA A HLA B HLA C HLA DR An ideal organ match would be one in which all 8 alleles are matched (remember 2 from each parent, four each = 8 alleles). Modern immunosuppressive regimes help to manage the potential rejection due to HLA mismatching. However, the greater the number of mismatches the worse the long term outcome will be. T lymphocytes will recognise antigens bound to HLA molecules and will then become activated. Clonal expansion then occurs with a response directed against that antigen. Types of organ rejection Hyperacute. This occurs immediately through presence of pre formed antibodies (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. Hyperacute Renal transplants at greatest risk and liver transplants at least risk. Although ABO incompatibility and HLA Class I incompatible transplants will all fare worse in long term. Acute All organs may undergo acute rejection. Mononuclear cell infiltrates predominate. All types of transplanted organ are susceptible and it may occur in up to 50% cases. Chronic Again all transplants with HLA mismatch may suffer this fate. Previous acute rejections and other immunosensitising events all increase the risk. Vascular changes are most prominent with myointimal proliferation leading to organ ischaemia. Organ specific changes are also seen such as loss of acinar cells in pancreas transplants and rapidly progressive coronary artery disease in cardiac transplants. Surgical overview-Renal transplantation A brief overview of the steps involved in renal transplantation is given. Patients with end stage renal failure who are dialysis dependent or likely to become so in the immediate future are considered for transplant. Exclusion criteria include; active malignancy, old age (due to limited organ availability). Patients are medically optimised. Donor kidneys, these may be taken from live related donors and close family, members may have less HLA mismatch than members of the general population. Laparoscopic donor nephrectomy further minimises the operative morbidity for the donor. Other organs are typically taken from brain dead or dying patients who have a cardiac arrest and in whom resuscitation is futile. The key event is to minimise the warm ischaemic time in the donor phase. The kidney once removed is usually prepared on the bench in theatre by the transplant surgeon immediately prior to implantation and factors such as accessory renal arteries and vessel length are assessed and managed. For first time recipients the operation is performed under general anaesthesia. A Rutherford-Morrison incision is made on the preferred side. This provides excellent extraperitoneal access to the iliac vessels. The external iliac artery and vein are dissected out and following systemic heparinisation are cross clamped. The vein and artery are anastamosed to the iliacs and the clamps removed. The ureter is then implanted into the bladder and a stent is usually placed to maintain patency. The wounds are then closed and the patient recovered from surgery. In the immediate phase a common problem encountered in cadaveric kidneys is acute tubular necrosis and this tends to resolve. Graft survival times from cadaveric donors are typically of the order of 9 years and monozygotic twin transplant (live donor) may survive as long as 25 years.

Answer 240

USS in 6 months At this point continue with ultrasound surveillance Abdominal aorta aneurysm Abdominal aortic aneurysms are a common problem in vascular surgery. They may occur as either true or false aneurysm. With the former all 3 layers of the arterial wall are involved, in the latter only a single layer of fibrous tissue forms the aneurysm wall. True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people. They are commonest in elderly men and for this reason the UK is now introducing the aneurysm screening program with the aim of performing an abdominal aortic ultrasound measurement in all men aged 65 years. Causes Several different groups of patients suffer from aneurysmal disease. The commonest group is those who suffer from standard arterial disease, i.e. Those who are hypertensive and have been or are smokers. Other patients such as those suffering from connective tissue diseases such as Marfan's may also develop aneurysms. In patients with abdominal aortic aneurysms the extracellular matrix becomes disrupted with a change in the balance of collagen and elastic fibres. Management Most abdominal aortic aneurysms are an incidental finding. Symptoms most often relate to rupture or impending rupture. 20% rupture anteriorly into the peritoneal cavity. Very poor prognosis. 80% rupture posteriorly into the retroperitoneal space The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less than 4cm in diameter will rupture over a 5 year period. This contrasts with 75% of aneurysms measuring over 7cm in diameter. This is well explained by Laplaces' law which relates size to transmural pressure. For this reason most vascular surgeons will subject patients with an aneurysm size of 5cm or greater to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy and planning treatment. Depending upon co-morbidities, surgery is generally offered once the aneurysm is between 5.5cm and 6cm. A CT reconstruction showing an infrarenal abdominal aortic aneurysm. The walls of the sac are calcified which may facilitate identification on plain x-rays Image sourced from Wikipedia Indications for surgery Symptomatic aneurysms (80% annual mortality if untreated) Increasing size above 5.5cm if asymptomatic Rupture (100% mortality without surgery) Surgical procedures Abdominal aortic aneurysm repair Procedure: GA Invasive monitoring (A-line, CVP, catheter) Incision: Midline or transverse Bowel and distal duodenum mobilised to access aorta. Aneurysm neck and base dissected out and prepared for cross clamp Systemic heparinisation Cross clamp (proximal first) Longitudinal aortotomy Atherectomy Deal with back bleeding from lumbar vessels and inferior mesenteric artery Insert graft either tube or bifurcated depending upon anatomy Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site) Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of myocardial events. Haemostasis Closure of aneurysm sac to minimise risk of aorto-enteric fistula Closure: Loop 1 PDS or Prolene to abdominal wall Skin- surgeons preference Post operatively: ITU (Almost all) Greatest risk of complications following emergency repair Complications: Embolic- gut and foot infarcts Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp Wound problems Later risks related to graft- infection and aorto-enteric fistula Special groups Supra renal AAA These patients will require a supra renal clamp and this carries a far higher risk of complications and risk of renal failure. Ruptured AAA Pre-operatively the management depends upon haemodynamic instability. In patients with symptoms of rupture (typical pain, haemodynamic compromise and risk factors) then ideally prompt laparotomy. In those with vague symptoms and haemodynamic stability the ideal test is CT scan to determine whether rupture has occurred or not. Most common rupture site is retroperitoneal 80%. These patients will tend to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg. Operative details are similar to elective repair although surgery should be swift, blind rushing often makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the aneurysm neck carries the risk of injury the vena cava that these patients do not withstand. Occasionally a supracoeliac clamp is needed to effect temporary control, although leaving this applied for more than 20 minutes tends to carry a dismal outcome. ``` EVAR Increasingly patients are now being offered endovascular aortic aneurysm repair. This is undertaken by surgeons and radiologists working jointly. The morphology of the aneurysm is important and not all are suitable. Here is a typical list of those features favoring a suitable aneurysm: Long neck Straight iliac vessels Healthy groin vessels ``` Clearly few AAA patients possess the above and compromise has to be made. The use of fenestrated grafts can allow supra renal AAA to be treated. Procedure: ``` GA Radiology or theatre Bilateral groin incisions Common femoral artery dissected out Heparinisation Arteriotomy and insertion of guide wire Dilation of arteriotomy Insertion of EVAR Device Once in satisfactory position it is released Arteriotomy closed once check angiogram shows good position and no endoleak ``` Complications: Endoleaks depending upon site are either Type I or 2. These may necessitate re-intervention and all EVAR patients require follow up . Details are not needed for MRCS.

Answer 241

AAA repair during next 48 hours Assuming he is fit enough. This would be a typical 'open ' case as the marked iliac disease would make EVAR difficult Abdominal aorta aneurysm Abdominal aortic aneurysms are a common problem in vascular surgery. They may occur as either true or false aneurysm. With the former all 3 layers of the arterial wall are involved, in the latter only a single layer of fibrous tissue forms the aneurysm wall. True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people. They are commonest in elderly men and for this reason the UK is now introducing the aneurysm screening program with the aim of performing an abdominal aortic ultrasound measurement in all men aged 65 years. Causes Several different groups of patients suffer from aneurysmal disease. The commonest group is those who suffer from standard arterial disease, i.e. Those who are hypertensive and have been or are smokers. Other patients such as those suffering from connective tissue diseases such as Marfan's may also develop aneurysms. In patients with abdominal aortic aneurysms the extracellular matrix becomes disrupted with a change in the balance of collagen and elastic fibres. Management Most abdominal aortic aneurysms are an incidental finding. Symptoms most often relate to rupture or impending rupture. 20% rupture anteriorly into the peritoneal cavity. Very poor prognosis. 80% rupture posteriorly into the retroperitoneal space The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less than 4cm in diameter will rupture over a 5 year period. This contrasts with 75% of aneurysms measuring over 7cm in diameter. This is well explained by Laplaces' law which relates size to transmural pressure. For this reason most vascular surgeons will subject patients with an aneurysm size of 5cm or greater to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy and planning treatment. Depending upon co-morbidities, surgery is generally offered once the aneurysm is between 5.5cm and 6cm. A CT reconstruction showing an infrarenal abdominal aortic aneurysm. The walls of the sac are calcified which may facilitate identification on plain x-rays Image sourced from Wikipedia Indications for surgery Symptomatic aneurysms (80% annual mortality if untreated) Increasing size above 5.5cm if asymptomatic Rupture (100% mortality without surgery) Surgical procedures Abdominal aortic aneurysm repair Procedure: GA Invasive monitoring (A-line, CVP, catheter) Incision: Midline or transverse Bowel and distal duodenum mobilised to access aorta. Aneurysm neck and base dissected out and prepared for cross clamp Systemic heparinisation Cross clamp (proximal first) Longitudinal aortotomy Atherectomy Deal with back bleeding from lumbar vessels and inferior mesenteric artery Insert graft either tube or bifurcated depending upon anatomy Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site) Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of myocardial events. Haemostasis Closure of aneurysm sac to minimise risk of aorto-enteric fistula Closure: Loop 1 PDS or Prolene to abdominal wall Skin- surgeons preference Post operatively: ITU (Almost all) Greatest risk of complications following emergency repair Complications: Embolic- gut and foot infarcts Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp Wound problems Later risks related to graft- infection and aorto-enteric fistula Special groups Supra renal AAA These patients will require a supra renal clamp and this carries a far higher risk of complications and risk of renal failure. Ruptured AAA Pre-operatively the management depends upon haemodynamic instability. In patients with symptoms of rupture (typical pain, haemodynamic compromise and risk factors) then ideally prompt laparotomy. In those with vague symptoms and haemodynamic stability the ideal test is CT scan to determine whether rupture has occurred or not. Most common rupture site is retroperitoneal 80%. These patients will tend to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg. Operative details are similar to elective repair although surgery should be swift, blind rushing often makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the aneurysm neck carries the risk of injury the vena cava that these patients do not withstand. Occasionally a supracoeliac clamp is needed to effect temporary control, although leaving this applied for more than 20 minutes tends to carry a dismal outcome. ``` EVAR Increasingly patients are now being offered endovascular aortic aneurysm repair. This is undertaken by surgeons and radiologists working jointly. The morphology of the aneurysm is important and not all are suitable. Here is a typical list of those features favoring a suitable aneurysm: Long neck Straight iliac vessels Healthy groin vessels ``` Clearly few AAA patients possess the above and compromise has to be made. The use of fenestrated grafts can allow supra renal AAA to be treated. Procedure: ``` GA Radiology or theatre Bilateral groin incisions Common femoral artery dissected out Heparinisation Arteriotomy and insertion of guide wire Dilation of arteriotomy Insertion of EVAR Device Once in satisfactory position it is released Arteriotomy closed once check angiogram shows good position and no endoleak ``` Complications: Endoleaks depending upon site are either Type I or 2. These may necessitate re-intervention and all EVAR patients require follow up . Details are not needed for MRCS.

Answer 242

Palliate He will not survive aortic surgery and whilst some may disagree, I would argue that taking this case to theatre would be futile Abdominal aorta aneurysm Abdominal aortic aneurysms are a common problem in vascular surgery. They may occur as either true or false aneurysm. With the former all 3 layers of the arterial wall are involved, in the latter only a single layer of fibrous tissue forms the aneurysm wall. True abdominal aortic aneurysms have an approximate incidence of 0.06 per 1000 people. They are commonest in elderly men and for this reason the UK is now introducing the aneurysm screening program with the aim of performing an abdominal aortic ultrasound measurement in all men aged 65 years. Causes Several different groups of patients suffer from aneurysmal disease. The commonest group is those who suffer from standard arterial disease, i.e. Those who are hypertensive and have been or are smokers. Other patients such as those suffering from connective tissue diseases such as Marfan's may also develop aneurysms. In patients with abdominal aortic aneurysms the extracellular matrix becomes disrupted with a change in the balance of collagen and elastic fibres. Management Most abdominal aortic aneurysms are an incidental finding. Symptoms most often relate to rupture or impending rupture. 20% rupture anteriorly into the peritoneal cavity. Very poor prognosis. 80% rupture posteriorly into the retroperitoneal space The risk of rupture is related to aneurysm size, only 2% of aneurysms measuring less than 4cm in diameter will rupture over a 5 year period. This contrasts with 75% of aneurysms measuring over 7cm in diameter. This is well explained by Laplaces' law which relates size to transmural pressure. For this reason most vascular surgeons will subject patients with an aneurysm size of 5cm or greater to CT scanning of the chest, abdomen and pelvis with the aim of delineating anatomy and planning treatment. Depending upon co-morbidities, surgery is generally offered once the aneurysm is between 5.5cm and 6cm. A CT reconstruction showing an infrarenal abdominal aortic aneurysm. The walls of the sac are calcified which may facilitate identification on plain x-rays Image sourced from Wikipedia Indications for surgery Symptomatic aneurysms (80% annual mortality if untreated) Increasing size above 5.5cm if asymptomatic Rupture (100% mortality without surgery) Surgical procedures Abdominal aortic aneurysm repair Procedure: GA Invasive monitoring (A-line, CVP, catheter) Incision: Midline or transverse Bowel and distal duodenum mobilised to access aorta. Aneurysm neck and base dissected out and prepared for cross clamp Systemic heparinisation Cross clamp (proximal first) Longitudinal aortotomy Atherectomy Deal with back bleeding from lumbar vessels and inferior mesenteric artery Insert graft either tube or bifurcated depending upon anatomy Suture using Prolene (3/0 for proximal , distal anastomosis suture varies according to site) Clamps off: End tidal CO2 will rise owing to effects of reperfusion, at this point major risk of myocardial events. Haemostasis Closure of aneurysm sac to minimise risk of aorto-enteric fistula Closure: Loop 1 PDS or Prolene to abdominal wall Skin- surgeons preference Post operatively: ITU (Almost all) Greatest risk of complications following emergency repair Complications: Embolic- gut and foot infarcts Cardiac - owing to premorbid states, re-perfusion injury and effects of cross clamp Wound problems Later risks related to graft- infection and aorto-enteric fistula Special groups Supra renal AAA These patients will require a supra renal clamp and this carries a far higher risk of complications and risk of renal failure. Ruptured AAA Pre-operatively the management depends upon haemodynamic instability. In patients with symptoms of rupture (typical pain, haemodynamic compromise and risk factors) then ideally prompt laparotomy. In those with vague symptoms and haemodynamic stability the ideal test is CT scan to determine whether rupture has occurred or not. Most common rupture site is retroperitoneal 80%. These patients will tend to develop retroperitoneal haematoma. This can be disrupted if Bp is allowed to rise too high so aim for Bp 100mmHg. Operative details are similar to elective repair although surgery should be swift, blind rushing often makes the situation worse. Plunging vascular clamps blindly into a pool of blood at the aneurysm neck carries the risk of injury the vena cava that these patients do not withstand. Occasionally a supracoeliac clamp is needed to effect temporary control, although leaving this applied for more than 20 minutes tends to carry a dismal outcome. ``` EVAR Increasingly patients are now being offered endovascular aortic aneurysm repair. This is undertaken by surgeons and radiologists working jointly. The morphology of the aneurysm is important and not all are suitable. Here is a typical list of those features favoring a suitable aneurysm: Long neck Straight iliac vessels Healthy groin vessels ``` Clearly few AAA patients possess the above and compromise has to be made. The use of fenestrated grafts can allow supra renal AAA to be treated. Procedure: ``` GA Radiology or theatre Bilateral groin incisions Common femoral artery dissected out Heparinisation Arteriotomy and insertion of guide wire Dilation of arteriotomy Insertion of EVAR Device Once in satisfactory position it is released Arteriotomy closed once check angiogram shows good position and no endoleak ``` Complications: Endoleaks depending upon site are either Type I or 2. These may necessitate re-intervention and all EVAR patients require follow up . Details are not needed for MRCS.

Answer 243

Survival following a successful Kasai procedure is approximately 45% at 5 years. - FALSE Alagille syndrome autosomal dominant disorder characterised by presence of paucity of bile ducts and cardiac defects. Only the embryonic form of biliary atresia is associated with cardiac and other embryological defects. Biliary atresia usually presents with obstructed jaundice. A Kasai procedure is best performed in the first 8 weeks of life. If a Kasai procedure is successful most patients will not require liver transplantation. 45% of patients post Kasai procedure will require transplantation. However, overall survival following a successful Kasai procedure is 80%. Biliary atresia 1 in 17000 affected Biliary tree lumen is obliterated by an inflammatory cholangiopathy causing progressive liver damage Clinical features Infant well in 1st few weeks of life No family history of liver disease Jaundice in infants > 14 days in term infants (>21 days in pre term infants) Pale stool, yellow urine (colourless in babies) Associated with cardiac malformations, polysplenia, situs inversus Investigation Conjugated bilirubin (prolonged physiological jaundice or breast milk jaundice will cause a rise in unconjugated bilirubin, whereas those with obstructive liver disease will have a rise in conjugated bilirubin) Ultrasound of the liver (excludes extrahepatic causes, in biliary atresia infant may have tiny or invisible gallbladder) Hepato-iminodiacetic acid radionuclide scan (good uptake but no excretion usually seen) Management Early recognition is important to prevent liver transplantation. Nutritional support. Roux-en-Y portojejunostomy (Kasai procedure). If Kasai procedure fails or late recognition, a liver transplant becomes the only option.

Answer 244

Bochdalek hernia The large hernia may displace the heart although true dextrocardia is not present. The associated pulmonary hypoplasia will compromise lung development. Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias are covered under their designated titles the remainder are addressed here. Spigelian hernia Interparietal hernia occurring at the level of the arcuate line Rare May lie beneath internal oblique muscle. Usually between internal and external oblique Equal sex distribution Position is lateral to rectus abdominis Both open and laparoscopic repair are possible, the former in cases of strangulation Lumbar hernia The lumbar triangle (through which these may occur) is bounded by: Crest of ilium (inferiorly) External oblique (laterally) Latissimus dorsi (medially) Primary lumbar herniae are rare, most are incisional hernias following renal surgery - Direct anatomical repair with or without mesh re-enforcement is the procedure of choice Obturator hernia Herniation through the obturator canal Commoner in females Usually lies behind pectineus muscle Elective diagnosis is unusual most will present acutely with obstruction When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated) Richters hernia Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type) They do not present with typical features of intestinal obstruction as lumenal patency is preserved Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate) Incisional hernia Occur through sites of surgical access into the abdominal cavity Most common following surgical wound infection To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described Bochdalek hernia Typically congenital diaphragmatic hernia 85% cases are located in the left hemi diaphragm Associated with lung hypoplasia on the affected side More common in males Associated with other birth defects May contain stomach May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high Morgagni Hernia Rare type of diaphragmatic hernia (approx 2% cases) Herniation through foramen of Morgagni Usually located on the right and tend to be less symptomatic More advanced cases may contain transverse colon As defects are small pulmonary hypoplasia is less common Direct anatomical repair is performed ``` Umbilical hernia Hernia through weak umbilicus Usually presents in childhood Often symptomatic Equal sex incidence 95% will resolve by the age of 2 years Surgery performed after the third birthday ``` ``` Paraumbilical hernia Usually a condition of adulthood Defect is in the linea alba More common in females Multiparity and obesity are risk factors Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation ``` Littres hernia Hernia containing Meckels diverticulum Resection of the diverticulum is usually required and this will preclude a mesh repair

Answer 245

Morgagni hernia Morgagni hernia may contain the transverse colon. Unless there is substantial herniation, pulmonary hypoplasia is uncommon. As a result, major respiratory compromise is often absent. Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias are covered under their designated titles the remainder are addressed here. Spigelian hernia Interparietal hernia occurring at the level of the arcuate line Rare May lie beneath internal oblique muscle. Usually between internal and external oblique Equal sex distribution Position is lateral to rectus abdominis Both open and laparoscopic repair are possible, the former in cases of strangulation Lumbar hernia The lumbar triangle (through which these may occur) is bounded by: Crest of ilium (inferiorly) External oblique (laterally) Latissimus dorsi (medially) Primary lumbar herniae are rare, most are incisional hernias following renal surgery - Direct anatomical repair with or without mesh re-enforcement is the procedure of choice Obturator hernia Herniation through the obturator canal Commoner in females Usually lies behind pectineus muscle Elective diagnosis is unusual most will present acutely with obstruction When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated) Richters hernia Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type) They do not present with typical features of intestinal obstruction as lumenal patency is preserved Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate) Incisional hernia Occur through sites of surgical access into the abdominal cavity Most common following surgical wound infection To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described Bochdalek hernia Typically congenital diaphragmatic hernia 85% cases are located in the left hemi diaphragm Associated with lung hypoplasia on the affected side More common in males Associated with other birth defects May contain stomach May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high Morgagni Hernia Rare type of diaphragmatic hernia (approx 2% cases) Herniation through foramen of Morgagni Usually located on the right and tend to be less symptomatic More advanced cases may contain transverse colon As defects are small pulmonary hypoplasia is less common Direct anatomical repair is performed ``` Umbilical hernia Hernia through weak umbilicus Usually presents in childhood Often symptomatic Equal sex incidence 95% will resolve by the age of 2 years Surgery performed after the third birthday ``` ``` Paraumbilical hernia Usually a condition of adulthood Defect is in the linea alba More common in females Multiparity and obesity are risk factors Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation ``` Littres hernia Hernia containing Meckels diverticulum Resection of the diverticulum is usually required and this will preclude a mesh repair

Answer 246

Obturator hernia The groin swelling in obturator hernia is subtle and hard to elicit clinically. There may be pain in the region of sensory distribution of the obturator nerve. The defect is usually repaired from within the abdomen. Hernias occur when a viscus or part of it protrudes from within its normal anatomical cavity. Specific hernias are covered under their designated titles the remainder are addressed here. Spigelian hernia Interparietal hernia occurring at the level of the arcuate line Rare May lie beneath internal oblique muscle. Usually between internal and external oblique Equal sex distribution Position is lateral to rectus abdominis Both open and laparoscopic repair are possible, the former in cases of strangulation Lumbar hernia The lumbar triangle (through which these may occur) is bounded by: Crest of ilium (inferiorly) External oblique (laterally) Latissimus dorsi (medially) Primary lumbar herniae are rare, most are incisional hernias following renal surgery - Direct anatomical repair with or without mesh re-enforcement is the procedure of choice Obturator hernia Herniation through the obturator canal Commoner in females Usually lies behind pectineus muscle Elective diagnosis is unusual most will present acutely with obstruction When presenting acutely most cases with require laparotomy or laparoscopy (and small bowel resection if indicated) Richters hernia Condition in which part of the wall of the small bowel (usually the anti mesenteric border) is strangulated within a hernia (of any type) They do not present with typical features of intestinal obstruction as lumenal patency is preserved Where vomiting is prominent it usually occurs as a result of paralytic ileus from peritonitis (as these hernias may perforate) Incisional hernia Occur through sites of surgical access into the abdominal cavity Most common following surgical wound infection To minimise following midline laparotomy Jenkins Rule should be followed and this necessitates a suture length 4x length of incision with bites taken at 1cm intervals, 1 cm from the wound edge Repair may be performed either at open surgery or laparoscopically and a wide variety of techniques are described Bochdalek hernia Typically congenital diaphragmatic hernia 85% cases are located in the left hemi diaphragm Associated with lung hypoplasia on the affected side More common in males Associated with other birth defects May contain stomach May be treated by direct anatomical apposition or placement of mesh. In infants that have severe respiratory compromise mechanical ventilation may be needed and mortality rate is high Morgagni Hernia Rare type of diaphragmatic hernia (approx 2% cases) Herniation through foramen of Morgagni Usually located on the right and tend to be less symptomatic More advanced cases may contain transverse colon As defects are small pulmonary hypoplasia is less common Direct anatomical repair is performed ``` Umbilical hernia Hernia through weak umbilicus Usually presents in childhood Often symptomatic Equal sex incidence 95% will resolve by the age of 2 years Surgery performed after the third birthday ``` ``` Paraumbilical hernia Usually a condition of adulthood Defect is in the linea alba More common in females Multiparity and obesity are risk factors Traditionally repaired using Mayos technique - overlapping repair, mesh may be used though not if small bowel resection is required owing to acute strangulation ``` Littres hernia Hernia containing Meckels diverticulum Resection of the diverticulum is usually required and this will preclude a mesh repair