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Round 2. SPOT QUESTIONS. 10yr old boy after bicycle accident with small bowel through an ABDO wall injury, bruising on chest and pelvis. What is your management?. Management: EMST approach A with C-spine protection, B, C, D, E

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slide2
10yr old boy after bicycle accident with small bowel through an ABDO wall injury, bruising on chest and pelvis.

What is your management?

slide3
Management:
    • EMST approach
      • A with C-spine protection, B, C, D, E
      • Simultaneous assessment, intervention + resuscitation (20ml/kg Ringer's lactate solution as bolus)‏
      • Complete adjuncts to primary survey (espec CXR)‏
      • Gastric and urinary decompression (intra-op)‏
    • Protect eviscerated bowel with sterile moist dressing
    • Liaise with anaesthetists, theatre, Paeds ICU, childs next of kin – inform and consent
    • Immediate laparotomy as coexisting injuries allow. Resect/debride devitalised tissue. Thorough washout and closure ABDO +/- drains. Watch for post-op ABDO cmptmt syndrome.
    • Be on alert for non-accidental injury scenario
slide4

1. Describe image

2. How do you image biliary tree non-operatively?

3. What are 2 advantages of MRCP over CT cholangiogram?

4. What are 4 contraindications to MRI?

slide5
MRCP showing distal CDB stone and moderate extrahepatic biliary dilatation
  • USS for CBD diameter and intra-hepatic duct dilation. Misses 70% CBD stones. MRCP more sensitive and specific for choledocholithiasis than USS. Misses 5% CBD stones. ERCP most sensitive and specific and allows therapeutic intervention, but invasive with inherent risks of morbidity (10% including from pancreatitis, perforation, bleeding, contrast reaction) and mortality (0.5%)‏
  • Pre-operative identification of anomalous biliary anatomy, absence of contrast administration
  • Metal-ware (eg cerebral aneurysm clips), pacemaker, cochlear implants, foreign bodies (eg metallic FB in eye), claustrophobia, critically ill, pregnancy (relative- not been looked at)
slide6

1. Diagnosis

2. Draw diagram illustrating likely extension of underlying fistulating process

3. Draw diagram illustrating classification system for this disease and illustrate relative incidence of the different classes of fistula

slide7
Perianal abscess at 11 O'clock position
  • Goodsall rule (NB: (1)rule does not apply if >3cm from anal verge opening – drain posteriorly with secondary extensions frequently); (2) holds true 90% posterior and 60% anterior fistulas; (3) 70% all fistulas are posterior)‏
slide8

Types:

Parks classification

I) intersphincteric

2) trans-sphincteric

3) supra-sphincteric

4) extra-sphincteric

[5) *superficial (16%) St Mark's 1977]

  • Classification
1 diagnosis 2 likely clinical presentation 3 classification of this disease 4 treatment
1. Diagnosis

2. Likely clinical presentation

3. Classification of this disease

4. Treatment

slide10
Diagnosis:
    • Choledochal cyst. Rare, usually presenting before age of 16yrs. 20% present in adults. F:M 3:1, mainly Asians. May cause cholangitis, stone formation, jaundice, pancreatitis, or undergo malignant transformation (up to 25% life-time risk). Pathogenesis unknown – infection, reflux of pancreatic enzymes into bile duct via a long common channel, genetic factors, distal biliary obstruction, biliary autonomic dysfunction
    • Clinical manifestations in children are recurrent abdo pain, episodic jaundice, and a RUQ mass. In adults, mass rare, more commonly symptoms of cholangitis, gallstones from biliary stasis and pancreatitis.
slide11
Todani classification (1977) according to site and shape:
    • Type 1; fusiform or saccular extra-hepatic
    • Type 2; isolated protrusion or diverticular outpouching CBD
    • Type 3; choledochocele with wide-mouth dilation CBD at confluence with the duodenum
    • Type 4; intra- and extra-hepatic ducts. 4a multiple intra-hepatic and extra-hepatic, 4b multiple extra-hepatic.
    • Type 5; multiple intra-hepatic with hepatic fibrosis (Caroli's - autosomal recessive with various anomalies also present eg polycystic kidney disease, renal tubular ectasia)‏)
      • 85% are either types 1 or 4.
slide12
Treatment:
    • Complete (or near-complete) excision with roux-en-Y hepaticojejunostomy and simultaneous cholecystectomy
    • Liver biopsy may assess biliary cirrhosis and portal hypertension in adults
    • Type III consider ERCP/Sx. Type II consider diverticulectomy.
slide13
1. Diagnosis

2. What is the congenital abnormality?

3. What are differential diagnoses?

3. Principles of operation

slide14
Right branchial cleft cyst
  • Branchial cleft cysts are the most common of congenital neck masses. These arise in the lateral aspect of the neck when the 2nd branchial cleft fails to close during embryonic development (2nd:1st 6:1). At about the 4th week of embryonic life, 4 branchial (or pharyngeal) clefts develop between 5 ridges known as the branchial (or pharyngeal) arches. These arches and clefts contribute to the formation of various structures of the head and neck. A tract of branchial origin may form a complete fistula, or one end may obliterate to form an external (most common) or internal sinus, or both ends may resorb, leaving an aggregate of cells forming a cyst. Internal opening in pharynx beside posterior pillar of fauces, outer at junction middle & lower 1/3rds anterior border of SCM. 15% are bilateral. Usually, they do not appear at birth, but become noticeable much later in life. If they get infected, they may form a deep neck abscess or a draining fistula.
slide15
Lymph node: benign (infective - suppurative lymphadenitis,Tb, viral; inflammatory – sarcoidosis, granulomatous lymphadenitis; lymphangioma), malignant – primary (lymphoma), secondary - metastasis eg SCC, melanoma. Vascular - haemangioma, carotid body tumour. Parotid tumour – benign (pleomorphic adenoma) or malignant.
  • Treatment:
    • Nearly all branchial abnormalities should be excised early in life since repeated infection is common, making resection more difficult.
    • Infected sinuses and cysts are initially incised & drained. Delayed excision of tract at 6/52.
    • Need to excise entire cyst wall and fistula tract (including the skin punctum if present) since recurrence and infection are common with incomplete removal.
    • Cautious dissection as adjacent facial, hypoglossal and glossopharyngeal nerves, as well as carotid artery branching and internal jugular vein.
1 diagnosis 2 likely presentation 3 treatment options 4 differentials 5 pathogenesis
1. Diagnosis

2. Likely presentation

3. Treatment options

4. Differentials

5. Pathogenesis

slide18
Psoas abscess or other retroperitoneal abscess
  • Symptoms: ABDO and flank pain 60-75%, fever and chills 30-90%, malaise 10-22%, weight loss 12%, referred pain → hip/groin/knee, durations of symptoms usually > 1 week. May be symptomless. Signs: none external, lies with hip flexed, pointing swelling lateral femoral region, pain with psoas stretch test, febrile
  • IVAB's. CT-guided drainage (up to 86% success rate). Operative drainage (for collections not amenable to percutaneous drainage eg multiloculated), failed percutaneous drainage (NB: stellate shape, necrotic debris), primary disease process necessitates surgery. Extraperitoneal approach via flank for upper retroperitoneal and perirenal; via perineum presacrally btwn anus and coccyx for pelvic. Surgical mortality rate 3-25%.
slide19
Retroperitoneal tumours (NB: invasion of peritoneal and fascial boundaries) and haematomas
  • Primary (haematogenous – G+ve staph aureus) or secondary (GI tract, renal or vertebral origin – polymicrobial, G-ve’s). Primary mostly in underdeveloped countries and in Australasia more commonly in children, young adults, immunocompromised and diabetics. Secondary causes include; appendicitis, diverticulitis, regional enteritis/inflammatory bowel disease, penetrating posterior ulcers, pancreatitis, pyelonephritis, vertebral osteomyelitis (incl. Tb) and disk space infections.
slide20
Q 1
  • This 70-yr-old woman presented with a large painless mass in her left quadriceps.
    • What is the most likely diagnosis?
    • What investigations would you undertake for this patient?
    • What are the principles of management?

Illustration of mass on medial aspect of thigh

of left lower limb 20 x 10cm

slide21
Q 2

Young female with HT

1. What does the CT show?

2. Differential diagnosis

3. Investigations

4. Treatment

slide22
Q3
  • Previous melanoma excised from foot
  • 1. Diagnosis
  • 2. Treatment options
  • 3. Prognostic features on pathology of initial biopsy
q 4 1 describe specimen 2 aetiology 3 complications
Q 4

1. Describe specimen

2. Aetiology

3. Complications

q 5 open gallbladder with stones and gb polyp 1 describe specimen 2 aetiology 3 complications
Q 5

Open gallbladder with stones and ? GB polyp.

1. Describe specimen

2. Aetiology

3. Complications

q 6 liver segments 1 draw number these from a diagram 2 explain how divided into segmental anatomy
Q 6

Liver segments.

1. Draw & number these from a diagram

2. Explain how divided into segmental anatomy.

slide26

Q 7

  • Band divided for SBO in 67yr old male. Intra-op incidental finding.
  • 1. How does this occur?
  • 2. Would you resect? Justify your answer.
slide27
Q 1
  • This 70-yr-old woman presented with a large painless mass in her left quadriceps.
    • What is the most likely diagnosis?
    • What investigations would you undertake for this patient?
    • What are the principles of management?

Illustration of mass on medial aspect of thigh

of left lower limb 20 x 10cm

slide28
Liposarcoma or rhabdomyosarcoma. Metastasis. Benign tumour (lipoma) much less likely.
  • Triple phase CT scan of thigh, plus staging CT ABDO/PELVIS and CHEST; MRI of thigh. Oncology consultant guided open biopsy of mass.
  • a) assess the patient b) assess the stage of disease – primary, secondary and nodes, and lungs c) identify nature of lesion (Histology) d) collaborative multiple speciality consultation, involving sarcoma specialist, orthopaedic surgeon, radiologist, radiotherapist, rehabilitation specialist, patient relatives and referring doctor, following compartmental clearance or radical wide excision including, if neurotropism present, the adjacent neurovascular bundle. Primary closure. Radiotherapy. No chemotherapy

This is colleges model answer 2005.

slide29
Q 2

Young female with HT

1. What does the CT show?

2. Differential diagnosis

3. Investigations

4. Treatment

r adrenal mass
R adrenal mass
  • Discrete, well circumscribed, moderately enhancing, slightly heterogenous mass in the right adrenal gland
  • Benign: adenoma (functioning/non-functioning - Phaeochromocytoma, Cushing's adenoma, Conn's adenoma), lipomatous, ganglioneuroma. Malignant: primary - adrenocortical carcinoma, secondary - metastases (melanoma, lung, breast, renal, colon, thyroid)‏
  • 24hr urinary fractionated catecholamines and metanephrines, overnight 1mg dexamethasone suppression test, morning plasma aldosterone concentration and renin activity (standing), (consider 24hr urinary Na with salt loading), routine renal function tests, contrast-enhanced MDCT with delayed images for contrast washout
  • <4cm functioning adenoma → Right adrenalectomy. <4cm non-functioning adenoma → surveillance. >4cm functioning or non-functioning → Right adrenalectomy. Endocrinology review for medical management peri-op for any functioning adenoma.

NB: new option still experimental = radiofrequency coagulation (ie RFA)‏

slide31
Q3
  • Previous melanoma excised from foot
  • 1. Diagnosis
  • 2. Treatment options
  • 3. Prognostic features on pathology of initial biopsy
slide32
1. Intransit malignant melanoma METS. Rare (<2%), appear as intracutaneous METS or 'satellites', those within 2cm of primary considered part of it, usually associated regional lymphadenopathy
  • 2. Resection for loco-regional disease only or for palliation, adjuvant systemic therapy (interferon [improves RFS, no overall survival benefit], immunotherapy, monoclonal antibodies, gene therapy, vaccines – none particularly effective), isolated limb perfusion (intra-arterial chemotherapy with melphalan +/- TNF-alpha, used with hyperthermia and hyperoxygenation, combined with lymphadenectomy). Indications limb perfusion: isolated intransit METS, irresectable local recurrence, adjuvant therapy for poor prognosis tumours, palliation to maintain limb function. Morbidity of isolated limb perfusion: mortality 2%, limb oedema 75%, persistent pain 60%, neuropathy 25%, venous thrombosis 10%, septicaemia & thrombocytopenia 3%.
slide33
Breslow thickness, Clark's level, ulceration, nodal metastases (size, number, extra-nodal extension), in-transit metastases, distant METS, mitotic rate, lymphocytic reaction, tumour regression status, incomplete or inadequate excision, sex, site, within naevus better, raised LDH level.
slide34
Prognostic factors primary malignancy:
    • Stage I and II
      • Depth of tumour (Breslow) and/or level of invasion (Clarks)‏
      • Tumour volume
      • Ulceration
      • Microscopic satellites or lymphatic invasion
      • Mitotic rate
      • HISTO type (desmoplastic & acral lentiginous higher rate LR)‏
      • Anatomical site (all mucosal (depth has no correlation – all bad), sole, palm, scalp, ears & subungual = poor prognosis)‏
      • Age (not independent prognostic variable but extremes of age influence SURG management)‏
      • Incomplete or inadequate primary tumour treatment
      • Miscellaneous: gender (F better than M), racial origin, regression, lymphocytic response, association with naevus (pre-existing naevus better), DNA ploidy
slide35
Prognostic factors primary malignancy:
    • Stage III:
      • Number and extent of lymph nodes involved
        • Solitary microscopic focus (<0.2mm) has equivalent survival to node -ve
        • >2 extensively involved nodes has very poor 5yr survival
      • Extranodal extension of tumour
      • Ulceration of primary tumour
    • Stage IV
      • Metastases present & resectability
q 4 1 describe specimen 2 aetiology 3 complications1
Q 4

1. Describe specimen

2. Aetiology

3. Complications

slide37
Cholelithiasis in chronically inflamed thick-walled gallbladder.
  • Imbalance of cholesterol (excessive chol.) and its solubilizing agents, bile salts and lecithin concentrations. Supersaturation + gallbladder hypomotility + crystal nucleation + accretion within GB mucous layer → GALLSTONES. May be cholesterol, pigment or mixed stones.
  • Complications (block, burst, burrow, become malignant):
    • Within the GB (biliary pain, acute & chronic cholecystitis, mucocele/GB empyema, Mirrizzi's syndrome, GB cancer). Or asymptomatic.
    • Within the biliary tree (obstructive jaundice, ascending cholangitis, pancreatitis)‏
    • Elsewhere (gallstone ileus)‏
q 5 1 describe specimen 2 differential 3 complications
Q 5

1. Describe specimen

2. Differential

3. Complications

slide40
Probable small GB mucosal polyp.
  • Cholesterol polyps: cluster of lipid-filled macrophages in the submucosa. Inflammatory polyps: reported but rare. Benign neoplasms of GB: adenomas – may be papillary but are particularly non-papillary, have been found in association with carcinoma-in-situ, >10mm have 10% risk malignancy (30% risk @ 20mm); adenomyomatosis – probably not pre-malignant, common coexisting condition with cholelithiasis, on USS has intraluminal convexity and central umbilication, usually found in fundus, ? relatively avascular on Doppler. Excise if >10mm, increasing in size, symptomatic, coexisting biliary cirrhosis. Malignant polyp.
  • Symptomatic, dislodge → obstructive effects, transform to malignancy, ? ↑ likelihood of cholelithiasis, haemobilia
q 6 liver segments 1 draw number these from a diagram 2 explain how divided into segmental anatomy1
Q 6

Liver segments.

1. Draw & number these from a diagram

2. Explain how divided into segmental anatomy.

slide42
Liver segments I -> VIII
  • Morphological division of liver into R and L lobes is via a principal plane through GB fossa up to the IVC, running parallel with the fissure of the round ligament (Cantlie's line). The R and L morphological lobes of liver have separate arterial and portal venous blood supply and biliary drainage. Each side can be further subdivided into 4 segments based on the branching of portal triads and hepatic veins (segments I-IV on L, V-VIII on R). The principal plane marks the course of the middle hepatic vein. The R hepatic vein further subdivides the R liver into anterior (V & VIII) and posterior (VI & VII) sectors. The umbilical fissure subdivides L liver into medial sector (IV) and left lateral sector (II & III – L hepatic vein between these 2 segments). Segment I is the caudate lobe at the back. Each segment is supplied by an independent portal pedicle, which forms the basis for sub-lobar segmental resections.
  • Hepatic veins mark the surgical landmarks for periphery of liver resections. Segmental anatomy dictates resectional anatomy: R lobectomy V-VIII, L lobectomy II-IV, L lateral segmentectomy II&III, extended R lobectomy + IV
slide43

Q 7

  • Band divided for SBO in 67yr old male. Intra-op incidental finding.
  • 1. How does this occur?
  • 2. Would you resect? Justify your answer.
slide44
Meckel's diverticulum. Remnant of the vitello-intestinal tract situated on antimesenteric border of ileum. Duct usually closes at 7 weeks gestation, if fails to obliterate may get: vitellointestinal fistula, umbilical sinus, enterocystoma, fibrous band to umbilicus, Meckel's diverticulum (95% of these scenarios).
  • Would not resect as lifetime risk of complications at age 50yrs = 1%, in elderly ~0%. Recent systematic review in adults shows greater harm with routine resection with a huge NNT for any benefit. Relative indications to resect however include: palpable heterotopia, narrow orifice (unlikely here, no real evidence narrow orifice is problematic), long diverticula, adhesions suggesting previous diverticulitis, presence of a band – possibly the band in this case?
  • Meckel’s Scan – 99Tc pertechnetate, enhanced by pentagastrin prior to scan
slide46
Management options:
    • Staging CT SCAN CHEST/ABDO/PELVIS (incl groins)‏
    • WLE of recurrence + SNBx if absent METS
    • Multiple local METS referred for isolated limb perfusion/infusion
    • PET CT scan if suspicion of METS and considering a curative resection
    • No effective chemotherapy at this stage. Refer for consideration for entry into trials (eg immunotherapy, interferon, monoclonal antibodies, tumour vaccines, gene therapy, etc)‏
    • Consider resection isolated METS (lung, liver, GI tract, brain)‏