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MRCS
Applied Basic Science
and Clinical Topics
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Stephen Parker BSc DipMedEd MS FRCS (Gen)
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Consultant General Surgeon
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University Hospitals of Coventry and
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Warwickshire NHS Trust
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Coventry, UK
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The rights of Stephen Parker to be identified as the author of this work have been asserted by him
in accordance with the Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this publication may be reproduced, stored or transmitted in any
form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as
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permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission in
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writing of the publishers. Permissions may be sought directly from JP Medical Ltd at the address
printed above.
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All brand names and product names used in this book are trade names, service marks, trademarks
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or registered trademarks of their respective owners. The publisher is not associated with any
product or vendor mentioned in this book.
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Medical knowledge and practice change constantly. This book is designed to provide accurate,
authoritative information about the subject matter in question. However readers are advised to
check the most current information available on procedures included or from the manufacturer of
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each product to be administered, to verify the recommended dose, formula, method and duration
of administration, adverse effects and contraindications. It is the responsibility of the practitioner
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to take all appropriate safety precautions. Neither the publisher nor the author assumes any
liability for any injury and/or damage to persons or property arising from or related to use the
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material in this book.
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This book is sold on the understanding that the publisher is not engaged in providing professional
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medical services. If such advice or services are required, the services of a competent medical
professional should be sought.
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Every effort has been made where necessary to contact holders of copyright to obtain permission
to reproduce copyright material. If any have been inadvertently overlooked, the publisher will be
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pleased to make the necessary arrangements at the first opportunity
ISBN: 978-1-907816-43-7
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British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
JP Medical Ltd is a subsidiary of Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India
MRCS Applied Basic Science and Clinical Topics has been written as a resource for candidates who are
preparing for postgraduate surgical examinations, in particular Parts A and B of the Intercollegiate
MRCS Examination. It has its foundation in my experience as a general surgical consultant with a
strong interest in medical education. The content has evolved over time, shaped by feedback from
previous candidates who have identified what they would have wanted when preparing for their
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examinations.
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The book aims to fill the gap between large surgical textbooks and smaller revision aids. This
has necessitated a selective approach to the topics included and the depth in which they are
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discussed: the basic science topics have been chosen for their direct bearing on clinical practice
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and the clinical topics are those commonly encountered both in the wards and in postgraduate
surgical examinations.
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Each chapter presents the basic science and clinical topics in a consistent format, in accordance
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with the MRCS syllabus. The clinical chapters aim to cover the whole breadth of surgical special-
ties at a level appropriate for the MRCS examination. Variations in surgical practice will inevitably
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mean that there will be disagreement with some of the views and recommendations that are
presented. In potentially contentious areas I have attempted to include opinions that are not too
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extreme, are supported by current research evidence and will hopefully satisfy most examiners.
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Within the space available, the book cannot hope to be exhaustive. Nevertheless, I hope that it
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will be a useful tool when working in and studying a particular surgical speciality, as well as serving
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as a revision tool and aide-mmoire immediately prior to the examinations.
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October 2012
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Contents
Preface v
The MRCS examination xi
Glossary xii
Chapter 1 Professional skills in clinical practice 1
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Duties of a doctor 1
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Communication skills 1
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Clinical governance 2
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Ethics and the law 5
Medical litigation 5
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Chapter 2 Perioperative care 7
Preoperative assessment 7
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Preparation for surgery 13
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Principles of anaesthesia 15
Care of the patient under anaesthesia 20
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Haematological problems in surgery 22
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Chapter 3 Postoperative management and critical care 33
Autonomic nervous system 33
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Pain 34
Metabolic and nutritional support 39
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Postoperative complications 43
Principles of intensive care 46
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Chapter 4 Surgical technique and technology 55
Surgical wounds 55
Surgical technique 57
Surgical procedures 61
Chapter 5 Evidence-based surgical practice 67
Evidence-based medicine 67
Chapter 6 Surgical pathology and microbiology 73
Surgical pathology 73
Surgical microbiology 74
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Prevention of infection 83
Surgery in hepatitis and HIV carriers 84
Chapter 7 Emergency medicine and the management
of trauma 87
Pathophysiology of trauma 87
Initial assessment of the trauma patient 88
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Traumatic wounds 92
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Compartment syndromes 94
The eye trauma and common infections 96
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Chapter 8 Principles of surgical oncology 99
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Cell proliferation 99
Epidemiology of common cancer 100
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NHS cancer screening programmes 101
Clinicopathological staging of cancer 102
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Principles of cancer treatment 103
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Chapter 9 Cardiothoracic surgery 109
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Applied basic sciences 109
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Cardiac disease 116
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Thoracic disease 123
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Chapter 10 General surgery 133
Abdominal trauma 133
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Abdominal emergencies 135
Chapter 11 The abdominal wall 147
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Applied basic sciences 147
Abdominal hernias 149
Intestinal fistulas 153
Chapter 12 Upper gastrointestinal surgery 155
Applied basic sciences 155
Oesophageal disease 159
Gastric disease 163
Chapter 13 Hepatobiliary and pancreatic surgery 169
Applied basic sciences 169
viii Hepatobiliary and pancreatic disease 172
Chapter 14 Colorectal surgery 189
Applied basic sciences 189
Colorectal disease 191
Perianal disease 201
Chapter 15 Breast disease 207
Applied basic sciences 207
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Breast disease 207
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Chapter 16 Endocrine surgery 221
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Applied basic sciences 221
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Thyroid and parathyroid disease 224
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Pituitary and adrenal disease 233
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Chapter 17 Vascular disease 239
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Applied basic sciences 239
Arterial disease 243
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Venous disease 254
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Lymphatics and spleen 260
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Renal failure and transplantation 264
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Chapter 18 Otorhinolaryngology and head and
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neck surgery 269
Applied basic sciences 269
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Ear, nose and throat disease 270
Salivary gland disease 276
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Chapter 19 Paediatric surgery 281
Applied basic sciences 281
Paediatric trauma 281
Correctable congenital abnormalities 282
Common paediatric surgical disorders 293
Orthopaedic disorders of infancy and childhood 300
Chapter 20 Plastic and reconstructive surgery 307
Applied basic sciences 307
Plastic surgery trauma 309
Pigmented skin lesions 315
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Chapter 21 Neurosurgery 323
Applied basic sciences 323
Neurosurgical trauma 325
Neurosurgical disorders 331
Chapter 22 Trauma and orthopaedic surgery 335
Applied basic sciences 335
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Skeletal fractures 344
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Degenerative and rheumatoid arthritis 351
Infections of bones and joints 354
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Disorders of the upper limb 357
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Disorders of the hand 359
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Knee injuries 362
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Disorders of the foot 363
Osteoporosis 364
Metabolic bone disease 364
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Locomotor pain 365
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Bone tumours and amputations 368
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Chapter 23 Urology 373
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Applied basic sciences 373
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Urological trauma 377
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Urinary tract infections and calculi 379
Haematuria 382
Urinary tract obstruction 385
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Pain and swelling in the scrotum 388
Aspects of pelvic surgery 392
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Index 397
x
The MRCS Examination
The Membership of the Royal College of Surgeons (MRCS) examination is a summative assessment
of candidates in the generality of surgery, whether in core surgical training or outside a training
programme. Its purpose is to determine that a trainee has acquired the knowledge, skills and
attributes required for the completion of core training and for those trainees following the
intercollegiate surgical curriculum programme, to determine their ability to progress to higher
specialist training. Passing the MRCS is mandatory to progress from ST2/CT2 to ST3/CT3.
Format of Part A
There is one 4-hour examination consisting of two 2-hour multiple choice question (MCQ) papers
that are sat consecutively. Paper 1 tests applied basic sciences and has single best answer (SBA)
questions. Paper 2 tests principles of surgery-in-general and has extended matching questions
(EMQs). Candidates score one mark for each correct answer. To pass Part A the overall pass mark
has to be met. The pass mark is set using a modified Angoff method. A score of at least 50% on
each paper has to be achieved. Candidates can have an unlimited number of attempts at this part.
Format of Part B
Part B is now in an objective structured clinical examination (OSCE) format. There are 16 stations
and four rest stations, each of 9 minutes. Candidates start at different points in the circuit. The
stations assess knowledge and skills in five main subject areas:
Anatomy and surgical pathology
Surgical skills and patient safety
Communication skills
Applied surgical science and critical care
Clinical skills
Twelve stations test generic knowledge and are compulsory for all candidates. To allow for
differences in training, there are four speciality stations. Candidates select their speciality context
at the time of application. In each of the five subject areas, six domains are tested:
Clinical knowledge
Clinical skill
Technical skill
Communication
Decision making and problem solving
Organisation and planning
Most of the stations have surgeon examiners and all examiners must have completed a training
course. The marking scheme is a matrix in which the stations are marked using several domains.
There is a structured mark sheet for each station. The mark sheet includes a holistic judgement of
the candidate. Candidates must reach the overall pass mark set for Part B. They must also achieve
a minimum score in each of the domains. A variant of the contrasting groups method is used for
setting the overall mark.
xi
Glossary
xii
FNAC Fine need aspiration cytology MAC Minimal alveolar concentration
FOB Faecal occult blood MCH Mean corpuscular haemoglobin
FRC Functional residual capacity MCHC Mean corpuscular haemoglobin
FVC Forced vital capacity concentration
MCPJ Metacarpophalangeal joint
GCS Glasgow coma score MCQ Multiple choice question
GIST Gastrointestinal stromal tumour MCV Mean corpuscular volume
GFR Glomerular filtration rate MEN Multiple endocrine neoplasia
GMC General Medical Council MI Myocardial infarction
GORD Gastroesophageal reflux MIBG Metaiodobenzylguanidine
GnRH Gonadotrophin-releasing hormone MODS Multiple organ dysfunction
syndrome
HCC Hepatocellular carcinoma MRA Magnetic resonance angiography
HCV Hepatitis C virus MRCS Membership of the Royal College
HDU High dependency unit of Surgeons
HIAA Hydroxyindolacetic acid MRSA Methicillin-resistant Staphylococcus
HIV Human immunodeficiency virus aureus
HNPCC Hereditary non-polyposis MRI Magnetic resonance imaging
colorectal cancer MSH Melanocyte-stimulating hormone
HRT Hormone replacement therapy MSU Mid-stream urine
MTPJ Metatarsophalangeal joint
IC Inspiratory capacity MUGA Multiple-gated apposition
ICP Intracranial pressure
IGF Insulin-like growth factor NCEPOD National Clinical Enquiry into
IMA Inferior mesenteric artery Perioperative Deaths
ILP Isolated limb perfusion NICE National Institute for Clinical
IPSP Inhibitory postsynaptic potential Excellence
IRV Inspiratory reserve volume NPI Nottingham Prognostic Index
ISCP Intercollegiate Surgical Curriculum NPV Negative predictive value
Programme NSAID Non-steroidal anti-inflammatory
ISS Injury Severity Score drugs
ITU Intensive therapy unit
IUCD Intrauterine contraceptive devise OCP Oral contraceptive pill
IVC Inferior vena cava OSCE Objective structured clinical
IVU Intravenous urogram examination
xiv
Chapter 1 Professional
skills in clinical
practice
works. The measure on its own is useful, but the effect of those that cannot be eliminated.
it is enhanced by considering whether the It establishes financial mechanisms to absorb
intervention is appropriate and whether it the consequences of the risks that remain.
represents value for money. In the modern Risk management involves consideration of:
health service, clinical practice needs to be Risks to patients
refined in the light of emerging evidence of Risks to practitioners
effectiveness. It also has to consider aspects of Risks to the organisation
efficiency and safety from the perspective of
Compliance with statutory regulations can
the patient.
help to minimise risks to patients. This can
Research and development be further reduced by ensuring that systems
are regularly reviewed and questioned.
Good professional practice has always
Maintenance of medical ethical standards
sought to change in the light of evidence
is also a key factor in maintaining patient
from research. The time lag for introducing
and public safety and wellbeing. It is vital
such change can be very long. Reducing
to ensure that clinicians work in a safe
the time lag and associated morbidity
environment. Poor quality is a threat to any
requires emphasis not only on carrying out
organisation. They need to reduce their own
and implementing research. Techniques
risks by ensuring high quality employment
such as critical appraisal of the literature,
practice, a safe environment and well-
project management and the development
designed policies on public involvement.
of guidelines, protocols and implementation
strategies are all tools for promoting the Risk management is essential to:
implementation of research practice. Providing a safe working environment
Meeting the personal and professional
Openness responsibility to patients
Poor performance and practice can too Complying with health and safety
often thrive behind closed doors. Processes legislation
which are open to public scrutiny, while Reducing the risk of litigation
respecting individual patient and practitioner Risks can be clinical or non-clinical. Once a
confidentiality are an essential part of quality risk is identified it must be analysed:
assurance. Open proceedings and discussion How often it is likely to occur?
about clinical governance issues should What are the potential effects of managing
occur. Any organisation providing high the risk?
quality care has to show that it is meeting What are the potential effects if the risk is
the needs of the population it serves. Health ignored?
needs assessment and understanding the How much is it likely to cost?
problems and aspirations of the community
require the cooperation between healthcare Consideration needs to be given to measures
organisations, public health departments, to control the risk. It may be possible to totally
local authorities and community health eliminate the risk. If it can not be eliminated,
councils. The system of clinical governance the risk should be minimised. Funding for
brings together all the elements which seek to risk management is part of every hospitals
promote quality of care. budget through the Clinical Negligence
Scheme for Trusts and existing liabilities
Risk management schemes.
Risk management can be defined as a Clinical audit
proactive approach that addresses the various
activities of an organisation. It identifies the Clinical audit is the review of clinical
risks that exist and assesses each risk for the performance and the refining of clinical
potential frequency and severity. It eliminates practice as a result and the measurement of
the risks that can be eliminated and reduces performance against agreed standards. It is
a systematic, critical analysis of the quality
4 Chapter 1 Professional skills in clinical practice
Choose topic
Agree standards
Assess conformity
to standards
Medical litigation 5
However negligent the defendant has been, brought, the solicitor issues a Letter of Claim.
the claimant must have suffered quantifiable A Letter of Response should be provided
harm. Quantifiable harm includes: within 3 months. If the case continues,
Loss of earnings claim forms are raised by the solicitor and
Reduced quality or quantity of life submitted to the court.
Disfigurement
Disability
Civil Procedure Rules 1998
Mental anguish The Woolf report in 1994 noted that in
medical negligence cases there was a
There may also be an element of contributory
disproportionate relationship between the
negligence. This occurs if the actions of the
costs and the amounts awarded. There were
claimant is judged to have made the situation
long delays in the settling of claims and
worse and can reduce the amount of damages
unmeritorious cases were often pursued.
awarded.
Clear-cut cases were defended longer than
Causation should have been and success rate was
lower than for any other personal injury
Causation is the link between actionable
litigation. There was less co-operation
harm and breach of duty of care. The harm
between opposing parties and 90% of litigants
has to have occurred as a result of the actions
were legally aided. Woolf has proposed
of the defendant.
case management by the courts, alternative
Legal process means of dispute resolution, court-based
experts and judges with specialist medical
The burden of proof lies with the claimant. knowledge. The future may include no-fault
The standard of proof is the civil standard compensation, early settlement using fixed
of balance of probabilities. Actions must be tariffs depending on the injury caused and
brought within 3 years. Different rules apply greater use of mediation to settle disputes.
for children and mentally ill. If a claim is
Chapter 2 Perioperative
care
Respiratory volumes
Figure 2.1 Respiratory volumes. IC = Inspiratory capacity. IRV = Inspiratory reserve volume. TV = Tidal volume.
VC = Vital capacity. FRC = Functional residual capacity. RV = Residual volume. ERV = Expiratory reserve volume.
TLC = Total lung capacity. (Reproduced from Thillai M and Hattotuwa K. Pocket Tutor Understanding ABGs and
Lung Function Tests. London: JP Medical Ltd, 2012.)
ECG
0 1 Time (sec)
A resting ECG is normal in 2550% of patients
with ischaemic heart disease. Characteristic
features of ischaemia or previous infarction may
Figure 2.2. Peak flow measurements. FVC = Forced
be present. An exercise ECG provides a good
vital capacity. FEV1 = forced expiratory volume in
one second indication of the degree of cardiac reserve.
Preoperative assessment 11
Adverse effects of inhalational anaesthetic
Decrease myocardial Depress ventilation Increase cerebral blood Decrease renal blood
contractility flow flow
Laryngospasm and
Reduce cardiac output airway obstruction Reduce cerebral Stimulate nausea and
metabolic rate vomiting
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Hypotension Decrease ventilatory
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response to hypoxia Increase risk of epilepsy Precipitate hepatitis
Arrhythmias and hypercapnia
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Increase myocardial Bronchodilatation Increase intracranial
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sensitivity to pressure
catecholamines
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Table 2.2 Adverse effects of inhalational anaesthetics
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cardiotoxic than halothane but causes greater approximately 1:7000 of population and is
respiratory depression. It reduces peripheral due to pseudocholinesterase deficiency.
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resistance and can cause a coronary steal. Malignant hyperpyrexia affects approximately
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Few adverse effects have been reported. 1:100,000 of population. It is due to increased
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calcium influx and uncontrolled metabolism
Nitrous oxide and results in a rapid increase in body
p
Nitrous oxide is a weak anaesthetic agent temperature with increased PaCO2.
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(MAC=103). It can not be used as an
Non-depolarising agents (e.g. vecuronium)
anaesthetic agent alone without causing
act over 23 minutes and the effects last for
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hypoxia. It is however a very potent analgesic
30 minutes to 1 hour. They act as competitive
agent. It is often used as a 50% N2O/50%
antagonists of acetylcholine receptor and are
O2 mixture known as Entonox. It is used in
used for intraoperative muscle relaxation.
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anaesthesia mainly for its analgesic properties.
Muscle relaxants
Perioperative monitoring
General anaesthesia removes the ability of a
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Muscle relaxants are either depolarising or
non-depolarising agents. Depolarising agents patient to protect themselves. The safety and
(e.g. suxamethonium) act rapidly within physiological control of the patient becomes
seconds and their effects last for approximately the responsibility of the anaesthetist. The
5 minutes. They are used during induction of anaesthetist needs to:
anaesthesia. Side effects include: Maintain airway and oxygenation
Histamine release producing a scoline Preserve circulation
rash Prevent hypothermia
Bradycardia Prevent injury
Somatic pain resulting from fasciculation Monitor during anaesthesia
Hyperkalaemia
Airway management
Increased intraocular pressure
General anaesthesia removes muscle
Increased gastric pressure
tone. Without assistance the airway will
Persistent neuromuscular blockade can be compromised. Methods of maintaining
result in scoline apnoea. This affects airway include:
Principles of anaesthesia 19
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monitoring of vital signs is obligatory.
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Facilities for cardiopulmonary resuscitation Arterial pressure monitoring
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should be immediately available. Monitoring Invasive arterial pressure monitoring
of the following is considered essential for all requires:
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patients:
An arterial cannula
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Temperature A monitoring line
Heart rate A transducer
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Blood pressure A monitoring system
is a
ECG
It provides information on systolic and
Oxygen content of inspiratory gas mix
diastolic pressure and arterial waveform.
End-tidal carbon dioxide
Complications and problems associated with
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Pulse oximetry
invasive monitoring include:
The following may be considered for major
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Over and under dampening
surgery:
Incorrect zeroing
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Invasive blood pressure monitoring Haematoma
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Central venous pressure Distal ischaemia
Urine output
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Inadvertent drug injection
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Alarms should indicate oxygen supply failure Disconnection and haemorrhage
and ventilator disconnection. Infection
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Invasive and non-invasive Central venous pressure
monitoring Clinical assessment of jugular venous
pressure is unreliable. The central venous
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Cardiac output is the gold standard measure
of cardiovascular function. Measurement system can be cannulated by the internal
normally requires invasive pressure jugular or subclavian routes to provide more
monitoring. Cardiovascular function can accurate information about central venous
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however be assessed non-invasively with: pressure and intravascular volume. It also
allows assessment of the cardiac pre-load.
Electrocardiogram
Complications of CVP lines include:
Blood pressure
Central venous pressure Pneumothorax
Urine output Arterial puncture
Air embolism
Blood pressure can be monitored with a cuff
Infection
(intermittent) or arterial line (continuous)
and in the absence of vasoconstriction The site at which transducers are zeroed are
provides a good estimate of cardiac output. very variable. They also change with patient
movement. Therefore changes in pressure
The ECG rather than absolute values are important.
An electrocardiogram (ECG) provides The pressure response to a fluid bolus (e.g.
information on both heart rate and rhythm. 200mL of colloid given as quickly as possible)
It also serves as a valuable monitor of give a good estimate of intravascular volume
electrolyte abnormalities. A 12-lead ECG status. A low CVP with a transient increase
20 Chapter 2 Perioperative care
with a fluid bolus indicates hypovolaemia. The derived haemodynamic data obtained
A high CVP with a persistent increase with a from a SwanGanz catheter includes:
fluid bolus indicates hypervolaemia. Cardiac index
Stroke volume
Cardiac output and left-sided pressures Stroke volume index
If both ventricle are functioning normally, Systemic vascular resistance
cardiac pre-load will allow an assessment of Systemic vascular resistance index
cardiac output. However, in ischaemic heart Pulmonary vascular resistance index
disease or sepsis, left ventricular function Left ventricular stroke work index
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can be reduced. Pulmonary hypertension Right ventricular stroke work index
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reduces right ventricular function. In these
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Oxygen delivery
situations, assessment of left heart pressures Oxygen consumption
may be important. Also a more direct
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measure of cardiac output may be needed. Recovery from anaesthesia
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Cardiac output can be measured either Recovery from anaesthesia should be
invasively with a pulmonary artery catheter monitored by a suitably trained nurse and it
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or non-invasively using an oesophageal should occur in a properly equipped recovery
Doppler.
is a
area. An anaesthetist should be immediately
available. Causes of failure to breath after
SwanGanz catheter general anaesthesia include:
A SwanGanz catheter is a balloon-tipped
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Obstruction of the airway
catheter inserted through a central vein. It
Central sedation due to opiates or
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is floated through the right side of heart into
anaesthetic agent
the pulmonary artery. The balloon allows
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Hypoxia
wedging in a branch of the pulmonary
.
Hypercarbia
artery. The pressure recorded is known as
Hypocarbia due to overventilation
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the pulmonary capillary wedge pressure.
Persistent neuromuscular blockade
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It is a good estimate of left atrial pressure.
Pneumothorax
The tip of the catheter contains a thermistor.
Circulatory failure leading to respiratory
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The cardiac output can be measured using
arrest
thermodilution principal. If blood pressure
and cardiac output are known then vascular
resistance can be calculated. Complications Care of the patient under
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of a SwanGanz catheter include:
anaesthesia
Arrhythmias
Knotting and misplacement Thermoregulation
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Cardiac valve trauma Mammals maintain a constant body
Pulmonary infarction temperature. They are known as
Pulmonary artery rupture homeotherms. Their body temperature
Balloon rupture is usually above the environmental
Catheter thrombosis or embolism temperature. Homeotherms have many
The primary haemodynamic data obtained advantages but do need a higher metabolic
from a SwanGanz catheter includes: rate.
Heart rate Body temperature results from a balance
Mean arterial pressure between production and heat loss. In a
Central venous pressure balanced state, production and loss of heat
Mean pulmonary artery pressure will be equal and the body temperature will
Mean pulmonary artery occlusion be constant. Tight control of temperature is
pressure essential for normal physiological functions.
Cardiac output The core temperature is invariably higher
Ventricular ejection fraction then the skin temperature.
Care of the patient under anaesthesia 21
preoperatively on the ward and it should be positioning of the patient. The commonest
maintained throughout the intraoperative nerves affected are the ulnar and common
phase. peroneal nerves and the brachial plexus.
Predisposing factors include:
Intraoperative phase Medical conditions associated with a
The patients temperature should be neuropathy (e.g. diabetes mellitus)
measured and documented before induction Nerve ischaemia due to hypotension
of anaesthesia. It should be repeated every 30 Local injections or direct nerve injury
minutes until the end of surgery. Induction The use of a tourniquets
of anaesthesia should not begin unless the
Most nerve injuries are due to a neurapraxia.
patients temperature is 36.0C or above.
About 90% undergo complete recovery.
Intravenous fluids (500mL or more) and
However about 10% are left with some
blood products should be warmed to 37C
residual weakness or sensory loss.
using a fluid warming device. Patients
who are at higher risk of inadvertent Ulnar nerve injuries are caused by
perioperative hypothermia and who are positioning the arms along side the patient
having anaesthesia for less than 30 minutes in pronation. The nerve is compressed at
should be warmed intraoperatively from the elbow between the operating table and
induction of anaesthesia using a forced air medial epicondyle. Injury can be prevented
warming device. All patients who are having by positioning arms in supination. Brachial
anaesthesia for longer than 30 minutes plexus injuries are caused by excessive arm
should be warmed intraoperatively from abduction or external rotation and can be
induction of anaesthesia using a forced air prevented by avoiding more than 60 of
warming device. abduction. Common peroneal nerve injuries
are caused by direct pressure on the nerve,
Postoperative phase often with the legs in lithotomy position.
The patients temperature should be The nerve can be compressed against the
measured and documented on admission to neck of the fibula. Injury can be prevented
the recovery room and then every 15 minutes. by adequate padding of lithotomy poles. The
Ward transfer should not be arranged unless radial nerve can damaged by a tourniquet or
the patients temperature is 36.0C or above. misplaced injection in the deltoid muscle.
If the patients temperature is below 36.0C, Injury can be prevented by adequate padding
they should be actively warmed using of any tourniquet used.
forced air warming until they are discharged
from the recovery room or until they are Haematological problems
comfortably warm.
in surgery
Prevention of injuries Function and components
General anesthesia removes many of the of blood
bodies natural protective mechanisms. If
Blood has both cellular and fluid
care is not taken, iatrogenic injuries are
components. The cellular components make
possible. Many of these injuries can produce
up 45% of the volume. The fluid component
lasting disability and can lead to litigation.
makes up 55% of the volume.
Recognition of risks and prevention is
essential. Tissues at risk include nerves, eyes, Plasma
teeth and skin. Plasma is the fluid component. Its normal
pH is 7.357.45. About 90% is water and 10%
Nerve injuries
is solutes. Solutes include albumin (60%),
The incidence of nerve injuries during
globulins (35%), fibrinogen, thrombin,
anaesthesia is unknown. However, in the
hormones, cholesterol, nitrogenous wastes,
USA, they account for 15% of postoperative
nutrients and electrolytes.
litigation claims. Most are due to careless
Haematological problems in surgery 23
Intrinsic pathway
Kallikrein Prekallikrein C1- inhibitor
HK HK
XI XIa TF
Ca2+ Ca2+
X Xa
Ca2+
Va
Protein S II IIa Ca2+
2+
Ca
XIII XIIIa
Protein C
Thrombomodulin Fibrinogen Fibrin
Plasmin Plasminogen
Figure 2.3 The clotting cascade (HK = High molecular weight kininogen. TF = Tissue factor. PAI-1 =
Plasminogen activator inhibitor-1. UK = Urokinase. SK = Streptokinase. tPA = Tisse plasminogen activator.)
Vasculitis
depends on the extent of the clotting factor (vWF). Haemostasis is impaired because of
deficiency. Patients with less than 1% clotting defective interaction between platelets and
factor activity have severe disease with the vessel wall. vWF mediates the adhesion of
life-threatening bleeding. Those with 15% platelets to sites of vascular injury and binds
activity have moderate disease with post- and stabilises the procoagulant protein factor
traumatic bleeding. Those with 520% activity VIII. Like haemophilia, it usually presents
have mild disease. with skin bruising, nose-bleeds, haematomas
and prolonged bleeding from trivial wounds.
Investigation Diagnosis is based on demonstrating a
Investigation will show the APPT to be deficiency of vWF. Treatment is usually with
prolonged. The PT is normal. The whole desmopressin.
blood coagulation time is prolonged and
Factor VIII levels are reduced. Recombinant factor VIIa
Factor VIIa is a trypsin-like serine protease.
Treatment It is an initiator of thrombin generation.
Bleeding episodes are treated with factor It acts via two pathways to activate Factor
VIII replacement given as either factor VIII Xa. One pathway is at the site of tissue
concentrate or cryoprecipitate. Bleeding injury complexed with Tissue Factor. The
is usually well-controlled if the factor VIII other pathway is on the platelet surface
levels are raised to above 20% of normal. independent of Tissue Factor. Tissue Factor
Desmopressin will increase intrinsic factor is found in the subendothelial layer of the
VIII levels. About 5-10% of patients develop vascular wall and is not normally available
antibodies to factor VIII which renders patients to complex with Factor VIIa. Following
refractory to factor replacement therapy. injury, the subendothelial layer is exposed
and Tissue Factor can bind to Factor VIIa.
von Willebrands disease Theoretically both mechanisms localise the
In 1926, Erik von Willebrand described a action of Factor VIIa to the site of trauma.
inherited bleeding disorder in a family from
the Aland Islands off the coast of Finland. Clinical uses
It is due to deficiency or dysfunction of a Recombinant Factor VIIa is licensed for use in
protein termed the von Willebrand factor haemophiliacs with antibodies to Factor VIII.
Haematological problems in surgery 29
O OO O Anti-A & B 46
A AA or AO A Anti-B 42
B BB or BO B Anti-A 9
AB AB AB None 3
Non-haemolytic transfusion
differentiate on clinical grounds alone. It
febrile reaction
may occur after infusion of a small volume
of incompatible or infected blood and is Non-haemolytic transfusion febrile reactions
associated with high morbidity and mortality. usually occur more than 30 minutes after the
In the unconscious patient, bleeding due start of a transfusion. Patient feels generally
to DIC may be the only sign. Most ABO well but may be shivering. Temperature
mismatched transfusions are due to human is usually less than 38.5C and the blood
error. The patient feels unwell and agitated. pressure is often normal. The transfusion
Symptoms include back pain and pain at the should be stopped and the possibility that
site of infusion. These may be associated with this may be a more significant reaction
Haematological problems in surgery 31
Both anaemia and polycythaemia increase of infection and increase the risk of tumour
postoperative mortality. A perioperative recurrence. If a blood transfusion is required,
haemoglobin concentration of approximately it should be given at least 2 days preoperatively
10g/dL is ideal. Preoperative transfusion may as blood transfused immediately prior to
induce immunosuppression, increase the risk operation has reduced O2 carrying capacity.
Chapter 3 Postoperative
management and
critical care
Sympathetic Parasympathetic
filtration and other functions not needed are found in autonomic ganglia. These
during emergencies. The adrenal medulla receptors are different to the nicotinic
behaves like a combined autonomic receptor found in neuromuscular junctions.
ganglion and postsynaptic sympathetic Muscarinic types are found on all organs with
nerve, It releases both adrenaline (80%) and parasympathetic innervation.
noradrenaline (20%).
Parasympathetic Pain
nervous system Pain is an unpleasant sensory and emotional
The parasympathetic nerves arise from experience associated with potential or actual
the cranial and sacral regions of the CNS. tissue damage. It is a complex interaction of
The cranial nerves involved are III, VII, IX, sensory, emotional and behavioural factors.
X. They have long preganglionic nerves Stimuli activate the nociceptive system
which synapse at ganglia near or on the which then conveys the information to the
organs innervated. Acetylcholine is the brain by an adaptable pathway. Pain is only
neurotransmitter released from both the experienced in the conscious brain.
pre- and postganglionic neurones.
The parasympathetic nervous system is
Types and physiology of pain
the rest and digest branch of the ANS. The Somatic pain
parasympathetic system promotes normal
maintenance of the body. It increases First pain
secretions and mobility of different parts First or fast pain is a protective response
of the digestive tract. It is also involved in which allows rapid withdrawal from a painful
urination and defecation. stimulus. It occurs due to stimulation of high
threshold thermo/mechanical receptors. The
Autonomic receptors information is transmitted by fast myelinated
There are multiple types of receptors in A fibres. They enter the dorsal horn of
the autonomic nervous system. For the the spinal cord. Secondary fibres in the
sympathetic system the major receptor spinothalamic tract transmit the stimulus to
types are a and b receptors. These are the posterior thalamic nuclei. Tertiary fibres
subdivided into -1, -2, -1 and -2. The transmit the stimuli to somatosensory post-
parasympathetic system has nicotinic and central gyrus.
muscarinic receptors.
Secondary pain
Receptors subtypes are not evenly
Secondary or slow pain is responsible
distributed throughout the body. The
for the delayed sensation of pain. It elicits
sympathetic and parasympathetic systems
behaviour to protect damaged tissue. It
often have opposing actions on the same organ.
initiates reflex responses such as tachycardia,
Adrenergic receptors are usually hypertension and increased respiratory rate.
stimulated by noradrenaline or adrenaline. It is due to stimulation of high threshold
The -1 receptor is found in the smooth polymodal receptors. They respond
muscle of arterioles and in the sphincter to mechanical, thermal and chemical
muscles of the gastrointestinal tract and stimuli. The information is transmitted by
bladder. The -2 receptor is found in slow unmyelinated C fibres which enter
presynaptic nerves and other parts of the the dorsal horn. Secondary fibres in the
gastrointestinal tract. The -1 receptor is the palaeo-spinothalamic tract transmit the
dominant type in the heart. The -2 receptor stimuli to the medial thalamic nuclei.
is found in the bronchioles of the lung and the Collateral fibres transmit the stimulus to the
muscles of the bladder. midbrain, medullary reticular formation
Cholinergic receptors are usually and hypothalamus. Further information is
stimulated by acetylcholine. Nicotinic types transmitted to the forebrain limbic system.
Pain 35
Spinal cord
Inhibitory Ascending
descending pathway pathways
Fast A fibres
Pain
Pain gate
Slow C fibres
Inhibitory
A spinal neuron
fibres
Touch
patient-controlled analgesia (PCA), morphine can be increased to 2 hours. The main toxicity
is administered intravenously but the patient is on central nervous and cardiovascular
determines their own analgesic requirement. systems. Plain lignocaine should be used for
A lock-out period prevents accidental local anaesthesia in digits and appendages
overdose. It is a safe means of administration as adrenaline containing solutions can cause
as sedation occurs before respiratory tissue ischaemia.
depression.
Lipid soluble opiates (e.g. fentanyl) can
Bupivacaine
be used for spinal or epidural injection/ Bupivacaine is chemically related to
infusion. They produces good analgesia lignocaine but has a more prolonged onset
with reduced risk of side effects. Intrathecal and longer duration of action. It acts for 68
morphine administration is an attractive hours. Like lignocaine its main toxicity is
analgesic technique since the opioid is on the central nervous and cardiovascular
injected directly into the cerebrospinal fluid, systems. Its duration of action can also be
close to the structures of the central nervous prolonged by the addition of adrenaline
system where the opioid acts. The procedure
is simple, quick, and relatively low-risk.
Spinal and epidural anaesthesia
Respiratory depression is however a major Spinal anaesthesia is the administration
safety concern. of local anaesthetic or opiate into the
cerebrospinal fluid (CSF) below the
Local and regional anaesthesia termination of the spinal cord at L1. Epidural
Local anaesthetic agents act by reducing anaesthesia is the use of local anaesthetic or
membrane permeability to sodium. They opiate administration into the fatty epidural
act on the small unmyelinated C fibre before space. A single bolus dose, can produce good
large A fibres. Therefore, they reduce pain and anaesthesia for several hours. The use of
temperature sensation before touch and power. both requires an experienced anaesthetist
as complications are common and can be
Lignocaine life-threatening (Table 3.2). The quality of the
Lignocaine is a weak base. At physiological block is often better with a spinal anaesthetic.
pH, it is mainly ionised. It has a rapid onset Contraindications to spinal or epidural
but short duration of action. With the anaesthesia are pre-existing neurological
addition of adrenaline, the duration of action disease, known coagulopathy and sepsis.
The afferent and efferent connections to the vomiting centre and chemoreceptor trigger zone
Higher centres
Vestibular input
Vomiting centre
histamine receptor H1
muscarinic acetylcholine receptor
5-hydroxytriptamine receptor 5- HT2
Figure 3.2 The afferent and efferent connections to the vomiting centre and chemoreceptor trigger zone
Maintenance requirements
Metabolic and nutritional Daily maintenance fluid requirements vary
support between individuals. For a 70kg male it is
Fluid and electrolyte about 3 litres of water, 120mmol sodium
and 70mmol potassium. For a 40kg
management woman it is 90mmol sodium and 40mmol
For the average 70kg man, the total body potassium. The daily maintenance fluid
water is 42 litres. This represents about 60% requirements for children can be estimated
of the body weight. This is made up of 28 as follows:
litres in the intracellular and 14 litres in the
010kg is 100mL/kg
extracellular compartments. The plasma
1020kg is 1000mL+50mL/kg for each kg
volume is 3 litres and the extravascular
more than 10
volume is 11 litres. The total body sodium
More than 20kg is 1500mL+25mL/kg for
is 4200mmol of which 50% is in the
each kg more than 20
extracellular fluid compartment. The total
body potassium is 3500mmol of which only Pre-existing and on-going losses
about 50mmol is in the extracellular fluid
Pre-existing and ongoing losses can be rich in
compartment. The normal osmolality of
electrolytes. Most surgical pre-existing and
extracellular fluid is 280295mosmol/kg.
ongoing losses are rich in sodium and should
When calculating fluid replacement for a
be replaced with 0.9% saline. They include:
patient, it is necessary to consider:
Vomit and diarrhoea
Maintenance requirements
Nasogastric aspirate
Pre-existing and ongoing losses
Stoma, drain and fistula output
Insensible losses
40 Chapter 3 Postoperative management and critical care
leads to increased duration of hospitalisation. All patients should have a clear diagnostic
Clinical features include a reduced level and monitoring plan documented
of consciousness, impaired thinking and on admission. Prompt recognition of
memory, perceptional abnormalities complications is essential. Patients often
and disturbances of emotion. Causes of require complex management and delay
postoperative confusion include: worsens outcome. Adequate and prompt
Hypoxia respiratory disease, cardiac access to emergency operating theatres is
failure, arrhythmia essential.
Trauma head injury The seniority of the staff involved a the
Infection intracranial, extracranial patients management should be guided by a
Neoplasia primary and secondary risk assessment. High-risk surgical patients,
cerebral tumours with a predicted hospital mortality of more
Vitamin deficiency thiamine (Wernicke than 5% should have direct diagnostic, surgical,
encephalopathy), B12 deficiency anaesthetic and critical care consultant input.
Endocrine hypothyroidism, Surgical procedures with a predicted mortality
hyperthyroidism, Addisons disease of more than 10% should be performed under
Degenerative the direct supervision of both a consultant
Vascular CVA, TIAs surgeon and anaesthetist. Each patient should
Drugs have their risk of death re-assessed at the
Metabolic derangement end of surgery and the optimum location for
postoperative care determined. All high-risk
Principles of intensive care patients should be admitted to critical care.
3 2 1 0 1 2 3
Heart rate (beats/min) <40 4150 51100 101110 111130 >130
Mean BP (mmHg) <70 7180 81100 101199 >200
Respiration rate <8 914 1520 2129 >30
(breaths/min)
Temperature <35 35.136.5 36.637.4 >37.5
Definition
Table 3.8 The definitions of systemic inflammatory response syndrome (SIRS), sepsis and septic shock
Principles of intensive care 49
is important and over hydration should The anion gap is the sum of the positive and
be avoided. The nutritional status should negative charges in the plasma. The cations
be addressed. Mechanical ventilation are sodium and potassium. The anions are
is important but the exact strategy is chloride, bicarbonate. The difference between
controversial. It is generally believed the two is the anion gap. If a metabolic
that ventilation with low tidal volumes is acidosis is due to anion excess the anion
beneficial. High tidal volumes can exacerbate gap is increased. If metabolic acidosis is
the lung injury. The role of positive end- due to bicarbonate loss the anion gap is
expiratory pressure is unclear. Inhaled nitric normal. Lactic acidosis and renal failure are
oxide or surfactant are of no proven benefit. associated with an increased anion gap.
Steroids may have some clinical effect.
Blood gas analysis
Acidbase balance A blood gas analyser measures:
pH is a logarithmic scale and the blood pH is Partial pressure oxygen
normally maintained at 7.367.44. A change Partial pressure carbon dioxide
in pH of 0.3 units is equivalent to a doubling pH
of the hydrogen ion concentration. Blood Other variables are derived using Henderson
pH is maintained by biological buffering Hasselbach equation and are summarised in
mechanisms involving proteins, bicarbonate Table 3.10.
and haemoglobin. The relationship between
serum pH and bicarbonate concentration Interpretation of results
is described by the HendersonHasselbach Blood gas results should be interpreted with
equation. Compensatory mechanisms exist knowledge of the patients clinical condition.
to compensate for changes in pH. Important It is important to check for the consistency
definitions include: within the blood gas sample. To fully interpret
Acidosis=a rise serum in hydrogen iron results it is important to:
concentration or fall in pH Look at the pH for the primary acidbase
Alkalosis=a reduction in hydrogen iron disorder
concentration or rise in pH Assess a respiratory component by looking
Respiratory acidosis=a fall in pH due to a at the partial pressure of carbon dioxide
rise in partial pressure of carbon dioxide Assess the metabolic component by
Respiratory alkalosis=a rise in pH due to a looking at the base excess
fall in partial pressure of carbon dioxide Calculate the anion gap
Metabolic acidosis=a fall in pH due to a
metabolic cause Lactic acidosis
Metabolic alkalosis=a rise in pH due to a Metabolic acidosis is defined as a state of
metabolic cause decreased systemic pH resulting from either
52 Chapter 3 Postoperative management and critical care
Normal value
Temperature 37C
pH 7.367.44
Partial pressure CO2 (pCO2) 4.65.6kPa
Partial pressure O2 (pO2) 10.013.3kPa
Bicarbonate 22 26mmol/L
Total carbon dioxide 2428mmol/L
Standard bicarbonate (SBC) 2226mmol/L
Base excess (BE) 2 to +2mmol/L
Standard base excess (SBE) 3 to +3mmol/L
Oxygen saturation >95%
Haemoglobin 11.516.5g/dL
venous pressure, cardiac filling and cardiac may need inotropic support. Some patients
output. Sympathetic stimulation causes require inotropes and vasopressor. Others
reduced splanchnic perfusion, cutaneous require inodilators to redistribute the blood
vasoconstriction and reduced renal perfusion. flow. The choice of inotrope depends on
The venous return is increased and myocardial their relative actions on the sympathetic
contractility is maintained. The renin/ nervous system.
angiotensin system is stimulated, antidiuretic
hormone is released and the urine output is Cardiogenic shock
reduced. If compensation is adequate, blood For patients who have low cardiac output
pressure is maintained and oxygen delivery to with high filling pressure and vascular
the essential tissues remains adequate. resistance, dobutamine is an inotrope that
reduces vascular resistance. Inodilators
Progression such as dopexamine are also useful. Pure
If compensatory mechanisms are inadequate, vasodilators such as nitrates or nitroprusside
ischaemia and hypoxia occur. Anaerobic also have a role.
metabolism results in increased lactate
production. Capillary permeability increases High output states
and pulmonary oedema may occur resulting In severe cases of sepsis, vasodilatation is
in ARDS. Renal hypoperfusion can result in often resistant to the use of vasoconstrictors.
acute tubular necrosis. The perfusion pressure can be restored with
noradrenaline. Dobutamine can be added
Irreversibility to increase cardiac output. Adrenaline
If compensatory mechanisms fail, then aggravates splanchnic ischaemia.
vasodilatation occurs and capillary
permeability is increased. Progressive tissue Acute renal failure
hypoxia occurs. When the systolic blood Acute renal failure is a reduction in renal
pressure falls below about 5060mmHg, excretory or regulatory function resulting
reduced coronary circulation results in in the retention of waste products normally
myocardial ischaemia. Cerebral ischaemia excreted by the kidney. A normal adult
causes vasomotor depression and visceral urine output is about 0.5mL/kg/hr. Renal
vasodilatation. Disseminated intravascular failure can be anuric, oliguric or polyuric.
coagulation occurs and water and electrolyte Biochemical changes of acute renal failure
disturbances develop. include:
Hyponatraemia
Acute blood loss
Hyperkalaemia
Following acute blood loss, the haemoglobin Hypocalcaemia
and packed cell volume (PCV) remain normal Metabolic acidosis
for the first 34 hours. Plasma volume then
expands and the haemoglobin and PCV fall, Management
associated with an increase in neutrophils The management of acute renal failure is
and platelets. The reticulocyte count increases to correct the precipitating cause. Most
on day 2 or 3 and this reaches a maximum surgical patients are hypovolaemic and
of 1015% by day 8 to 10. Without treatment require volume resuscitation. If there is
haemoglobin begins to rise by day 7. inadequate renal perfusion pressure then
consideration needs to be given to inotropic
Cardiovascular support
support. Oxygen should be administered.
In all forms of shock, there is a need to re- Consideration should be given to the use
establish adequate cardiac output and tissue of bicarbonate if the base excess is more
perfusion. The aim is to achieve a mean than 10 or the arterial pH less than 7.
arterial pressure of at least 80mmHg. For Hyperkalaemia requires urgent treatment if
this to occur it requires preload optimisation the patient is:
with volume replacement and patients
54 Chapter 3 Postoperative management and critical care
Factors that influence wound healing can be Keloid and hypertrophic scars
both systemic and local. All scars become red and thickened during
Systemic factors include: the normal healing process. After several
Age and sex months maturation results in flattening of the
Nutrition wound. In some scars collagen formation is
Vitamin and trace element deficiencies excessive resulting in elevated and red scar.
vitamin C, vitamin A, zinc If this process is confined to the area of the
Drugs steroids, chemotherapy, wound the scar is described as hypertrophic.
immunosuppression If it extends beyond the wound into normal
Systemic disease diabetes, jaundice, tissue the scar is described as keloid scar.
malignancy Keloid scars are seen particularly in patients
Hypoxia of Afro-Caribbean origin and often affect the
presternal and deltoid areas. Treatment can
Local factors include:
be difficult. Treatment options include:
Blood supply
Intra-lesional steroid injections (e.g.
Infection
triamcinolone)
Foreign bodies
Compression dressings with elasticated
Surgical technique
compression garments
Scars and contractures Silastic gel therapy
Excision and radiotherapy
Factors that influence scar formation Laser therapy
include:
Individual genetic make up Principles of anastomoses
Race
Gastrointestinal anastomoses
Anatomical site
An anastomosis is a surgically created join
Wound tension
between two hollow viscera or vessels
Age
in order to create a confluent channel.
Placement of incision
Anastomoses can be fashioned in various
Surgical technique
ways including:
To minimise the degree of postoperative
End-to-end
scarring:
End-to-side
Incisions should run along Langer lines Side-to-side
The finest suture possible should be used
Any anastomotic technique is required to
Tension should be avoided
maintain apposition of the two sides of the
Sutures should be removed as soon as
anastomosis until collagen is laid down.
possible
Gastrointestinal anastomoses show serosal
Traumatic wounds should be clean and
healing and require a good blood supply and
edges excised
minimal tension. Anastomotic leak or failure
Exposure to sunlight should be avoided in
my occur if there is:
the early postoperative period
Distal obstruction
Contractures result if scars shorten. They
Peri-anastomotic sepsis
are particularly seen in badly aligned scars
Peri-anastomotic haematoma
not corresponding to Langer lines. They
Hypotension
can reduce joint mobility and may require
Hypoxia
surgery such as a Z-plasty or skin graft to
Jaundice
correct the deformity. Depressed scars occur
Corticosteroids
if skin becomes attached to deep tissue. They
Uraemia
can be treated by the release of normal skin
from margins of scar. The scar can then de- An anastomosis should promote primary
epithelialised and skin edges closed over the healing by accurate alignment and minimal
top. disruption of the local vasculature. It should
Surgical technique 57
is concern about possible wound infection, 50=0.10mm
consideration should be given to leaving the 40=0.15mm
skin wound open. 30=0.20mm
Sutures should be removed as early as 20=0.30mm
possible. On the head and face, limbs and 0=0.35mm
abdomen they should be removed at 5, 7 and 1=0.40mm
10 days respectively. 2=0.5mm
/
The purpose of a suture is to hold a wound Five types of needle points are in common
r
together, in good apposition, until such time use and are shown in Figure 4.3:
.i
as the natural healing process is sufficiently Cutting needle
well established to make the support from the Reverse cutting needle
s
suture material unnecessary and redundant. Round-body needle
s
The ideal suture material should: Taper cutting needle
Blunt point needle
n
Have good handling characteristics
Not induce a significant tissue reaction Needles vary in their diameter and the
is a
Allow secure knots circumference of the curve as shown in
Have adequate tensile strength Figure 4.4.
Not cut through tissue
Other techniques of wound closure
r
Be sterile
Be non-allergenic SteriStrips are self adhesive tapes. They
e
Be cheap can be used to reduce tension on a wound
and are particularly useful for superficial
p
The choice of suture will depend on:
.
lacerations. Tension from the tapes can cause
Properties of the suture material skin blisters. Tissue adhesive is based on
p
Absorption rate cyanoacrylate monomer. It is simple and pain
iv
Handling and knotting properties free to use but wounds does need to be clean
Size of suture and tension free.
/: /
Type of needle
Wound dressings
Suture characteristics
The ideal wound dressing should:
tt p
Suture materials vary in their physical
characteristics. Monofilament sutures (e.g. Maintain a moist environment at the
polypropylene) are smooth. They slide well wound interface
in tissues but if handled inappropriately Remove excess exudate without allowing
h
they can fracture. Multifilament sutures (e.g. strike through to the surface of dressing
polyglactin) are braided. They have a greater Provide thermal insulation and
surface area. They are easier to handle and mechanical protection
knot well. Some suture materials have a Act as a barrier to micro-organisms
memory and return to former shape when Allow gaseous exchange
tension is removed. Absorbable suture Be non-adherent and easily removed
are broken down by either proteolysis or without trauma
hydrolysis. The rate of breakdown varies Leave no foreign material in the wound
between individual suture materials. Be non-toxic, non-allergenic and non-
sensitising
Suture sizes Hydrocolloids
Sutures are sized by the USP (United States Hydrocolloids are a matrix of cellulose and
Pharmacopoeia) scale. The available sizes other gel forming agents such as gelatin and
and diameters are: pectin. They form an occlusive dressing and
60=0.07mm should be avoided if infection is a risk. This
Surgical technique 59
needle point
Round bodied
Cutting
Reverse cutting
r/
.i
Blunt point
s
Taper cutting
n s
Figure 4.4 The common profiles
is a
of needle curves
1/2 Circle 3/8 Circle 1/4 Circle J Shape Straight
e r
type of dressing promotes autolysis and aids
.p Debriding agents
p
granulation. It can remain in place for up to a Debriding agents remove eschar and
iv
week. Over-granulation can occur. necrotic tissue. They do not maintain a moist
environment and need frequent changes.
/: /
Alginates They damage granulation tissue and can
Alginates are made from calcium and potentially delay healing.
sodium salts of alginic acid obtained form
tt p
seaweed. They are highly absorbent. They Negative pressure topical dressings
are useful in medium to heavily exudating Negative pressure topical dressings apply
wounds and form a gel in contact with pressure via a foam dressing. They remove
wound exudates.
h
wound exudate and reduce extravascular
and interstitial fluid. They improve blood
Foam dressings supply to the wound during the phase
Foam dressings are useful for moderately of inflammation. The mechanical effect
exudating wounds. They prevents strike appears to stimulate cellular proliferation.
through of exudate to wound surface. They A polyurethane or polyvinyl-alcohol foam
deslough wounds by maintaining a moist dressing is cut to the shape of the wound.
environment. The foam is then covered with an adhesive
dressing with a small hole. A therapeutic
Hydrogels regulated accurate care (TRAC) pad is
Hydrogels have a high water content which applied over the hole and is connected to a
creates a moist wound surface. They debride negative pressure generator. The pressures
wounds by a combination of hydration and achieved at the TRAC padfoam interface
promotion of autolysis. They will absorb light are regulated. A pressure of approximately
exudates but are not appropriate for heavily 125mmHg is often used. Intermittent
exudating wounds. application of pressure may be advantageous.
60 Chapter 4 Surgical technique and technology
The dressings should be changed every 4872 Diathermy can interfere with pacemaker
hours. Wounds suitable for negative pressure function. Arcing can occur with metal
topical dressings include those resulting from instruments and implants. Superficial burn
trauma, burns, pressure sores, leg ulcers and can occur if a spirit-based skin preparation is
infection. Contraindications include grossly used. A burn can occur under the indifferent
infected and bleeding wounds, malignancy electrode if the plate is not properly applied.
and exposed vessels and bowel. Channeling effects can occur if diathermy is
used on a viscus with a narrow pedicle (e.g.
Diathermy penis or testis).
/
Diathermy is the use of high frequency
r
electrical current to produce heat. It is used Bipolar diathermy
.i
to either cut and destroy tissue or to produce With bipolar diathermy (Figure 4.6), the two
coagulation. Mains electricity is 50Hz electrodes are combined in the instrument
s
and produces intense muscle and nerve (e.g. forceps) and the current passes between
s
activation. The electrical frequency used by the tips and not through the patient. The
diathermy is in the range of 300kHz to 3MHz. advantage of bipolar diathermy is that the
n
The patients body forms part of the electrical electrical current does not pass through parts
circuit but the current has little effect on of the body which are not being treated. It is
is a
muscles and the myocardium. possible to be much more precise with the
quantity of tissue being coagulated.
Monopolar diathermy
r
With monopolar diathermy (Figure 4.5), Lasers
e
an electrical plate is placed on the patient Laser is an acronym for Light Amplification
and acts as an indifferent electrode. The by the Stimulated Emission of Radiation.
p
current passes between the instrument and Laser emissions vary and are:
.
the indifferent electrode. As the surface area Collimated parallel output beam results
p
of the instrument is an order of magnitude in little energy loss
iv
less than that of the plate, localised heating Coherent waves are all in phase resulting
is produced at the tip of instrument and in little loss of energy
/: /
minimal heating effect is produced at the Monochromic all of the same wave
indifferent electrode. The effects of diathermy length
depend on the current intensity and wave-
The effects of a laser depends on its
tt p
form used. Coagulation is produced by
photochemical, photomechanical and
interrupted pulses of current (50100/
photothermal effects. Tissue penetration
second) and the use of a square wave-form.
increases with wavelength. Pulsing of output
Cutting is produced by continuous current in
h
can reduce thermal damage.
a sinus wave-form.
an intense tissue reaction allowing a tract The diameter of the catheter (10Fr to 24Fr)
to form and have specific uses in modern The number of channels (two or three)
surgical practice. In some situations this may The size of the balloon (5mL to 30mL)
be useful (e.g. biliary T-tube). Drains can be The shape of the tip
open or closed and can be active or passive. When using a catheter it should be of an
Open drains include corrugated rubber or appropriate size, inserted using an aseptic
plastic sheets. The drain fluid collects into a technique and never with the use of force.
gauze pad or stoma bag. Open drains can be The balloon should not be inflated until urine
associated with an increased risk of infection. has been seen coming from the catheter.
A closed drain consists of a tube draining into The residual volume should be recorded.
a bag or bottle. Examples include chest and A catheter introducer should not be used
abdominal drains. With closed drains the unless the operator has been trained in its
risk of infection is reduced. Active drains are use. If difficulty is encountered inserting a
maintained under suction with either low or urethral catheter consider a suprapubic route.
high pressure. Passive drains have no suction. The catheter should be removed as early as
They function by the differential pressure possible. Special catheters exist such as:
between body cavities and the exterior.
Gibbon catheters
Nasogastric tubes Nelaton catheters
Tiemann catheters
Following abdominal surgery,
Malecot catheters
gastrointestinal motility is reduced for a
variable period of time. Gastrointestinal Indications for a urinary catheter include:
secretions accumulate in the stomach and The management of acute urinary
proximal small bowel. This may result in retention or bladder outlet obstruction
postoperative distension and vomiting The measurement of urine output in a
and the risk of an aspiration pneumonia. critically ill patient
Nasogastric tubes are often used to remove During surgery to assess fluid status
fluid and secretions. There is little clinical During and following specific surgeries of
evidence available to support their routine the genitourinary tract
use following elective gastrointestinal surgery The management of haematuria associated
and they may actually increase the risk of with clots
pulmonary complications. They are of proven The management of an immobilised patients
value for gastrointestinal decompression The management of patients with a
in intestinal obstruction and following neurogenic bladder
emergency abdominal surgery. Nasogastric Intravesical pharmacologic therapy
tubes are usually left on free drainage and Improved patient comfort for end of life care
aspirated on an intermittent basis. They The management of patients with urinary
should be removed when the volume incontinence
of nasogastric aspirate has reduced and The only absolute contraindication to
gastrointestinal motility has returned. the placement of a urethral catheter is
the presence of urethral injury. Relative
Urinary catheters contraindications include a urtethral stricture
A urinary catheter is a form of drain. It is or recent urinary tract surgery.
commonly used to alleviate or prevent
Complications of urethral catheterisation
urinary retention or to monitor urine
include:
output. It can be inserted transurethrally or
suprapubically. Catheters vary by: Paraphimosis
Blockage
The material from which they are made
By-passing
(latex, plastic, silastic, Teflon-coated)
Infection
The length of the catheter (38cm male or
Failure of balloon to deflate
22cm female)
Urethral strictures
Surgical procedures 65
Hierarchy of evidence
Level Description
Number
Median
Range (100%)
distribution the median equals the mean and whether a statistical hypothesis is true
68%, 95% and 99.7% of variable lies with one, would be to examine the entire population.
two and three standard deviations of the mean. Since that is often impractical, researchers
typically examine a random sample from the
Statistical hypothesis population. If sample data are not consistent
A statistical hypothesis is an assumption about with the statistical hypothesis, the hypothesis
a population parameter. This assumption may is rejected. There are two types of statistical
or may not be true. The best way to determine hypotheses.
70 Chapter 5 Evidence-based surgical practice
Null hypothesis is the hypothesis that statistical test can be selected. When
sample observations result purely from selecting an appropriate statistic test it is
chance necessary to decide whether the variables
Alternative hypothesis is the hypothesis are matched, paired or independent
that sample observations are influenced by and to define both the input and output
some non-random cause variables. Both variable can be categorical
or quantitative. Statistical tests for paired
Calculation of sample size or matched variables are shown in
The sample size needed to test a hypothesis Table 5.2. Appropriate statistical tests for
depends on four factors: independent observations and categorical
Expected difference in means between the outcome variables are shown in Table 5.3.
two groups Appropriate statistical tests for independent
Variability of the data observations and quantitative outcome
Power of the study and the probability that variables are shown in Table 5.4.
any difference is real (usually 90%) A test of a statistical hypothesis, where the
Level of significance accepted (usually 5%) region of rejection is on only one side of the
sampling distribution, is called a one-tailed
Type I and Type II errors test. A test of a statistical hypothesis, where
A Type I error is rejection of null hypothesis the region of rejection is on both sides of the
when it is in fact true: sampling distribution, is called a two-tailed
No difference is present between the test.
samples Quality of life
The statistical method used identified a
Diseases and their treatment have an
difference
impact on patient wellbeing. Quality of life
A Type II error is rejection of null hypothesis (QoL) is a measure of an illness, disease
when difference between groups exists: and its treatment on patient welfare. It has
A difference is present between the samples dimensions beyond physical measures of
The statistical method used failed to patients progress. No universal definition
identify it of QoL exists. It has three fundamental
characteristics:
Choice of statistical test Multidimensional physical, social,
Prior to analysing data it is necessary psychological
to define the hypothesis being tested. Subjective
If no hypothesis is proposed then no Dynamic
Table 5.3 Statistical tests for independent observations and categorical outcome variables
Table 5.4 Statistical tests for independent observations and quantitative outcome variables
Different items on the questionnaire tap Specific instruments are used for specified
various dimensions of QoL. QoL instruments disease or condition. Several types exist
can be either generic or specific. including:
Generic instruments assess many Domain specific (e.g. hospital anxiety and
dimensions and produce a global concept depression scales)
of QoL. Two types of generic questionnaires Disease specific (e.g. EORTC QLQ-C30 for
exist: cancer patients)
Health profiles (e.g. SF-36) Population specific (e.g. children or elderly)
Health indices (e.g. Quality adjusted life Symptom specific (e.g. McGill pain
years) questionnaire)
Chapter 6 Surgical
pathology and
microbiology
drainage of the abscess, possibly by a it spreads slowly and often results in skin
percutaneous route. Antibiotics can be ulceration. It lacks the severe systemic toxicity
changed when sensitivities are known. seen with necrotising fasciitis. Treatment
Surgery may be more appropriate in should be with antibiotics including
secondary abscesses when the underlying benzylpenicillin. Surgical debridement of the
pathology may require surgical correction. affected area may be required.
Lines of clostridial
innoculation Opacification due to
lecinthase activity of
alpha toxin
are inefficient compared to autoclaves. They organisms are highly sensitive where as
require temperatures of 160C for 2 hours or clostridial and mycobacterial species are
180C for 30 minutes. very resistant. Disinfectants are suitable for
heat-sensitive items but are less effective
Ethylene oxide than heat. Chemicals used for disinfection
Ethylene oxide is highly-penetrative gas that include:
is active against bacteria, spores and viruses. Clear soluble phenolics
Unfortunately, it is also flammable, toxic Hypochlorites
and expensive and leaves toxic residue on Alcohols
/
sterilised items. Instruments therefore need Quaternary ammonium compounds
r
to be stored for prolonged period before use.
.i
It is suitable for sterilisation of heat-sensitive
items. Surgery in hepatitis and
s
Sporicidal chemicals
HIV carriers
s
Sporicidal chemicals are often used Hepatitis B
n
as disinfectants but can also sterilise The hepatitis B virus is a single-stranded
instruments if used for prolonged period. DNA virus. It consists of 42nm Dane particle
is a
They are inexpensive and suitable for heat- (HbsAg) and 22nm core (HbcAg). The
sensitive items. They are toxic and irritant. hepatitis B surface antigen (HbsAg) is also
2% Glutaraldehyde is the most widely used know as the Australia antigen. The virus also
r
liquid sporicidal chemical. Most bacteria contains the hepatitis B e antigen (HbeAg).
e
and viruses are killed within 10 minutes but The body produces antibodies to the surface
spores can survive several hours. antigen (HbsAb).
p
In the UK, the prevalence of HbsAg
.
Irradiation
positivity is about 12% and is seen
p
Gamma rays and accelerated electrons are particularly in drug addicts, homosexuals,
iv
excellent at sterilisation and are used as an dialysis patients and occasionally medical
industrial rather than hospital-based method staff. In Asia, Middle East and South
/: /
of sterilisation. America the prevalence of HbsAg positivity is
between 2030%. It is transmitted by vertical
Disinfection
transmission, inoculation, oral and sexual
Disinfection is a reduction in the number of
tt p
contact. The incubation period is between 6
viable organisms. It can be achieved by: weeks and 6 months. The period of infectivity
Low-temperature steam is from 6 weeks, before the onset of symptoms
Boiling water
h
and possibly indefinitely after. About 10% of
Chemical disinfectants infected patients become chronic carriers.
The risk of chronic infection varies with age at
Low-temperature steam which infection is acquired and is greatest in
Most bacteria and viruses are killed by young children.
exposure to moist heat. This is usually
achieved with dry saturated steam at 73C Clinical features
for greater than 10 minutes. It is effective and There are three common clinical pictures:
reliable and suitable for instrument with a Acute hepatitis with clinical recovery
lumen but is not suitable for heat-sensitive Acute fulminating hepatitis leading to death
items. Chronic active hepatitis with risk of
cirrhosis and hepatocellular carcinoma
Chemical disinfectants
Chemical disinfectants destroy micro- Serological results
organisms by chemical or physicochemical HbsAg positivity is the first indicator of
means. Different organisms vary in their infection and is seen throughout the course of
sensitivity to disinfectants. Gram-positive
Surgery in hepatitis and HIV carriers 85
the disease. Persistence is a marker of failure was isolated in 1983. In 1984, a serological test
to clear infection. HbsAb positivity is a marker for antibodies to the virus became available.
of protection due to either previous infection About 3050% of HIV positive patients are
or immunisation. HbeAg positivity is closely unaware of their infection. HIV is a treatable
associated with infectivity of the patient. disease. Where therapy is available, infected
individuals have the same rate of death as
Prevention of infection aged-matched uninfected controls.
It is important to avoid contact with the virus.
It requires care with needles and body fluids. Immunology
/
After a needle stick injury from a high-risk HIV is a double-stranded RNA retrovirus that
r
patient, hyperimmune anti-hepatitis B IgG attaches to human immune cells through the
.i
should be given, ideally within 2448 hours CD4 molecule. It produces DNA by the use of
after exposure and repeated at 1 month. All the enzyme reverse transcriptase. DNA is then
s
paramedical staff should be immunised. incorporated into host cells. The incorporated
s
Hepatitis B vaccine should be given and viral DNA produces new viral components
repeated at 1 and 6 months. A HbsAb levels which are spliced and assembled using a viral
n
of more than 1000/L indicates an adequate protease. HIV infection results in widespread
response and confers protection for up to 5 immunological dysfunction. It results in a fall
is a
years . in CD4 lymphocytes, monocytes and antigen-
presenting cells. Immunological dysfunction
Hepatitis C results in opportunistic infections and
r
The hepatitis C virus (HCV) is a small, increases the risk of malignancy. The virus is
e
enveloped, single-stranded RNA virus. The transmitted in bodily fluids by:
infection is often asymptomatic, but chronic Heterosexual intercourse
p
infection can occur. The HCV is spread by Homosexual intercourse
.
blood-to-blood contact. The virus persists in Blood transfusions
p
the liver in about 85% of those infected. During Intravenous drug abuse
iv
the first 12 weeks after infection with HCV, most Perinatal transmission
people suffer no symptoms. For those who do,
/: /
the main manifestations of acute infection are Natural history
generally mild and vague, and rarely point to Up to 3 months after infection, there is often
a specific diagnosis of hepatitis C. The HCV is an asymptomatic viraemia and patients are
tt p
usually detectable in the blood by PCR within 1 infective during this period. The ELISA test for
to 3 weeks after infection, and antibodies to the HIV antibodies is negative. At seroconversion
virus are generally detectable soon after that. an acute seroconversion illness (ASI) can
Chronic hepatitis C is defined as infection with
h
occur and may be followed by persistent
the hepatitis C virus persisting for more than generalised lymphadenopathy (PGI).
6 months. Clinically, it is often asymptomatic, Progression to symptomatic disease occurs
and it is mostly discovered accidentally, within several years. AIDS develops within 5
following the investigation of elevated liver to 10 years. AIDS is diagnosed by the presence
enzyme levels. One-third of untreated patients of an AIDS indicator disease with a positive
will progress to cirrhosis within 20 years. HIV test. The median survival with AIDS is 5
Treatment is generally recommended for years. The virological, serological and clinical
patients with proven hepatitis C virus infection response to HIV infection is shown in Figure
and persistently abnormal liver function 6.2. AIDS indicator diseases include:
tests. Current treatment is a combination of Multiple recurrent bacterial infections
interferon-a-2a and the antiviral drug ribavirin. Tracheal or bronchial candidiasis
Invasive cervical carcinoma
HIV infection Extrapulmonary or disseminated
Acquired immunodeficiency syndrome (AIDS) coccidioidomycosis
was first recognised in the USA in the 1970s Cryptosporidiosis
and the human immunodeficiency virus (HIV) Cytomegalovirus retinitis
86 Chapter 6 Surgical pathology and microbiology
Figure 6.2 The virological,
The virological, serological and clinical response to HIV
serological and clinical
response to human
Seroconversion immunodeficiency virus
infection. AIDS = Acquired
Window Latent stage Symptomatic AIDS
immunodeficiency syndrome
period stage
r/
s .i
n s
is a
Plasma viraemia
r
CD4 lymphocyte count
Antibody response
e
HIV-specific cytotoxic T lymphocyte response
.p
iv p
HIV encephalopathy Osteomyelitis
Disseminated or extrapulmonary Septic arthritis
/: /
histoplasmosis Epididymo-orchitis
Kaposis sarcoma Pelvic inflammatory disease
Lymphoma Appendicitis
Disseminated mycobacteriosis
tt p
Pneumocystis carinii pneumonia Management
Progressive multifocal HIV therapies are available that prevent
leukoencephalopathy virus entry into cells, inhibit the viral reverse
h
Cerebral toxoplasmosis transcriptase and viral protease. Combination
Sites of pyogenic infections in AIDS include: therapy with anti-HIV drugs inhibits viral
replication, reduces viraemia to undetectable
Thoracic empyema
levels, leads to reconstitution of immune
Anorectal abscesses
dysfunction and prevents opportunistic
Skin boils, carbuncles and cellulitis
disease. Stopping therapy often leads to re-
Necrotising fasciitis
emergence of the viraemia.
Pyomyositis
Chapter 7 Emergency
medicine and the
management of
trauma
The local response is usually the cardinal mobile intensive care units often attend the
signs of inflammation. The systemic response scene of an accident. This has been described
includes: as stay and play.
Increased ECF volume and hypovolaemia
Increased vascular permeability and
Initial action
oedema Potential problems at the scene of an accident
Early reduced urine output and increased depend on the hostility of the environment,
urine osmolality the lack of familiarity with surroundings
Reduced free water clearance and the presence of intrusive onlookers. It is
Late diuresis and increased sodium loss important to assess the ongoing safety of the
Pyrexia in the absence of infection emergency services and any casualties and if
Early reduction in metabolic rate necessary, it is vital to make the accident site as
Late increased metabolism, negative safe as possible before treating any casualties.
nitrogen balance and weight loss It is important to determine the nature of the
Lipolysis and ketosis accident and likely mechanism of injuries. At
Gluconeogenesis via amino acid road traffic accidents, the number, direction
breakdown and types of vehicles involved and the degree
Reduced serum albumin of intrusion of damages vehicles should be
Hyponatraemia due to impaired sodium assessed along with whether occupants were
pump action wearing seatbelts.
Acidbase disturbance usually a Important indicators of potential
metabolic alkalosis or acidosis significant trauma are:
Immunosuppression Penetrating injury to chest and abdomen
Hypoxia and coagulopathy Two or more proximal long bone fractures
The inflammatory response can be limited by: Burns involving more than 15% of body
Reducing the degree of trauma with surface area
appropriate and careful surgery Burns to face and airway
Reducing infection with wound care and Abnormal physiological variables
antibiotics Evidence of high-energy impact include:
Maintaining enteral nutrition Fall more than 6m
Controlling pain Crash speed greater than 20mph
Correcting hypovolaemia Inward deformity of car of more than 0.6m
Correcting acidbase disturbance Rearward displacement of front axle
Correcting hypoxia Ejection of passenger from vehicle
Rollover of vehicle
Initial assessment of the
Death of another car occupant
Pedestrian hit at great than 20mph
trauma patient
Prehospital trauma care Prehospital resuscitation
Prehospital resuscitation should follow
Epidemiology of trauma the same principles as that in hospital but
Trauma is the commonest cause of death in will need to be adapted to circumstances.
young adults. Road traffic accidents each year Airway management can be difficult but an
in UK result in 320,000 minor injuries, 40,000 airway can usually be maintained with basic
serious injuries and 3400 deaths. Up to 30% measures. Intubation without anaesthesia
of prehospital deaths may be preventable. and rapid sequence induction is ill advised as
Prehospital care is important. The philosophy it can induce vomiting and raise intracranial
of prehospital care varies between countries. pressure. The cervical spine should be
In the USA, only basic resuscitation is immobilised with a hard collar. Oxygen
performed at the scene. This has been should be given. Haemorrhage should be
described as scoop and run. In France, controlled with direct pressure.
Initial assessment of the trauma patient 89
Triage categories
Anterior
Lateral
Tibia
Fibula
Deep
posterior
Superficial
posterior
Compartment syndromes 95
into the maxillary sinus. Clinical features of reactions. Siderosis from iron causes staining
a blow-out fracture include, enophthalmos, of the iris, cataract formation and retinal
restriction of eye movement, especially on atrophy. Chalcosis from copper deposition
upward gaze and loss of sensation over the causes endophthalmitis and rapid visual loss.
region supplied by infra-orbital nerve. Sinus Ferrous foreign bodies can be removed with
x-ray will shows clouding of the affected sinus a powerful electromagnet. Non-magnetic
and may be able to identify herniated tissue. foreign bodies should be mechanically
CT scanning is able to more clearly define removed.
the extent and the site of injury. Surgical
correction is often required. Acute red eye
Common causes of an acute red eye include:
Penetrating injuries Conjunctivitis
Penetrating injuries can result in: Keratitis
Corneoscleral lacerations Iritis
Intraocular foreign bodies Acute glaucoma
Sympathetic ophthalmitis Episcleritis
Scleritis
Intraocular foreign bodies
Intraocular foreign bodies are usually Chalazion
caused by metal fragment hitting the eye at A chalazion is due to inflammation of the
high speed. The patient is usually aware of meibomian gland. It presents as a painless,
something having stuck the eye. In the early hard lump close to margin of eye lid. It
stages after the injury there is no significant is more common in the upper lid and
visual loss and the clinical signs may be easily can increases in size over days or weeks.
missed. An x-ray of the orbit is essential. Small lesions require no treatment. Large
Foreign body may also be identified on CT or symptomatic lesions can be incised and
ultrasound. Retained iron and copper foreign curetted. This can be performed under local
bodies can give rise to serious chemical anaesthesia via a conjunctival incision.
Chapter 8 Principles of
surgical oncology
Hyperplasia
Carcinogenesis
All cells have mechanisms for regulating
Hyperplasia is an increase in tissue or organ
their growth, differentiation and death.
size due to cell proliferation (e.g. benign
Cancer develops when cells escape from the
prostatic hyperplasia). Causes include
normal control mechanism and proliferation
chronic infection and increased hormonal
is uncontrolled. Cells develop the ability
activity.
to invade and metastasise. Carcinogenesis
Hypertrophy is a multi-step process. Cells accumulate a
succession of gene mutations. Each mutation
Hypertrophy is an increase in tissue or organ
overcomes natural anti-cancer defence
size due to enlargement of cell size (e.g. left
mechanisms. Growth regulation is lost. Most
ventricular hypertrophy in hypertension).
cancers result from a series of genetic errors.
There is no increase in cell number and it is
due to increased functional requirements.
Cancer genes
Metaplasia Genes related to cancer development may
be divided into oncogenes and tumour
Metaplasia is a change of one type of
suppressor genes. In health, the activity of
differentiated tissue to another (e.g.
these genes is closely regulated. They allow
squamous metaplasia in the bronchial
differentiated growth of normal tissues. In
epithelium). It is usually of the same class
cancer, the balanced control of growth is lost.
of tissue but the new tissue type may be less
specialised. It occurs in both epithelial and
Oncogenes
connective tissue and is often associated with
Oncogenes are regulatory genes whose
hyperplasia.
activity is abnormally increased after a
Dysplasia genetic alteration. Oncogene activation may
occur after chromosomal translocation, gene
Dysplasia is disordered cell development that
amplification or mutation within a coding
may accompany hyperplasia or dysplasia.
sequence of an oncogene. Oncogenes act in
It is due to increased mitosis. Cells become
100 Chapter 8 Principles of surgical oncology
treatments. There are approximately 300,000 The natural history of the disease should
new cases of cancer diagnosed in the UK each be well understood with a recognisable
year. Every 2 minutes someone is diagnosed early stage
with cancer and more than 1 in 3 people will A specific and sensitive test for the early
develop some form of cancer during their detection of the disease must be available
lifetime. Breast, lung, bowel and prostate There should be good evidence that
cancers together account for over half of all the screening test can result in reduced
new cancers each year. Cancer can develop at mortality and morbidity in the targeted
any age, but is most common in older people. population
More than 60% of cancers are diagnosed in The test must be acceptable, producing a
people aged 65 and over. Approximately 1% high participation rate
of cancers occur in children, teenagers and There should be suitable facilities for
young adults. diagnosis and treatment of detected
Overall, cancer incidence rates have abnormalities
increased by more than a quarter since the There should be appropriate treatment
late 1970s, but the rates have been fairly options
stable since the late 1990s. Cancer incidence The benefits of screening should outweigh
rates have risen by 16% in males and by 34% any adverse effects
in females. There have been increases in the The benefit must be of an acceptable
incidence of renal cell, malignant melanoma, financial cost
oral and endometrial cancers. Over the last The results of the implementation require
decade the incidence rate of stomach cancer audit to ensure they meet the above
has decreased by more than a quarter in both criteria
sexes. Cervical and ovarian cancer have each
decreased by more than 10% and the lung
Bias within screening programmes
cancer incidence rate in males decreased by Various biases exist which can skew the
almost a fifth. apparent success of a screening programme:
Prostate cancer has overtaken lung cancer Selection bias patients select themselves
as the commonest cancer diagnosed in men. into one group by attending
The apparent incidence of prostate cancer Lead time bias early detection appears
is rising due to the widespread use of PSA to improve survival by increasing the time
testing. Lung cancer is the second most from diagnosis to death, yet mortality is
common cancer in men. The incidence of unchanged. The patient is simply aware
lung cancer in men is falling. Breast cancer that they have the disease for longer
is the commonest cancer in women and Length bias Slower growing better
accounts for 30% of all female cancer. The prognosis tumours are more likely to be
second commonest cancer in women is detected by screening
colorectal cancer.
Sensitivity and specificity
A screening test can give a positive or negative
NHS cancer screening result. It does not imply that the patient has
programmes or does not have the disease. The test results
can be:
Criteria for an effective
True positive (TP)=A positive test result in
screening programme the presence of the disease
To justify establishing a screening True negative (TN)=A negative test result
programme, the World Health Organization in the absence of the disease
has recommended that the following criteria False positive (FP)=A positive test result
be met: in the absence of the disease
The disease screened for must be an False negative (FN)=A negative test result
important problem in the presence of the disease
102 Chapter 8 Principles of surgical oncology
The sensitivity of a test is the ability of the test achieved nation wide coverage by 2010. If
to identify the disease in the presence of the offers screening by faecal occult blood (FOB)
disease (=TP/(TP+FN)). The specificity of a test testing every 2 years to all men and women
is the ability of the test to exclude the disease in aged 60 to 69. Patient with a positive result are
the absence of the disease (=TN/(TN+FP)). The invited for a colonoscopy. About 1 in 50 FOB
positive predictive value (PPV) is the probability tests are abnormal.
of a positive test reflecting the true presence of
the disease. The negative predictive value (NPV)
is the probability of a negative test reflecting the Clinicopathological
true absence of the disease. staging of cancer
National heath service breast Staging is the clinical or pathological
assessment of the extent of tumour spread.
screening programme Clinical staging is a preoperative assessment. It
The National Health Service Breast Screening is based on clinical, radiological and operative
Programme was introduced in 1988 following information and is used to determine
the Forest Report in 1986. All women between treatment offered to the patient. Pathological
50 and 70 years are invited for 3-yearly two- staging is a postoperative assessment. It
view mammography. The age limit is being provides useful prognostic information.
extended from 4773 years. If an abnormality It allows decisions to be made regarding
is seen on a mammogram women are recalled adjuvant therapy and comparison of treatment
to a screening assessment clinic for a clinical outcomes.
examination, further imaging and fine needle
aspiration cytology or core biopsy as required. Staging systems
About 70% of screen detected abnormalities The ideal staging system should be:
are shown to be of no clinical significance
following assessment. Easy to use and remember
Reproducible not subject to inter or
National health service cervical intra-observer variation
screening programme Based on prognostically important
pathological factors
The National Health Service Cervical
Screening Programme was established in TNM system
1988. Women are screened between 25 and The TNM system is based on the anatomical
64 years, 2549 every 3 years and 5064 every extent of spread:
5 years. Cervical cells are obtained by either a T refers to the extent of primary tumour
smear or brush. Brush samples are analysed N refers to the extent of nodal metastases
by liquid based cytology. About 1:10 smear M refers to the presence or absence of
tests are abnormal. Non-neoplastic causes of distant metastases
an abnormal smear include:
Two classifications are described for each site:
Infection
Clinical classification (TNM)
Presence of blood or mucus
Pathological classification (pTNM)
Inadequate specimen
Poorly preserved specimen The TNM system is generally accepted but
does not recorded all factors (e.g. grade,
Abnormal smears are reported as:
contiguous organ involvement) that are
CIN 1=Mild dyskariosis prognostically important.
CIN 2=Moderate dyskariosis
CIN 3=Severe dyskariosis T primary tumour
Tx=Primary tumour can not be assessed
National health service bowel To=No evidence of primary tumour
cancer screening programme Tis=Carcinoma in situ
The NHS Bowel Cancer Screening Programme T14=Increasing size and local extent of
started being rolled out in July 2006 and primary tumour
Principles of cancer treatment 103
M G0
G2 G1
G0 = resting phase
G1 = protein and RNA synthesis
S = DNA synthesis
S G2 = RNA synthesis
M = mitosis
Principles of cancer treatment 105
Specific side effects that are seen with certain Selective oestrogen receptor modulators
agents include: tamoxifen, raloxifene
Pulmonary fibrosis bleomycin Aromatase inhibitors anastrozole,
Haemorrhagic cystitis letrozole and exemestane
cyclophosphamide Progestogens megestrol acetate
Cardiomyopathy doxorubicin
Hepatic damage methotrexate
Uses of hormonal treatment
Skin pigmentation 5-flurouracil Hormonal treatment in breast cancer can be
used as adjuvant treatment or in metastatic
Uses of chemotherapy disease. In the adjuvant setting, tamoxifen or
Chemotherapy is used with curative intent in: an aromatase inhibitor are given for 5 years.
They have been shown to reduce the risk of
Acute lymphoblastic leukaemia
recurrence, reduce the risk of contralateral
Germ cell tumours
breast cancer and improve survival. In
Choriocarcinoma
patients with metastatic disease, the use of
Hodgkins disease
hormonal therapy depends on the ER status
Wilms tumour
of the tumour, the duration of disease-free
A significant response to chemotherapy is interval, the location of metastases, previous
seen in: therapy and the patients performance
Breast carcinoma status.
Ovarian carcinoma
Lymphoma Prostate cancer
Osteosarcoma The aim of hormonal treatment in prostate
Tumours that are poorly responsive to cancer is to ablate androgen production.
chemotherapy include: About 80% of prostate cancers respond
to medical or surgical androgen ablation.
Pancreatic carcinoma
Surgical ablation is by orchidectomy and
Melanoma
produces a rapid reduction in testosterone
Soft tissue sarcomas
levels. Medical ablation is reversible and the
Colorectal carcinoma
effect may take several weeks to occur. The
Gastric carcinoma
side effects of androgen ablation include
impotence, loss of libido, osteoporosis,
Hormonal treatment gynaecomastia and hot flushes. The site of
Hormonal treatment is used in that action of hormonal treatment are:
management of several cancers. It usually
Pituitary gland LH-RH analogues,
works by reducing steroid hormone
stilbeostrol, cyproterone acetate
production.
Adrenal gland ketoconazole,
Breast cancer aminoglutethamide
The aim of hormonal treatment in breast Prostate flutamide, cyproterone acetate
cancer is to reduce oestrogenic growth Testis orchidectomy
stimulation of cancer cells. Hormonal
Uses of hormonal treatment
treatment is effective in women with
Androgen ablation is used in both the
oestrogen and/or progesterone receptor-
neoadjuvant setting and in metastatic disease.
positive tumours. About 60% of breast
In neoadjuvant setting is used in combination
cancers are ER positive and 80% of receptor-
with external beam radiotherapy. LH-RH
positive tumours will respond to hormonal
analogues are commonly used in metastatic
manipulation. The response in hormone
disease. The median duration of response
receptor-negative tumours is minimal. The
is about 18 months and about 20% patients
types of hormonal treatment include:
achieve a response that may last several
Ovarian ablation surgical, LHRH years. The response can be measured by
analogues
106 Chapter 8 Principles of surgical oncology
assessing the PSA level. LH-RH analogues are Liverpool Care Pathway
give by monthly injection. The first injection The Liverpool Care Pathway for the dying
my induce LH-RH release, a rise in PSA and patient was developed to transfer good
worsening of symptoms. Cyproterone acetate practice from the hospice model to other care
should be give for first 2 weeks of treatment to settings such as hospitals. The key aims are to:
reduce this effect.
Discontinue or alter delivery of
Palliative care medications
Discontinue interventions
Principles of palliative care Document cardiopulmonary resuscitation
Palliative care is the active, total management status
of patients at a time when their disease is no Deactivate implanted cardiac defibrillators
longer responsive to curative treatment and Discontinue inappropriate nursing
when control of pain (or other symptoms) interventions
is of paramount importance. Dealing with Communicate with the patient and assess
psychological, social and spiritual problems their insight
is important. It affirms life and regards dying Assess and meet religious and spiritual
as normal. It neither hastens nor postpones needs
death. It perceives the patient and family Keep the family informed
as a unit and creates a caring, comforting Provided bereavement advice for relatives
environment. It coordinates care and
provides relief from distressing symptoms. Pain
It aims to maintain the independence of Pain is the commonest and most feared
the patient for as long as possible, provide symptom associated with cancer. Chronic pain
information and endeavours to reduce fear can be controlled in more than 80% of patients.
and anxiety. It promotes an atmosphere The WHO analgesia ladder (Figure 8.2) forms
where an open and honest exchange of views the most common template for pain control
can take place and helps the patient to come and consists of a three-stepped ladder. With
to terms with impending death. It offers a increasing pain, increasing strength of analgesia
support system to the family to help them is required. On each step of the ladder the
cope with illness and bereavement. maximum dose and frequency should be used.
Severe
Moderate
Mild
Drugs should be prescribed on a regular basis antidepressants may have useful effect.
not as required. Co-analgesic agents often Neurolytic blocks may be considered if the pain
have a synergistic effect and may increase the fails to respond to pharmacological agents.
efficacy of a particular analgesic agent.
Liver capsule pain
Control of pain Liver capsule pain is often distressing and
Morphine non-steroidal anti-inflammatory drugs
often have excellent additive effects in this
Morphine is the most commonly used strong
situation. Steroids can reduce swelling,
analgesic in palliative care. It should initially be
inflammation and pain. Dexamethasone is
prescribed as an immediate release preparation
usually the drug of choice.
(e.g. Oramorph) and can be given as required
every 4 hours. The dose can be increased every Dyspnoea
24 hours until pain is adequately controlled.
Dyspnoea is not always due to underlying
Once pain has been controlled the total daily
malignancy and consideration should be
dose can be calculated. Immediate release
given to treatment of any underlying infection
can then be substituted for delayed release
or cardiac failure. Causes of breathlessness
preparations. Immediate release preparations
related to malignancy include pleural
can still be given for breakthrough pain. No
effusion, lymphangitis carcinomatosis,
ceiling exists for the maximum permissible
intrapulmonary metastases and constricting
dose of morphine. Laxative should be
chest wall disease. Aspiration of a pleural
prescribed to prevent constipation. Patients
effusion often produces symptomatic
may also require an antiemetic. Complications
improvement. Pleurodesis with talc or
of opiate analgesia include itch, hallucinations
bleomycin is only effective if the pleural
and dry mouth, but respiratory depression
effusion can be drained to dryness. A pleuro-
is rarely a problem. Physical dependence
peritoneal shunt may produce symptomatic
may occur. Psychological dependence and
improvement. Steroids produce symptomatic
addiction are not a problem in the palliative
improvement in those with lymphangitis and
care setting. If the oral route is unavailable
intrapulmonary metastases. The respiratory
subcutaneous or percutaneous administration
depressant effect of morphine will also
may be appropriate.
reduce dyspnoea.
Co-analgesia
Nausea and vomiting
Co-analgesics have little intrinsic analgesic
activity but have additive effects to analgesic Nausea and vomiting is usually multifactorial
agents. in origin and causes include, hypercalcaemia,
liver metastases, constipation, drug
Non-steroid anti-inflammatory drugs may side effects and intestinal obstruction.
be useful in bone pain. Anticonvulsants and Metoclopramide, domperidone and
antidepressants are useful in neuropathic cyclizine are useful if there is gastric stasis or
pain. Steroids increase wellbeing and intestinal obstruction. 5-HT3 blockers (e.g.
benzodiazepines reduce muscle spasm. ondansetron) are useful for chemotherapy-
induced nausea. Haloperidol is useful in
Other symptoms
morphine-induced nausea.
Bone pain
Bone pain is often well controlled with a single Constipation
fraction of radiotherapy and non-steroid Treatment of constipation should be
anti-inflammatory drugs may have useful continuous and anticipatory. It is often a
co-analgesic effect. Bisphosphonates reduce predictable side effect of opiate analgesia. It
osteoclastic activity and reduce bone pain. can be worsened by inactivity, dehydration
and hypercalcaemia. Opiate-induced
Neuropathic pain constipation is best treated with compound
Neuropathic pain is often resistant preparations containing both a stool softener
to treatment. Anticonvulsants and and stimulant (e.g. co-danthrusate).
Chapter 9 Cardiothoracic
surgery
Figure 9.1 The anatomy of the coronary arteries. (Reproduced from James S and Nelson K. Pocket Tutor ECG
Interpretation. London: JP Medical Ltd, 2011.)
nerves. The sympathetic and parasympathetic The atrioventricular bundle is also known
nerves form cardiac plexuses. The superficial as the Bundle of His. It is the only normal
cardiac plexus lies in front of the right pathway that connects the myocardium
pulmonary artery. The deep cardiac plexus of the atria and the ventricles. It descends
lies in front of the tracheal bifurcation. through the fibrous skeleton of the heart. At
the lower part of the membranous portion
Conduction system of the ventricular septum it divides into
The conduction system of the heart is by two branches, one for each ventricle. The
specialised muscle fibres. The sinoatrial (SA) right bundle branch travels down the right
node is located in the wall of the right atrium ventricle wall. The left bundle branch travels
just to the right of the opening to the superior down the left ventricular wall and splits into
vena cava. This node gives a spontaneous anterior and posterior branches. Purkinje
impulse that spreads in all directions through fibres cover the ventricle wall and ensure
the myocardium of the atria and causes the that the whole of each ventricle contracts at
atrial muscle to contract. The atrioventricular once.
node is located on the lower part of the
atrial septum, just above the tricuspid valve. Pericardium
It is activated by the excitation wave that The pericardium is a made up of two
passes through the atria from the sinoatrial fibroserous layers that enclose the heart and
node.From this node the impulse moves to roots of the great vessels. The serous layer has
the atrioventricular bundle, from where it an inner visceral layer and outer parietal layer.
travels on down through the ventricles. Both layers are continuous around the great
Applied basic sciences 111
+20 mV
1 2
0 mV
0
3
4 4
96 mV
200 ms
112 Chapter 9 Cardiothoracic surgery
60
Left
arterial Left
pressure ventricular
pressure
0
Left ventricular volume
120
Left ventricular
end-diastolic
(mL)
80 volume
Left
ventricular
40
end-systolic
S4 S1 S2 S3 volume
Sounds
0 0.4 0.8
Heart sounds
Determinants of stroke volume
The stroke volume depends on several factors
There are four heart sounds:
including:
S1 due to closure of the atrioventricular
Preload
valves
Contractility
S2 due to closure of the aortic and
Afterload
pulmonary valves
S3 due to rapid ventricular filling Preload is a measure of how much the
S4 due to atrial contraction and blood myocyte is stretched before contraction. It
flow into the ventricle is represented by the end diastolic volume
Applied basic sciences 113
CO2
50 Increased :
temperature
2,3 BPG
CO2
Half saturation
points
50 100
pO2 (mm Hg)
The curve is shifted to the left in venous heat exchanger controls blood temperature.
blood. This improves carbon dioxide Surgery is often performed with 510C of
transport and is known as Haldane effect. It hypothermia. A 40mm filter removes air
occurs because deoxygenated haemoglobin bubbles. A pump returns blood into aorta
is a weaker acid and allows more carbon distal to a cross clamp. Suction is used to
dioxide to combine with haemoglobin. remove blood from operative field and this
is returned to the patient via the cardiotomy
reservoir.
Cardiac disease Prolonged bypass induces cytokine
Cardiopulmonary bypass activation and an inflammatory response. This
Cardiopulmonary bypass with the use of a results in red cell damage, haemoglobinuria,
pump and oxygenator was first described thrombocytopenia, clotting abnormalities.
in the 1950s. The components of a Reduced pulmonary gas exchange and
cardiopulmonary bypass circuit are shown cerebrovascular accidents.
in Figure 9.6. A cannula is inserted into right
atrium to drain the venous return. Venous Coronary artery surgery
blood then passes into venous reservoir under Pathology
gravity. It is oxygenated and CO2 is removed Coronary artery disease is the commonest
by the use of a membrane oxygenator. A cause of death in both men and women in
Aorta
Arterial line
RA LA Cardiotomy suction
RV LV
Venous
resevoir
Figure 9.6 The components of a coronary artery bypass circuit. RA = Right atrium, LA = Left atrium, RV = Right
ventricle, LV = Left ventricle
Cardiac disease 117
the UK. It is progressive, generally begins in nitrates, b-blockers, statins and calcium-
childhood but manifests clinically in middle channel blockers. Revascularisation of
to late adult life. Atherosclerosis occurs in the the coronary arteries can be by either
proximal portions of the three main vessels percutaneous coronary intervention (PCI)
supplying the heart. The main treatable risk or coronary artery bypass surgery (CABG).
factors for coronary artery disease are: In the UK, about three times more patients
Hypercholesterolaemia undergo PCI than CABG.
Hypertension Percutaneous coronary intervention
Diabetes
The use of PCI has increased dramatically
Smoking
over recent years and has become one of the
Depending on the number of vessels most common medical interventions. PCI
involved, the patient is described as having describes a range of coronary interventions
double or triple vessel disease. The prognosis from angiography to angioplasty and stent
depends on both the number of vessels insertion. Indications for PCI include:
involved and left ventricular function.
Acute ST elevation myocardial infarction
Clinical features (STEMI)
Non ST elevation acute coronary
The symptoms of coronary artery disease
syndrome
vary widely. Some patients with mild disease
Stable angina
may present with clinically significant
Mildly symptomatic patients with
symptoms and signs. Some patients with
evidence of severe ischemia on
advanced disease may have no symptoms
noninvasive testing
and experience no functional impairment.
The spectrum of presentations includes: Contraindications to PCI include:
Asymptomatic state Left main stem stenosis in a patient who is
Stable angina pectoris a surgical candidate
Unstable angina Diffusely diseased small-caliber artery
Myocardial infarction Other coronary anatomy not amenable to
Chronic ischaemic cardiomyopathy percutaneous intervention
Congestive heart failure
Coronary artery bypass surgery
Sudden cardiac arrest
Coronary artery bypass surgery is indicated
Investigation for severe stenosis (>70%) with left main
An ECG will often show evidence of cardiac stem or triple vessel disease. No improved
ischaemia. Left ventricular function can survival has been shown in patients with
be assessed by measuring the ejection single or double-vessel disease. Improved
fraction on echocardiography, coronary survival is also seen in those with poor left
angiography or multiple-gated acquisition ventricular function. Similar survival is seen
(MUGA) scan. Coronary angiography allows in patients undergoing angioplasty for multi-
both confirmation of the diagnosis and vessel disease. Patients at greatest risk have
preoperative planning of the use of stents or the most to gain from surgical intervention.
the site of a coronary artery graft. Mortality risk can be estimated using
various scoring tools. Risk can be calculated
Management by summating individual risk factors. The
The prevention and treatment of Parsonnet score and Euroscore are the most
atherosclerosis requires control of the known commonly used validated scoring system
modifiable risk factors for the disease. This (Table 9.1).
includes lifestyle changes and the medical Choice of conduit The conduits for CABG
treatment of hypertension, hyperlipidemia, surgery can be either venous or arterial. Long
and diabetes mellitus. The mainstays of saphenous vein is easy to harvest by a second
pharmacologic therapy of angina includes surgeon and allows multiple grafts to be
118 Chapter 9 Cardiothoracic surgery
fashioned. Venous conduits have a patency occurs and angina recurs in 20% at 5 years and
rate of 60% at 10 years. The left internal 40% at 10 years.
mammary artery is often used to graft the left
anterior descending. Arterial conduits have a Valvular heart disease
patency rate of 90% at 10 years. Aetiology
The principal causes of valvular heart disease
Surgery For CABG surgery, the chest is
differ between Western and developing
entered via a median sternotomy and the
countries. Common causes include:
left internal mammary artery is dissected.
The long saphenous vein can be harvested Congenital valvular abnormalities
and prepared by second surgeon. The heart (e.g. bicuspid aortic valve)
is cannulated and the patient is placed on Infective endocarditis
bypass. The aorta is cross clamped. Injury to Rheumatic fever
heart is reduced by cardioplegic solutions. Degenerative valve disease
Cardioplegia can be either warm (37C) or Ischaemic heart disease
cold (4C). Recent advances include off-
pump coronary artery surgery and minimally
Pathology
invasive direct coronary artery surgery. Both Rheumatic fever results from immune-
can avoid either bypass or median sternotomy. mediated inflammation of the heart valves.
It results from cross reaction between Group
Complications The mortality rate following A b haemolytic streptococcus and cardiac
CABG depends on the risk associated with proteins. Valve disease results in either
patient groups but is generally around 2%. stenosis or incompetence. Stenosis causes
The risk is higher in the acute or emergency pressure load on the proximal chamber.
setting. Complications of coronary artery Incompetence causes volume load on
bypass surgery included bleeding, atrial the proximal chamber. Thrombus may
fibrillation, wound infection, poor cardiac form in the dilated left atrium resulting in
function and stroke. With time restenosis peripheral embolisation.
Age greater than 70 years +7% Age for each 5 years over 60 years +1%
Age greater than 75 years +12% Female sex +1%
Age greater than 80 years +20% Chronic respiratory disease +1%
Female sex +1% Extracardiac arteriopathy +2%
Hypertension +3% Neurological dysfunction +2%
Diabetes +3% Creatinine greater than 200mol/L +2%
Obesity +3% Previous cardiac surgery +3%
Good ejection fraction Nil Unstable angina +2%
Moderate ejection fraction +2% Recent myocardial infarction +2%
Poor ejection fraction +4% Good ejection fraction Nil
Moderate ejection fraction +1%
Poor ejection fraction +3%
Table 9.1 Risk changes as assed by the Parsonnet Score and Euroscore
Cardiac disease 119
Table 9.2 Dukes Clinical Criteria for the diagnosis of infective endocarditis
122 Chapter 9 Cardiothoracic surgery
I II III
Type A Type B
Figure 9.7 The Stanford and DeBakey Classification of Aortic Dissection. Stanford classification = I, II, III.
DeBakey Classification = A and B
Thoracic disease 123
Haemothorax
Thoracic disease A haemothorax is common after both
Thoracic trauma penetrating and blunt trauma. Each pleural
Thoracic trauma accounts for only 5% of cavity can hold up to 3 litres of blood and 1
admissions to a trauma centre but is second litre may easily accumulate before becoming
only to head injury as the commonest cause apparent on a chest x-ray. About 90% of
of death. The mortality for isolated thoracic cases of haemothorax are due to injury to
trauma is 5% but approaches 35% in those internal mammary or intercostal vessels. The
with concomitant abdominal or head injuries. remaining 10% occur due to bleeding from
the pulmonary vasculature. The bleeding
Chest injuries detected during the primary
usually stops when the lung is re-expanded
survey include:
and most require no more than simple chest
Airway obstruction drainage.
Tension pneumothorax
Open pneumothorax Pericardial tamponade
Massive haemothorax Pericardial tamponade is a major
Flail chest complication of penetrating chest trauma. A
Cardiac tamponade haemopericardium prevents diastolic filling
Chest injuries detected during the secondary of the heart. The classic signs of pericardial
survey include: tamponade are the Becks triad of:
Pulmonary contusion Hypotension
Myocardial contusion Venous distension
Aortic disruption Muffled heart sounds
Traumatic diaphragmatic hernia Pericardial tamponade may be associated
Tracheobronchial disruption with pulsus paradoxus an exaggerated
Oesophageal disruption drop in systemic blood pressure during
inspiration. A chest x-ray shows a globular
Management of the unstable patient heart. An unstable patient requires urgent
Indications for an emergency room thoracotomy. In a stable patient, the diagnosis
thoracotomy are: can be confirmed by echocardiography
Acute pericardial tamponade or pericardiocentesis. Subxiphoid
unresponsive to cardiac massage pericardiotomy is both a diagnostic and
Exsanguinating intra-thoracic therapeutic procedure.
haemorrhage
Intra-abdominal haemorrhage requiring Cardiac stab wounds
aortic cross clamping With cardiac stab wounds, the right side of the
Need for internal cardiac massage heart is more commonly injured than the left.
124 Chapter 9 Cardiothoracic surgery
Patients with a right ventricular wound are Treatment of a flail chest requires:
more like to survive than with left-sided injury. Adequate ventilation
The atria, inflow and outflow tracts may also Humidified oxygen
be damaged. Patients usually present with Adequate analgesia
pericardial tamponade and treatment consists
Consideration should be given to intubation
of resuscitation and pericardiocentesis.
and ventilation if:
Stab wounds can be accessed via a median
sternotomy and can be directly repaired Significant other injuries
without cardiopulmonary bypass. Teflon- Respiratory rate more than 35 per min
pledgeted prolene sutures are generally Partial pressure oxygen less than 8.0kPa
used. Partial pressure carbon dioxide greater
than 6.6kPa
Injuries to the great vessels Vital capacity less than 12mL/kg
Injury to the great vessels should be Right to left shunt of more than 15%
suspected from the mechanism or site of Operative fixation is not normally required.
penetrating injury. The patient usually
presents with shock or pericardial Chest drains
tamponade. A chest x-ray may show: A chest drain is a conduit to remove air or
Widening of the mediastinum to greater fluid from the pleural cavity. The fluid can be
than 8cm blood, pus or a pleural effusion. It also allows
Depression of the left main bronchus to re-expansion of the underlying lung. It must
greater than 140 degrees prevent entry of air or drained fluid back into
Haematoma in the left apical area the chest. A chest drain must therefore have
Massive left haemothorax three components:
Deviation of oesophagus to the right An unobstructed chest drain
Loss of the aortic knob contour A collecting container below chest level
Loss of the paraspinal pleural stripe A one-way mechanism such as a water seal
Injury to the great vessels requires an or Heimlich valve
emergency thoracotomy or sternotomy. Drainage occurs during expiration when the
Injuries to the descending thoracic aorta pleural pressure is positive. Fluid from within
requires left anterior thoracotomy. Injuries pleural cavity drains into the water seal. Air
to the proximal aorta and proximal carotid also bubbles through water seal to the outside
arteries require median sternotomy. world. The length of drain below the fluid
level is important. If greater than 23cm,
Flail chest it increases the resistance to air drainage
A flail chest is associated with multiple (Figure 9.8).
rib fractures on the same side. The flail
Indications for chest drain insertion include:
segment does not have continuity with
the remainder of the thoracic cage and Pneumothorax
results in paradoxical chest wall movement Malignant pleural effusion
with respiration. It is often associated Empyema and complicated
with an underlying pulmonary contusion. parapneumonic pleural effusion
Paradoxical movement results in impaired Traumatic haemopneumothorax
ventilation and the work of breathing is Post thoracotomy, oesophagectomy and
increased. Ventilation-perfusion mismatch cardiac surgery
and arterio-venous shunting occurs. A chest
x-ray will show:
Insertion
Unless performed in an emergency situation,
Multiple rib fractures
then a pre-procedure chest x-ray should be
Underlying lung contusion
performed. The drain is usually inserted under
Haemopneumothorax
local anaesthesia using an aseptic technique.
Other associated injuries
Thoracic disease 125
Removal
A chest drain should be removed as soon
as it has served it purpose. For a simple
pneumothorax it can often be removed within
24 hours. To remove the drain, ask the patient
to perform a Valsalva manoeuvre and remove
drain at the height of expiration. The pre-
inserted purse-string or Z-stitch can then be
tied. A post-procedure chest x-ray should be
performed to exclude a pneumothorax.
Dos and donts of chest drains include:
Early Late
from a suture line and is particularly seen epithelial lining and arise from rupture of the
in those with factors impairing wound alveolar wall. Apical blebs are found in 85%
healing. It most commonly occurs 710 of patients undergoing thoracotomy. The
days after surgery. It presents with sudden frequency of spontaneous pneumothorax
breathlessness and expectoration of increases after each episode and most
bloodstained fluid. The fluid is that which recurrences occur within 2 years of the initial
normally fills the postpneumonectomy space. event.
Emergency treatment consists of lying the
patient with the operated side downwards. Secondary spontaneous
/
Oxygen should be administered and a pneumothorax
r
pleural drain inserted. Thoracotomy and Secondary spontaneous pneumothorax
.i
repair of the fistula may be required. The accounts for 1020% of spontaneous
repair may be reinforced with an omental pneumothoraces due to:
s
or intercostal muscle patch. A thoracoplasty Chronic obstructive pulmonary disease
s
may be necessary to obliterate the with bulla formation
postpneumonectomy space. Interstitial lung disease
n
Primary and metastatic neoplasms
Pneumothorax
is a
EhlersDanlos syndrome
Pneumothorax is the presence of air within the Marfans syndrome
pleural space usually due to disruption of the
parietal, visceral or mediastinal pleura. The Traumatic pneumothorax
r
classification of pneumothoraces is shown Traumatic pneumothorax results from
e
in Table 9.4. A tension pneumothorax occurs either blunt or penetrating trauma.
when the pleura forms a one-way flap valve. Tracheobronchial and oesophageal injuries
p
Tension pneumothorax is a medical emergency.
.
can cause both mediastinal emphysema and
a pneumothorax. Iatrogenic pneumothorax is
Primary spontaneous
p
common and occurs after:
iv
pneumothorax
Pneumonectomy
Primary spontaneous pneumothorax Thoracocentesis
/: /
usually occurs in healthy young adult men. High-pressure mechanical ventilation
Approximately 85% of patients are less than Subclavian venous cannulation
40 years of age. The male:female ratio is
tt p
6:1 and in 10% of cases they are bilateral. Clinical features of pneumothorax
It usually occurs as result of rupture of an The predominant symptom is acute pleuritic
acquired subpleural bleb. Blebs have no chest pain. Dyspnoea results from pulmonary
h
Spontaneous
Classification of a pneumothorax
Traumatic
/
affected side and the neck veins may be below the level of the patient.
r
engorged. Tension pneumothorax is a clinical
.i
diagnosis. In other cases the diagnosis can be Tension pneumothorax
confirmed with a chest x-ray. Prophylactic chest drains should be inserted in
s
patients with rib fractures prior to ventilation
Investigation to reduce the risk of a tension pneumothorax.
s
A chest x-ray will confirm the diagnosis Tension pneumothorax requires immediate
n
(Figure 9.9). This usually shows radiolucency needle aspiration. A canula should be inserted
and absence of the lung vascular markings on anteriorly through the 2nd intercostal space
is a
the affected side. There may be mediastinal prior to chest drain placement.
shift and the percentage volume of the
Surgery
pneumothorax can be calculated. The cause
r
Surgery is required for a pneumothorax if an
of the pneumothorax, such as fractured ribs,
air leak persists for more than 10 days, there is
e
may also be visible.
failure of lung re-expansion, or for a recurrent
p
Management spontaneous pneumothorax. The surgical
.
options include:
Spontaneous pneumothorax
Partial pleurectomy
p
The management of a spontaneous
iv
Operative abrasion of pleural lining
pneumothorax depends the symptoms and the Resection of pulmonary bullae
/: /
Figure 9.9 Chest x-ray showing a
Chest x-ray showing a right spontaneous pneumothorax
right spontaneous pneumothorax
tt p
h
130 Chapter 9 Cardiothoracic surgery
Poor-risk patients may benefit from chemical often multiloculated. Lung empyemas are
pleurodesis with tetracycline. also seen following oesophageal perforation
or rupture, blunt or penetrating thoracic
Pneumonia, lung abscess trauma, nasopharyngeal sepsis that has
and empyema spread to the chest and thoracic surgical
procedures. If the diagnosis is delayed, the
Lung abscess
empyema will develop a thick, fibrous wall
Some patients with pneumonia develop focal
making future management more difficult.
necrosis and a lung abscess. This particularly
occurs in patients with malignancy and
/
Clinical features
malnutrition. It can also occur following
r
An empyema usually presents with features
.i
aspiration or inhalation of a foreign body. The of pneumonia that fails to improve with
diagnosis can be difficult. antibiotics. There is often pleuritic chest pain
s
and breathlessness. Examination may show
Clinical features
s
features of pleural effusion.
Patients usually present with clinical features
of a pneumonia that fails to improve with
n
Investigation
antibiotics. They can develop pleuritic chest A chest x-ray will show fluid within the
is a
pain and haemoptysis. The volume of sputum pleural cavity and a CT scan will confirm
produced may increase. Patients are usually the diagnosis. Percutaneous aspiration will
systemically unwell with a swinging pyrexia. provide microbiological samples for culture.
r
Examination usually shows signs of pneumonia.
The commonest complication is an empyema. Management
e
The differential diagnosis includes: Appropriate antibiotic therapy should be
p
Primary lung neoplasm given based on sputum culture results. Pleural
.
Tuberculosis drainage should be with adequate (28Fr) chest
Aspergillosis
p
drain. Thoracoscopy may be required to break
iv
Lung cyst down loculi. Decortication of the visceral
and parietal pleura may be required to allow
Investigation
/: /
lung expansion. Following surgery, adequate
A chest x-ray may show a pulmonary cavity drainage is required. Pneumothorax is not a
with air/fluid level. CT scanning will confirm risk due to the resulting pleural scarring.
the diagnosis if a chest x-ray is inconclusive.
tt p
Bronchoscopy should be considered to Bronchiectasis
exclude a foreign body. Bronchiectasis is chronic bronchial
dilatation with parenchymal infection and
h
Management
an inflammatory reaction. It typically affects
Initial management should include the basal segments of the lower lobes.
appropriate antibiotic therapy based on Acquired infections are the most common
sputum culture results. Percutaneous cause, typically when occurring in childhood.
aspiration should be considered if the abscess Congenital causes include:
fails to improve with antibiotic therapy. For
abscesses greater than 5cm diameter, open Cystic fibrosis
drainage may be required. Thoracotomy Kartagener syndrome
and lung resection should be considered in Various immunodeficiency disorders
complicated cases. Bronchopulmonary sequestration
/
lavage. CT may be used to delineate the mass further.
r
Contrast-enhancement is useful in defining
.i
Management vascularity and the extent of invasion. The
Medical therapy is the primary approach, diagnosis can be confirmed by biopsy taken
s
using antibiotics, humidification and at anterior mediastinoscopy. The Masaoka
s
bronchodilators. Surgical intervention is staging system is as follows:
indicated for: Stage 1 Encapsulated tumour with no
n
Failure of medical management gross or microscopic invasion
is a
Persistent symptoms Stage 2 Macroscopic invasion into
Recurrent pneumonias mediastinal fat or pleura
Haemoptysis Stage 3 Invasion of pericardium, great
r
vessels or lung
The ideal surgical candidate has unilateral
Stage 4 Pleural or pericardial metastatic
disease confined to one lobe. Most patients
e
spread
have bilateral disease. Surgery should be
Stage 5 Lymphatic or haematogenous
p
reserved for localised disease, operating on
spread
.
the worst side first.
p
Thymoma Management
iv
Treatment depends on the stage of the
The thymus is a lymphoid organ located in the
disease. Stage 1 disease can be managed
/: /
anterior mediastinum composed of epithelial
by complete surgical excision. Stages 2
cells and lymphocytes. It is responsible for
and 3 disease requires surgical excision
maturation of cell-mediated immunity and
and postoperative radiotherapy. Stages 4
reaches maximum size at puberty. It regresses
tt p
and 5 disease requires surgical debulking,
in later life.
radiotherapy and chemotherapy.
Pathology Thymectomy
h
Thymoma is the most common neoplasm The initial management of most thymomas
of the anterior mediastinum and accounts is by surgery, usually performed via
for 25% of all mediastinal tumours. The peak a median sternotomy. Resection may
incidence is between 40 and 50 years of require excision en-bloc of any involved
age. It originates from epithelial cells of the pericardium, pleura and phrenic nerves.
thymus gland. No clear aetiological factors If possible, damage to the phrenic nerves
have been defined. It is associated with the should be avoided. Clips should be placed
development of myaesthenia gravis. No clear to aide subsequent radiotherapy planning.
distinction between benign and malignant Prognosis is worse for symptomatic
tumours exist. Malignant tumours can invade thymomas. The most important factor that
the vasculature and adjacent structures. determines prognosis is invasion of adjacent
Death often occurs from cardiac tamponade structures. Stage 1 disease is associated
or cardiorespiratory complications. with greater than 90% 5-year survival. Stage
4 disease is associated with less than 25%
Clinical features 5-year survival.
Almost 50% of thymomas are asymptomatic
r/
s.i
n s
is a
e r
.p
ivp
/: /
tt p
h
Chapter 10 General
surgery
perforation is possibly due to increased anti- have no demonstrable gas on a chest x-ray.
inflammatory use in the elderly. About 80% of If diagnostic doubt exists, then a CT scan
perforated duodenal ulcers are Helicobacter will confirm a perforation even if it can
pylori positive. not always show the site. Perforated peptic
ulceration can be associated with elevated
Clinical features serum amylase but not to same level as in
Most perforated peptic ulcers occur in pancreatitis.
patients with pre-existing dyspepsia. Only
about 10% of patients have no previous Management
symptoms. The classic presentation is Most patients require surgery after
with sudden onset of epigastric pain with appropriate resuscitation. Conservative
rapid generalisation. Examination shows management may be considered if there is
generalised peritonitis with absent bowel significant co-morbidity but this is more likely
sounds. About 10% patients have an to fail if perforation is of a gastric ulcer. Fluid
associated episode of melaena. resuscitation with monitoring of the urine
output is required. Analgesia and antibiotics
Investigation should be administered and a nasogastric
Free gas under the diaphragm on an erect tube placed.
chest x-ray is a classical radiological sign Following adequate resuscitation, the
(Figure 10.1). However, 10% of patients perforation should be oversewn with an
omental patch. If the surgeon is unable to having ischaemic heart, cerebrovascular and
find the perforation, it is important to open peripheral vascular disease respectively.
the lesser sac. It should also be remembered
that multiple perforations can occur. If Investigation
closure is secure and adequate peritoneal No single investigation provides pathognomic
lavage has been performed then a drain is evidence of mesenteric ischaemia. The serum
not required. white cell count is often raised. Arterial blood
Pre-pyloric gastric ulcers behave as gases may show a metabolic acidosis. The
duodenal ulcers. All gastric ulcers require serum amylase is raised in 50% of patients.
biopsy to exclude malignancy. Definitive An abdominal x-ray may be normal early in
ulcer surgery is probably not required as the disease process. Late radiological features
50% patients develop no ulcer recurrence. include dilated small bowel and thumb
Postoperatively, patients should receive printing of the bowel wall due to mucosal
Helicobacter pylori eradication therapy. oedema. Mesenteric angiography may
Surgery is increasingly performed confirm the diagnosis.
laparoscopically and is associated with no
Management
increased morbidity and reduced hospital
stay. The operative mortality depends on the Following angiography, a papaverine infusion
time from perforation to admission, age, co- into the superior mesenteric artery (SMA)
morbidity and the presence of hypovolaemia may be beneficial. If this fails to rapidly
on admission. improve symptoms, then laparotomy may
be indicated. Surgery allows confirmation
Acute mesenteric ischaemia of diagnosis and assessment of the extent of
ischaemia, the opportunity to revascularise
Acute mesenteric ischaemia was first
the SMA if appropriate and to resect necrotic
recognised by Virchow in 1852. It occurs
bowel. Revascularisation may be achieved
as result of either superior mesenteric
by embolectomy, bypass or endarterectomy.
arterial or venous occlusion and can affect
Resection and primary anastomosis may
the bowel from the 2nd part of duodenum
be possible. If doubt exists over the bowel
to the transverse colon. Embolic arterial
viability then a second-look laparotomy may
occlusion, atheromatous arterial occlusion
be considered. If there is extensive necrosis in
and venous thrombosis account for 50%, 25%
an elderly patient, then palliative care may be
and 10% of cases, respectively. Whatever the
the preferred option.
underlining aetiology, reduced capillary flow
causes intestinal necrosis. Overall mortality is Upper gastrointestinal
approximately 90%.
haemorrhage
Clinical features Clinical features
No single clinical feature provides conclusive The presentation of an upper gastrointestinal
evidence of the diagnosis. As a result, the haemorrhage depends on the amount and
diagnosis is difficult and often delayed. location of bleeding but invariably it causes
Early diagnosis requires a high index of haematemesis, coffee ground vomiting or
suspicion. Severe central abdominal pain is a melaena. Patients may also present with
common presentation. The pain is often out complications of anaemia, including chest
of proportion to the apparent clinical signs. pain, syncope, fatigue and shortness of
Vomiting and rectal bleeding may also occur. breath. Examination should assess the vital
Features of chronic mesenteric ischaemia signs in order to determine the severity of
such a postprandial abdominal pain and the bleeding and the timing of intervention.
weight loss may also be present. There may Abdominal examination may be normal
be evidence of an embolic source (e.g. recent but there may be stigmata of chronic liver
myocardial infarct, cardiac arrhythmia) and disease. Causes of upper gastrointestinal
there may be features of atherosclerotic haemorrhage include:
disease with 75%, 25% and 10% of patients
140 Chapter 10 General surgery
conservatively with intravenous fluids and distension depends on the level of the
blood transfusion, if required. If bleeding obstruction. Distension may be minimal in
persists, an upper gastrointestinal endoscopy high obstruction. Absolute constipation is
should be performed to exclude an upper a late feature of small bowel obstruction.
gastrointestinal cause. In those patients with Dehydration is associated with tachycardia,
significant or ongoing bleeding, consideration hypotension and oliguria. Features of
should be given to a laparotomy and on- peritonism indicate strangulation or
table lavage and panendoscopy. If right- perforation. Auscultation may show high-
sided angiodysplasia is confirmed, a right pitched or tinkling bowel sounds.
hemicolectomy is the operation of choice.
If bleeding diverticular disease is likely, a Investigation
sigmoid colectomy is the operation of choice. A supine abdominal x-ray may show dilated
If the source of colonic bleeding is unclear a small bowel. The valvulae coniventes
subtotal colectomy and end-ileostomy may differentiate the small from large intestine.
be required. An x-ray may be normal if there is no airfluid
interface. An erect abdominal film rarely
Small bowel obstruction provides additional information. A CT scan
Aetiology will confirm the diagnosis and may show the
Small bowel obstruction accounts for 5% level and cause of the obstruction.
of all acute surgical admissions. In the
UK, the commonest causes of small bowel Management
obstruction are: Adequate resuscitation prior to surgery is
vital. Patients may have severe dehydration
Adhesions (60%)
and may require several litres of intravenous
Strangulated hernia (20%)
crystalloid. Adequacy of resuscitation should
Malignancy (5%)
be judged by measurement of the urine
Volvulus (5%)
output or assessment of the central venous
Pathophysiology pressure. Surgery in under-resuscitated
patients is associated with increased
Dilatation of the bowel occurs above the
mortality. If the cause of obstruction is
level of the obstructing lesion. This results
presumed to be due to adhesions and
in the accumulation of gas and fluid and
there are no features of peritonism, then
reduced fluid reabsorption. Dilation of
conservative management for up to 48
the gut wall produces mucosal oedema.
hours is often safe. Patients undergoing
This initially impairs the venous and
conservative management requires regular
subsequently the arterial blood flow.
clinical review and the willingness to
Intestinal ischaemia eventually results in
consider surgical intervention if conservative
infarction and perforation of that segment
management fails. If there are features of
of bowel. Ischaemia also results in bacterial
peritonism or systemic toxicity present, then
and endotoxin translocation. The overall
it is necessary to consider early operation.
effect is progressive dehydration, electrolyte
The exact procedure will depend on the
imbalance and systemic toxicity.
underlying cause. Absolute indications for
Clinical features surgery include generalised or localised
The cardinal clinical features of intestinal peritonitis, visceral perforation or the
obstruction are: presence of an irreducible hernia. Relative
indications include a palpable mass lesion, a
Colicky central abdominal pain virgin abdomen or failure to improve with
Vomiting conservative management.
Abdominal distension
Absolute constipation Paralytic ileus
Vomiting is an early feature of high Paralytic ileus is a functional obstruction
obstruction. The degree of abdominal most commonly seen after abdominal
Abdominal emergencies 143
reversed. With a single stage procedure, a the scope is advanced beyond this point there
stoma is avoided. Anastomotic leak rates of is often a dramatic release of flatus and liquid
less than 4% have been reported following stool. A flatus tube can be inserted and left in
on-table lavage and primary anastomosis. situ for 2 or 3 days. Overall, 80% of patients
Despite this, the total perioperative mortality will settle with conservative management
of malignant large bowel obstruction remains and if adequate decompression is achieved,
at about 20%. no emergency surgical treatment is required.
Unfortunately, about 50% patients will have
Sigmoid and caecal volvulus a further episode of volvulus within 2 years.
A volvulus is defined as rotation of the gut If decompression fails or there are clinical
on its own mesenteric axis. It produces features of peritonitis, the various surgical
partial or complete intestinal obstruction. options are:
The blood supply to the segment of intestine
Sigmoid colectomy and primary
is compromised resulting in intestinal
anastomosis
ischaemia. Venous congestion leading to
Hartmanns procedure
infarction can occur. The arterial supply is
Paul Mikulicz colostomy
rarely compromised. A long narrow-based
mesentery predisposes to a volvulus. Caecal volvulus
The incidence of caecal volvulus is less than
Sigmoid volvulus
that of sigmoid volvulus. It accounts for about
The sigmoid colon is the commonest site of a
25% cases of colonic volvulus. Incomplete
colonic volvulus. A sigmoid volvulus accounts
midgut rotation is a predisposing factor.
for 5% of cases of large bowel obstruction in
Incomplete rotation results in inadequate
the UK. It is usually seen in the elderly or in
fixation of the caecum to the posterior
those with psychiatric disorders. It is a more
abdominal wall and the volvulus usually
common cause of obstruction in Africa or
occurs clockwise around the ileocolic vessels.
Asia. The incidence is 10 times higher than in
It usually also involves the terminal ileum
Europe or USA.
ileum and ascending colon.
Clinical features and investigation Clinical features and investigation
The clinical presentation is that of
A caecal volvulus usually presents with
large bowel obstruction. Pain may be
clinical features of proximal large bowel
minimal and the abdominal distension
obstruction. Colicky abdominal pain and
disproportionate. About 50% patients have
vomiting are common and abdominal
had a previous episode. Severe pain and
distension may occur. A plain abdominal
abdominal tenderness suggests ischaemia.
x-ray shows a comma-shaped caecal
A plain abdominal x-ray may show large
shadow in the mid-abdomen. Small bowel
bean shaped loop of large bowel arising
loops may lie to the right of the caecum.
from pelvis. If diagnostic doubt exists,
If diagnostic doubt exists, consideration
consideration should be given to a CT scan
should be given to a CT scan or water-soluble
or water-soluble contrast enema. Either
contrast enema. A contrast enema will show
investigation should demonstrate the site of
a beaked appearance in the ascending
obstruction.
colon.
Management Management
Resuscitation with intravenous fluids is
Colonoscopic decompression may be
essential. Conservative management can be
appropriate if the patient is unfit for surgery.
attempted if there are no clinical features of
It is successful in only about 30% of patients.
ischaemia or perforation. A rigid or flexible
A laparotomy is normally required. If
sigmoidoscopy can be both diagnostic and
colonic ischaemia is present, then a right
therapeutic. The obstruction is encountered
hemicolectomy should be performed though
at about 15cm from the anal margin. When
Abdominal emergencies 145
is formed by the arched fibres of the conjoint Boundaries of the femoral canal
tendon. The anatomical boundaries of the femoral
canal are:
Contents of the inguinal canal
Anterior inguinal ligament
The inguinal canal contains the spermatic
Posterior pectineal ligament
cord in males and the round ligament of
Medial lacunar ligament
the uterus in females. In both, the inguinal
Lateral femoral vein
canal contains the ilioinguinal nerve. Each
anterior abdominal wall layer gives rise to Incisions and
a layer of the spermatic cord. From within
outwards the coverings are derived as
laparoscopic access
follows: Abdominal incisions are based on anatomical
principles. They must allow adequate assess
Internal spermatic fascia from fascia
to the abdomen and should be capable of
transversalis
being extended if required. Ideally muscle
Cremaster fascia from internal oblique
fibres should be split rather than cut and
muscle
nerves should not be divided. The rectus
External spermatic fascia from external
muscle has a segmental nerve supply and,
oblique muscle
as a result, it can be cut transversely without
The spermatic cord contains the: weakening a denervated segment of muscle.
Vas deferens Above the umbilicus, tendinous intersections
Artery to vas deferens (branch of the prevent retraction of the muscles. Commonly
inferior vesical artery) used incisions are shown in Figure 11.1.
Testicular artery (branch of the abdominal
aorta) Figure midline incision
Testicular vein A midline incision (Figure 11.2) is the
Testicular lymphatics commonest approach to the abdomen and
Testicular nerve fibres the following structures are divided:
Processus vaginalis Skin
Cremasteric artery (branch of the inferior Linea alba
epigastric artery) Transversalis fascia
Nerve to cremaster (genital branch of Extraperitoneal fat
genitofemoral nerve) Peritoneum
4 3
8 9
10
Abdominal hernias 149
The incision can be extended by cutting of the general surgical workload. A hernia
through or around the umbilicus. Above the consists of a sac, its coverings and contents.
umbilicus, the falciform ligament should be Hernias can be:
avoided. The bladder can be accessed via an Reducible
extraperitoneal approach through the space Irreducible
of Retzius. The wound can be closed using a Obstructed or incarcerated
mass closure technique. Strangulated
Paramedian incision Irreducible hernias have either a narrow neck
or the contents of the hernia are adherent
A paramedian incision (Figure 11.3) is made
to the sac wall. Obstructed or incarcerated
parallel to and approximately 3cm from the
hernias contain compromised but viable
midline. The incision transverses the:
intestine. Strangulation occurs when the
Skin venous drainage from the contents of the sac
Anterior rectus sheath is compromised.
Rectus retracted laterally
Posterior rectus sheath above the arcuate Inguinal hernias
line About 3% of adults will require an operation
Transversalis fascia for inguinal hernia at some stage in their lives
Extraperitoneal fat and 80,000 operations are performed each
Peritoneum year in UK. The male:female ratio is 12:1 and
The potential advantages of this incision are the ratio of elective to emergency operation is
that the rectus muscle is not divided and the also about 12:1. The peak incidence is in the
incisions in the anterior and posterior rectus 6th decade.
sheath are separated by muscle. The incision
is closed in layers and takes longer to make Direct inguinal hernia
and close. In the past, it was reported that A direct inguinal hernia is due to weakness
paramedian incisions has a lower incidence in the abdominal wall musculature. It is
of incisional hernias. more common in older patients. The sac is
found medial to inferior epigastric artery.
Complications are unlikely due to the wide
Abdominal hernias neck of the hernial sac. In adult males, 35% of
A hernia is a protrusion of an organ through inguinal hernias are direct. Predisposing factors
the wall that normally contains it. The wall include smoking, ilioinguinal nerve damage
can be the abdomen, muscle fascia or the and abdominal straining. A pantaloon hernia
diaphragm. Hernias can be congenital is a special type of direct inguinal hernia. The
or acquired. Abdominal wall hernias are sac has two parts, one is medial and the other is
common and account for approximately 10% lateral to inferior epigastric artery.
150 Chapter 11 The abdominal wall
a b
Intestinal fistulas 153
Serosa
Longitudinal muscle
Circular muscle
Submucosa
Muscularis mucosa
Mucosa
Epithelial lining
Mesentery
156 Chapter 12 Upper gastrointestinal surgery
the submucosa. It is the smooth muscle layer of the left gastric vein and the tributaries of the
responsible for peristalsis and segmentation. azygos vein. Although no anatomical sphincter
It is divided into two layers, an inner circular can be demonstrated, at the lower end of the
layer and an outer longitudinal layer. In oesophagus, a multifactorial physiological
several sites the circular layer is thickened to sphincter mechanism is present. The lower
form a sphincter. These regulate the passage oesophageal sphincter functions by:
of materials through the gut. The serosa is the Basal tone
outermost layer of the intraperitoneal organs. Adaptive pressure changes
It is also known as the visceral peritoneum. Transient lower oesophageal sphincter
It consists of a simple squamous epithelium relaxation
overlying thin areolar connective tissue. The
External mechanical factors in preventing
oesophagus has an adventitia rather than a
gastro-oesophageal reflux include:
serosa. This is a layer of fibrous connective
tissue that firmly supports the organ. Flap valve mechanism
Retroperitoneal digestive organs have both a Cardio-oesophageal angle
serosa and an adventitia. Diaphragmatic pinchcock
Mucosal rosette
Anatomy of the oesophagus Distal oesophageal compression
The oesophagus is approximately 25cm in Phreno-oesophageal ligament
length and is divided into cervical, thoracic Transmitted abdominal pressure
and intra-abdominal parts. It extends from
the pharynx, at the level of C6 vertebra, to
Anatomy of the stomach
the cardia of the stomach in the abdomen. For descriptive purposes the stomach has two
It traverses the diaphragm at the level of curvatures and is divided into various regions
T10 vertebra. It is lined throughout by a (Figure 12.2) as follows:
stratified squamous mucosa. It has a rich Lesser curve
blood supply from the inferior thyroid artery, Greater curve
branches directly from the aorta and from the Fundus
oesophageal branch of the left gastric artery. Incisura angularis
At the lower end there is a porto-systemic Body
anastomosis between the oesophageal branch Pylorus
The lesser omentum connects the lesser known as gastric pits. The gastric pits lead
curve of the stomach to the liver. The greater into gastric glands which secrete gastric
omentum is connected to the greater curve of juice. Mucous cells secrete acidic mucus
the stomach. and function as stem cells for the surface
mucosa. Parietal cells secrete hydrochloric
Blood supply acid and intrinsic factor. The chief cells secrete
The five main arteries that supply the stomach pepsinogen, an inactive form of pepsin. This is
(Figure 12.3) are as follows: activated to pepsin initially by hydrogen ions
Left gastric and by pepsin itself. Neuroendocrine cells
Right gastric secrete multiple hormones into the plasma.
Right gastro-epiploic The most important of these is gastrin.
Left gastro-epiploic
Short gastric The vagus nerve
Both of the vagi enter the abdomen through
The left gastric artery arises from the
the oesophageal hiatus. The left vagus nerve
coeliac access. The right gastric artery
passes on to the anterior and the right vagus
arises from the common hepatic artery.
nerve passes on to the posterior walls of the
The right gastro-epiploic artery arises from
stomach. The anterior vagus runs along the
the gastroduodenal artery. The left gastro-
lesser curve. The nerve of Latarjet supplies
epiploic artery arises from the splenic artery.
the pylorus. The posterior vagus supplies the
The short gastric arteries are branches of the
coeliac ganglion.
splenic artery.
Lymphatic drainage
Anatomy of the small intestine
The stomach drains into four groups of nodes The small intestine is the longest part of the
as follows: alimentary canal. It is divided into three regions
1
3
Left gastro-epiploic
Gastroduodenal
Right gastro-epiploic
158 Chapter 12 Upper gastrointestinal surgery
First part is continuation of the pylorus intestinal glands (crypts of Lieberkuhn). They
and runs transversely contain absorptive cells and neuroendocrine
Second part runs vertically in front of the cells. The submucosa is unremarkable except
hilum of the right kidney in the proximal duodenum and terminal
Third part runs horizontally below the ileum. The proximal duodenal submucosa
pancreas contains alkaline mucus glands (Brunners
Fourth part runs upward to the glands) and the terminal ileal submucosa
duodenojejunal junction contains aggregates of lymphoid tissue know
The ligament of Treitz connects the as Peyers patches.
duodenojejunal flexure to the right crus
of the diaphragm. The duodenal papilla
Gastric physiology
is found on the medial wall of the second The motility of the stomach is increased by
part. It is the site of entry of the common both distension and parasympathetic activity,
bile duct and pancreatic duct. The blood via acetylcholine and gastrin. It is decreased
supply of the duodenum is from the superior by low pH stomach contents which inhibits
pancreaticoduodenal artery, a branch of gastrin release. Fats stimulate the release of
the gastroduodenal artery and the inferior cholecystokinin. Acid stimulates the release
pancreaticoduodenal artery, a branch of of secretin. Hyperosmolality of duodenal
the superior mesenteric artery. The venous contents reduces gastric emptying. The rate
drainage is into the portal and superior of emptying also depends on the type of food.
mesenteric vein. The lymphatic drainage is to Carbohydrate-rich content is faster than
the coeliac and superior mesenteric nodes. protein-rich and fatty food. The stomach
produces about 2500mL of secretion per
Jejunum and ileum day. The pH is acidic and can be close to
The jejunum and ileum are about 6m one. Gastric secretions are rich in potassium,
long. The proximal 40% is the jejunum. hydrogen ions, chloride and bicarbonate. It
The jejunum begins at the duodenojejunal also contains intrinsic factor and pepsin.
junction. The ileum ends at the ileocaecal
valve. The ileum is connected to the Secretion of gastric acid
posterior abdominal wall by the small bowel A H+/K+ ATPase is present in the apical
mesentery. The blood supply is from the membrane of the parietal cells. It pumps H+
superior mesenteric artery and branches ions into the gastric gland lumen against their
form arcades within the mesentery. The concentration gradient. Potassium is actively
lower part of the ileum is supplied by the pumped into the parietal cell in exchange.
ileocolic artery. The venous drainage is into Potassium then diffuses back into the lumen
the superior mesenteric vein. The lymphatic of the gastric glands. Chloride diffuses from
drainage is into the superior mesenteric the parietal cell into the lumen passively
nodes. down its electrochemical gradient. High
concentrations of potassium and chloride
Histology are maintained within the parietal cell and
The small intestine is highly modified for chloride and bicarbonate exchanged on the
absorption of fluid and nutrients. Structures basolateral membrane.
that maximise the surface area include the:
Control of gastric acid
Plicae circulares deep permanent folds of
Gastrin acts in two ways. It stimulates
the mucosa and submucosa
gastrin receptors on the parietal cells and
Villi finger-like extensions of the mucosa
stimulates the release of histamine from
Microvilli projections of the plasma
enterochromaffin-like cells. Gastrin leads to
membrane of each absorptive epithelial cell
an increase in intracellular Ca2+. Histamine
The epithelium of the small intestine is a then acts on H2 on the parietal cells. These are
simple columnar layer with goblet cells. G protein mediated receptors. They lead to
Epithelial invaginations are known as the
Oesophageal disease 159
Several types of fundoplication have epithelium extending more than 3cm above
been described (Figure 12.4). Following gastro-oesophageal junction. The significance
fundoplication about 3% of patients of short segment Barretts, less than 3cm
develop dysphagia and 11% develop gastric long, is unclear.
bloat. A partial fundoplication, is associated
with less dysphagia and fewer gas-related Management
symptoms. If recognised at endoscopy, most patients with
Barretts oesophagus are started on life-long
Oesophageal carcinoma acid suppression. There is little evidence that
Barretts oesophagus it causes regression of metaplasia. Anti-reflux
surgery may reduce progression to dysplasia
Barretts oesophagus was first described
and cancer. Recent interest has been shown in
by Norman Barrett in 1950. It consists of
endoscopic mucosal ablation and this is usually
a columnar cell-lined distal oesophagus
achieved with photosensitisers and laser
due intestinal metaplasia of the distal
therapy. The role of endoscopic surveillance
oesophageal mucosa. It is a pre-malignant
of Barretts oesophagus is controversial. The
condition and can progress to dysplasia
aim of surveillance is to detect dysplasia before
and adenocarcinoma. Barretts oesophagus
progression to carcinoma. However, about
increases the risk of malignancy by 30-fold.
40% of patients with dysplasia already have a
It is an acquired condition due to gastro-
focus of adenocarcinoma. Oesophagectomy
oesophageal reflux. Bile reflux appears to be
for oesophageal dysplasia has an 80% 5-year
an important aetiological factor. About 10%
survival.
of patients with gastro-oesophageal reflux
develop Barretts oesophagus. Approximately Oesophageal carcinoma
1% of patients with Barretts oesophagus per
Oesophageal cancer is the sixth leading cause
year progress to oesophageal carcinoma.
of cancer death worldwide. It accounts for
Clinical features about 7000 deaths per year in the UK. Of all
oesophageal carcinomas, 90% are squamous
Barretts oesophagus per se is usually
cell carcinomas. They usually occur in the
asymptomatic, recognised as an incidental
upper or middle third of the oesophagus.
finding at endoscopy. It appears as velvety
Types of fundoplication
Only 510% are adenocarcinomas and operation regularly. The operative mortality
these usually occur in the lower third of the should be less than 5%. Preoperative
oesophagus. Wide variation in incidence has chemotherapy may improve survival. The
been reported both between countries and operative approach needs to ensure 10cm
in different ethnic groups and populations proximal clearance to avoid submucosal
within a country. There is a clear positive spread. The approach depends on the site and
association with social deprivation. type of tumour and can involve:
Risk factors for squamous cell carcinoma are: Total gastrectomy via a thoracoabdominal
Alcohol/tobacco approach
Diet high in nitrosamines Subtotal two-stage oesophagectomy (Ivor
Aflatoxins Lewis)
Trace element deficiency molybdenum Subtotal three-stage oesophagectomy
Vitamin deficiencies vitamins A and C (McKeown)
Achalasia Transhiatal oesophagectomy
Coeliac disease Complications of surgery include:
Genetic tylosis Chest infection/pleural effusion
High incidence in Transkei, areas of Anastomotic leak
Northern China and the Caspian littoral Chylothorax
region Recurrent laryngeal nerve damage
Benign anastomotic stricture
Clinical features
Of those undergoing curative treatment
The classical clinical presentation of
less than 40% survive 1 year. Overall, 5-year
oesophageal carcinoma is progressive
survival is very poor and is at best 20%.
dysphagia, first with solids and then with
liquids. Respiratory symptoms may occur Palliative treatment
due to overspill of fluid or solids into the
In those with inoperable disease, the
respiratory tract or occasionally because of the
aim of palliative treatment is to relieve
formation of a trachea-oesophageal fistula.
obstruction and dysphagia with minimal
Weight loss is usually a prominent feature.
morbidity. This may be achieved with
Investigation oesophageal intubation or stenting.
Open surgical intubation (Celestin or
The diagnosis can be confirmed by
MousseauBarbin tubes) is now obsolete.
endoscopy plus biopsy. Most tumours are
Endoscopic or radiological placement is
irresectable and incurable at presentation.
now most commonly practiced. An Atkinson
The resectability and fitness for surgery can
tube can be placed endoscopically but
be assessed by:
requires dilatation with risk of oesophageal
CT scanning perforation. There has been a recent
Lung function tests increased use of self-expanding stents that
Endoscopic ultrasound require no pre-dilatation. Complications
Bronchoscopy of stents and tubes include oesophageal
Laparoscopy perforation, tube displacement or migration
and tube blockage due to ingrowth or
Management
overgrowth of tumour. Endoscopic laser
Adenocarcinomas are not radiosensitive ablation produces good palliation in over
and surgery is the mainstay of treatment. 60% of cases buy may need to be repeated
Squamous cell carcinomas can be treated every 4 to 6 weeks. It is associated with
with either surgery or radiotherapy. the risk of oesophageal perforation in
Surgery about 5% cases. Squamous carcinomas are
radiosensitive and its use may produce some
Less than 50% of patients are suitable for
palliation but at the risk of forming a tracheo-
potentially curative treatment. Treatment
oesophageal fistula.
should be in centres that perform the
162 Chapter 12 Upper gastrointestinal surgery
important. The pathological features are oesophageal reflux and 3% a peptic stricture.
similar to Chagas disease which is due to Some centres combine a cardiomyotomy with
Trypanosoma cruzi infection. an antireflux operation.
Clinical features
Achalasia is most commonly seen in patients
Gastric disease
between 4070 years. The incidence is Gastric cancer
the same in either sex. Symptoms include Gastric cancer is one of the commonest causes
dysphagia, weight loss, regurgitation and of cancer deaths world wide. It accounts for
chest pain. About 5% of patients develop 7000 deaths per year in the UK. The incidence
squamous carcinoma of the oesophagus. The increases with age. The male: female ratio is
differential diagnosis includes: 2:1. Despite an overall decline in the incidence
Diffuse oesophageal spasm rates of gastric cancer, several countries,
Infiltrating carcinoma including the UK, have seen an increase in the
Hypertrophic lower oesophageal sphincter incidence of adenocarcinomas of the gastric
Scleroderma cardia, sometimes referred to as proximal
Chagas disease gastric cancer.
Risk factors include:
Investigation
Diet low in Vitamin C
A chest x-ray may show widening of the
Blood group A
mediastinum with an air/fluid level and
Pernicious anaemia
absence of the gastric fundus gas bubble.
Hypogammaglobulinaemia
A barium swallow may show oesophageal
Post gastrectomy
dilatation, with food residue, small tertiary
contractions and a rat tail appearance of the Precursor states include:
distal oesophagus. Oesophageal manometry Helicobacter pylori infection
will show an absent primary peristaltic wave Atrophic gastritis
and non-propulsive tertiary contractions. Intestinal metaplasia
An endoscopy is essential to exclude Gastric dysplasia
pseudoachalasia due to a submucosal Gastric polyps
oesophageal carcinoma. It will also show
a tight lower oesophageal sphincter which Pathology
relaxes with gentle pressure. Macroscopically, the appearance of tumours
vary. Malignant gastric ulcers typically
Management have raised everted edges and sometimes a
Management of achalasia is by either balloon necrotic base (Figure 12.5). Colloid tumours
dilatation or cardiomyotomy. In balloon are large gelatinous growths. Linitis plastica is
dilatation, a Rider Moeller balloon is placed a diffusely infiltrating tumour of the mucosa
across the lower oesophageal sphincter and and submucosa with marked fibrosis leading
is inflated to 300mmHg for 3 minutes. With to a shrunken thickened stomach that fails to
this approach 60% of patients are dysphagia distend. Most tumours are adenocarcinomas
free at 5 years. The procedure may need to be with varying degrees of differentiation.
repeated. The risk of oesophageal perforation Anaplastic signet-ring tumours have a
following balloon dilatation is about 3%. poor prognosis. Spread is typically via the
Cardiomyotomy was described by Heller lymphatics or portal system. Transcoelomic
(1914) and Grenveldt (1918). It may be spread to the ovaries can occur (Krukenberg
performed laparoscopically. The muscle tumours).
fibres of the lower oesophagus are incised
along an 810cm length down to the mucosa. Clinical features
Following this procedure 85% of patients New onset dyspepsia over the age of 50 years
are dysphagia free. About 10% develop is suspicious of a gastric carcinoma as is
164 Chapter 12 Upper gastrointestinal surgery
Management
Surgery offers the only prospective of
cure. Antral tumours may be suitable for
Figure 12.5 Macroscopic appearance of a gastric
a partial gastrectomy usually with Polya
cancer
reconstruction. Other tumours will need a
total gastrectomy with oesophagojejunal
constant or worsening dyspepsia that fails anastomosis and Roux-en-Y biliary diversion.
to respond to treatment. Weight loss and an A tumour is considered resectable if it is
epigastric mass are worrying signs. Some confined to the stomach or only the N1 or N2
patients will develop an iron-deficiency nodes involved. Nodes less than 3cm from
anaemia. Dysphagia and early postprandial tumour are N1 nodes. Nodes greater than
vomiting occur with proximal obstructing 3cm from tumour are N2 nodes.
tumours. Late postprandial vomiting If the tumour and N1 nodes are resected
especially of altered food and with no bile it is regarded as a D1 gastrectomy. If the
suggests gastric outlet obstruction. Most tumour and N2 nodes are resected then it is
patients present late and are not amenable to regarded as a D2 gastrectomy. The evidence
radical surgery. to support the use of D2 gastrectomy is
incomplete. A D2 gastrectomy is associated
Investigation with increased postoperative mortality but
Upper gastrointestinal endoscopy should may have improved long-term survival.
be considered in patients with dyspeptic Even in patients with incurable disease,
Stage Description
a b
Classification
In organoaxial volvulus, the axis of rotation Figure 12.7 Schematic representation of organoaxial
extends from gastro-oesophageal junction (A) and mesentericoaxial (B) gastric volvulus
to the pylorus. The gastric antrum rotates
in the opposite direction to fundus. This is
commonest type of volvulus and is usually Progressive distension and non-productive
associated with diaphragmatic defect. retching may develop. Haematemesis is a late
Strangulation occurs in about 10% of cases. feature. Borchardt triad describes:
In mesentericoaxial volvulus, the axis of Epigastric pain
rotation bisects the lesser and greater curves. Retching
The gastric antrum rotates anteriorly and Inability to pass a nasogastric tube
superiorly and the posterior surface of Chronic gastric volvulus presents with
stomach lies anteriorly. Rotation is usually intermittent epigastric pain and distension.
incomplete. The diaphragm is usually intact Early satiety, dyspepsia and dysphagia may
and strangulation is rare. occur. The symptoms are often minimal and
the diagnosis can be difficult.
Clinical features
Acute gastric volvulus usually presents with Investigation
sudden onset of severe epigastric or left A chest x-ray may shows a retrocardiac gas-
upper quadrant pain. If part of the stomach filled viscus. A plain abdominal x-ray may
is in the thorax, then chest pain may occur. show a distended stomach. The diagnosis
168 Chapter 12 Upper gastrointestinal surgery
can be confirmed by a contrast study or abdominal pain and fatigue. There may also
abdominal CT scan. be features of malabsorption. Anaemia can
develop due to iron, folic acid or B12 deficiency.
Management Calcium and vitamin D malabsorption may
Endoscopic reduction may be attempted in cause osteopenia. A mild coagulopathy may
both acute and chronic cases. However, it develop due to vitamin K malabsorption.
should not be attempted if there is clinical
suspicion of strangulation. A PEG can be Investigation
inserted after reduction to reduce the risk Several investigations can be used to assist in
of recurrence. Surgery is often required the diagnosis but many tests are only useful if
and involves reduction of the volvulus, the patient is still on a normal diet containing
assessment of viability of the stomach and gluten. Endoscopy with duodenal biopsies is
resection if required. An anterior gastropexy the gold standard.
may be considered to prevent recurrence. Multiple biopsies are required. Most
Mortality following surgery for acute gastric patients with coeliac disease have a small
volvulus is about 10%. bowel that appears normal on endoscopy.
Endoscopy may show scalloping of the small
Coeliac disease bowel folds and a mosaic pattern to the
Coeliac disease is an autoimmune disorder mucosa. Serological tests have a high sensitivity
of the small bowel. It occurs in genetically and specificity. Serological tests include the
predisposed individuals. It affects about detection of IgA antibodies against reticulin
1% of the population and can present in or gliadin. The pathological changes of coeliac
either childhood or adulthood. It is caused disease in the small bowel are categorised by
by a reaction to gliadin, a gluten protein the Marsh classification as follows:
found in wheat. Long term it leads to an
Stage 0 Normal mucosa
increased risk of both adenocarcinoma and
Stage 1 Increased number of intra-
lymphoma. Coeliac disease has been linked
epithelial lymphocytes
with a number of conditions including IgA
Stage 2 Proliferation of the crypts of
deficiency, dermatitis hepatiformis, other
Lieberkuhn
autoimmune diseases including autoimmune
Stage 3 Partial or complete villous
thyroiditis and primary biliary cirrhosis
atrophy
and undefined neurological disorders and
Stage 4 Hypoplasia of the small bowel
epilepsy.
architecture
Pathophysiology The changes classically improve or reverse
The vast majority of coeliac patients have one after gluten is removed from the diet. Repeat
of two types of HLA DQ, a gene that is part of biopsies should be considered after 6 months
the MHC class II antigen-presenting receptor. of gluten exclusion.
There are seven HLA DQ variants (DQ2
and D4 through 9). Two of these variants
Management
DQ2 and DQ8 are associated with coeliac The only effective treatment is a life-long
disease. The gene is located on the short arm gluten-free diet. No medication exists that
of chromosome 6. The receptors formed by will prevent damage when gluten is present.
these genes bind to gliadin peptides. Coeliac Adherence to the diet allows the intestines
disease shows incomplete penetrance. to heal and leads to the resolution of all
symptoms in the vast majority of cases. A tiny
Clinical features minority of patients suffer from refractory
Many patients are asymptomatic. In those with disease. Steroids or immunosuppressants
symptoms they include, diarrhoea, weight loss, may be considered in this situation.
Chapter 13 Hepatobiliary
and pancreatic
surgery
Coronary ligament
Diaphragm
Left lobe
Right lobe
Falciform
ligament
Gallblader
Inferior Round
border ligament
170 Chapter 13 Hepatobiliary and pancreatic surgery
Common Fibrous
hepatic duct connection
Gallbladder Cystic
duct
Low
Common junction
a bile dict B C D E
Figure 13.2 Anatomical variations of the cystic duct. A = Normal; B = Low insertion of cystic duct; C = No
cystic duct; D = Cystic duct joins right hepatic duct; E = Cystic duct passes in front of common bile duct
Applied basic sciences 171
artery. The inferior pancreaticoduodenal The remaining 25% is arterial blood from
artery is a branch of the superior mesenteric the hepatic artery. Terminal branches of the
artery. The splenic artery supplies the body hepatic portal vein and hepatic artery enter
and tail. It is a direct branch of the coeliac sinusoids in the liver (Figure 13.5). Sinusoids
trunk. The venous drainage corresponds to are distensible vascular channels lined with
the arterial supply and drains into the portal highly fenestrated endothelial cells and
system. bounded circumferentially by hepatocytes.
About 80% of the mass of pancreas is As blood flows through the sinusoids,
composed of acinar cells. These form the plasma is filtered into the space between the
exocrine portion of the gland. The Islets of endothelium and hepatocytes. Blood flows
Langerhans are dispersed within the gland through the sinusoids and empties into the
and are islands of endocrine tissue. The islets central vein of each lobule. Central veins
consist of Type A (20%), B (70%) and D (10%) coalesce into the hepatic veins which leave
cells. Type A, B and D cells produce glucagon, the liver and drain into the vena cava.
insulin and somatostatin respectively.
The intrahepatic biliary apparatus
Physiology of the liver The biliary system is a series of channels and
Approximately 75% of the blood entering the ducts that conveys bile from the liver into the
liver is venous blood from the portal vein. lumen of the small intestine. Hepatocytes are
172 Chapter 13 Hepatobiliary and pancreatic surgery
arranged in plates with their apical surfaces system of the spleen. It is not water soluble
facing and surrounding the sinusoids. The and is transported to the liver bound to
basal surfaces of adjoining hepatocytes are albumin. In the liver it is conjugated with
joined together by junctional complexes glucuronic acid, rendering it water soluble
to form bile canaliculi. A canaliculus is the and allowing its excretion in bile.
dilated intercellular space between adjacent
hepatocytes. Hepatocytes secrete bile into
the canaliculi which flows parallel to the
Hepatobiliary and
sinusoids, but in the opposite direction to pancreatic disease
the blood flow. At the ends of the canaliculi, Obstructive jaundice
bile enters into the bile ducts, which are true
In healthy individuals, serum bilirubin
ducts lined by epithelial cells. Bile ducts are
concentrations are low. When biliary
in close proximity to the terminal branches of
obstruction occurs, the serum levels of
the portal vein and hepatic artery, and form
conjugated bilirubin are increased, resulting
the portal triad.
in its accumulation in tissues and its excretion
Bile is a complex fluid containing in the urine. The causes of obstructive
water, electrolytes, bile acids, cholesterol, jaundice are shown in Table 13.1. Obstructive
phospholipids and bilirubin. Adults produce jaundice can result in several systemic
approximately 500mL of bile each day. complications.
Bile acids are derivatives of cholesterol
synthesised in the hepatocyte. Cholesterol Clinical features
is converted into the bile acids, cholic and Accumulation of bilirubin in tissues produces
chenodeoxycholic acids, which are then jaundice, characterised by the deposition of
conjugated to an amino acid (glycine or yellow bilirubin pigments in the skin, sclerae,
taurine) to yield a conjugated form that is mucous membranes and other tissues.
actively secreted into canaliculi. Bile acids Patients often complain of itch and may
are important for digestion and absorption notice pale stools and dark urine.
of fats and fat-soluble vitamins in the small
intestine. Complications
Waste products, including bilirubin, are Vitamin K is required for the -carboxylation
eliminated from the body by secretion into of the clotting factors II, VII, IX, XI. It is a fat
bile. Bilirubin is a tetrapyrrole and is a normal soluble vitamin that is not absorbed in the
product of haem catabolism. Unconjugated presence of obstructive jaundice. Deranged
bilirubin is formed in the reticuloendothelial production of clotting factors can result in
Hepatobiliary and pancreatic disease 173
symptomatic. Over 10% of those with stones Biliary colic and acute cholecystitis
in the gallbladder have stones in the common Biliary colic arises as a result of intermittent
bile duct. obstruction of the cystic duct due to the
presence of gallstones within Hartmanns
Pathophysiology pouch. Acute cholecystitis results from
Three types of stones are recognised: persistent obstruction of the cystic duct.
Cholesterol stones (15%) Increased pressure within the gallbladder
Mixed stones (80%) results in an acute inflammatory response.
Pigment stones (5%) Secondary bacterial infection may occur
Cholesterol stones result from a change in in about 20% of cases. The most common
the solubility of bile constituents. Bile acids organisms implicated are Escherichia coli,
act as a detergent keeping cholesterol in Klebsiella and Strep. faecalis.
solution. Bile acids, lecithin and cholesterol
result in the formation of micelles. Bile is Clinical features
often supersaturated with cholesterol and Biliary colic typically presents with right
this favours the formation of cholesterol upper quadrant abdominal pain precipitated
microcrystals. Biliary infection, stasis by food. The pain may radiate to the back and
and changes in gallbladder function can scapula and usually resolves spontaneously
precipitate stone formation. Bile is infected after 30 minutes to a few hours. Systemic
in 30% of patients with gallstones. Gram- upset is mild and abdominal signs may be
negative organisms are the most common minimal. In contrast, acute cholecystitis
isolated. Mixed stones are probably a variant presents with constant pain of longer
of cholesterol stones. Pigment stones are duration. This is often associated with fever,
small, dark stones made of bilirubin and tachycardia and localised tenderness in right
calcium salts. They contain less than 20% of upper quadrant. Murphys sign, guarding in
cholesterol (Figure 13.6). Only about 10% right upper quadrant on deep inspiration,
of gallstones are radio-opaque. The clinical may be present. Jaundice is uncommon in
presentations of gallstones include: uncomplicated acute cholecystitis.
Biliary colic Complications of acute cholecystitis
Acute cholecystitis include:
Empyema of the gallbladder Gangrenous cholecystitis
Mucocele of the gallbladder Gallbladder perforation
Flatulent dyspepsia Cholecystoenteric fistula
Mirizzis syndrome Gallstone ileus
Obstructive jaundice
Pancreatitis Investigation
Acute cholangitis Ultrasound is the initial investigation of
choice. In patients with biliary colic, stones
may be seen within a normal gallbladder.
In acute cholecystitis, the diagnostic
Multiple pigment stones in a gallbladder features include the presence of gallstones,
a distended thick-walled gallbladder,
pericholecystic fluid and Murphys sign
demonstrated with the ultrasound probe. The
common bile duct should also be visualised
and its diameter assessed. Liver function tests
are often normal but inflammatory markers
may be raised. A dilated common bile duct
and deranged liver function indicate the need
for further assessment for the presence of
Figure 13.6 Multiple pigment stones in a gallbladder common bile duct stones.
Hepatobiliary and pancreatic disease 175
due to local complications. Mortality from Ransoms criteria are not ideal. They can not
pancreatitis is due to: be applied fully for 48 hours and are also a
Early multiple organ failure poor predictor later in the disease. They have
Late infected pancreatic necrosis been described as a single snapshot in a
Haemorrhage whole feature length of the film. APACHE II
Associated co-morbidity is a multivariate scoring system. It measures
objective parameters vital signs and
Most patients with acute pancreatitis have
biochemical analysis. It takes account of the
mild disease which accounts for less than 5%
premorbid state and age and can be used
of the mortality from the disease. The aim
throughout the course of the illness.
of prognostic scores is to identify patients
with severe disease, allowing them to be Management
more closely monitored in an intensive care
The aims of treatment of acute pancreatitis
environment. The scoring systems need to
are to halt the progression of the local disease
have a high sensitivity and specificity and
and to prevent remote organ failure. In severe
ideally should be applicable on admission.
disease, this requires full supportive therapy
Ransons criteria are measured both on
often in ITU or HSU environment.
admission and at 48 hours.
All patients should be monitored with a
Ransoms criteria scored on admission:
urinary catheter. A CVP line and arterial line
Age more than 55 years should be considered in those with significant
WCC more than 16,000 physiological derangement. There should
LDH more than 600U/L be regular assessment of serum electrolytes,
AST more than 120U/L calcium, blood sugar and liver function tests.
Glucose more than 10mmol/L Patients require fluid resuscitation with both
Ransoms criteria scored within 48 hours: colloid and crystalloid, correction of hypoxia
Haematocrit fall more than 10% with an increased FiO2 and the administration
Urea rise more than 0.9mmol/L of adequate analgesia.
Calcium less than 2mmol Antibiotic prophylaxis is useful in those
pO2 less than 60mmHg with severe pancreatitis. ERCP maybe of
Base deficit more than 4 benefit within the first 48 hours in patients
Fluid sequestration more than 6L with predicted severe gallstone disease.
Hepatobiliary and pancreatic disease 179
CA125 may be raised. The diagnosis can be presence of vascular invasion. Spiral CT has
confirmed by CT or MRI. An ERCP can be improved on the resolution of conventional
both diagnostic and therapeutic. Specimens CT imaging. Contrast-enhanced triple-phase
can be obtained for cytology or histology and imaging is the imaging modality of choice.
a biliary stent can be inserted. It has sensitivity of greater than 95% for
detection of pancreatic tumours and until
Management recently was probably the most useful of
Surgery offers the only chance of cure. staging investigations. MRI is increasingly
The tumour is resected and biliary been used for imaging of the pancreas.
reconstruction is performed. The aim is However, both ultrasound and CT often
for resection with tumour-free margins. fail to detect small hepatic metastases.
Determinants of resectability are the Laparoscopy will identify liver or peritoneal
extent of the tumour, vascular invasion, metastases in 25% of patients deemed
hepatic lobar atrophy and the absence of resectable after conventional imaging. The
metastatic disease. Liver transplantation in use of laparoscopic ultrasound may improve
cholangiocarcinoma is controversial due to the predictability of resection.
high recurrence rates.
Management
Pancreatic carcinoma Pancreatic resection is the only hope of
Pancreatic carcinoma is the second cure but only 15% of tumours are deemed
commonest tumour of the digestive system. resectable. Resectability is determined by
The incidence is increasing in the Western assessment of tumour size (<4cm), absence
world. It is uncommon below 45 years of age. of invasion of the superior mesenteric
More than 80% of cases occur between 60 and artery or portal vein and the absence of
80 years of age. The male:female ratio is 2:1. ascites, nodal, peritoneal or liver metastases.
Most tumours are adenocarcinomas. More Overall, 75% of patients have metastases at
than 80% occur in the head of the pancreas. presentation. Preoperative biliary drainage
Overall 5-year survival is less than 5%. The is of unproven benefit and has not been
prognosis of ampullary tumours is much shown to reduce postoperative morbidity or
better. mortality.
Endocrine tumours arise from the Islets of the presence of metastatic disease. Octreotide
Langerhans and may produce hormones. may help control symptoms.
They may be associated with the multiple
endocrine neoplasia (MEN) syndromes. Chronic pancreatitis
Chronic inflammation of the pancreas
Insulinomas results in irreversible destruction of both the
Insulinomas are rare. The annual incidence endocrine and exocrine pancreatic tissue.
in the UK is 12 per million population. The male to female ratio is approximately
They are usually solitary and can occur at 4:1. The mean age of onset is 40 years.
any age. They are slightly more common in The incidence is increasing. Chronic
women. Approximately 90% are less than pancreatitis increases the risk of pancreatic
2cm in diameter, 90% are benign and 10% are carcinoma. Early stages of the disease
associated with MEN Type 1 syndrome. The may be characterised by episodes of acute
symptoms of an insulinoma are non-specific pancreatitis and the pancreas may appear
and variable and may be induced by exercise. macroscopically normal. The late stages
The symptoms are those of hypoglycaemia. of disease are characterised by pancreatic
The diagnosis can be difficult. It is necessary fibrosis and calcification. Pancreatic duct
to demonstrate hypoglycaemia in the dilatation and stricture formation may occur.
presence of symptoms. Insulin levels are Cysts form within the pancreatic tissue.
usually normal or raised. Serum C-peptide Aetiological factors include:
levels are often increased. The diagnosis can Alcohol
be confirmed by CT. Resection offers the only Tobacco
chance of cure. The 10-year survival rate is Pancreatic duct strictures
over 90%. Hepatic artery embolisation and Pancreatic trauma
chemotherapy maybe required in metastatic Hereditary pancreatitis
disease. Tropical pancreatitis
Gastrinomas Clinical features
Gastrinomas occur in both the duodenum Pain is the principal symptom in most
and pancreas. Gastrin over-production results patients, usually epigastric and radiating
in the ZollingerEllison syndrome. Patients to the back. The pain may be continuous
presents with severe peptic ulcer disease and or episodic, often interferes with life and
diarrhoea. About 20% of patients have MEN may lead to opiate abuse. Weight lost may
type 1 syndrome. Gastric acid hypersecretion occur. Loss of exocrine function produces
can be controlled by either a proton pump malabsorption and steatorrhoea. Loss of
inhibitor or surgery. Historically, total endocrine function results in diabetes.
gastrectomy was performed and the tumour
was left in situ. Today the tumour can be Investigation
removed by either distal pancreatectomy, The serum amylase is often normal. A plain
enucleation, duodenectomy or a Whipples abdominal x-ray may show pancreatic
procedure. Patients with metastatic disease calcification. CT or MRI is the most useful
can be managed with chemotherapy or investigation for imaging the pancreas and
-interferon. may confirm pancreatic enlargement, fibrosis
and calcification. ERCP has a high sensitivity
Glucagonomas
for detecting chronic pancreatitis. An MRCP
Glucagonomas are rare and occur as part of will outline the state of the pancreatic ducts.
the MEN type 1 syndrome. Metastatic disease Pancreatic function test rarely provide useful
is often detected at presentation. Symptoms information.
are often non-specific but patients may have a
characteristic rash and mucositis. The diagnosis Management
is confirmed by the detection of a raised serum Treatment of the early stages of the disease
glucagon. Surgery may be beneficial even in is with a low fat diet. Alcohol abstention is
186 Chapter 13 Hepatobiliary and pancreatic surgery
essential. Opiate analgesia should be avoided The aetiology of portal hypertension can be
if possible. Pancreatic enzyme supplements prehepatic, intrahepatic or posthepatic
may reduce both the steatorrhoea and the (Table 13.3).
frequency of painful crises.
Pathophysiology
Surgery Increased portal pressure reduces portal
Surgery is associated with significant venous flow. It encourages the development
morbidity and mortality. It does not of porto-systemic anastomoses. Theses
arrest the loss of endocrine and exocrine develop at sites of connections between the
/
function. The aim of surgery is to remove portal and systemic circulation at the:
r
any mass lesion and relieve pancreatic duct Gastro-oesophageal junction
.i
obstruction. A mass lesion can be removed Lower rectum
by pancreaticoduodenectomy or a Begers Peri-umbilical veins
s
procedure resection of the pancreatic Retroperitoneal veins of Retzius
s
head with preservation of the duodenum. Peri-hepatic veins of Sappey
Pancreatic duct obstruction can be relieved
n
by pancreaticojejunostomy or a Freys Clinical features
procedure in which the diseased portion of
is a
Cirrhosis is the commonest cause of
the pancreatic head is excised and a lateral portal hypertension in the UK. Cirrhosis
pancreaticojejunostomy is fashioned. Disease produces features of hepatocellular failure,
confined to pancreatic tail may require distal portal hypertension, variceal bleeding and
r
pancreatectomy. Surgery relieves symptoms ascites. About 90% of patients with cirrhosis
e
in about 75% of patients. will develop oesophageal varices. Upper
gastrointestinal bleeding will occur in 30%
p
Portal hypertension of these patients. The severity of cirrhosis
.
The normal portal venous pressure is can be assessed using the ChildPugh
p
510mmHg. Portal hypertension is defined classification (Table 13.4) and can be divided
iv
as a portal pressure more than 12mmHg. into three groups:
/: /
Aetiology of portal hypertension
tt p
Prehepatic Intrahepatic Posthepatic
Portal vein thrombosis Presinusoidal Caval abnormality
h
Splenic vein thrombosis Schistosomiasis Constrictive pericarditis
Tropical splenomegaly Primary biliary cirrhosis
Arterio-venous fistula Chronic active hepatitis
Sarcoidosis
Sinusoidal
Cirrhosis post hepatitic, alcohol,
cryptogenic, metabolic
Non-cirrhotic cytotoxic drugs, Vitamin A
intoxication
Postsinusoidal
BuddChiari syndrome
Veno-occlusive disease
Variable Score
1 point 2 points 3 points
Encephalopathy Absent Mild/moderate Severe or coma
Bilirubin (mol/L) Less than 34 3451 More than 51
Albumin (g/L) More than 35 2835 Less than 28
/
Prothrombin time (sec above 14 46 More than 6
r
normal)
.i
Ascites None Mild Moderate or severe
s
Table 13.4 ChildPugh classification of the severity of cirrhosis
s
n
Class A score 56 Total shunts have a wide diameter and
Class B score 79 decompress all of the portal circulation.
is a
Class C score more than 10 Following a total shunt, there is no portal
venous flow to the liver. Over 90% long-
Management term patency can be achieved but 3040%
r
In patients with known oesophageal of patients will develop encephalopathy.
e
varices, the risk of oesophageal bleeding Examples of total shunts are:
can be reduced by the use of blockers. End-to-side portocaval shunt
p
Sclerotherapy of varices does not prevent Side-to-side portocaval shunt
.
bleeding. Transjugular intrahepatic Mesocaval C-graft
p
portosystemic shunting (TIPPS) involves the Central splenorenal shunt
iv
creation of an intrahepatic portosystemic
Partial shunts have a narrow diameter and
shunt. The hepatic vein is cannulated via the
partially decompress the portal circulation.
/: /
internal jugular vein. The intrahepatic portal
Some portal vein flow is maintained. About
vein is punctured percutaneously. A guide
20% of partial shunts will either stenose or
wire is passed from the portal to hepatic
occlude but only 10% of patients will develop
vein. A stent is then passed along guide wire.
tt p
encephalopathy. An example of a partial
Complications include encephalopathy
shunt is the small bore portocaval H-graft.
and liver failure. The role TIPPS in primary
prevention of oesophageal bleeding is at Selective shunts decompress part of the
h
present unknown. portal circulation and portal vein flow is
maintained. Examples of selective shunts are
Surgical shunts the distal splenorenal and splenocaval shunts.
The aims of surgical shunts are to reduce
portal venous pressure. Portocaval shunts
Ascites
were commonly performed until the Ascites is free fluid within the abdominal
mid-1980s. Their use has decreased due cavity. Over 70% cases are due to liver disease.
to the introduction of TIPPS and liver
Pathophysiology
transplantation in end-stage liver disease. The
current roles of surgical shunts are to control The normal peritoneal cavity contains
variceal bleeding when there is no access to approximately 100mL of fluid. It is a
TIPPS, to reduce portal hypertension in those transudate and has a 50% turnover every
patients awaiting transplantation, to relieve hour. Peritoneal fluid is produced by the
intractable ascites and to reduce bleeding visceral capillaries and is drained via the
from rectal, colonic or stomal varices. Shunts diaphragmatic lymphatics. In cirrhotic
can be total, partial or selective. ascites, the pathophysiology is complex.
188 Chapter 13 Hepatobiliary and pancreatic surgery
Portal hypertension results in splanchnic Investigation
vasodilatation. This results in sodium A diagnostic peritoneal tap allows peritoneal
retention due to alterations in systemic fluid to be sent for analysis. This includes
haemodynamics, neurohumeral control and protein estimation, cytology, bacteriology and
renal function. Impaired free-water excretion biochemistry. A transudate has a total protein
results in dilutional hyponatraemia. Renal less than 30g/L. Causes of a transudate include
vasoconstriction can result in the hepatorenal cirrhosis and heart failure. An exudate has a
syndrome. total protein more than 30g/L . Causes of an
exudate include carcinomatosis and infection.
/
Aetiology
r
The causes of ascites include: Management
.i
Hepatic cirrhosis, veno-occlusive Effective treatment of ascites in cirrhosis is
disease difficult. Medical measures include sodium
s
Cardiac right ventricular failure, restriction and diuretics. Spironolactone
s
constrictive pericarditis is usually the drug of choice. In those with
Renal nephrotic syndrome, renal failure ascites refractory to medical therapy options
n
Malignancy ovarian, gastric, colorectal include:
is a
carcinoma Repeated large-volume paracentesis
Infection tuberculosis Peritoneovenous shunting
Pancreatitis Portocaval shunting
r
Lymphatic congenital anomaly, trauma Transjugular intrahepatic portosystemic
Malnutrition shunting
e
Myxoedema Liver transplantation
.p
iv p
/: /
tt p
h
Chapter 14 Colorectal
surgery
Applied basic sciences medial surface of the caecum and arises below
the level of the ileocaecal valve. It is covered in
Anatomy of the large intestine peritoneum and has a short mesentery known
The caecum and appendix as the mesoappendix. It is related to the
The caecum is situated in the right iliac fossa anterior abdominal wall one third of the way
and lies below the level of the ileocaecal valve. along a line joining the anterior superior iliac
It is completely covered with peritoneum. spine and umbilicus (McBurney point). The
Peritoneal folds create the superior, inferior tip of the appendix can be found in various
and retrocaecal fossae. Like the remainder of positions including hanging down into the
the colon, the caecum has three longitudinal pelvis related to the right pelvic wall, behind
bands of muscle knows as the taeniae coli. the caecum in the retrocaecal fossa, projecting
These converge on base of the appendix. The upward along the lateral side of the caecum
anterior relations of the caecum include the or in front or behind the terminal ileum. The
greater omentum and anterior abdominal blood supply is from the appendicular artery a
wall. The posterior relations of the caecum branch of the posterior caecal artery.
include the psoas and iliacus muscle and The colon and rectum
femoral nerve. The blood supply is from the The colon is divided into the ascending,
anterior and posterior caecal arteries. These transverse, descending and sigmoid colon.
are terminal branches of the ileocolic artery. The blood supply of the ascending colon is
The appendix contains a large amount of from the ileocolic and right colic arteries, the
lymphoid tissue. It has a complete covering of proximal transverse colon is from the middle
longitudinal muscle formed from the taeniae colic artery, the distal transverse colon is
coli. The base is attached to the posterior from the superior left colic artery and the
descending and sigmoid colon is from the The perineum and anal sphincter
inferior left colic artery (Figure 14.1). The The anus has two sphincters internal and
ileocolic, right and middle colic arteries are external (Figure 14.2). The internal anal
branches of the superior mesenteric artery. sphincter is smooth muscle. The external
The superior and inferior left colic arteries are sphincter is striated muscle. The mucosa of
branches of the inferior mesenteric artery. the upper third of anal canal has no somatic
The venous and lymphatic drainage follows sensation. The mucosa of the lower two thirds
the blood supply. of the anal canal has somatic innervation
The rectum is about 15cm long and begins from the inferior rectal nerves. Anal glands
in front of the third sacral vertebra. It passes occur in intersphinteric plane and open at
through pelvic diaphragm and is continuous level of the dentate line.
with anal canal. Peritoneum covers the The levator ani muscle is a broad, thin
anterior and lateral surfaces of the upper muscle, situated on the side of the pelvis. It
third and the anterior surface only of the is attached to the inner surface of the side of
middle third of the rectum. The lower third of the lesser pelvis and unites with its fellow of
the rectum has no peritoneal covering. The the opposite side to form the greater part of
rectum has an outer longitudinal and inner the floor of the pelvic cavity. It supports the
circular muscle coat. The mucous membrane viscera in the pelvic cavity and surrounds the
forms three transverse folds. The blood supply various structures which pass through it. In
of the rectum is from the superior, middle and combination with the coccygeus muscle, it
inferior rectal arteries. The superior rectal forms the pelvic diaphragm.
artery is a branch of the inferior mesenteric
The anal canal above the dentate line is
artery. The middle rectal artery is a branch
supplied by the terminal branches of the
of the internal iliac artery. The inferior rectal
superior rectal artery, which is the terminal
artery is branch of the internal pudendal
branch of the inferior mesenteric artery.
artery. The venous drainage corresponds to
The middle rectal artery and inferior rectal
the arterial supply. The superior rectal vein
artery supply the lower anal canal. Deep to
drains into the inferior mesenteric vein. The
the skin of the anal canal lies the external
middle rectal vein drains into the internal
haemarrhoidal plexus of veins which drain
iliac vein. The inferior rectal vein drains into
into systemic veins. Above the dentate line
the internal pudendal vein. The lymphatic
lies the internal haemarrhoidal plexus of
drainage is into the pararectal nodes. It
veins, which drain into the portal venous
follows the superior rectal artery to the
system. The anorectum is, therefore,
inferior mesenteric nodes.
Levator
ani
Anal Puborectalis
columns
Deep external
Internal sphincter
sphincter
Superficial
Dentate external
line sphincter
Subcutaneous
external
sphincter
Colorectal disease 191
polyposis colorectal cancers and the criteria obstruction a CT scan is the investigation of
are as follows: choice. CT scanning also allows staging of the
At least three relatives with colorectal disease.
cancer
One must be a first-degree relative of the
Management
other two Any surgical resection for a colorectal cancer
At least two successive generations should requires 5cm proximal and 2cm distal
be affected clearance for colonic lesions (Figure 14.3).
One colorectal cancer should be A 1cm distal clearance of rectal lesions is
diagnosed before the age of 50 years adequate if the mesorectum is resected. The
mesorectum is fatty tissue directly adjacent
It is recommended to start colonoscopic
to the rectum that contains blood vessels and
screening 5 years before the youngest affected
lymph nodes. The radial margin should be
relative.
histopathologically free of tumour if possible.
Clinical features Lymph node resection should be performed
to the origin of the feeding vessel including
Colorectal cancer can present via the
an en bloc resection of adherent tumours.
outpatient clinic or as an emergency.
The value of a no-touch techniques remains
About 40% of cancers present as a surgical
unproven. Depending on site of the tumour
emergency with either obstruction or
the surgical options are:
perforation. Right-sided colonic lesions may
present with iron deficiency anaemia due Caecum, ascending colon, hepatic flexure
occult blood loss, weight loss or a right iliac Right hemicolectomy
fossa mass. Left-sided colonic lesions often Transverse colon Extended right
present with abdominal pain and alteration hemicolectomy
in bowel habit or rectal bleeding. Emergency Splenic flexure, descending colon Left
presentation and management is associated hemicolectomy
with a poorer outcome. Sigmoid colon High anterior resection
Upper rectum Anterior resection
Investigation Lower rectum Abdomino-perineal
In elective cases, the diagnosis can be resection
confirmed by a combination of flexible Transanal microsurgery is an option for small
sigmoidoscopy, colonoscopy or CT scanning. lower rectal cancers. Laparoscopic surgery
In patients presenting with large bowel is increasingly utilised. Early studies raised
The relative contraindications for surgical either complete cytoreduction with curative
resection are: intent or palliative debulking. Complete
Hilar and coeliac nodal involvement cytoreduction is usually combined with
Distant metastases intraperitoneal chemotherapy. Careful
Poor cardiovascular reserve patient selection is required. Complete
Preoperative portal vein embolisation cytoreduction is a major undertaking and
atrophy of segments to be excised the postoperative mortality is about 5%.
Neoadjuvant chemotherapy Intra-abdominal sepsis occurs in about 30%
patients. Surgery is indicated if complete
Liver metastases can be palliated by:
removal of tumour is achievable or palliative
Cryotherapy debulking will improve quality of life.
Hepatic artery infusion therapy
Debulking involves removal of mucin and
Laser photo-coagulation
tumour bulk. Limited resectional procedures
Pseudomyxoma peritonei may be performed. The aim of cytoreduction
is to remove all the macroscopic disease. No
Pseudomyxoma peritonei is a rare borderline tumour deposits more than 3mm should
malignant condition. There are approximately be left. This will maximise the effect of
100 cases per year in UK. It is more common chemotherapy. Six peritonectomy procedures
in women than men. It is characterised by may be necessary including:
the production of large volumes of mucinous
ascites. It often presents with advanced Greater omentectomy and splenectomy
disease and may be associated with ovarian Stripping of the left hemidiaphragm
or appendicular pathology. Depending on Stripping of the right hemidiaphragm
the degree of cytological atypia, the pathology Cholecystectomy and lesser omentectomy
has been classified as either disseminated Distal gastrectomy
peritoneal adenomucinosis or peritoneal Pelvic peritonectomy and anterior
mucinous carcinomatosis. resection
Intraperitoneal chemotherapy
Clinical features
Systemic chemotherapy if of limited value in
The clinical features of pseudomyxoma
pseudomyxoma peritonei. Intraperitoneal
peritonei are those of raised intra-abdominal
chemotherapy may be beneficial and should
pressure including bloating, an abdominal
be give after adequate cytoreduction. It
wall hernia and a uterovaginal prolapse. There
is of limited benefit if significant residual
may be features mimicking appendicitis.
disease exists. Intraoperative Mitomycin C
Patients may have a palpable abdominal mass.
is followed by postoperative 5-flurouracil.
There may be features of advanced malignancy
Chemotherapeutic agents are heated to 41C
including anorexia, weight loss and ascites.
as heat seems to have a synergistic effect to
Investigation the drugs. It does, however, increases the risk
of fistula formation and anastomotic leak.
Abdominal CT is the first line investigation
of choice. An omental cake is often apparent. Anal carcinoma
Scalloping of the diaphragmatic surface
of the liver is characteristic. Segmental Anal carcinoma is a relatively uncommon
narrowing of the small bowel is a poor tumour. However, the incidence appears to
prognostic sign. Patients are often anaemic. be increasing. There are about 300 cases per
Serum inflammatory markers can be raised. year in the UK and they account for 4% of
Tumours markers (CEA, CA19.9 and CA125) anorectal malignancies.
are often elevated.
Aetiology
Management Anal carcinoma is more common in
The management of pseudomyxoma homosexuals. It is also increasingly seen in
peritonei is controversial. Surgery consists of those with genital warts. Patients with genital
196 Chapter 14 Colorectal surgery
abscess can result in purulent peritonitis. the cautious use of laxatives. In patients
Intraperitoneal rupture of an inflamed with acute diverticulitis, the bowel should
diverticulum, allowing direct communication be rested by restricting oral intake and
between the lumen and peritoneal cavity, can the use of intravenous fluids. Intravenous
result in faecal peritonitis. A fistula can form antibiotics should be administered and active
if there is rupture into an adjacent organ such observation maintained for the development
as the bladder or vagina. of complications.
If pericolic abscess formation occurs, then
Clinical features percutaneous drainage under radiological
Uncomplicated diverticular disease is guidance is usually possible. Subsequent
often asymptomatic or at worse causes elective resection and primary anastomosis
intermittent left iliac fossa pain. There may is often required. Patients who develop
be a tendency towards constipation. Acute generalised peritonitis invariably require
diverticulitis usually presents with more emergency surgery. Sigmoid resection and
severe and persistent left iliac fossa pain. an left iliac fossa end colostomy (Hartmanns
The patient may be pyrexial and tachycardic procedure) is usually required. The
and on examination they may have left iliac postoperative mortality is high especially
fossa tenderness with signs of peritonism. A (about 40%) in those with faecal peritonitis.
diverticular abscess often causes prolonged
left iliac fossa pain associated with signs Inflammatory bowel disease
of systemic sepsis and swinging pyrexia. Colonic inflammation is common and the
Both purulent and faecal peritonitis cause causes include:
generalised abdominal pain and signs of
generalised peritonitis. Patients are more Infection bacteria, viruses, parasites
likely to have features of severe sepsis with Ulcerative colitis
faecal peritonitis. A colovesical fistula Crohns disease
usually presents with recurrent urinary tract Radiation enteritis
infections and pneumaturia the passage of Ischaemic colitis
air per urethra. A colovaginal fistula usually Microscopic colitis
presents with the passage of faeces from Drug-induced colitis
the vagina. A colonic stricture presents with
Epidemiology
features of large bowel obstruction, often
against the background of repeated episodes Inflammatory bowel disease has a bimodal
of acute diverticulitis. age distribution with peaks in adolescence and
the elderly. Ulcerative colitis is more common
Investigation than Crohns disease with a prevalence of 80
A plain abdominal x-ray with positive and 40 per 100,000 population, respectively.
diagnostic features (e.g. free intraperitoneal The incidence of both conditions is increasing,
gas or gas in the bladder) is a useful possibly due to increased recognition.
examination but a normal abdominal x -ray Ulcerative colitis is slightly more common in
can not exclude complications of diverticular men. Crohns disease is slightly more common
disease. An abdominal CT with intravenous in women. Both diseases tend to occur in
and rectal contrast may be useful for imaging higher socio-economic groups.
abscesses or fistulae and identifying the site
Pathophysiology
of perforation. A flexible sigmoidoscopy may
be required to differentiate a benign and Crohns disease and ulcerative colitis
malignant colonic stricture. have some pathophysiological features in
common. They both result from inappropriate
Management activation of the mucosal immune system.
Minimally symptomatic diverticular This process seems to be driven by the normal
disease should be managed by dietary luminal bacteria flora. The pathological
modification, stool bulking agents and processes may result from defective barrier
198 Chapter 14 Colorectal surgery
function of the intestinal epithelium. Genetic Systemic features include tachycardia, fever,
factors contribute to the susceptibility as anaemia, hypoalbuminaemia. Disease can be
demonstrated by a variable prevalence categorised as:
in different populations and increased Mild Less than 4 stools per day.
incidence in first degree relatives, increased Systemically well
concordance in monozygotic twins and Moderate More than 4 stools per day.
concordance in site and type of disease in Systemically well
affected families. Possible environmental Severe More than 6 stools per day.
factors include smoking, and the use of Systemically unwell
anti-inflammatory drugs. The pathological
features of ulcerative colitis and Crohns Clinical features of Crohns disease
disease are summarised in Table 14.2. The clinical features of Crohns disease
depends on the site of disease. About 50%
Clinical features of ulcerative colitis of patients have ileocaecal disease and
In 30% of patients with ulcerative colitis, the 25% present with colitis. Extraintestinal
disease is confined to the rectum. However, manifestations may occur and systemic
15% of patients develop more extensive features are more common than in ulcerative
disease over a 10-year period. About 20% colitis. Extraintestinal manifestations
patients have total colonic involvement from associated with disease activity affect the skin,
the outset. Patients generally fall into the joints, eyes and liver. They include erythema
following categories: nodosum, pyoderma gangrenosum, an
Severe acute colitis asymmetrical non-deforming arthropathy,
Intermittent relapsing colitis anterior uveitis, episcleritis, conjunctivitis and
Chronic persistent colitis acute fatty liver. Extraintestinal manifestations
Asymptomatic disease unrelated to disease activity include sacroiliitis,
Assessment of disease severity depends ankylosing spondylitis, primary sclerosing
on measurement stool frequency and cholangitis, cholangiocarcinoma, chronic
observation of the systemic response. active hepatitis, amyloid and nephrolithiasis.
Investigation Corticosteroids
In patients presenting with acute colitis, Corticosteroids are often used in those in
lower gastrointestinal endoscopy is the whom 5-ASA therapy is inadequate. They
investigation of choice. It confirms the are also used in those presenting with acute
presence of colitis, allows assessment of the severe disease. They can be given orally,
extent of disease and biopsies can be taken to topically or parenterally. Their use should
possibly differentiate ulcerative colitis from be limited to acute exacerbations of disease.
Crohns disease. Ulcerative colitis is usually They are of no proven value as maintenance
confluent, extending proximally from the therapy in either ulcerative colitis or Crohns
rectum. Crohns disease may be patchy with disease and their use must be balanced
skip lesions. Caution should be exercised against potential side effects.
in performing a colonoscopy in those with
Immunosuppressive agents
severe disease. The endoscopic grading of
ulcerative colitis is as follows: Immunosuppressive and immunomodulatory
agents are often used in those in whom
0 Normal
steroids can not be tapered or discontinued.
1 Loss of vascular pattern or granularity
Agents used include:
2Granular mucosa with contact bleeding
3Spontaneous bleeding Azathioprine
4Ulceration Methotrexate
Cyclosporin
In those with severe colitis, investigation
Infliximab
of the degree of systemic inflammation is
important. Useful markers are haemoglobin, Surgery for ulcerative colitis
white cell count, serum albumin and Approximately 20% of patients with ulcerative
C-reactive protein. A plain abdominal x-ray is colitis will require surgery at some time and
useful is there is suspected toxic megacolon 30% of those with total colitis will require
or perforation. a colectomy within 5 years. Surgery may
be required as an emergency. Emergency
Management indications include:
The management of inflammatory bowel
Toxic megacolon
disease depends on the type and site of
Perforation
disease and its severity. Different drugs may
Haemorrhage
be used for those with active disease and
Severe colitis failing to respond to medical
those in remission.
treatment
5-Aminosalicylic acid Elective indications include:
5-aminosalicylic acid (5-ASA) is used in Chronic symptoms despite medical therapy
mild to moderate ulcerative colitis and Carcinoma or high-grade dysplasia
Crohns disease. It blocks the production
In an emergency, often the only option
of prostaglandins and leukotrienes.
appropriate is a subtotal colectomy with
Sulfasalazine was the first agent described.
ileostomy and mucus fistula formation. For
Now compounds are available that release
elective surgery, the options include:
5-ASA at the site of disease activity.
Mesalazine is 5-ASA conjugated in such Panproctocolectomy and ileostomy
a way so as to prevent absorption in the Subtotal colectomy and ileorectal
small intestine. Topical preparations may anastomosis
be used in those with left-sided colonic Restorative proctocolectomy with ileal
disease. Maintenance therapy is of proven pouch formation.
benefit in those with ulcerative colitis but is A subtotal colectomy and ileorectal
of unproven benefit in those with Crohns anastomosis maintains continence but
disease. proctitis often persists within the rectal stump.
200 Chapter 14 Colorectal surgery
Triplicated S DuplicatedJ
a b
c d
202 Chapter 14 Colorectal surgery
associated with intersphinteric sepsis A low fistula can often simply be laid open
and consideration should be given to the with either a fistulotomy or fistulectomy. A
possibility inflammatory bowel disease or high fistula requires staged surgery, often
neoplasia as the underlying cause. with the placement of a seton. A seton is a
non-absorbable suture or surgical-grade
Management cord of material passed along the fistula
The initial surgery for anorectal sepsis should tract, out through the anus and tied loosely
simple and usually requires no more than to encourage drainage. The seton may be
incision and drainage of an acute abscess. An sequentially tightened to cut through tissue
inexperienced surgeon should avoid looking and allow healing of the tract. In some
for a fistula at the time of the initial surgery patients, an anorectal advancement flap may
as, in the presence of acute inflammation, this be considered to allow early wound healing.
may result in damage to the anal sphincter.
If there is clinical suspicion of an underlying Haemorrhoids
fistula, this can be further assessed by MRI Haemorrhoids are dilated veins in the lower
or a subsequent elective admission for an rectum and anal canal. They affect 50% of
examination under anaesthetic. About 80% the population over the age of 50 years. The
of recurrent abscesses are associated with a following factors appear to be important in
fistula. Deferred elective surgery has less risk their aetiology:
of damage to the sphincter. Dilatation of venous plexus
In those with an anorectal fistula, the Distension of arterio-venous anastomoses
puborectalis muscle is the key to future Displacement of the anal cushions
continence and damage to this and the About 80% of patients have high resting anal
other sphincter muscles should be avoided. pressures.
Curved tracts
Ex
ce
pt
Transverse line
ion
3 cm
Straight tracts
Perianal disease 203
Rectal prolapse
A complete rectal prolapse is a full thickness
Figure 14.7 A pilonidal sinus in the natal cleft prolapse of the rectum through the anus.
Perianal disease 205
It contains two layers of the rectal wall and diagnosis in an adult is haemorrhoids, a
has an intervening peritoneal sac. It usually prolapsing rectal tumour or anal polyp and
occurs in elderly adults. The female to male abnormal perineal descent.
ratio is approximately 6:1. It is invariably
associated with weak pelvic and anal Management
musculature. The sigmoid colon and rectum Many patients with a complete prolapse
are often floppy and redundant. are elderly and too frail for surgery. They
An incomplete rectal prolapse is limited should be given bulk laxatives and carers
to the rectal mucosa. It occurs in both taught how to reduce the prolapse. Urgent
children and adults and is often associated treatment is however required if the prolapse
with excessive straining, constipation and is irreducible or ischaemic. If the patient is fit
haemorrhoids. In children, it is associated for surgery, the operation can be performed
with cystic fibrosis. A concealed prolapse is via either a perineal or abdominal approach.
an internal intussusception of the upper into Abdominal procedures may be performed
the rectum. The prolapse does not emerge laparoscopically. Perineal options include:
through the anus. Perineal sutures (Thiersch procedure)
Delorme procedure
Clinical features Perineal rectopexy
Rectal prolapse occurs in the extremes of life.
Abdominal or sacral options include:
A rectal prolapse in a child is usually noted
by parents and need to be differentiated Abdominal rectopexy
from colonic intussusception and a Anterior resection rectopexy
juvenile rectal polyp. In adults, it usually In children, improvement of incomplete
presents with a prolapsing anal mass after rectal prolapse is often seen with dietary
defaecation. It may be reduce spontaneously advice and the treatment of constipation.
or manually. Bleeding, mucus discharge Surgery is rarely required. In adults,
or incontinence may be troublesome. the management is similar to that of
Examination usually shows poor anal tone haemorrhoids. This includes injection
and the prolapse may be visible on straining. sclerotherapy, mucosal banding or formal
Most prolapses that are longer than 5cm haemorrhoidectomy. Occasionally an anal
in length are complete. The differential sphincter repair is required.
Chapter 15 Breast disease
Deep
pectoral fascia
Fat lobule
2nd rib
Areola
Pectroralis
major
Nipple
Intercostal
Lactiferous muscles
sinus
Lactiferous duct
208 Chapter 15 Breast disease
and 10mL syringe. Gentle suction is applied disease, implying a pathological process.
whilst the needle is advanced and withdrawn Aberrations of normal development and
through the lesion. In the management of involution (ANDI) is now the preferred term
cysts, FNA will allow the cyst to be drained. used to describe most benign breast diseases
In the assessment of a solid lesion, FNA (Table 15.1). It is based on the fact that
allows tissue to be obtained for cytological most benign breast disorders are relatively
assessment. The material is washed from the minor aberrations of the normal processes
hub of the needle into an alcohol-containing of development, cyclical hormonal response
solution for fixation. The specimen is then and involution.
centrifuged, applied to a microscope slide
and stained. Breast pain
A core or Tru-cut needle biopsy is Breast pain or mastalgia is the commonest
obtained under local anaesthesia. A core reason for referral to a breast clinic and
of tissue is removed from the lesion and accounts for 50% of all referrals. Only 7% of
fixed in formalin. It is be submitted for patients with breast cancer report breast pain.
histopathological assessment. A core biopsy Assessment may be helped by the keeping of
allows more information to be obtained a breast pain chart. The pain can be divided
about the lesion then with FNA but the risks into cyclical and non-cyclical mastalgia.
associated with the procedure are higher.
The procedure can result in quite extensive Cyclical mastalgia
bruising. Rare complications include a Cyclical mastalgia is usually bilateral, affects
pneumothorax. the upper outer quadrant, is mostly minor and
accepted by many women as part of normal
Benign breast disease life. The average age of onset is about 24 years.
Benign breast conditions are practically a No consistent hormonal abnormality has been
universal phenomenon. Previously there identified. Prolactin levels may be increased.
was a tendency to include all benign breast Essential fatty acid profiles may be abnormal.
disorders under the designation of fibrocystic No evidence of psychopathology has been
demonstrated. In those with no palpable mass
repeatedly or there is a residual lump after recurrent breast sepsis. Repeated aspiration
aspiration. is the treatment of choice. Formal incision
and drainage through small incision should
Breast infections be considered if an abscess does not resolve
Lactational breast abscess with conservative management. Definitive
treatment may be necessary when sepsis
Lactational breast sepsis is usually due
is quiescent with appropriate antibiotic
to Staphylococcus aureus infection. Any
prophylaxis. This usually involves a major
resulting abscess is usually peripherally
duct excision. Spontaneous discharge or
situated. Surgery may be pre-empted
surgical excision can result in a mammary
by early diagnosis. If the diagnosis is
duct fistula.
suspected then there should be an attempt
at aspiration, ideally under ultrasound Nipple discharge
guidance. Repeated aspiration may be
A nipple discharge is the efflux of fluid from
required and formal incision and drainage
the nipple and accounts for about 5% of
can often be avoided. Appropriate
referrals to a breast clinic. A discharge can be
antibiotics should be given. Patients should
elicited in approximately 20% of all women
be advised to express milk from the affected
by squeezing the nipple and this can often be
side and to continue breast feeding from the
regarded as physiological especially during
opposite breast. There is no need to suppress
the neonatal period, pregnancy, lactation and
lactation.
following mechanical stimulation. It can also
Non-lactational breast abscess represent duct pathology such as:
Non-lactational breast sepsis often occurs in Duct ectasia
the periareolar tissue (Figure 15.2). Bacterial Duct papilloma
culture often yields Bacteroides, anaerobic Breast cancer
streptococci or enterococci. It is usually a
manifestation of duct ectasia or periductal Description of nipple discharge
mastitis. It most commonly occurs in women A nipple discharge can be described as:
between 30 and 60 years. It is more common Unilateral or bilateral
in smokers who often give a history of Single or multiple ducts
Causes of galactorrhoea
Causes Examples
axillary surgery in breast cancer is to eradicate Axillary clearance possibly gains better
local disease and to determine prognosis to local control
guide adjuvant therapy. Clinical evaluation Avoids complications of axillary
of the axilla is unreliable. Axillary ultrasound radiotherapy
and fine needle aspiration or core biopsy may Avoids morbidity of axillary recurrence
provide preoperative staging information and The arguments for axillary sampling include:
may allow a tailored approach to the axilla.
Avoids morbidity of axillary node
Surgical evaluation of the axilla is important
clearance
and should be considered for all patients with
Axillary sampling only stages the axilla
invasive cancer.
Must be followed by axillary in those with
The axilla can be staged by: lymph node involvement
Axillary node clearance Avoids unnecessary surgery in 60% of
Axillary four node sample patients with node negative disease
Sentinel lymph node biopsy The combination of axillary clearance and
The levels of axillary clearance are assessed radiotherapy is avoided
in relation to the pectoralis minor muscle as Reduces the risk of lymphoedema
follows: Sentinel lymph node biopsy is now regarded
Level 1 Below pectoralis minor as the optimal method of staging in those
Level 2 Up to the upper border of with a clinically and radiologically negative
pectoralis minor axilla. It aims to accurately stage the axilla
Level 3 To the outer border of the 1st rib without the morbidity of axillary clearance.
The technique is used to identify the first
The arguments for axillary clearance include:
nodes that tumour drains to by mapping the
Axillary clearance both stages and treats axilla following the injection of either:
the axilla
Radioisotope
Axillary sampling potentially misses nodes
Blue dye
and under stages the axilla
Combination of isotope and blue dye
216 Chapter 15 Breast disease
The technique allows more detailed examina- variables in the form of an index allows
tion of nodes removed. The significance of identification of patients with different
micrometastatic deposits identified in sentinel prognoses. The Nottingham Prognostic Index
nodes is unclear. Histological assessment of (NPI) incorporates the three factors of tumour
the nodes removed can now be performed size, nodal status and histological grade
intraoperatively, allowing those with nodal (Table 15.4). The Nottingham prognostic
disease to proceed on to an axillary clearance index (NPI)=0.2size (cm)+Node
under the same anaesthetic. stage+Tumour grade.
Number of nodes involved Lymph node score (L) Tumour grade (G)
0 1 1
13 2 2
>3 3 3
women. High-dose chemotherapy with stem migration. The HER2 gene is over amplified
cell rescue produces no overall survival in 20% of breast cancers. HER2 positivity
benefit. is an independent poor prognostic factor.
Trastuzumab (herceptin) is a monoclonal
Endocrine therapy antibody that binds selectively to the HER2
Tamoxifen receptor. It has been shown to improve
Tamoxifen is an oral anti-oestrogen. It is an survival in both the adjuvant and metastatic
oestrogen receptor antagonist. It is effective setting. It only works in patients with HER2
in both the adjuvant setting and in advanced positive cancers. Response to therapy can
disease. It is only effective in those with be predicted by immunocytochemistry and
oestrogen receptor positive disease. Little fluorescent in situ hybridisation (FISH)
benefit is seen in oestrogen receptor negative testing. The major side effects are cardiac and
tumours. In the adjuvant setting, it has been its use is associated with cardiac dysfunction
shown that 5 years of treatment is better than in 5% cases.
2 years. The value of treatment beyond 5 years
Locally advanced breast cancer
is unknown. The risk of contralateral breast
Locally advanced breast cancers can be
cancer is reduced by 40%. Benefit is seen in
regarded as tumours that are not surgically
both pre- and post-menopausal women.
resectable (Figure 15.5). Clinical features of
Aromatase inhibitors locally advanced tumours include:
Several new endocrine therapies are Skin ulceration
available. The aromatase inhibitors reduce Dermal infiltration
the peripheral conversion of androgens to Erythema over the tumour
oestrogens. They are only effective in post- Satellite nodules
menopausal women and may be superior to Peau dorange
tamoxifen in high-risk women. To date, they Fixation to chest wall, serratus anterior or
have not been shown to have survival benefit intercostal muscles
compared with tamoxifen. Fixed axillary nodes
If locally advanced tumours are oestrogen
Biological therapy receptor-positive, they can usually treated
The human epidermal growth factor receptors with primary hormonal therapy. If oestrogen
are proteins embedded in the cell membrane. receptor-negative, chemotherapy may be
They regulate cell growth, adhesion and useful. Radiotherapy may be useful in the
Foramen
Body of caecum
tongue
Epiglottis
Hyoid
bone
Position of
thyroglossal Thyroid
cysts cartilage
Cricoid
cartilage Thyroid
gland
follicles are made of a single layer of thyroid lower serum calcium. It acts on skeletal tissue
epithelial cells. These secrete thyroxin (both and bone. It inhibits osteoclast activity and
T3 and T4). Inside the follicles is a colloid bone resorption. It stimulates osteoblast
which is rich in a thyroglobulin. It serves as activity. It inhibits release of ionic calcium
a reservoir of materials for thyroid hormone from bone.
production. The spaces between the thyroid
follicles contain other type of thyroid cells
Parathyroid anatomy
parafollicular cells C cells. These secrete and physiology
calcitonin. Parathyroid embryology
Thyroid physiology The parathyroid glands are derived from the
pharyngeal pouches (Figure 16.2). The 3rd
The gland is composed of follicles lined by
pharyngeal pouch gives rise to the inferior
cuboidal epithelium, which produce T3 and
parathyroid glands. The 4th pharyngeal pouch
T4. Within the follicles T3 and T4 is stored
gives rise to the superior parathyroid glands.
bound to thyroglobulin. When and as needed,
Abnormalities of position and number of the
they are secreted. In the circulation T3 and T4
parathyroid glands are common. About 5%
are bound to albumin, thyroxine binding pre-
of the population have less than four glands
albumin and thyroxine binding globulin. Only
and 25% have supernumerary glands often in
about 1% of the hormones remain unbound.
aberrant positions.
Unbound hormones are physiologically active.
T3 is quick acting (hours) and T4 is slow acting Parathyroid anatomy
(days). rT3 (reverse T3) is T3 produced in the
There are four small (2040mg) parathyroid
peripheries from conversion of T4.
glands found near the posterior aspect of
Thyroid hormones promote carbohydrate, the thyroid gland. They have a distinct,
protein and lipid metabolism. They act on encapsulated, smooth surface that differs
most cells of the body except the brain. They from the thyroid gland. They are typically
increase basal metabolic rate and oxygen light brown in colour, which relates to their fat
consumption. They regulate tissue growth content and vascularity.
and development.
The superior parathyroid glands are
Calcitonin is produced by the located close to the superior pole of the
parafollicular C cells. Its main action is to thyroid gland near the cricothyroid cartilage.
Applied basic sciences 223
Maxillary process
Ultimobranchial body
Figure 16.2 Embryology of the parathyroid glands. Numbered structures are the pharyngeal pouches and
sinuses.
They are most commonly found 1cm above The anterior lobe of the pituitary is
the intersection of the inferior thyroid artery formed in the embryo from Rathkes pouch
and the recurrent laryngeal nerve. The and consists of the pars anterior and pars
inferior parathyroid glands are more variable intermedia. Its blood supply reaches the lobe
in location and are most commonly found via the infundibulum and transports hormones
near the lower pole of the thyroid. from the hypothalamus. Cells are classified as
chromophils or chromophobes. Chromophils
Parathyroid physiology are either basophilic or eosinophilic. The
Parathyroid hormone is an 84 amino acid posterior lobe is a downgrowth of the floor
protein. It has half life measured in minutes. of the 3rd ventricle. Nerve fibres extend from
It acts on cell membrane receptors to increase hypothalamus to the posterior pituitary.
intracellular cAMP. In bone, it increases
The gland is overhung by the anterior and
turnover and calcium release. In the kidney
posterior clinoid processes, dorsum sellae
it increases the production of 1,25 dihydroxy-
and diaphragma sellae. The infundibulum
vitamin D3. In the gut it increases calcium
passes posterior to optic chiasma. Superior to
absorption.
optic chiasma is the anterior communicating
Pituitary anatomy artery. A cavernous sinus lies on each side of
the gland. In the lateral wall of each cavernous
and physiology sinus lies the III, IV, ophthalmic branch of V, VI
Anatomy of the pituitary gland cranial nerves and the internal carotid arteries.
The pituitary gland is situated below the Symptoms of pituitary tumours occur due
3rd ventricle. It lies in the pituitary fossa of to endocrine effects and pressure on adjacent
the sella turcica of the sphenoid bone. It is structures. Visual changes include:
covered by a fold of dura mater known as Bitemporal hemianopia
the diaphragma sellae. It is connected to the III nerve palsy
brain by the infundibulum and is divided into Palsies of IV and VI nerves are rare
anterior and posterior lobes. Proptosis
224 Chapter 16 Endocrine surgery
Graves disease
A thyroglossal cyst
Toxic nodular goitre
Toxic solitary nodule
Thyroiditis
Clinical features
The clinical features of thyrotoxicosis are
numerous and include:
Palpitations, tachycardia, cardiac
arrhythmias, cardiac failure
Sweating and tremor
Hyperkinetic movements
Nervousness
Myopathy
Tiredness and lethargy
Weight loss
Heat intolerance
Diarrhoea and vomiting
Irritability
Emotional disturbance
Behavioural abnormalities
Ophthalmic signs
Irregular menstruation and amenorrhoea
Pretibial myxoedema
Thyroid acropachy
Vitiligo
Alopecia
Figure 16.3 A thyroglossal cyst
Pretibial myxoedema occurs in 12% of
patients with Graves disease. It presents with
painless thickening of the skin in nodules
can be found as far lateral as the lateral tip
or plaques. They usually occurs on the shins
of hyoid bone. As they are attached to the
or dorsum of foot. The presence of pretibial
foramen caecum, they move up on protruding
myxoedema is strongly associated with
the tongue. They often present as an infected
ophthalmopathy. Thyroid acropachy occurs
cyst due lymphoid tissue in the cyst wall.
in less than 1% of patients with thyrotoxicosis.
A fistula may occur following rupture or
It closely resembles finger clubbing. Almost
drainage of an infected thyroglossal cyst.
all patients also have ophthalmopathy or
Treatment pretibial myxoedema.
A Sistrunk operation is the surgery of choice.
Graves disease
A transverse skin crease incision is made.
Graves disease usually occurs in
Platysma flaps are raised and the cyst
women between 20 and 40 years. It is an
dissected. The middle third of the hyoid bone
immunological disorder due to production
and any suprahyoid tract extending into the
of thyroid stimulating IgG antibodies. These
tongue is dissected and excised.
bind to TSH receptors stimulating thyroid
Thyrotoxicosis hormone production. It produces a diffuse
goitre. Clinically, patients have features of
Thyrotoxicosis is due to over production of
thyrotoxicosis often with eye signs including:
thyroxine. It affects 2% women and 0.2% of
men. The commonest causes of thyrotoxicosis Exophthalmos and proptosis usually
are: bilateral
226 Chapter 16 Endocrine surgery
Diplopia due to weakness of the external for 4 months after treatment. The advantage
ocular muscles of radio-iodine treatment is that surgery or
Chemosis and corneal ulceration prolonged drug therapy are avoided. The
disadvantages are that 80% of patients will be
Investigation hypothyroid at 10 years and long-term follow-
The diagnosis of thyrotoxicosis can be up is required.
confirmed by measurement of TSH level.
A normal TSH excludes the diagnosis of Surgery
thyrotoxicosis (except in rare case of TSH Surgery is indicated in patients with Graves
secreting pituitary tumours). The serum free disease if there is relapse after an adequate
T4 is normally increased. The serum total T4 course of anti-thyroid drugs, a large goitre
can be variable due to changes in thyroid or high T4 levels at diagnosis. Subtotal
binding globulin. Occasionally free T3 is thyroidectomy is the treatment of choice. It
increased in isolation in T3-toxicosis. preserves about 4g (10%) of thyroid tissue.
Patients must be euthyroid prior to operation.
Management The advantages of surgery are that the goitre
In patients with severe thyrotoxicosis, rapid is removed and the cure rate is high. The
symptomatic relief can be achieved with disadvantages are that 5% develop recurrent
b-blockers. Thyroid function can be reduced thyrotoxicosis, 20% develop postoperative
by anti-thyroid drugs, radioactive iodine or hypothyroidism and 0.5% develop
surgery. parathyroid insufficiency.
in children are cancers and 70% will have risk of malignancy. Evidence of fixation or
cervical and 15% pulmonary metastases on nodal involvement suggests malignancy. Most
presentation. However, childhood tumours patients will be clinically and biochemically
have good prognosis with greater than 80% euthyroid. Obstructive signs include stridor,
10-year survival. tracheal deviation, neck vein engorgement.
Overall, If all nodules were removed Hoarseness and vocal cord paralysis suggests
less than 10% would prove to be malignant. a recurrent laryngeal nerve palsy.
Thyroid surgery is not without complications. Investigation
There is a need for a selective surgical
Investigation of a solitary thyroid nodule
excision policy for thyroid nodules.
should include:
Conservative management is appropriate if
malignancy can be reasonably excluded. Biochemical assessment of thyroid
functional status
Clinical features Ultrasound
Rapid painless growth suggests malignancy. Isotope scanning
Sudden painful growth suggests haemorrhage Fine needle aspiration cytology
into a degenerating colloid nodule. Family
history is important. About 20% medullary Biochemical assessment
carcinomas are familial and associated The thyroid functional status should be
with multiple endocrine neoplasia (MEN) assessed by measurement of free T4 and TSH.
2 syndrome. A history of radiation exposure Anti-thyroglobulin and anti-microsomal
should also be sought. In 1940s to 1960s antibodies should also be measured. If there
large numbers of children were exposed in is a family history suggestive of medullary
the USA to low dose irradiation. It was used carcinoma then serum calcitonin should also
in the treatment of many benign conditions be measured. If there is suspicion of MEN2
including tonsillar hypertrophy, acne, thymic syndrome, the patient will need 24-hour
enlargement. Radiation exposure increases urinary catecholamine estimation to exclude
the incidence of thyroid malignancy usually a phaeochromocytoma prior to surgery.
papillary tumours.
Ultrasound
Examination needs to assess whether the An ultrasound scan will define whether a
lesion is a true solitary nodule or a dominant lesion is a solitary or dominant nodule. It
nodule within goitre. True solitary nodules will also distinguish between solid and cystic
have 10% risk of malignancy. Dominant lesions. Most sonographically solid lesions
nodules in a multinodular goitre have a 25% are benign and cancers can occur in the
wall of a cystic lesion. There are no reliable When on clinical grounds the index of
sonographic criteria to distinguish benign suspicion of malignancy is high even if the
and malignant lesions. Features that might cytology report suggests it is benign
suggest malignancy include: A definitive FNAC allows:
Hypoechogenicity Non-operative treatment of benign disease
Microcalcification Appropriate surgical treatment of thyroid
Irregular margins cancers at the initial operation
Increased blood flow on Doppler Surgery to be avoided in anaplastic
Regional lymphadenopathy tumours and lymphomas
Isotope scanning A reduction in the total number of thyroid
131I , 123I or 99Tch scanning provides a lobectomies
Increased yield of thyroid cancers
functional assessment of the thyroid. Nodules
can be classified as cold, warm or hot. Isotope Thyroid neoplasms
scanning is unable to differentiate benign
Thyroid tumours can be classified as either
and malignant nodules. Most solitary thyroid
benign of malignant (Table 16.2). The
nodules are cold. Most cancers arise in cold
commonest malignant tumours are papillary
nodules. The risk of cancer in a cold nodule
and follicular carcinomas.
is about 10%. The risk of tumour in a hot
nodule is negligible. As a result, scintigraphy Benign thyroid tumours
is of minimal use in the evaluation of solitary
Most benign thyroid tumours are follicular
thyroid nodules. It is of increased use in the
adenomas. Papillary adenomas are rare.
assessment of recurrent thyroid swellings and
All papillary tumours should be considered
retrosternal goitres.
malignant.
Fine needle aspiration cytology
Fine needle aspiration cytology (FNAC)
Follicular adenoma
should be one of the first-line investigations Of all follicular lesions, 80% are benign and
of a solitary thyroid nodule. With an 20% are malignant. They are encapsulated,
experienced cytologist, the diagnostic smooth and discrete lesions with a glandular
accuracy can be more than 95%. The accuracy or acinar pattern. Follicular adenomas
is improved if the sample is performed can not be differentiated from carcinoma
under ultrasound guidance. Possible on FNAC alone. The diagnosis requires
cytopathological diagnoses are: histological assessment to exclude capsular
invasion.
Benign
Malignant Toxic adenoma
Indeterminate Toxic adenomas account for 5% of all
Inadequate cases of thyrotoxicosis. The female to
FNAC can distinguish benign and malignant male ratio is approximately 9:1. Clinical
tumours, except for follicular neoplasms. The presentation is with a thyroid nodule (50%)
diagnosis of follicular carcinoma depends or thyrotoxicosis (40%). Thyrotoxicosis is not
on visualisation of capsular involvement. usually associated with the eye signs seen
If a follicular neoplasm is found on FNAC, in Graves disease. Scintigraphy shows a hot
the lesion will require surgical excision. nodule with suppression of normal thyroid
Indications for surgery after FNA cytology are: uptake. Treatment is by thyroid lobectomy.
All proven malignant nodules Postoperative management requires thyroxine
All cytologically diagnosed follicular until the suppressed gland returns to normal.
neoplasms
All lesions exhibiting an atypical but non- Malignant thyroid tumours
diagnostic cellular pattern Differentiated thyroid cancer accounts for
Cystic nodules which recur after aspiration 80% of thyroid neoplasms. The female to
Thyroid and parathyroid disease 229
male ratio is approximately 4:1. Malignant lobectomy with frozen section. If the frozen
thyroid tumours usually present with a section confirms a carcinoma then total
solitary thyroid nodule in a young or middle thyroidectomy should be performed. If
age adult. Papillary and follicular tumours are frozen section confirms an adenoma, no
biologically very different (Table 16.3). further surgery is required. All patients
require suppressive thyroxine therapy. Total
Papillary tumours thyroidectomy allows detection of metastases
Most papillary tumours are less than 2cm using 123I scanning during follow-up.
diameter at presentation. Tumours less than
1cm diameter should regarded as minimal Anaplastic carcinoma
or micropapillary lesions. Approximately 50% Anaplastic carcinoma accounts for less than
of papillary tumours are multicentric with a 5% of all thyroid malignancies. They occur
simultaneous tumour in the contralateral lobe. in the elderly and are usually an aggressive
Psammoma bodies and orphan Annie nuclei tumour. Local infiltration causes dyspnoea,
are characteristic histological features. Early hoarseness and dysphagia. Incision biopsy
spread occurs to the regional lymph nodes. should be avoided as it often causes
A lateral aberrant thyroid almost always uncontrollable local spread. Thyroidectomy
represents metastatic papillary carcinoma. is seldom feasible. Radiotherapy and
Thyroid lobectomy is adequate for minimal chemotherapy are important modes of
lesions. Total thyroidectomy is otherwise treatment. Death often occurs within 6
the surgery of choice. Many tumours are months.
TSH dependent and TSH suppression with
postoperative thyroxine is appropriate. The Thyroid lymphoma
role of prophylactic lymph node dissection at Thyroid lymphoma accounts for 2% of all
time of initial surgery is unclear. Lymph node thyroid malignancies. It often arises in a
dissection does not improve survival. If nodal thyroid gland with Hashimotos thyroiditis.
metastases are present, then a modified neck It presents as a goitre in association with
dissection is required. generalised lymphoma. Diagnosis can often
be made by FNAC. Radiotherapy is the
Follicular tumours treatment of choice. Prognosis is good, often
Follicular adenoma and carcinoma can not with more than 85% 5-year survival.
be differentiated on FNAC alone. Treatment
of all follicular neoplasms is by thyroid Medullary carcinoma
Medullary carcinoma accounts for 8% of all
thyroid malignancies. They arises from the
Classification of thyroid tumours
Benign Malignant
Comparison of papillary and
follicular tumours
Follicular adenoma Papillary carcinoma
Teratoma Follicular carcinoma Papillary Follicular
Mixed papillary
follicular carcinoma Multifocal Solitary
para-follicular C-cells. About 20% of cases are Recurrent laryngeal nerve palsy
familial with autosomal dominant inheritance Hypocalcaemia
with almost complete penetrance. It can also Pneumothorax
occur as part of the MEN IIa and MEN IIb Air embolism
syndromes. Genetically determined cases are Recurrent hyperthyroidism
often bilateral and multifocal. At risk patients Hypothyroidism
can be identified by looking for a missense
mutation in the RET proto-oncogene and can Recurrent laryngeal nerve palsy
be offered prophylactic thyroidectomy. About The recurrent laryngeal nerve is a branch
80% of cases are sporadic. Sporadic cases of the vagus nerve that supplies motor
are usually unilateral. Tumours metastasise function and sensation to the larynx. The left
to the regional nodes and also via blood to recurrent laryngeal nerve loops under the
bone, liver and lung. About 50% of cases arch of the aorta, posterior to the ligamentum
have lymph node metastases at presentation. arteriosum before ascending. The right
Tumours produce calcitonin, calcitonin recurrent laryngeal loops around the right
gene-related peptide and carcinoembryonic subclavian artery. The nerves supply all the
antigen. Serum calcitonin estimation can be laryngeal muscles except for the cricothyroid,
used in follow-up to look for the presence of which is innervated by the external branch of
metastatic disease. Total thyroidectomy is the the superior laryngeal nerve. The recurrent
treatment of choice. laryngeal nerve can easily be damaged during
thyroid surgery. If the damage is unilateral,
Management the patient may present with voice changes
The role of either total thyroidectomy including hoarseness. Bilateral nerve
or lobectomy in the management of damage can result in stridor and aphonia.
differentiated thyroid is controversial. It is essential to document the movement
Arguments for total thyroidectomy include: of the vocal cords by indirect or fibreoptic
laryngoscopy prior to thyroid surgery as
Multifocal disease occurs in the opposite
some patients have asymptomatic recurrent
lobe in 50% cases
laryngeal nerve palsies.
Total thyroidectomy reduces the risk of
local recurrence Follow-up of thyroid carcinoma
Ablation with radioiodine is facilitated
Annual 123I scanning should be considered
Serum thyroglobulin can be used as
in order to detect asymptomatic recurrence.
a tumour marker for progression or
Treatment of such recurrence can still be
recurrence
curative. The patient needs to be off T4 for at
In experienced hands, the morbidity of
least 1 month with conversion to T3. Serum
total thyroidectomy is low
thyroglobulin is also important in follow-
Arguments for thyroid lobectomy alone up. Increasing levels are often the first sign
include: of recurrence and may allow detection of
Many patients do not require radioiodine recurrence without the inconvenience of
Progression to undifferentiated carcinoma scintigraphy.
is rare
The significance of micro-foci in the Thyroiditis
contralateral lobe is uncertain de Quervains thyroiditis
No evidence that more extensive surgery is
de Quervains thyroiditis is also known as
associated with a better prognosis
granulomatous or subacute thyroiditis. It is
The higher incidence of
believed to be due to a viral infection. It often
hypoparathyroidism after total
follows an upper respiratory tract infection. It
thyroidectomy
presents with a painful swelling of one or both
Complications of thyroidectomy include: thyroid lobes, usually associated with malaise
Haemorrhage and fever. Patients often have clinical features
Respiratory obstruction of mild hyperthyroidism and the free T4 and
Thyroid and parathyroid disease 231
ESR is usually raised. It is usually a self- years of age. Most patients are asymptomatic
limiting illness with spontaneous recovery. and most cases are identified when
Long-term, a few patients develop mild hypercalcaemia is detected on testing for
hypothyroidism. Symptomatic improvement other conditions. Causes of hypercalcaemia
can occur with the use of anti-inflammatory include:
drugs. Steroids may speed resolution in those Primary hyperparathyroidism
with severe symptoms. Malignancy
Granulomatous disease sarcoidosis,
Hashimotos thyroiditis tuberculosis
Hashimotos thyroiditis is also known as Drugs thiazide diuretics, vitamin D
lymphomatous thyroiditis and is due to an toxicity, lithium, milk alkali syndrome
autoimmune disease. It produces diffuse Familial hypercalciuric hypercalcaemia
swelling of the thyroid gland. Histologically, Endocrine thyrotoxicosis, adrenal crisis
the thyroid is infiltrated with lymphocytes Immobilisation
and plasma cells. It may progress to Renal failure
secondary lymphoid nodule formation and Aluminium intoxication
stromal fibrosis. Serum anti-thyroglobulin
Hyperparathyroidism can be
and anti-microsomal antibodies are raised.
primary, secondary or tertiary. Primary
Patients eventually become hypothyroid.
hyperparathyroidism is due to overproduction
Thyroxine replacement therapy suppresses
of parathyroid hormone by the parathyroid
TSH and reduces the size of the gland.
glands. Primary hyperparathyroidism can be
Surgery is rarely required. Long-term the risk
due to:
of thyroid lymphoma is increased.
Parathyroid adenoma (85%)
Riedels thyroiditis Parathyroid hyperplasia (15%)
Riedels thyroiditis is also known as acute Parathyroid carcinoma (<1%)
fibrous thyroiditis. It is a rare but important Secondary hyperparathyroidism is a reactive
disease as it often clinically mimics increase in parathyroid hormone production
malignancy. Histologically there is a diffuse to compensate for a disturbance in calcium
inflammatory infiltrate throughout the homeostasis. Tertiary hyperparathyroidism
thyroid gland which may extend beyond the is a condition in which reactive parathyroid
capsule into adjacent structures. Clinically hyperplasia results in parathyroid hormone
it is associated with sclerosing cholangitis, hypersecretion despite correction of
retroperitoneal and mediastinal fibrosis. the underlying aberration of calcium
Surgery is rarely required but division of the homeostasis.
isthmus may be necessary to decompress the
trachea. Clinical features
The clinical features of hyperparathyroidism
Acute suppurative thyroiditis include:
Acute suppurative thyroiditis is due to a General polydipsia, weight loss
bacterial or fungal infection. It produces an Renal colic, haematuria, back pain,
acutely inflamed thyroid gland. The diagnosis polyuria
is confirmed by fine-needle aspiration Cardiovascular hypertension, heart
cytology. Treatment is by parenteral block
antibiotics. Musculoskeletal non-specific aches
and pains, bone pain, pathological
Parathyroid disease fractures
Hyperparathyroidism Gastrointestinal anorexia, nausea,
Hyperparathyroidism is a common disorder dyspepsia, constipation
affecting approximately 1 in 1000 of the Neurological depression, lethargy,
population. It affects 1 in 500 women over 45 apathy, weakness, psychosis
232 Chapter 16 Endocrine surgery
Chronic effects include hypovolaemia and tumours are malignant, in others they are
cardiomyopathy. Phaeochromocytomas can benign. Benign or malignant tumours of non-
be associated with: endocrine tissues also occur as components
Multiple endocrine neoplasia syndrome of some of these syndromes.
(Type 2)
Neurofibromatosis
MEN 1 syndrome
Von Hippel Lindau syndrome (Wermers syndrome)
Hyperparathyroidism (90%)
Investigation Pancreatic islet cell tumours (60%)
To confirm the diagnosis of a Gastrinoma (60%)
phaeochromocytoma, it is necessary to Insulinoma(10%)
demonstrate catecholamine excess by: Vipoma
24-hour urinary vanniyl mandelic acid Glucagonoma
(VMA) Pituitary tumours (5%)
24-hour urinary total catecholamines Prolactinoma
Serum adrenaline or noradrenaline GH, ACTH, TSH secreting tumours
Thyroid adenoma
Tumour can be localised with Adrenal adenoma
either abdominal CT, MRI or meta- Carcinoid tumours
iodobenzylguanidine (MIBG) scanning.
MEN 2a syndrome
Management (Sipples syndrome)
Usually, the clinical features of a Medullary thyroid carcinoma (100%)
phaeochromocytoma can not be controlled Phaeochromocytoma (50%)
pharmacologically. Adrenalectomy is Hyperparathyroidism (10%)
invariably necessary after appropriate
preoperative preparation. Surgery for MEN 2b syndrome
a phaeochromocytoma requires close Medullary thyroid carcinoma (100%)
cooperation between the surgeon Phaeochromocytoma (50%)
and anaesthetist. Preoperative Multiple mucosal neuromas (100%)
preparation requires a-blockade with Ganglioneuromatosis of the gut (100%)
phenoxybenzamine for at least 2 weeks. Marfanoid appearance (100%)
b-blockade after a-blockade may be
required. b-blockade without a-blockade The MEN 1 gene
can cause a hypertensive crisis. Preoperative MEN1 syndrome follows Knudsons
hypovolaemia should be corrected. two-hit model for tumour suppressor
Potential intraoperative problems include gene carcinogenesis. The first hit is a
hypertension associated with handling heterozygous MEN1 germ line mutation,
of the tumour and hypotension following inherited from one parent. The second hit
devascularisation of the tumour. Tight is a MEN1 somatic mutation that occurs in
intraoperative blood pressure control is predisposed endocrine cells. MEN1 gene
necessary and can be achieved with fluids, mutations can be identified in 7095% of
nitroprusside and dopamine infusions. MEN1 patients. The same mutations are
also seen in about 20% of familial isolated
Multiple endocrine hyperparathyroidism cases. Almost all
neoplasia syndromes patients are heterozygous for mutations.
The term multiple endocrine neoplasia About 50% of patients develop signs and
(MEN) encompasses several distinct symptoms by 20 years of age. More than
syndromes. Each syndrome features tumours 95% or patients have symptoms by 40 years
of endocrine glands, each with its own of age. About one-third of patients affected
characteristic pattern. In some cases, the with MEN1 will die early from an MEN1-
Pituitary and adrenal disease 237
Renal artery stenosis Primary aldosteronism Oral contraceptives Coarctation of the aorta
Glomerulonephritis Cushings syndrome Corticosteroids Pre-eclampsia
Pyelonephritis Phaeochromocytoma Sympathomimetics Raised intracranial
pressure
Interstitial nephritis
Obstructive nephropathy
Polycystic disease
can occur within or outside the vascular Embolism to the lungs (pulmonary arteries)
system in life or post mortem. Thrombus originates in the deep veins. Embolism to
consists of fibrin, platelets and entrapped organs and the limbs originates in the heart or
red blood cells. Contact with damaged large arteries. An embolus can be made up of:
endothelium or atheromatous plaque Thrombus
contents triggers the coagulation cascade. It Atheromatous plaque
converts fibrinogen monomer to the fibrin Infected thrombus
polymer. On contact with fibrin or collagen, Endocardial or valve vegetations
platelets release granules which promote Fat
aggregation of adjacent platelets. It forms Gas
a mass which covers an endothelial defect. Amniotic fluid
Factors which promote thrombosis include: Tumour
Vessel wall changes Foreign material
Changes in blood constituents
Changes in blood flow Ischaemia and infarction
These are known as the Virchow Triad. Ischaemia occurs when an organ or tissue
Thrombi can occlude a vessel which may has perfusion lower than its metabolic needs.
result in infarction. Released fragments of Infarction occurs when tissue necrosis results
thrombus can travel in the bloodstream from ischaemia. Both can occur as a result of
to occlude distal vessels. Thrombosis arterial, venous or capillary disease. Arterial
can be cleared by the fibrinolytic system. ischaemia can occur as a result of:
Plasminogen activator released from Atheromatous narrowing
endothelial cells converts plasminogen to Thrombosis
plasmin which dissolves fibrin. Thrombus can Embolism
also undergo recanalisation. Endothelial cells Low flow states
grow out from the vessel wall and create new Vasculitis
channels through the thrombus. Hypertensive vascular disease
Spasm
Embolism The outcome of ischaemia depends on the:
An embolus is a mass of material in the blood
Adequacy of cardiac function
which can lodge in a vessel and block its lumen.
Arterial disease 243
Doppler probe can be used to assess the Toe pressure can provide an accurate
arterial system. It can be used to measure assessment of the distal arterial circulation.
arterial pressures. Measurements can be They are not influenced by calcification in
made at both rest and after exercise. pedal vessels, particularly seen in diabetics.
In a normal individual, the lower limb Normal toe pressures are 90100mmHg. Toe
arterial pressures are greater than upper pressures less than 30mmHg suggests critical
limb pressures. The AnkleBrachial Pressure limb ischaemia.
Index (ABPI) is the ratio of best foot systolic Duplex ultrasound
pressure to the brachial systolic pressure
Duplex ultrasound is a combination of pulsed
and can be used to assess the severity of
Doppler and real time B-mode ultrasound. It
peripheral vascular disease (Figure 17.3). The
allows imaging of vessels and any associated
ratio falls with increasing disease severity. In
stenotic lesion. Both arterial blood flow and
a normal individual, the ABPI is great than
pressure wave form can be simultaneously
one. In patients with claudication, the ratio is
assessed. In normal individuals, a triphasic
usually 0.4 to 0.7. In patients with critical limb
wave is obtained with rapid antegrade flow
ischaemia it is usually 0.1 to 0.4. In normal
during systole, transient reverse flow in
individuals, pressures do not fall flowing
early diastole and slow antegrade flow in
exercise. In claudicants, the ABPI falls following
late diastole. An arterial stenosis results in a
exercise and recovery is delayed. In the diabetic
reduced rate of rise of the antegrade flow, a
lower limb, pressures can be falsely elevated
decreased amplitude of the forward velocity
due to calcification in the vessel wall.
and loss of reverse flow. This is known as
1.0
Anke-brachial pressure index
0.5
0.0
Normal Intermittent Critical Gangrene
claudication ischaemia
Arterial disease 245
a biphasic wave form. At the site of the of the agent through the arteries. Time-of-
stenosis, velocity is increased. Severe stenosis flight methods use a short echo time and flow
results in a monophasic wave form compensation to make flowing blood much
(Figure 17.4). Duplex ultrasound has brighter than stationary tissue. This technique
sensitivity and specificity of 80% and 90%, avoids the use of contrast.
respectively for the detection of stenotic
lesions in the femoral and popliteal arteries. Invasive vascular assessment
Angiography
Pulse-generated run-off Angiography is usually performed using
Proximal occlusion of an artery often causes digital subtraction techniques. A catheter
poor filling of crural vessels. One of the most is inserted in an accessible artery using a
important prerequisites prior to femoro-distal Seldinger technique. The femoral artery
bypass is the identification of patent distal is commonest site of vascular access. It is
vessels. Rapid cycling of a proximal cuff, generally a safe procedure performed under
termed pulse generated run-off, artificially local anaesthetic. Potential complications
generates arterial pulse waves allowing are either technique or contrast related and
functional testing of distal arterial patency. include:
Time
Retrograde
flow
Figure 17.4 Doppler wave forms from normal and diseased arteries
246 Chapter 17 Vascular disease
However spiral CT and reconstruction can the ABPI will allow assessment of the
provide detailed images and is particularly severity of peripheral vascular disease.
useful for the assessment of aneurysmal Investigation should also be aimed at
disease. identifying risk factors such as diabetes and
hypercholesterolaemia.
Peripheral vascular disease
Intermittent claudication Management
The management of claudication is usually
About 5% of males over the age of 50 years
conservative, at least initially. Risk factor
have intermittent claudication. About 5% of
reduction is important and should involve
claudicants progress to critical ischaemia
stopping smoking, controlling hypertension,
each year. However, with appropriate
the use of lipid-lowering drugs, anti-platelet
management, more than 75% of patients with
medication and good diabetic control, if
intermittent claudication remain stable or
appropriate. Patients should lose weight
even show clinical improvement. Peripheral
and undertake regular exercise, as part of
vascular disease is an independent risk factor
a supervised exercise program. Indications
for other cardiovascular disease. At 5 years
for operative intervention in peripheral
of follow-up, 10% of claudicants and 50% of
vascular disease are disabling claudication
those with critical ischaemia have had an
or critical limb ischaemia. Angiography is
amputation. Also, 20% of claudicants and 50%
essentially a preoperative investigation and
of those with critical ischaemia have died,
is not required in the routine assessment
usually from ischaemic heart disease.
of claudication. The two options for
Clinical features intervention are percutaneous angioplasty or
Intermittent claudication is calf or thigh pain bypass surgery.
precipitated by exercise and relieved by rest.
Critical limb ischaemia
It usually occurs after a predictable distance
Critical limb ischaemia (CLI) can be defined
and is often described by patients as cramp or
as persistently recurring ischaemic rest pain
tightness. The location of pain, varies with the
requiring regular analgesia for more than 2
vessels that are involved. The usual relationship
weeks, associated with ulceration or gangrene
between the site of the pain and the site of
of the foot or toes, with an ankle pressure of
arterial disease can be summarised as follows:
less than 50mmHg or toe pressures of less
Buttock and hip aortoiliac disease than 30mmHg.
Thigh common femoral artery or
aortoiliac disease Clinical features
Calf superficial or popliteal femoral CLI is characterised by rest pain. It occurs or
artery is worsened when foot is elevated (e.g. in bed)
Foot claudication tibial or peroneal and is improved with the foot dependent. It is
artery almost invariably associated with ulceration
Assessment of progression of symptoms is or gangrene (Figure 17.5). Foot pulses are
important worsening or improvement. usually absent.
Peripheral pulses can be present in patients
with intermittent claudication. The impact Investigation
on social function should also be identified. CLI requires investigation to confirm
Claudication needs to be differentiated from the diagnosis and identify the site of any
spinal stenosis which also causes exercise- underlying stenosis or occlusion. The
induced leg pain. Spinal stenosis is usually diagnosis can be confirmed by measuring the
associated with neurological symptoms and ABPI. The site of the stenosis can be identified
relieved by spinal flexion. using duplex ultrasound. MRA allows more
accurate non-invasive assessment of the
Investigation arterial system and is especially useful when
Intermittent claudication is essentially planning interventional radiological or
a clinical diagnosis. Measurement of surgical interventions.
Arterial disease 247
leading cause of non-traumatic lower limb cutting and suitable footwear. In those with
amputation. ulceration, assessment should be made of
potential infection and vascular insufficiency.
Pathophysiology In diabetic feet, wound swabs often show
The diabetic foot results from a combination both Gram-negative, Gram-positive and
of a peripheral neuropathy and ischaemia. anaerobic bacteria. If osteomyelitis occurs,
The neuropathy has sensory, motor and it is usually due to Staphylococcus aureus
autonomic components. Sensory loss results infection. Plain radiography or MRI may
in loss of protective sensation and unnoticed demonstrate the extent of the infection. The
foot injuries. Loss of motor control to the threshold for antibiotic use should be low.
small muscles of the feet results in a claw foot The antibiotics selected should be based on
deformity. Autonomic neuropathy leads to culture and sensitivities.
vasomotor denervation and arteriovenous
Surgery may be required if there is
shunting. This compromises the ability to
progression of infection despite antibiotic
direct blood flow to the capillary beds. As a
treatment. All patients with diabetic
result, ischaemia can affect both the large and
ulceration should undergo non-invasive
small vessels. Large vessels disease results
vascular assessment. The ABPI should be
in atheroma of the femoral, popliteal and
calculated. This may be falsely elevated due to
tibial vessels. Small vessel disease affects the
arterial calcification and normal values may
microcirculation. Other contributing factors
still be recorded in diabetics with significant
include poor vision, limited joint mobility,
major vascular disease.
cerebrovascular disease and peripheral
oedema. In patients with foot ulceration, Revascularisation should be considered
healing is impaired. This results from impaired if arterial insufficiency is present. Diabetics
fibroblast function, deficiency in growth have a predisposition for disease in the
factors and abnormalities of the extracellular medium-sized vessels especially at the
matrix. popliteal trifurcation. The distal pedal vessels
are often spared. Femorodistal bypass
Management grafting may be required.
Prevention of complications is far preferable
to the need for active management.
Abdominal aortic aneurysms
Patients should be monitored and self-care An abdominal aortic aneurysm (AAA) is an
encouraged. They should be educated about increase in the aortic diameter by greater
washing, care of corns and calluses, toenail than 50% of normal and is usually regarded
as an aortic diameter of greater than 3cm
250 Chapter 17 Vascular disease
expansion but they still have a 1% per year aneurysms. About 50% of popliteal aneurysms
risk of aneurysm rupture. Complications of are bilateral and 50% are associated with
endovascular repair include: an abdominal aortic aneurysm. About 50%
Graft migration are asymptomatic. Symptomatic aneurysms
Endovascular leak present with features of compression of
Graft kinking adjacent structures (veins or nerves), rupture
Graft occlusion or limb ischaemia due to emboli or acute
thrombosis. Treatment is by proximal and
Popliteal artery aneurysms distal ligation with revascularisation of the
A popliteal aortic aneurysm is defined as leg by a femoropopliteal bypass. About
a popliteal artery diameter greater than 20% patients with a symptomatic popliteal
2cm. It accounts for 80% of all peripheral aneurysm will undergo an amputation.
252 Chapter 17 Vascular disease
stroke in these patients is 1 to 2% per year. The The diagnosis of blunt vascular trauma is
surgical mortality of endarterectomy ranges often delayed. The types of vascular injury are
from 1% to as much as 10%. Surgeons are described as:
divided over whether asymptomatic patients Contusion
should be treated with medication alone or Puncture
should be considered for surgery. Surgery is Laceration
currently not routinely indicated in this group Transection
of patients.
Carotid endarterectomy is a surgical
Clinical features
procedure used to prevent stroke, by The clinical features depends on site,
correcting a stenosis in the common mechanism and extent of injury. Signs of
carotid artery. The internal, common and vascular injury are classically divided into
external carotid arteries are clamped, the hard and soft sign
lumen of the internal carotid artery is Hard signs of vascular injury are:
opened and the atheromatous plaque is Absent pulses
removed. Some surgeons use a temporary Bruit or palpable thrill
shunt to ensure the blood supply to the Active haemorrhage
brain during the procedure. The procedure Expanding haematoma
may be performed under general or local Distal ischaemia
anaesthesia. The latter allows for direct
Soft signs of vascular injury are:
monitoring of neurological status by
intraoperative verbal contact and testing Haematoma
of grip strength. With general anaesthesia History of haemorrhage at scene of
indirect methods of assessing cerebral accident
perfusion must be used such as transcranial Unexplained hypotension
Doppler analysis and carotid artery stump Peripheral nerve deficit
pressure monitoring. Investigation
Carotid stenting Hard signs of vascular injury often require
Angioplasty and stenting is being increasingly urgent surgical exploration without prior
used to dilate stenoses. It involves selective investigation. If time permits, angiography
catheterisation of common carotid artery. should be considered to confirm the extent of
A wire is advanced into the external carotid the injury in a stable patient with equivocal
artery and a sheath is placed in the normal signs or to exclude vascular injury in a patient
segment of the common carotid artery. The without hard signs but a strong suspicion. The
stenotic lesion is negotiated with a distal role of Doppler ultrasound in vascular trauma
protection device. This is placed in the remains to be defined.
internal carotid artery and involves either a
balloon occlusion system or polyurethane Management
sac. Its use requires a patent contralateral The management of vascular trauma often
internal carotid artery. Angioplasty is then requires a multidisciplinary approach with
performed, a stent deployed and the distal orthopaedic and plastic surgeons. The aims
protection device is retrieved. of surgery are to control life-threatening
haemorrhage and to prevent limb ischaemia.
Vascular trauma If surgery is delayed more than 6 hours
Vascular trauma can result from either blunt revascularisation is unlikely to be successful.
or penetrating injury. The pattern of injury The use of arterial shunts is controversial but
differs according to the mechanism of injury. they may reduce ischaemic time and allow
Penetrating injury is more common in the early fixation of fractures.
USA than Europe. Blunt vascular trauma is Vascular repair is usually performed
often associated with significant fractures, after gaining proximal control and wound
tissue loss and an increased amputation rate. debridement. The options include:
254 Chapter 17 Vascular disease
Investigation Sclerotherapy
Duplex scanning should be considered if Sclerotherapy is only suitable for
there is: below knee varicose veins. Before
considering sclerotherapy it is necessary
Suspected short saphenous incompetence
to exclude saphenofemoral junction
Recurrent varicose veins
(SFJ) or saphenopopliteal junction (SPJ)
Complicated varicose veins (e.g.
incompetence. The main role of sclerotherapy
ulceration, lipodermatosclerosis)
is in persistent or recurrent varicose veins
History of deep venous thrombosis
after previously adequate saphenous surgery.
Management The principal sclerosants available are:
The management of varicose veins can be: 5% Ethanolamine oleate
Conservative 0.5% Sodium tetradecyl sulphate
Radiofrequency ablation Recently foam (a mixture of air and
Endovascular obliteration sclerosant) has been shown to be more
Sclerotherapy effective than sclerotherapy alone. The
Surgery needle is placed in the vein when full with
Absolute indications for intervention are: the patient standing. The vein is then empted
prior to injection. Immediately after injection,
Lipodermatosclerosis leading to venous compression is applied and maintained
ulceration for 6 weeks. The main complications of
Recurrent superficial thrombophlebitis sclerotherapy are extravasation of sclerosants
Bleeding from a ruptured varix causing pigmentation or ulceration and deep
Radiofrequency ablation venous thrombosis.
Radiofrequency ablation uses high frequency Surgery
alternating current delivered via a bipolar For LSV surgery, the patient should be placed
catheter. The catheter is placed intraluminally in the Trendelenburg position with 2030
under duplex guidance. Local heating results head down. The legs should be abducted 10
in venous spasm and a collagen seal. It is 15. The SFJ is found 2cm below and lateral
usually performed under general anaesthesia. to pubic tubercle. It is essential to identify the
The long saphenous vein is accessed at SFJ before performing flush ligation of the
the knee using a Seldinger technique and LSV. It is then necessary to individually divide
90% vein occlusion can be achieved in the and ligate all tributaries of the LSV which are
first week after treatment. It is associated the:
with less pain than open surgery, improved
quality of life and an earlier return to work. Superficial circumflex iliac vein
Complications include paraesthesia and skin Superficial inferior epigastric vein
burns. Recurrence rates are similar to open Superficial and deep external pudendal
surgery. vein
The femoral vein should be checked clear of
Endovascular laser treatment direct branches for 1cm above and below
Endovascular laser treatment uses laser the SFJ. Stripping of LSV reduces the risk of
energy delivered via a narrow laser fibre used recurrence. However, the LSV should only be
to obliterate the vein. It causes heat injury to stripped to upper calf. Stripping to the ankle is
the vessel wall. It is usually performed under associated with an increased risk of saphenous
local anaesthesia. Clinical and symptomatic neuralgia. Postoperative care should involve
improvement is seen in 95% of patients. elevation of the foot of the bed for 12 hours and
Patient satisfaction is high and early return Class 2 compression stockings should be worn
to work is possible. Complications include for at least 2 weeks.
256 Chapter 17 Vascular disease
For SSV surgery, the patient should be placed insufficiency and distal vein hypertension.
prone with 2030 head down. The SPJ has a very It is usually the result of the post thrombotic
variable position and preoperative localisation syndrome but can be due to primary valvular
with duplex ultrasound is recommended. It incompetence. Venous insufficiency can
is important to identify and preserve the sural be classified as primary or secondary.
nerve. Stripping of the SSV is associated with a Primary insufficiency has no obvious
risk of sural nerve damage. Subfascial ligation cause of valvular dysfunction. Insufficiency
of the SSV alone is inadequate. The significance results in early refilling of the venous
of perforator disease is unclear. Perforator pool after muscle contraction. It causes a
disease may be improved by superficial vein progressive and sustained increase in calf
surgery alone. Surgery to the perforator veins vein pressure. This is known as ambulatory
(e.g. Cockett and Todd procedure) is associated venous hypertension and results in capillary
with high morbidity. Subfascial endoscopic dilatation and leakage of plasma proteins.
perforator surgery (SEPS) has been described Incompetent perforating veins expose the
but is not indicated for uncomplicated primary superficial veins to high pressures during
varicose veins. It may have a role in addition muscle contraction. This is known as the
to saphenous surgery in those with venous hydraulic ram effect. It produces localised
ulceration. venous hypertension, filtration oedema and
continues until tissue pressures rise to restore
Recurrent varicose veins equilibrium. Accumulation of leukocytes
About 1525% of varicose vein surgery is occurs in dependent limbs of those with
for recurrence. The outcome of recurrent venous hypertension. Trapping of white
varicose veins surgery is less successful. The cells is associated with activation. Hypoxic
need for recurrent surgery can be avoided endothelial cells stimulate adherence of white
with adequate primary surgery. The reasons cells. Following activation they release O2
for recurrence are often: radicals, collagenases and elastases which
Inaccurate clinical assessment injure the surrounding tissue.
Inadequate primary surgery
Failure to strip the LSV Clinical features
Injudicious use of sclerotherapy Patients often have a history of leg swelling
Neovascularisation and skin changes consistent with chronic
venous insufficiency. The history and
Venous hypertension and examination should exclude other causes of
leg ulceration leg ulceration. Signs of venous hypertension
include:
Leg ulceration has a high prevalence and
presents a considerable economic burden. Perimalleolar oedema
Most cases of leg ulceration are due to Pigmentation
venous hypertension and 40% of venous Lipodermatosclerosis
ulcers are due to superficial venous disease. Eczema
Management of ulceration due to deep Ulceration
venous disease can prove difficult. However, Clinical assessment should identify any
surgical correction of superficial venous previous deep vein thrombosis and assess the
disease often results in healing. Rare causes of presence of arterial disease. It should identify
ulceration include: varicose veins and underlying valvular
Rheumatoid arthritis incompetencies.
Malignancy
Syphilis
Investigation
A hand-held Doppler can be used to assess
Venous hypertension the presence of venous reflux. The LSV,
Venous hypertension affects 12% of the SSV and perforators should be assessed.
population. It is due to chronic venous The patency of the femoral and popliteal
Venous disease 257
veins should be checked. Flow can be accounts for about 10% of all hospital deaths.
augmented by compression of the calf, deep At least 20% of patients who develop a deep
inspiration or a Valsalva manoeuvre. Duplex venous thrombosis (DVT) will progress to
ultrasonography allows anatomical and a post-thrombotic limb. Most calf DVTs are
functional assessment and the flow rate and clinically silent. About 80% of calf DVTs lyse
anatomy can be documented. spontaneously without treatment but 20% of
calf DVTs will propagate to the thigh and have
Management increased risk of pulmonary embolus.
The initial management of venous
hypertension is usually conservative. Surgery Pathophysiology
is rarely required and the outcomes can be Thrombus formation and propagation
disappointing. Elastic compression stockings depends on the presence of Virchows triad:
provide graduated compression and Venous stasis
produce local alteration of the microvascular Hypercoagulable state
haemodynamics. They have minimal effect Endothelial damage
on deep vein dynamics. They do not cure
Risk factors for venous thrombosis are
hypertension, but do protect the skin from the
shown in Table 17.1. Immobility contributes
effects.
to venous stasis. A hypercoagulable state
The aims of surgery are to cure venous can be caused by drugs or malignancy.
hypertension and heal the ulceration. A Endothelial damage can result from external
combination of superficial venous surgery compression. It is estimated that about
and compression may be beneficial. Possible 1:250 of the population have a congenital
surgical strategies include: thrombophilia. The potential for venous
Skin grafting thrombosis can be investigated by a
Free flap grafting thrombophilia screen:
Superficial vein stripping FBC and blood film
Perforating vein interruption Clotting studies APPT/PT/TT
Valve plasty Reptilase test
Thrombolysis, dilation, stenting Protein C and S and antithrombin III assay
Lupus anticoagulant
Marjolin ulceration
Marjolin ulceration was first described by Jean Risk assessment
Nicholas Marjolin in 1828. It is a squamous The risk of venous thrombosis depends on the
cell carcinoma arising at sites of chronic age of the patient, their co-morbidity and the
inflammation. Recognised underlying causes nature of the procedure. Surgical procedure
include chronic venous ulceration, burns can be divided into low, moderate or high-
and osteomyelitis. There is usually a long risk.
period between the injury and malignant
Low-risk is defined as:
transformation. This period may be 1025
years. About 40% of Marjolin ulcers occur Minor surgery (less than 30min)+no risk
on the lower limb. The malignant change factors other than age
is usually painless and nodal involvement Major surgery (more than 30min), age less
is uncommon. Diagnosis is confirmed by than 40 years+no other risk factors
biopsy of the edge of the ulcer. Management Minor trauma or medical illness
involves adequate excision and skin-grafting. Moderate risk is defined as:
Amputations are sometimes required. Major general, urological, gynaecological,
cardiothoracic, vascular or neurological
Venous thrombosis and surgery+age more than 40 years or other
thromboprophylaxis risk factor
Venous thrombosis is a significant cause of Major medical illness or malignancy
morbidity and mortality. Pulmonary embolus Major trauma or burn
258 Chapter 17 Vascular disease
Risk factors for venous thrombosis
/
Pregnancy Lower limb paralysis
.i r
Puerperium Infection
High-dose oestrogen therapy Inflammatory bowel disease
s
Previous deep vein thrombosis or pulmonary Nephrotic syndrome
s
embolism
Thrombophilia Polycythaemia
n
Deficiency of antithrombin III Paraproteinaemia
is a
Antiphospholipid antibody Paroxysmal nocturnal haemoglobinuria
Lupus anticoagulant Behets disease
r
Homocystinuria
e
Table 17.1 Risk factors for venous thrombosis
p
.
Minor surgery, trauma or illness in stockings and intermittent pneumatic
p
a patient with previous DVT, PE or compression (e.g. Flowtron boots). Graduated
iv
thrombophilia compression stockings reduce the incidence
High-risk is defined as: of DVT by 50%. The stocking profile should
/: /
be:
Fracture or major orthopaedic surgery of
the pelvis, hip or lower limb 18mmHg at the ankle
14mmHg at the mid-calf
tt p
Major pelvic or abdominal surgery for
cancer 8mmHg at the upper thigh
Major surgery, trauma or illness in Staff should be trained in the use and fitting of
a patient with previous DVT, PE or the stockings. Stockings should be worn from
h
thrombophilia the time of admission until the resumption
of normal mobility. Intermittent pneumatic
Prevention of thromboembolism compression devices should also be used
The risk of venous thromboembolic disease during surgery.
can reduced by both patient education, Pharmacological methods invariably
physical and pharmacological mechanisms. include the use of heparin. Heparin is an
Patient information and education is vital. acidic mucopolysaccharide. Unfractionated
Women on the contraceptive pill should be heparin has a molecular weight of 15kDa.
advised to stop it 4 weeks before elective Low molecular weight heparin (LMWH) has
surgery. Patients should be advised that a molecular weight of 5kDa. Both potentiate
immobility before or after surgery increases antithrombin III activity by inactivating
the risk. Before surgery, they should be give activated clotting factors. LMWH does
verbal and written information on the risk of not have a significant effect on the APPT.
DVT and effectiveness of prophylaxis. Side effects of unfractionated heparin
Physical methods of prophylaxis include include osteoporosis and idiosyncratic
early mobilisation, graduated compression thrombocytopenia. Unfractionated and
Venous disease 259
/
calf DVT are calf pain and tenderness, pyrexia
r
and persistent tachycardia. Homans sign is Acute pulmonary embolism is a common and
.i
pain on passive dorsiflexion of the ankle and often fatal disease. Mortality can be reduced
is non-specific. Occlusion of the ileofemoral by prompt diagnosis and therapy. Pulmonary
s
vein can result in venous gangrene embolism accounts for 10% of hospital
(phlegmasia cerulea dolens). inpatient deaths. Untreated, it has a mortality
s
of up to 30%. With treatment, the mortality
Investigation
n
can be reduced to about 2%. Only 10%
D-dimers are a fibrin degradation product patients presenting with pulmonary embolus
is a
that can be assayed in plasma. Levels are have clinical signs of a DVT.
raised in the presence of recent thrombus.
A negative result almost excludes the Clinical features
r
presence of venous thrombosis. Compression The challenge in diagnosing a pulmonary
ultrasound is the imaging modality of embolism is that patients rarely display
e
choice. The decision whether to proceed to the classic presentation of abrupt onset of
p
ultrasound is often based on D-dimer results. pleuritic chest pain, shortness of breath and
.
The technique has three components all hypoxia (Table 17.2). Studies of patients who
operator dependent. died unexpectedly from pulmonary embolism
iv p
Venous compressibility have shown that patients often had symptoms
Detection of Doppler flow for several weeks before their death.
/: /
Visualisation of clot
Investigation
In the femoro-popliteal segment it has a
Investigation of a possible pulmonary
sensitivity and specificity of 95% and 100%,
embolus should include:
tt p
respectively. In the calf veins, both the
sensitivity and specificity are less. However, Arterial blood gases hypoxia, hypocarbia
ultrasound is able to exclude femoro- but may be normal
popliteal or major calf DVT in symptomatic ECG Signs of right heart strain
h
patients. classically S1Q3T3
Chest x-ray show oligaemia and excludes
Management other pathologies
The aims of treatment of venous thrombosis CT pulmonary angiogram
are prevention of pulmonary embolus and Ventilation/Perfusion scanning
restoration of venous and valvular function Lower limb investigations for a DVT
to prevent the post-thrombotic limb.
Anticoagulation is the main component of Management
treatment, initially with LMWH followed The management of a pulmonary embolus
by oral anticoagulation. The treatment of depends on the degree of suspicion and
isolated calf DVTs is of unproven benefit and whether the patient is haemodynamically
the optimal duration of treatment unknown. stable. If there is high degree of suspicion
There is no proof that treatment beyond but the patient is stable the patient should be
36 months is required. Thrombolysis is of anti-coagulated with LMWH, oxygen given
unproven benefit. and analgesia administered. The patient
should be warfarinised for at least 3 months.
260 Chapter 17 Vascular disease
Clinical presentation of Lymphatics and spleen
pulmonary embolus
Lymphoedema
Symptoms Signs Lymphoedema presents with gradual, often
Dyspnoea Low-grade pyrexia bilateral, limb swelling (Table 17.3). It is due
to progressive failure of the lymphatic system.
Pleuritic chest Central cyanosis
Primary lymphoedema has no obvious cause
pain
and is classified as:
Haemoptysis Tachycardia
/
Congenital (age less than 1 year) familial
r
Tachypnoea or non-familial
.i
Hypotension Praecox (age less than 35 years) familial
Neck vein distension
or non-familial
s
Tarda (age more than 35 years)
Pleural rub
s
Secondary lymphoedema can be due to:
Increased pulmonary
Malignant disease
n
second sound
Surgery axillary surgery or groin
is a
dissection
Table 17.2 Clinical presentation of pulmonary Radiotherapy
embolus Infection parasitic (e.g. filariasis)
r
Pathology
e
If the patient is haemodynamically unstable Primary lymphoedema is more common
consideration should be given to a pulmonary in women and is usually bilateral. It is
p
thrombolysis via a pulmonary artery
.
the result of a spectrum of lymphatic
catheter. If thrombolysis is contraindicated, a disorders. It can be due to aplasia,
p
pulmonary embolectomy may be required. hypoplasia or hyperplasia of lymphatics.
iv
Inferior vena caval filters are inserted In 80% of patients, obliteration of the distal
percutaneously usually via the femoral lymphatics occurs. A proportion of patients
/: /
vein. They present a physical barrier to have a family history (Milroys disease).
emboli. They are indicated if recurrent In 10% of patients, proximal occlusion of
pulmonary emboli occur despite adequate the lymphatics in the abdomen and pelvis
tt p
anticoagulation or there is extensive proximal is seen. In 10% of patients, lymphatic
venous thrombosis and anticoagulation is valvular incompetence develops. Chronic
contraindicated. lymphoedema results in subcutaneous
h
Bilateral pitting oedema
Causes of lower limb swelling
Causes of lymphadenopathy
25
Basiliximab Rejection
Daclizumab About 12% of patients undergoing renal
Sirolimus transplantation develop acute rejection.
Basiliximab and daclizumab are anti- Acute rejection is characterised by pyrexia,
interleukin-2 receptor antibodies. Newer drugs graft tenderness and increasing creatinine.
are associated with fewer side effects. The The diagnosis can be confirmed by a renal
incidence of hypertension and hyperuricaemia biopsy. Management is with high dose
are reduced. The rate of adverse lipid profiles steroids and OKT3, a monoclonal antibody
is lessened. Newer drugs may have a reduced against the T cell receptor-CD3 complex and
incidence of chronic allograft nephropathy. anti-T cell monoclonal antibodies.
Chapter 18 Otorhinolaryn-
gology and head
and neck surgery
Applied basic sciences cavity opposite the upper second molar. The
parotid papilla marks the opening of the
Salivary gland anatomy duct.
Parotid gland Although the facial nerve runs through the
The parotid gland is found overlying the gland, it does not supply its parasympathetic
ramus of the mandible (Figure 18.1). It lies innervation. Secretion of saliva is controlled
anterior and inferior to the external ear and by postsynaptic parasympathetic fibres
occupies the parotid fascial space. It extends originating in the inferior salivary nucleus.
from the zygomatic arch to the angle of the These leave the brain via the tympanic nerve
mandible. The facial nerve and its branches branch of glossopharyngeal nerve, travel
pass through the gland. The external carotid through the tympanic plexus, and then form
artery also passes through the gland and gives the lesser petrosal nerve before reaching
off its two terminal branches, the maxillary the otic ganglion. After synapsing in the otic
artery and the superficial temporal artery ganglion, the postganglionic fibres travel
within the gland. Posteriorly, it is related as part of the auriculotemporal nerve to
to the posterior belly of the digastric, the reach the parotid gland. Sympathetic nerves
stylohyoid and the sternocleidomastoid originate from the superior cervical ganglion,
muscles. The gland has four surfaces superior, giving rise to the external carotid nerve
superficial, anteromedial and posteromedial. plexus and reaching the gland by traveling
The surfaces are separated by three borders, along the external carotid arterial branches.
anterior, posterior and medial. The parotid Parasympathetic stimulation produces
duct (Stenson duct) drains into the buccal a water rich, serous saliva. Sympathetic
Ducts of the
sublingual gland
Sublingual gland
Submandibular
duct
Submandibular gland
270 Chapter 18 Otorhinolaryngology and head and neck surgery
stimulation leads to the production of a low composition varies between the types of
volume, enzyme-rich saliva. There is no salivary glands.
inhibitory nerve supply to the gland.
Submandibular gland Ear, nose and throat disease
The submandibular glands lie superior to Inflammatory conditions of the
the digastric muscles. Each submandibular
gland is divided into superficial and deep
ear, nose and throat
lobes, separated by the mylohyoid muscle. The Otitis externa
superficial portion is larger and the mylohyoid Inflammatory disorders of the external ear
muscle runs below it. Secretions are delivered are common. They can be either an acute or
into Whartons ducts on the superficial portion. chronic disorder and are often associated
The gland hooks around the posterior edge of with generalised skin disorders. Common
the mylohyoid muscle. The submandibular pathogens include staphylococcal species
ducts are crossed by the lingual nerve and and Pseudomonas aeruginosa. Fungi, candida
drain into the sublingual caruncles on either and aspergillus may also be involved. The
side of the lingual frenulum. This occurs along condition is often bilateral. Treatment is with
with the major sublingual duct. topical antibiotics and steroids. Debris should
The parasympathetic innervation to the be suctioned under direct vision. Systemic
submandibular glands is provided by the antibiotics are rarely required.
superior salivary nucleus via the chorda
tympani, a branch of the facial nerve that Acute suppurative otitis media
synapses in the submandibular ganglion. Acute suppurative otitis media is a common
It follows the lingual nerve leaving it disorder in childhood. The commonest
as it approaches the gland. Increased pathogens are Streptococci pneumoniae and
parasympathetic activity promotes the Haemophilus influenzae. It usually presents
secretion of saliva. The sympathetic nervous with severe ear ache. The child is usually
system regulates the submandibular systemically unwell. The tympanic membrane
secretions through vasoconstriction of the is often red and bulging. Pain may be relieved
arteries that supply it. Increased sympathetic when rupture of the tympanic membrane
activity reduces glandular blood flow and occurs. Treatment is with oral antibiotics.
decreases salivary secretions, producing an Complications of acute suppurative otitis
enzyme-rich serous saliva. media include:
Chronic suppurative otitis media
Salivary gland physiology Adhesive otitis media
Saliva Tympanosclerosis
About 1500mL of saliva is secreted each day Ossicular destruction
under the control of parasympathetic system. Acute mastoiditis
Parasympathetic stimulation promotes Intracranial complications
secretion. Saliva is formed in the acini of
salivary glands. This initial production is Chronic suppurative otitis media
similar to intestinal secretions and is isotonic. Chronic suppurative otitis media (CSOM) is
As it passes through the ducts, sodium and classified into two types. The tubotympanic
chloride are reabsorbed and potassium disease is associated with perforation of
and bicarbonate are secreted. This is more the pars tensa. The atticoantral disease is
pronounced during low salivary flow rates. associated with a retraction pocket of the
Water is not reabsorbed. Saliva is thus pars flaccida.
hypotonic and has a pH between 7 and 8.
Saliva is low in sodium and chloride and rich Tubotympanic CSOM
in potassium and bicarbonate. It contains Tubotympanic CSOM usually follows acute
amylase, small amounts of lipase, mucin, otitis media or trauma. It results in chronic
antibodies, lysozyme and lactoferrin. The perforation of the tympanic membrane and
Ear, nose and throat disease 271
Absolute Relative
obstruction and should be performed with the sub-glottis and the tracheostomy tube
caution if acute epiglottis is a possible diagnosis. is inserted using an obturator. When it is
Patients should be managed with humidified confirmed that the tracheostomy tube is in
oxygen and antibiotics. If there is potential the correct position, the endotracheal tube
compromise of the airway then intubation or can be removed. The tube is secured with
tracheostomy should be considered. tapes.
Complications of tracheostomy
Brainstem
Motor
nucleus Vll
Geniculate Greater
Superior
ganglion petrosal nerve
salivatory
nucleus
Pterygopalatine
Solitary tract ganglion
Spinal nucleus
V Carotid
plexus
Internal
acoustic
meatus Motor Vll
Visceral efferent
Tympanic Visceral afferent
membrane
Sympathetic visceral
efferent
Parasympathetic
Stylomastoid foramen Chorda tympani visceral efferent
Somatic afferent
usually associated rheumatoid arthritis or in the elderly. The aetiology is unknown but
systemic lupus erythematosis. The risk of B-cell upper oesophageal sphincter dysfunction
lymphoma is increased. A sialogram shows may be an important aetiological factor. A
characteristic sialectasis and parenchymal carcinoma can develop within the pouch.
destruction. The diagnosis can be confirmed
by labial gland biopsy. Treatment is Clinical features
symptomatic. No treatment will reverse the The commonest symptoms are dysphagia,
keratoconjunctivitis and xerostomia. regurgitation of undigested food and a cough.
Recurrent aspiration can result in pulmonary
Common neck swellings complications. Clinical signs are often absent.
There are many causes of lumps in the neck. A cervical lump may be present that gurgles
The most common cause is lymphadenopathy on palpation.
as a result of bacterial or viral infections or
malignancy. A lump can also arise in either Investigation
the salivary or thyroid gland. In children, Indirect or fibreoptic laryngoscopy may show
most neck lumps are caused by treatable a pooling of saliva within the pyriform fossa.
infections. In adults the likelihood of A barium swallow may show a residual pool
malignancy increases. of contrast within the pouch (Figure 18.6).
Hyoid
bone
Thyropharyngeus Thyroid
cartilage
Cricopharyngeus Cricoid
cartilage
Pharyngeal pouch
Dohlmans procedure
A Dohlmans procedure is performed
endoscopically. A double-lipped
oesophagoscope is used and the wall between
the diverticulum and oesophageal wall is
exposed. The hypopharyngeal bar is divided
with diathermy or laser. This minimally
invasive techniques allows a:
Shorter duration of anaesthesia
More rapid resumption of oral intake
Shorter hospital stay
Figure 18.6 A barium swallow showing a
pharyngeal pouch
Quicker recovery
Chapter 19 Paediatric
surgery
Causes of malformations
Cause Percentage
and palate also occur as part of over 100 altered anatomy of the lip and soft palate and
syndromes including: dysfunction of the palatal muscles. Hearing
Pierre Robin syndrome may be affected as the abnormal palate
Stickler syndrome interferes with eustachian tube function.
Downs syndrome Dentition is abnormal if the alveolus is
Treacher Collins syndrome involved.
The aims of surgery for cleft lips and palate
Embryology are:
The cleft lip deformity is usually established To achieve a normal appearance of the lip,
in the first 6 weeks of life due to failure of nose and face
fusion of the maxillary and medial nasal To allow normal facial growth
processes. It may be due to incomplete To allow normal speech
mesodermal ingrowth into the processes. The
Many different techniques have been
extent of the deficiency determines the extent
advocated. Cleft lip repair is usually performed
of the cleft. Palatal clefts result from failure of
between 3 and 6 months of age. Cleft palate
fusion of the palatal shelves of the maxillary
repair is usually performed between 6 and
processes.
18 months. Two or more operations may be
Clinical features required. A multidisciplinary team approach
The typical distributions of cleft types are: is essential. Other aspects that need to be
addressed included:
Cleft lip alone (15%)
Cleft lip and palate (45%) Hearing
Isolated cleft palate (40%) Speech therapy
Dental
Cleft lips are more common on the left. Orthodontics
Management Congenital heart disease
Antenatal diagnosis of a cleft lip may be
The commonest classification of congenital
possible. The degree of functional and
heart disease is into:
aesthetic deficit is related to the type and
severity of the cleft. Feeding is rarely a Septal defects
difficulty. Breast feeding may be achieved Obstructive defects
or modified teats for bottle feeding may be Cyanotic defects
required. Major respiratory obstruction is The commonest congenital heart defects are
uncommon. Speech may be affected by the shown in Table 19.2.
Upper pouch
Tracheo-
oesophageal
Oesophageal fistula
atresia
nasogastric tube can not be passed more than features are often similar. Bile-stained
10cm. On a chest x-ray, if there is gas in the vomiting is never normal in a neonate and
stomach, there must be a distal TOF. implies obstruction. Approximately 95%
of normal babies pass meconium within
Management the first 24 hours of life. Failure to pass
Feeding should be withheld and suction meconium should be regarded also as a
applied to the oesophageal pouch. The feature of obstruction until proved otherwise.
patient should be nursed in an upright The degree of abdominal distension is
position. The presence of other associated variable.
congenital abnormalities should be
assessed. Surgery is required within the Duodenal atresia
first 24 hours of life. The operation involves Duodenal atresia occurs in 1 in 10,000
a right thoracotomy and an extrapleural live births. The site of the obstruction is
approach. The azygos vein and any TOF are most commonly in the 2nd part of the
divided. The oesophagus is mobilised and duodenum. The proximal the duodenum
a primary anastomosis is usually achieved. become hypertrophied. About 50% cases
If an anastomosis is impossible, then a are associated with polyhydramnios and
staged procedure is required. With the latter 60% of such pregnancies are complicated
approach, a gastrostomy is performed and or end prematurely. Approximately 30% of
the fistula divided at the initial operation. babies with duodenal atresia have Downs
The oesophagus can be replaced by colon or syndrome. Other associated abnormalities
stomach after a few months. Complications are cardiac anomalies, intestinal malrotation
following surgery for oesophageal atresia and biliary atresia. Duodenal atresia can
include: often be diagnosed by antenatal ultrasound.
Oesophageal dysfunction Postnatally, it presents with bilious or non-
Dilated proximal pouch bile stained vomiting. An abdominal x-ray
Gastro-oesophageal reflux may show a double-bubble and no gas
Anastomotic stricture within the bowel distal to the obstruction
Recurrent fistula (Figure 19.3).
be given and major cardiac and delayed. Meconium filled loops of bowel may
other defects should be excluded. A be palpable. An abdominal x-ray may show a
duodenoduodenostomy should be performed ground-glass appearance, especially in the
once the patient is resuscitated. right upper quadrant.
and acidosis due to intestinal infarction. mucosa and increased unmyelinated nerves
It can present late with intermittent bile- in the bowel wall.
stained vomiting and distension. Radiological
investigations are often unhelpful. Management
An initial defunctioning stoma should be
Management fashioned to relieve the obstruction. Definitive
After resuscitation, an early laparotomy is treatment involves either a bypass of the
required. Any volvulus should be reduced. affected segment (Duhamel or Soave bypass)
Resection may be required if there has or excision of the aganglionic segment and
been small bowel infarction. Any Ladd anastomosis (Swenson procedure).
bands should be divided. The base of the
mesentery should be elongated. The colon Anorectal anomalies
should be placed on the left of the abdomen. Anorectal malformations comprise a wide
The small bowel should be placed on the spectrum of abnormalities. They affect 1 in
right. An inversion appendicectomy should 5000 live births and are often associated with
be performed to prevent future diagnostic other congenital malformations. Prognosis
uncertainty. depends on the severity of the malformation
and the extent of other anomalies. Early
Hirschsprungs disease treatment of neonates with anorectal
Hirschsprungs disease is due to absence of anomalies is required.
the autonomic ganglion cells in Auerbachs
plexus of the distal large intestine. It Clinical assessment
commences at the internal anal sphincter and Clinical inspection of the perineum is
progresses for a variable distance proximally. important. In 80% of patients, clinical
It affects 1 in 5000 live births and the examination and urinalysis allows a decision
male:female ratio is 4:1. It accounts for 10% to be made as to whether a colostomy is
of cases of neonatal intestinal obstruction. required. A flat perineum and absence of
Some cases appear to be due to autosomal anal dimple suggest poor perineal muscle
dominant inheritance. About 75% cases are development. These features are associated
confined to the recto-sigmoid but 10% cases with high anorectal malformations.
have total colonic involvement. Meconium at the perineum and a skin tag
associated with an anal dimple or membrane
Clinical features suggests a low malformation. Even if a
Approximately 80% of cases present in the perineal fistula is present, meconium may not
neonatal period with delayed passage of be passed for 24 hours.
meconium. This is followed by increasing Approximately 50% of all patients with
abdominal distension and vomiting. The anorectal malformations have an associated
child is at increased risk of enterocolitis and urogenital anomaly. Renal abnormalities
perforation. It occasionally presents with include:
chronic constipation in infancy.
Renal agenesis
Diagnosis Vesicoureteral reflux
A plain abdominal x-ray will confirm Neurogenic bladder
intestinal obstruction. A contrast enema Renal dysplasia
may show a contracted rectum, cone shaped Megaureter
transitional zone and proximal dilatation. Hydronephrosis
Anorectal manometry may show a recto- Ectopic ureter
sphincteric inhibition reflex on rectal
Investigation
distension. The diagnosis is confirmed by
a rectal biopsy which will show absence of If the clinical signs are unclear, than
ganglion cells in the submucosa, increased radiological investigations may be useful. A
acetylcholinesterase cells in the muscularis cross-table lateral x-ray with the baby prone,
Correctable congenital abnormalities 291
Proximal hypospadias without a chordee clinical sign is often a tuft of hairs or skin
can be treated by a skin flap advancement. dimple at the site of the defect. Neurological
If a chordee is present it should be excised deficit is rare. It may present with subtle
and an island flap urethroplasty performed. neurological abnormalities such as enuresis
Complications of hypospadias surgery include or incontinence.
a urethral fistula and stricture formation.
Meningocele and myelomeningocele
Neural tube defects If the meninges bulge through vertebral
Embryology defect, it results in either a meningocele or
myelomeningocele. A meningocele does not
The central nervous system develops from
contain spinal cord elements (Figure 19.6).
the dorsal ectoderm. The lateral edges of the
A myelomeningocele contains the spinal
neural plate fold to form the neural groove.
cord and nerve routes and may be associated
Fusion of the edges of the neural groove
with caudal displacement of medulla and
generates the neural tube. Fusion starts
cerebellum. This can result in hydrocephalus
cranially and progresses caudally. Both the
(ArnoldChiari malformation). It may
caudal and cranial ends of the tube remain
also be associated with other congenital
temporarily open. The anterior neuropore
abnormalities.
usually closes at about 25 days. The posterior
neuropore usually closes at about 27 days. Clinical features
Spina bifida A myelomeningocele occurs in 23 per 1000
live births. It can be detected prenatally by
The term spina bifida covers a range of
increased maternal serum a-fetoprotein.
vertebral and neural tube defects. It results
The spinal defect is clinically obvious
from failure of the posterior vertebral arch
and can result in various degrees of limb
to fuse and most commonly occur in lumbo-
weakness, sensory loss, joint dislocation and
sacral region (Figure 19.5).
contractures and urinary disorders. Of all
Spina bifida occulta patients with a myelomeningocele, one-third
have complete paralysis and loss of sensation
Spina bifida occulta is the commonest
below the level of the defect, one-third have
form of spina bifida. Its true prevalence is
preservation of distal segments below the
unclear. Isolated laminar defects are seen
level of the defect and one-third have an
on about 5% of lumbar spine x-rays. The
incomplete lesion. About 90% of children
spinal cord is usually normal. The only
develop urinary problems.
Spinal
cord
A palpable tumour in right upper quadrant diverticulum, duplication cyst or tumour. The
of the abdomen is best felt from left during a commonest site involved is the ileocaecal
test feed. Visible peristalsis is often seen. junction.
Management Investigation
Dehydration should be corrected over The diagnosis can be confirmed with water
a 24 to 72 hour period prior to surgery. soluble contrast enema or ultrasound.
A nasogastric tube is often required.
Ramstedt described his pyloromyotomy in Management
1911. The operation can be performed via Resuscitation with intravenous fluids and
either a transverse right upper quadrant or nasogastric tube is required. In the absence
circumumbilical incision. A longitudinal of peritonitis, reduction with air or contrast
incision should be made in the pylorus enema under radiological guidance can be
down to the mucosa. The incision should attempted. If there is clinical evidence of
extend from the duodenum proximally on peritonitis, shock or a failed reduction then
to the gastric antrum. Mucosal perforation surgery is required. The intussusception
should be avoided. Feeding is re- should be reduced. If there is necrosis of
established within 1224 hours of surgery. the bowel, then resection with primary
Recurrence rarely occurs. Complications anastomosis should be performed.
are rare and mortality is negligible.
Persistent postoperative vomiting may be Necrotising enterocolitis
due to delayed return of normal gastric Necrotising enterocolitis affects about 1 per
motility, gastro-oesophageal reflux or an 1000 live births. The aetiology is unknown
inadequate pyloromyotomy. The operation but bacterial infection and hypoxia appear
has been described using a laparoscopic to be important. It occurs in premature or
approach but no clear benefit has been low birth weight infants and is associated
demonstrated over a circumumbilical with premature rupture of membranes,
approach. prolonged labour and respiratory distress. It
is also well recognised following umbilical
Intussusception artery catheterisation. It usually affects the
Intussusception occurs when one part of the terminal ileum and colon to a variable extent
bowel invaginates (the intussusceptum) into and is characterised by mucosal necrosis
an adjacent section (the intussuscipiens) with progression to intestinal infarction and
resulting in intestinal obstruction and venous perforation.
compression. If uncorrected, it can progress
to arterial insufficiency and necrosis. It is Clinical features
the commonest abdominal emergency in Necrotising enterocolitis usually occurs in
infants between 3 months and 2 years. The the first week of life. The child is lethargic
peak incidence is 6 to 9 months. Most are and apathetic with vomiting and increasing
idiopathic with the lead point due to enlarged abdominal distension. Bloody diarrhoea is
Peyers patches as a result of a viral infection. a late feature. Abdominal examination may
About 5% of cases are due to a polyp, Meckels show peritonitis or a mass.
Common paediatric surgical disorders 295
Treatment Nephroblastoma
Initial treatment involves vigorous A nephroblastoma (Wilms tumour) originates
resuscitation and medical management. The from the embryonal kidney. Pathologically,
placement of a nasogastric intubation and it contains renal tissue with various degrees
use of antibiotics are important. Parenteral of differentiation. It affects about 1 in 10,000
nutrition should be considered. Indications live births. Approximately, 60% present before
for surgery include: the age of 3 years and 10% of tumours are
bilateral. The presentation is with an:
Increasing peritonitis
Failure of stabilisation with medical Abdominal mass (90%)
treatment Abdominal pain (20%)
Development of an abdominal mass Haematuria (30%)
Persistent loop or free gas on an The diagnosis can be confirmed by an
abdominal x-ray abdominal CT scan. About 40% of patients
Surgical treatment will involve resection have metastatic spread at presentation
with possible primary anastomosis. Overall, but this does not prevent cure. Treatment
the prognosis is poor. The mortality of those is with nephrectomy and postoperative
undergoing medical treatment is about 20%. chemotherapy and radiotherapy. Stage 1
The mortality of those coming to surgery is disease (localised to the kidney) has a 3-year
about 30%. Amongst survivors, about 30% survival of more than 80%. Stage 4 disease
develop ischaemic colonic strictures. (haematogenous spread) has a 3-year survival
less than 30%.
Abdominal masses in children
The identification of an abdominal mass Neuroblastoma
in a child is a cause for concern because Neuroblastomas arises from neural crest
of the possibility of malignant disease. tissue, usually the adrenal medulla or
sympathetic ganglia. They show a range of regional variation in incidence. They are
malignancy from benign ganglioneuroma most commonly seen in Japan (1 in 1000
to malignant neuroblastoma. They affects live births) and are relatively rare in Western
about 1 in 8000 live births and usually occur Europe (1 in 100,000 live births). The
in first 5 years of life. Tumours in children are male:female ratio is 1:4 and the aetiology is
usually malignant. About 75% are abdominal unknown.
and 25% arise in the thorax, pelvis or neck.
Clinical presentation depends on the site of Pathology
the tumour and the presence or absence of The cyst wall consists of fibrous tissue
metastases. Bone and pulmonary metastases without muscle and the cyst may contain
are relatively common. Symptoms are often a large volume of bile. The cyst is often
due to metastatic spread and include: associated with distal common bile duct
Pallor, weight loss, irritability (40%) stenosis. If undiagnosed, the condition can
Limb pain and hypertension (15%) progress to biliary fibrosis, cirrhosis and liver
Abdominal mass or pain (30%) failure. Three types of choledochal cysts are
described.
About 90% of patients have increased urinary
VMA and HVA levels. A plain abdominal x-ray Clinical features
often shows diffused speckled calcification. The Choledochal cysts may be diagnosed
diagnosis can be confirmed by an abdominal prenatally on ultrasound. About 25% present
CT scan. Treatment is with surgery and in neonates with prolonged jaundice and
postoperative radiotherapy. Prognosis is best cholestasis. The other 75% present later in
in children presenting before 2 years. Stage childhood with the triad of abdominal pain,
1 disease (localised to kidney) has a 3-year abdominal mass and intermittent jaundice.
survival of more than 90%. Stage 4 disease The differential diagnosis includes biliary
(haematogenous spread) has a 3-year survival atresia and neonatal hepatitis. Complications
less than 30%. include:
Choledochal cysts Recurrent cholangitis
Hepatic fibrosis
Choledochal cysts are localised cystic
Biliary cirrhosis and portal hypertension
dilatations of all or part of the common bile
Rupture with biliary peritonitis
duct (Figure 19.7). About 80% of choledochal
Pancreatitis
cysts present in childhood. There is a large
1 1 1
2 2
presents with painless rectal bleeding. or posterior triangle of the neck my give an
It is best diagnosed with a radioisotope indication of the underlying pathology.
scan. Other complications include Neck lumps in the anterior triangle include:
intussusception, small bowel obstruction,
Lymphadenopathy infective, neoplastic
Meckels diverticulitis or a gastrointestinal
Thyroglossal cysts
perforation.
Dermoid cyst
Circumcision Goitre
Branchial cyst
A circumcision was first performed on
Abraham at the age of 90 years! Several Neck lumps in the posterior triangle include:
other references to circumcision exist in Lymph nodes
the Old Testament. It is also depicted on Cystic hygroma
Egyptian tombs and murals. Each year 21,000 Sternomastoid tumours
circumcisions are performed in the UK where Parotid swellings
4% of boys will have had a circumcision by
the age of 15 years. In Scandinavia, only 2% Branchial remnants
of boys are circumcised. Many operations are Branchial cysts arise from the second branchial
probably unnecessary. sinus and are found on the anterior border of
At birth the prepuce is normally sternomastoid. They are often bilateral and
adherent to the glans penis. This produces extend deep into the neck. An internal opening
a physiologically non-retractile foreskin. is occasionally found in the tonsillar fossa.
Only 4% of boys have a retractile foreskin at Treatment is by surgical excision.
birth. By 5 years, in 90% of boys the foreskin
Cystic hygroma
will be retractile. Only 1% of boys have a
true phimosis and 3% of boys have recurrent A cystic hygroma is a hamartomatous
balanitis. Indications for circumcision are: lymphatic malformation resulting in a multi-
cystic mass. About 60% are found in the
Social and cultural neck region and they often present in early
Phimosis due to balanitis xerotica childhood as an expanding mass. They contain
obliterans, lichen sclerosis or trauma clear fluid and transilluminate brightly. Large
Balanitis or posthitis lesions can be diagnosed prenatally and can
Ballooning of foreskin result in obstructed labour. Surgical excision
Paraphimosis is difficult and can result in a poor cosmetic
Technique result. The use of sclerosants may be useful.
All preputial adhesions should be freed. It is
Sternomastoid tumours
important to avoid excessive tension in order
to preserve skin. To avoid injury to the glans, A sternomastoid tumour is a mass in the
blind dissection of the foreskin is ill-advised. middle third of the sternomastoid muscle. It
Sutures or bipolar diathermy should be used results from muscle damage during labour
for haemostasis. Excessive numbers of skin and presents with a neck lump and torticollis
sutures should be avoided. Complications are away from the affected side. Treatment should
rare but include ulceration of the glans and involve physiotherapy to correct the torticollis.
urethral meatitis. About 1% need reoperation Surgery to remove the lump is rarely required.
for bleeding or haematoma.
Paediatric hernias
Neck lumps in children Inguinal hernias
Neck lumps are common in children but An inguinal hernia is the commonest surgical
neoplasia is rare. Most head and neck lumps condition encountered in Childhood.
result from congenital or inflammatory Approximately, 2.5% of children require
processes. The position in either the anterior an operation for a hernia. The incidence is
increased in premature and low birth weight
Common paediatric surgical disorders 299
capsules, skin and bones. Muscle balance within the acetabulum and requires the
is restored and spasticity diminished by presence of a normal femoral head. The
tendon lengthening, tendon transfers, partial female:male ratio is 5:1. Ligamentous laxity
denervation and splintage. Surgery is most may be an important aetiological factor. Other
valuable in the lower limb and the timing of important factors include:
surgery is important. Family history
Breech presentation
Hip disorders Foot deformity
Accurate diagnosis and treatment of Torticollis
paediatric hip disorders is important because Neuromuscular disorders
of the potential for complications, which may Skeletal dysplasias
lead to degenerative joint disease in adult life.
Different disorders have a propensity to occur Clinical features
at different ages (Table 19.5). Developmental dysplasia of the hip can
present as:
Development dysplasia of the hip
A neonate with hip instability
This condition is often described as congenital
An infant with limited hip abduction
dislocation. Developmental dysplasia of
A toddler with a limp
the hip is a more accurate term as common
An adult with degenerative hip changes
features include dysplasia of the acetabulum
and femoral neck anteversion. The apparent All neonates should be screened for hip
incidence of developmental dysplasia depends instability. The hips are flexed to 90 and
on the age of the child. Approximately 20 per instability detected by reduction of the
1000 neonates have clinical evidence of hip dislocation by abduction and forward
instability but only 1 per 1000 have evidence of pressure (Ortolanis test) and dislocation of
hip dislocation at 3 months. the hip by adduction and backward pressure
(Barlows test). Examination may also show
Pathophysiology limb shortening, an extra thigh skin crease
The acetabulum develops from a triradiate and hip external rotation. At an older age,
cartilage and three ossification centres. Galeazzis sign may be elicited. It is a sign
Normal growth is dependent on apposition of unilateral hip displacement. The child is
supine with hips and knees flexed and one
90
Apex
Cobbs angle
90
adduction and cavus deformity, then the Posterior part of deltoid ligament
whole foot varus deformity and finally the Posterior part of ankle joint and subtalar
equinus deformity are addressed, in that joint capsules
order. False correction of the deformity can Fibulocalcaneal and fibulotalar ligaments
occur leading to a rocker-bottom foot. Peroneal tendon sheaths
Talonavicular joint capsule
Surgery
Tendons that may require lengthening include:
Surgery is required in 10%, 50% and 90% of
patients with Grade 1, 2 and 3 deformity, Achilles tendon
respectively. By 3 months of age, it is usually Tendon of flexor digitorum longus
clear whether conservative management will be Tendon of flexor hallucis longus
effective. The timing of surgery is controversial. Tendon tibialis posterior
Most surgeons recommend surgery between Percutaneous wires may be need to
9 and 12 months of age. Plaster can then be maintain correction and the foot is kept
removed at the time the child begins to walk. in plaster for about 6 weeks. Following
The aim of surgery is release all the tight plaster removal, a splint is required until the
structures and lengthen muscles. child is walking normally. Late problems
Structures that may need to be divided following surgery include dynamic forefoot
include the: adduction and varus, recurrent deformity and
overcorrection. Most children undergoing
Plantar fascia
surgery achieve a plantigrade foot and most
Tendon sheaths of tibialis posterior, flexor
can wear normal shoes.
hallucis longus, flexor digitorum longus
Chapter 20 Plastic and
reconstructive
surgery
The ability of the skin to repair depends on of body surface area (BSA) involved. This can
the depth of the burn. Burns can be classified be calculated from either a Lund and Browder
as: Chart or by the Wallace Rule of Nines (Table
Superficial burns 20.1). Also, the surface area covered by the
Partial thickness burns patients hand with fingers closed is about 1%
Full-thickness burns the BSA. In a child, the body proportions are
different. The head is relatively larger (19%
Superficial burns vs. 9%) and each lower limb relative smaller
Superficial burns need to be differentiated (13% vs. 18%). The other body proportions are
from simple skin erythema. In a superficial similar to adults.
burn, only the epidermis and papillae are Fluid replacement
involved. This results in red serum-filled
Patients with extensive burns require
blisters. The skin blanches on pressure. The
significant fluid resuscitation. To assess fluid
burn is painful and sensitive. Healing occurs
replacement it is necessary to know:
in about 10 days without scarring.
Time of injury
Partial-thickness burns Patients weight
In partial-thickness burn, the epidermis is Percentage BSA involved
lost with varying degrees of dermis. The burn Intravenous fluid replacement needs to be
is usually coloured pink and white and may given for burns affecting more than 10%
or may not blanche on pressure. Variable BSA in a child and 15% BSA in adult. Many
degrees of reduced sensation may be present. formulas have been devised to estimate the
Epithelial cells are present in hair follicles fluid requirement. The most widely used
and sweat glands resulting in regeneration are the Muir and Barclay formula and the
and spread. Healing occurs in about 14 Parkland formula.
days. Some depigmentation of the scar may The Muir and Barclay formula provides the
occur. A partial-thickness burn requires skin volume (inmL) of colloid to be given in the
grafting. first 4 hours. This volume should be repeated
every 4 hours for the first 12 hours, every 6
Full-thickness burns hours between 12 and 24 hours and once
In a full-thickness burn, both the epidermis between 24 and 36 hours.
and dermis are destroyed. The burn appears
white and does not blanche. Sensation is
absent and without grafting healing occurs
Weight (kg) % BSA /2 per period
The ATLS formula gives the total volume
from the edge of the wound. (inmL) to be infused in the first 24 hours. Half
Assessment
Initial assessment of a patient with burns
The Wallace Rule of Nines
should be with ATLS principles. Good early
management is required to prevent morbidity
or mortality. In the airways assessment it is Body area Percentage (%)
important to look for signs of inhalation injury
Head 9
including facial burns and soot in nostrils
or sputum. When assessing breathing, there Each upper limb 9
needs to be an awareness of carbon monoxide Each lower limb 18
poisoning. The patient may appear pink with Front of trunk 18
a normal pulse oximeter reading. The fluid
Back of trunk 18
loss from a burn is significant and can result
in hypovolaemic shock and acute renal failure. Perineum 1
Escharotomy
Skin grafts
A skin graft is an autograft from one part of
Deep circumferential burns of the torso can
the body to another and can be partial or
impair respiration. In a limb, they can impair
full thickness depending on the amount of
the distal circulation. In both situations,
dermis taken.
escharotomies should be considered. No
anaesthetic is required. The burn should be
Partial-thickness skin grafts
incised into subcutaneous fat and release of
Partial-thickness skin grafts contains
the underlying soft tissue should be ensured.
epidermis and the superficial part of dermis.
On the chest wall, escharotomies should be
It is usually taken from the donor site with a
performed bilaterally in the anterior axillary
dermatome or Humby knife. The donor site
lines. Bleeding may be significant and a blood
epithelium grows back from sweat glands
transfusion may be required.
and hair follicles. Grafts can be meshed to
Respiratory burns increase the area that can be covered. Excess
skin can be stored in a fridge and reused for
Smoke inhalations should be suspected if
up to 3 weeks. Partial-thickness grafts can
there is:
not be used on infected wounds and are
Explosion in an enclosed environment not suitable for covering bone, tendon or
Flame burns to the face cartilage. The cosmetic result is often poor
Soot in mouth or nostrils (Figure 20.2).
Hoarseness or stridor
Intubation may be required. Blood Full-thickness skin grafts
carboxyhaemoglobin levels can give an Full-thickness skin grafts contains epidermis
indication of the extent of lung injury. and all of the dermis. They can only be used
312 Chapter 20 Plastic and reconstructive surgery
to cover small defects. Good cosmetic results the use of delaying techniques. The flap is
can be obtained. The donor site needs to partially raised and replaced prior to use.
be closed with primary suture or a partial This encourages the flap to increase its blood
thickness graft. Common donor sites include supply through the pedicle.
the postauricular skin and supraclavicular
fossa. Tube pedicle grafts
Tube pedicle grafts are frequently raised
Skin flaps from the abdomen or inner arm. Parallel skin
Skin flaps are classified according to their incisions allow a tube of skin to be formed.
blood supply. The skin defect is then closed. The length of
the tube should not be greater than twice
Random pattern grafts the base and the long axis of the tube should
A random pattern graft receives its blood parallel to the direction of the cutaneous
supply from a segmental anastomotic or blood vessels. It is a good means of delaying
axial artery. Examples include advancement tissue transfer over a long distance and can
(Figure 20.3) and rotation flaps (Figure 20.4). produce a good cosmetic result.
the distal phalanx. The metacarpal bones 2. From insertion of flexor digitorum
and phalanges form the dorsal wall. Synovial superficialis to the proximal edge of the A1
sheaths form the volar and lateral walls. pulley
The synovial sheath for the index to ring 3. From the proximal edge of the A1 pulley to
finger begins at the neck of the metacarpals. the distal edge of the carpal tunnel
The synovial sheath of the little finger is 4. Within the carpal tunnel
continuous with the ulna bursa. Extensor 5. Proximal to the carpal tunnel
tendons are extra-synovial, except at the Extensor tendons are divided into eight
wrist. They are surrounded by extensive zones. Zones 1, 3 and 5 lie over the
paratenon with segmental arterial input. The distal interphalangeal (DIP), proximal
extensor retinaculum prevents bowstringing interphalangeal (PIP) and MCP joints
of the extensors. The main action is extension respectively.
of the metacarpophalangeal (MCP) joints.
Flexor tendon injuries
Zones of injury
Flexor tendons are divided into five zones Assessment
(Figure 20.5). Zone 1 is distal and Zone 5 is An accurate history is essential. It is important
proximal. The five zones are: to know the handedness of the patient and his
1. Distal to the insertion of flexor digitorum or her occupation. Observation of the hand at
superficialis rest may indicate which tendons are involved.
Zone TII
Zone TII
Zone TIII
Zone TIII
Zone TIV
Zone TIV
Zone TV
Zone TV
Pigmented skin lesions 315
The level of tendon injury may corresponds should be elevated to reduce swelling. Early
to the site of any laceration but not always. mobilisation is required to reduce adhesion
If both flexor tendons are divided the finger formation and improve tendon healing and
will be extended. If the profundus tendon the final functional outcome. This requires
alone is divided then only the DIP joint will close supervision by a hand physiotherapist.
be extended. Further assessment should Mobilisation can begin as early as the first
involve testing of individual tendons of flexor postoperative day. Passive extension should
digitorum superficialis and flexor digitorum be avoided.
profundus. Neurovascular assessment is also
required. Extensor tendon injuries
For extensor tendon injuries, open
Management exploration and repair is required. They can
Early exploration and repair is required and often be repaired under local anaesthetic.
ideally surgery should be performed within Management depends on the zone of
24 hours of injury. Primary repair is the gold the injury. Proximal injuries require
standard but may not be possible if there has immobilisation with the wrist extended and
been delayed presentation or if the tendons the MCP joint flexed. Active movement can
have retracted. Antibiotic prophylaxis is begin after 3 weeks. Distal injuries require
required if presentation has been delayed longer periods of immobilisation.
or there is wound contamination. The ideal
tendon repair requires:
Sutures easily placed in the tendon
Pigmented skin lesions
Secure suture knots Malignant melanoma
Smooth junction of the tendon ends Epidemiology
Minimal gapping at the repair site
Malignant melanoma is a tumour of
Minimal interference with tendon
epidermal melanocytes. It accounts for less
vascularity
than 5% of skin cancers but more than 75%
Sufficient repair strength
of skin-cancer related deaths. The incidence
Many techniques of tendon repair have been of melanoma is doubling every 10 years,
described. They invariably involve a core especially in sunny climates. Approximately
suture and epitendinous suture. For Zone 1 40 and 4 cases per 100,000 population are
injuries, direct repair is usually possible. A seen each year in Queensland, Australia
periosteal flap can be raised and the tendon and the UK, respectively. In the UK it
anchored with a core suture. For Zone 2 to accounts for about 1000 deaths. Patient
5 injuries, wounds should be excised and education is increasing the number of thin
irrigated. They may need to be extended to tumours detected but the number of thick
retrieve and repair tendons. Incisions should tumours detected remains constant. It is the
be avoided that cross skin creases. Careful commonest cancer seen in 20 to 40-year-olds
planning of incisions is required to prevent and is more common in women. Risk factors
skin necrosis or contracture. Incisions may be include:
required in tendon sheaths between the main
Giant melanocytic naevus
pulleys. The neurovascular bundles should
Total number of naevi
be identified and repaired is necessary.
Dysplastic naevus syndrome
Tendons should be repaired using a standard
History of recurrent sunburn
technique.
Skin type
Postoperative management Family history
After repair, the hand should be placed in a Pathology
back-slab with the wrist at 030 of flexion, About 20% of melanomas arise in pre-existing
the MCP joints at 6090 of flexion and the naevi. Tumours have an initial radial and
PIP and DIP joints in full extension. The hand followed by a vertical growth phase. These
316 Chapter 20 Plastic and reconstructive surgery
Regional lymphadenectomy
In patients with malignant melanoma,
about 20% of clinically palpable nodes
are histologically negative. About 20%
of palpably normal nodes have occult
metastases. Patients with palpable nodes
should undergo fine needle aspiration
Figure 20.9 A subungual melanoma cytology. Confirmed nodal metastases in the
318 Chapter 20 Plastic and reconstructive surgery
2
Level I
Level II 3
Level III 4
Level IV
Level V
Lymphoedema
Major and minor signs of Seroma
malignant melanoma Functional deficit
Major signs Minor signs Wound infection
Persistent pain
Change in size Inflammation
Change in shape Bleeding Adjuvant therapy
Patients at high-risk of recurrence should be
Change in colour Sensory changes
considered for systemic adjuvant therapy.
Diameter >7mm High-risk patients include those with a
primary tumour more than 4mm thick
and resectable positive locoregional lymph
Table 20.2 Major and minor signs of malignant nodes. No standard adjuvant therapy exists
melanoma
but the use of interferon a2b has shown
promising results. It has been shown to
absence of systemic spread is an indication increase disease-free and overall survival.
for regional lymph node dissection. Sentinel
Isolated limb perfusion
lymph node biopsy should be considered for
Isolated limb perfusion (ILP) is the use of
those with impalpable nodes.
intra-arterial chemotherapy administered
Therapeutic lymph node dissection into the limb isolated from the remainder
provides regional control and prognostic of the circulation. Commonly used
information but produces no improvement agents include melphalan +/ TNF-a. It is
in survival. For tumours less than administered with hyperoxygenation and
0.75mm thick about 90% are cured by hyperthermia at temperature of 4142C.
local excision alone. For tumours more Perfusion generally lasts about 1 hour.
than 4.0mm thick about 70% have distant Indications for ILP include:
metastases at presentation. For these
In-transit metastases
two groups, lymphadenectomy provides
Irresectable local recurrence
no added survival benefit. The role of
Adjuvant therapy for poor prognosis
lymphadenectomy for intermediate
tumours
thickness tumours remains controversial.
Palliation to maintain limb function
The complications of lymphadenectomy
The complications of ILP include:
include:
Mortality
Pigmented skin lesions 319
/
commonest cutaneous malignancy. The
malignancy. It occurs on sun exposed skin
r
commonest sites involved are the face and
.i
particularly the face above a line from the
the hands (Figure 20.12). Initially, it usually
angle of mouth to the ear (Figure 20.11).
presents a red plaque. With time it invariable
It usually presents as a pearl-coloured
s
ulcerates and has hard and irregular edges.
nodule with rolled edges. As it enlarges,
s
Predisposing factors include solar keratosis,
central ulceration can occur. Predisposing
Bowens disease, viral warts and chronic
factors include xeroderma pigmentosa and
n
ulceration or sinuses (Marjolin ulcers). The
radiotherapy. They are locally invasive and
differential diagnosis includes:
is a
rarely metastasise.
Keratoacanthoma
Clinical features Basal cell carcinoma
r
The clinical types of a basal cell carcinoma are: Amelanotic melanomas
Nodular or ulcerative Skin adnexal tumours
e
Cystic Treatment is by wide local excision, skin
p
Pigmented grafting and possible elective lymph node
.
Sclerosing dissection.
Cicatrical
p
Benign skin lesions and
iv
Superficial
manifestations of systemic
Management disease
/: /
Treatment is by local excision with 0.5cm
margins and may require a full thickness graft. PeutzJeghers syndrome
Other treatments modalities are radiotherapy PeutzJeghers syndrome is inherited as
tt p
and Mohs micrographic surgery. This is a autosomal dominant disorder. It presents
procedure in which the tumour is excised at with circumoral mucocutaneous pigment
h
A basal cell carcinoma
A squamous cell carcinoma
Figure 20.11 A basal cell carcinoma Figure 20.12 A squamous cell carcinoma
320 Chapter 20 Plastic and reconstructive surgery
lesions on the lower lip, buccal mucosa and they often involute over 6 months leaving an
palate. It is associated with hamartomatous irregular pitted scar. The differential diagnosis
polyps in the small intestine. The polyps have is a squamous cell carcinoma. Treatment is by
fibrous and smooth muscle core with normal excision biopsy.
epithelium and may presents in childhood
with gastrointestinal bleeding, anaemia or Pigmented skin lesions
intussusception. The polyps are pre-malignant. Melanocytes are of neuroendocrine origin
and migrate to the skin during the first three
External angular dermoid months of intrauterine development. They
/
An external angular dermoid is a produce melanin from tyrosine. Melanin is
r
sequestration dermoid lined by epidermis. stored in melanosomes before being exported
.i
They occur on face at lines of fusion of to keratinocytes. A freckle is increased
embryonic processes. The commonest site is melanin by a normal number of melanocytes.
s
around eye at the site of fusion of the frontal A naevus is a pigmented lesion due to an
s
and maxillary processes. They occasionally increased number of melanocytes. Naevi
extend into the orbit and skull. are believed to evolve from junctional via
n
compound to intradermal lesion.
Tricholemmal cyst
is a
Tricholemmal cysts are inherited as Junctional, compound and
autosomal dominant condition. About 90% intradermal naevi
occur on scalp and are often multiple. They A junctional naevus usually presents as
r
are derived from hair follicles and should not a small flat macule and often appears in
e
be regarded as simple epidermoid cysts. childhood as a homogenous brown or black
skin lesion with increased melanocytes in
p
Pyogenic granuloma the rete pegs. A compound naevus presents
.
Pyogenic granulomas are neither pyogenic as raised papule. It is often pale brown with a
p
or granulomas. They are capillary junctional component and nest of cells in the
iv
haemangiomas often with a traumatic dermis. An intradermal naevus appears as a
aetiology. They present as bright red, friable flesh coloured papule. They have an increased
/: /
nodules characterised by contact bleeding. prevalence in middle age with no junctional
The commonest site affected is the hands. activity and only intradermal nests.
Treatment is by curettage or diathermy.
Blue naevus
tt p
Cylindroma A blue naevus is a dome-shaped blue or
Cylindromas are benign tumour of eccrine black papule seen in middle-age. They are
sweat glands. They occur on the scalp and more common in women. The commonest
h
can be solitary or multiple. Multiple tumours site is the scalp and face. They have a dermal
are often referred to as Turban tumours. collection of spindle melanocytes with
Treatment is by local excision. melanin in dendritic cells. They possibly
arise as a result of incomplete migration of
Dermatofibroma melanocytes to the epidermis.
Dermatofibromas or benign histiocytomas
are more common in women than men. They Halo naevus
present with small firm pigmented nodules, A halo naevus is a benign naevus with pale
usually pink or brown. The commonest site is rim. It needs to be differentiated form a
the leg. Treatment is by local excision. melanoma with regression. It results from
a naevus with lymphocytic invasion and
Keratoacanthoma melanocyte destruction.
Keratoacanthomas are more common in men
than women. They present as rapidly growing Juvenile melanoma
skin lesions over 68 weeks. They are usually A juvenile melanoma or Spitz naevus is a
dome-shaped with a keratin filled crater and benign tumour that histologically mimics a
may be up to 3cm in diameter. If untreated, melanoma. It has regular melanocytes with a
Pigmented skin lesions 321
vascular stroma and epidermal hypertrophy. shoes, poor foot care and inappropriate nail
It is most commonly seen in young adults cutting.
and is more common in women. It presents
as a single pink domed-shaped nodule and Management
is most frequently seen on the head and In the early stages, conservative management
neck. should be attempted. This includes regular
soaking and washing of the feet, careful
Nail disorders drying after washing and the wearing of
Ingrowing toenails properly fitting shoes. Patients should be
/
Ingrowing toenails are a common problem in taught to cut their nails transversely. The use
r
adolescents and young adults. They usually of pledgets of cotton wool placed under the
.i
affects the hallux but other nails may also be nail may encourage it to grow out.
affected. It is due to the lateral edge of the nail Surgery may be required if conservative
s
growing into the adjacent soft tissue (Figure measures fail. The nail can be removed by
s
20.13). Bacterial or fungal infection may be avulsion or wedge resection. Recurrence is
superimposed. Attempted healing may result common. If simple avulsion fails, ablation of
n
in over-granulation of the nail bed. Possible the nail bed should be considered. This can
aetiological factors include poorly fitting
is a
be achieved either chemically or surgically.
Chemical ablation can be achieved with
phenol. Surgical removal usually involves a
Zadek procedure. Avulsion and phenolisation
r
Bilateral ingrowing toe nails is more effective than surgical procedures.
e
Subungual haematoma
p
Subungual haematoma results from blunt
.
trauma to the hallux and nail bed. Blood
p
collects under the nail. Increased pressure
iv
causes severe pain. The nail initially appears
red but becomes purple as the blood
/: /
coagulates. The differential diagnosis includes
a subungual melanoma, a glomus tumour
or Kaposis sarcoma. The haematoma can
tt p
be evacuated by nail trephine with a heated
needle or drill. Blood under pressure is
Figure 20.13 Bilateral ingrowing toe nails released and the symptoms immediately settle.
h
Chapter 21 Neurosurgery
Skull
Dura
Arachnoid mater
Pia mater
Grey matter
White matter
324 Chapter 21Neurosurgery
sinuses. The arachnoid villi transport the CSF cerebrospinal fluid (CSF) which absorbs
from the subarachnoid space to the dural physical shocks to the brain, distributes
sinuses. Two cavities border the arachnoid: nutrients to and removes wastes from the
the subdural space is outside the arachnoid nervous tissue. It provides a chemically stable
and the subarachnoid space is within the environment. The two lateral ventricles are
arachnoid. This space contains blood vessels found in the cerebral hemispheres. The
and circulates CSF. The pia mater is the third ventricle is connected by a passage
innermost layer. It tightly covers the brain and (interventricular foramen) to each of the
carries blood vessels that provide the nervous two lateral ventricles. The fourth ventricle
tissues. is connected to the third ventricle (via the
cerebral aqueduct) and to the central canal
The brain of the spinal cord. Additional openings in the
There are three major divisions of the brain. fourth ventricle allow CSF to flow into the
They are the forebrain, the midbrain, and the subarachnoid space.
hindbrain. The forebrain is responsible for a A network of capillaries called the
variety of functions including receiving and choroid plexus projects into each ventricle.
processing sensory information, thinking, Ependymal cells surround these capillaries.
perceiving, producing and understanding Blood plasma entering the ependymal
language, and controlling motor function. cells from the capillaries is filtered as it
There are two major divisions of forebrain: passes into the ventricle, forming CSF. Any
the diencephalon and the telencephalon. material passing from the capillaries to the
The diencephalon contains structures such ventricles of the brain must do so through
as the thalamus and hypothalamus which the ependymal cells. Tight junctions linking
are responsible for such functions as motor these cells prevent the passage of plasma
control, relaying sensory information, between them. Thus, the ependymal cells
and controlling autonomic functions. The maintain a bloodCSF barrier, controlling the
telencephalon contains the largest part of composition of the CSF.
the brain, the cerebrum. Most of the actual
information processing in the brain takes Intracranial pressure
place in the cerebral cortex. The midbrain As the cranial vault is essentially a closed,
and the hindbrain together make up the fixed bony structure, its volume is constant.
brainstem. The midbrain is the portion of The contents are the brain, CSF and blood.
the brainstem that connects the hindbrain All these components are non-compressible
and the forebrain. This region of the brain is and as a result any increase in one of the
involved in auditory and visual responses as components must be at the expense of the
well as motor function. The hindbrain extends other two. This relationship is known as the
from the spinal cord and is composed of the MonroKellie doctrine. Once the cranial vault
metencephalon and myelencephalon. The is filled, pressure rises dramatically.
metencephalon contains structures such as Normal intracranial pressure (ICP) is
the pons and cerebellum. These regions assist 510mmHg. Due to autoregulation, cerebral
in maintaining balance and equilibrium, perfusion pressure (CPP), the pressure of
movement coordination, and the conduction blood flowing to the brain, is normally fairly
of sensory information. The myelencephalon constant. A rise in ICP reduces cerebral blood
is composed of the medulla oblongata which flow by reducing the cerebral perfusion
is responsible for controlling autonomic pressure. Some compensation is possible as
functions. CSF and blood move into the spinal canal and
extracranial vasculature, respectively. There is
Neurophysiology however a point where further compensation
Cerebrospinal fluid is impossible and ICP rises dramatically
There are four cavities in the brain, called (Figure 21.2), CPP falls and cerebral ischaemia
ventricles. The ventricles are filled with occurs. Common causes of raised ICP include:
Neurosurgical trauma 325
Intracranial volume
About 5% patients with a severe head injury Amnesia (antegrade or retrograde) lasting
have a cervical spine injury. Patients who more than 5 minutes
have sustained a head injury and present with Abnormal drowsiness
any of the following risk factors should have Three or more discrete episodes of
full cervical spine immobilisation: vomiting
GCS less than 15 on initial assessment by Clinical suspicion of non-accidental injury
the healthcare professional Post-traumatic seizure but no history of
Neck pain or tenderness epilepsy
Focal neurological deficit GCS less than 14, or for a baby under 1
Paraesthesia in the extremities year GCS less than 15
Any other clinical suspicion of cervical Suspicion of open or depressed skull injury
spine injury or tense fontanelle
Any sign of a basal skull fracture
Investigation Focal neurological deficit
CT is the primary investigation of choice for Dangerous mechanism of injury
clinically significant brain injury. Indications Plain x-rays of the skull should not be used
for an immediate CT in an adult are: to diagnose significant brain injury without
GCS less than 13 at any point since the prior discussion with a neuroscience unit.
injury Skull x-rays have a role in the detection of
GCS equal to 13 or 14 at 2 hours after the non-accidental injuries in children.
injury
Suspected open or depressed skull fracture Management
Any sign of a basal skull fracture Criteria for admission and observation after a
Post-traumatic seizure head injury are:
Focal neurological deficit Altered level of consciousness
More than one episode of vomiting Skull fracture
Amnesia for greater than 30 minutes of Neurological symptoms or signs
events before impact Difficult assessment drugs or alcohol
If LOC in patients older then 65 years, No responsible carer
coagulopathy or dangerous mechanism of
Observations should be performed and
injury
recorded on a half-hourly basis until a
Indications for an immediate CT in a child
GCS equal to 15 has been achieved. The
are:
minimum frequency of observations for
Loss of consciousness lasting more than 5 patients with GCS equal to 15 should be as
minutes follows:
Neurosurgical trauma 327
A
4 cm
2 cm
External
auditory
meatus
Zygomatic
arch
328 Chapter 21Neurosurgery
Clinical features
The classical presentation is of an elderly
patient with a history of falls who presents
with deteriorating neurological function. The
patient often has headaches, confusion or
focal mass effect hemiparesis or dysphasia.
Investigation
A CT scan may show a crescent-shaped mass
between the inner table of the cranium and
the outer surface of the cortex (Figure 21.5).
Most haematomas are located in the fronto-
parietal region. The natural history if for the
clot to be initially hyperdense early after injury
and then to become hypodense with time.
Bilateral isodense subdural haematomas can
easily be missed.
Management
Small haematomas without significant mass
effect can be managed conservatively. If the
haematomas are large and have significant Patients with a partial lesion may regain
mass effect, then burr holes should be substantial or even normal neurological
considered. Craniotomy is indicated if the function even though the initial neurological
clot does not completely liquify or becomes deficit may be severe. The presence of the
loculated. Over 90% of operated cases show bulbocavernous reflex or analcutaneous
residual blood on early postoperative imaging reflex indicates sacral sparing and a more
and as many as 20% of cases require further favourable prognosis.
surgery. Patients may develop respiratory failure due
to:
Spinal cord injuries
Intercostal paralysis
All patients with multiple trauma should be
Partial phrenic nerve palsy
suspected of having a spinal injury. Failure to
Impaired ability to cough
detect usually results from failure to suspect.
Ventilationperfusion mismatch
The cervical spine and thoraco-lumbar
Variable intercostal nerve paralysis
junction are the commonest site of injury. The
Associated chest injuries
percentage of nerve injuries seen in patients
with spinal fractures are: Respiratory failure may develop as a late
feature due to ascending oedema in the
Cervical spine 40%
cervical cord. The abdomen may be flaccid
Thoracic spine 10%
with absent sensation. Features of peritonism
Thoraco-lumbar junction 35%
may be absent. Priapism may develop.
Lumbar spine 5%
All injuries should be assumed to be unstable Partial cord lesions
until proved otherwise. With partial cord lesions, function may be
preserved distal to the level of cord injury.
Initial assessment The diagnosis may be missed if it does not
At the scene of the accident, it is vital to fit the classical injury pattern. The clinical
maintain in-line spinal immobilisation. This features of partial cord lesions are as follows:
requires supporting of the neck with a stiff
Central cord lesion flaccid paralysis of
collar and sandbags. The patient should be
the upper limbs
transported on a spinal board. During the
Anterior cord lesion loss of temperature
primary survey, if intubation is required in-
and sensation
line immobilisation should be maintained.
Posterior cord lesion loss of vibration
Cervical spine injuries reduce sympathetic
sensation and proprioception
outflow. Therefore, in patients with spinal
BrownSequard syndrome loss of
cord injuries, pharyngeal stimulation with an
ipsilateral power and contralateral pain
airway or endotracheal tube can cause vagal
and temperature
discharge and cardiac arrest. Patients may
be both hypotensive and bradycardic and Radiological assessment
may require the use of atropine and inotropic Approximately 20% patients with spinal cord
support. Aggressive fluid resuscitation can injury have no radiological evidence of bony
induce pulmonary oedema. injury. Lateral cervical spine x-rays were until
recently the commonest means of assessing
Clinical features
the cervical spine. With the increasing
The level of the cord lesion is conventionally
availability of CT scanning, this is being more
defined as the most caudal location with
commonly used to assess possible cervical
normal motor and sensory function (Table
spine injuries.
21.2). Spinal shock may mimic a complete
cord lesion with total loss of motor and Lateral cervical spine x-ray should be
sensory function distal to the injury. However, taken during the primary survey. It should
if the lesion is incomplete some function will ensure that the junction between C7 and T1
return. Almost all patients with a complete is seen. Anterio-posterior and odontoid peg
cord lesion will not show functional recovery. views should be taken during the secondary
330 Chapter 21Neurosurgery
survey. If unable to see the C7/T1 junction Compression of a vertebral body more
consider a swimmers view. On a lateral than 25%
cervical spine film it is necessary to assess: Kyphotic angle of more than 10%
Anterior vertebral alignment Facet joint widening
Posterior vertebral alignment Teardrop fracture
Posterior facet joint margins Base of odontoid peg fracture
Anterior border of spinous processes Atlanto-axial gap more than 3mm
Posterior border of spinous processes Atlanto-occipital dislocation
Integrity of vertebral bodies, laminae, Various reports confirm a higher sensitivity and
pedicles and arches specificity of CT sacnning versus conventional
Pre-vertebral space plain films in cervical spine injury The chance
Retropharyngeal space should be less than of finding additional information, like bony
6mm ligamentous avulsion or dorsal arch fractures is
Retrotracheal space should be less than substantially higher with CT.
22mm
Interspinous gaps Management
Radiological signs of spinal instability A spinal cord injury is a medical emergency
include: requiring immediate treatment to reduce
Neurosurgical disorders 331
the long-term effects. The time between Posterior communicating artery (30%)
the injury and treatment is a critical factor Anterior communicating artery (25%)
affecting the eventual outcome. Steroids Middle cerebral artery (25%)
may be used to reduce the swelling of the Most aneurysms remain asymptomatic but
spinal cord. Decompressive surgery may they are a common cause of sudden death.
be necessary to remove bony fragments or About 15% of aneurysms are multiple.
stabilise the spine.
The rehabilitation process following a Clinical features
spinal cord injury should begin in the acute The classic presentation of a subarachnoid
care setting. Physiotherapists, occupational haemorrhage is with a sudden onset of
therapists, social workers, psychologists and a severe headache often associated with
other healthcare professionals work as a team nausea, vomiting, photophobia and neck
to determine an individualised management stiffness. Neurological symptoms and signs
plan. In the acute phase, management may be present. The level of consciousness
focuses on the patients respiratory status, may be reduced. Fundoscopy may show
prevention of complications, maintaining the subhyoid haemorrhages. The clinical
range of motion and muscle bulk. course is unpredictable. Overall mortality is
Complications of a spinal cord injury approximately 40%. Many patients die before
include: reaching hospital.
Deranged blood pressure control Investigation
Chronic kidney disease The diagnosis can often be confirmed by an
Deep vein thrombosis early CT or MRI. CT has a sensitivity of 90%
Pulmonary infections if performed within the first 24 hours. The
Pressure sores sensitivity is reduced to 50% by 72 hours
Contractures as blood is reabsorbed. The CT may also
Urinary tract infections identify the source of haemorrhage. Fluid-
Incontinence attenuated inversion recovery (FLAIR) is
Loss of sexual function the most sensitive MRI pulse sequence for
Muscle spasticity the detection of subarachnoid hemorrhage.
On FLAIR images, blood appears as high
Neurosurgical disorders signal-intensity in normally low signal-
intensity CSF spaces. MRA may be useful for
Subarachnoid haemorrhage evaluating aneurysms and other vascular
Subarachnoid haemorrhage accounts lesions. If the diagnosis is in doubt then
for approximately 5% of cerebrovascular lumbar puncture may be indicated and will
accidents. The outcome depends on show uniform blood-staining of CSF and
the degree of neurological deficit. The xanthochromia.
lower the GCS on presentation, the
worse the prognosis. About 70% are due Complications
to berry aneurysms. The remainder are The major complications of a subarachnoid
due to arteriovenous malformations and haemorrhage are:
hypertension. Rebleed
Delayed ischaemic neurological deficit
Pathology Hydrocephalus
Berry aneurysms are found in 8% of
The risk of rebleed is 4% at 24 hours, 25% at
individuals at post mortem. They are thin
2 weeks and 60% at 6 months. Rebleeding
walled saccular aneurysms found at arterial
is associated with a 60% mortality. Delayed
bifurcations on the Circle of Willis. They
ischaemic neurological deficit (DIND) is
occur due to turbulent flow and damage to
due to intense vasospasm. Treatment is
the internal elastic lamina of the intracranial
by maintaining cerebral perfusion with
arteries. The commonest site of aneurysms are:
332 Chapter 21Neurosurgery
Pathology Management
From a local focus of infection, bacteria can The principles of treatment of intracranial
penetrate the skull through the diploeic veins. abscess are:
Also, local osteomyelitis may result in venous Drain intracranial collection
sinus thrombosis. As the dura is normally Administer effective antibiotic therapy
a good barrier to the intracranial spread of Eliminate primary source of infection
infection, pus in the extradural space usually
Supratentorial abscesses can be drained via
causes an extradural empyema. Subdural
a burr hole. Pus should be aspirated and
sepsis causes oedema and cortical venous
sent for culture. Clinical progress can be
thrombosis. Brain penetration causes an
monitored by serial CT scans. Stereotactic
early diffuse cerebritis. A localised abscess
drainage may be required for multiple
may develop with oedema and increased
or multiloculated abscesses. Cerebellar
intracranial pressure. The abscess usually
abscesses may require a suboccipital
forms in the subcortical white matter near to
craniectomy and open drainage. Subdural
the septic focus. Haematogenous abscesses
empyemas are often diffuse and difficult
may be multiple.
to drain and may require craniectomy and
Clinical features open drainage. Parenteral antibiotic should
be administered for at least 2 weeks. The
Intracranial abscesses can affect any
choice of antibiotics depends on the primary
age or sex. The systemic upset is often
pathology and antibiotic sensitivities.
mild. Symptoms of increased intracranial
pressure include headache and vomiting, Prompt treatment results in a mortality
often associated with progressive clouding of less than 10%. Delayed treatment results
of consciousness. As the abscess develops, in mortality greater than 50%. About 50% of
focal neurological symptoms may evolve. survivors have neurological sequelae including
As a result, symptoms of increased hemiparesis, visual field losses and epilepsy.
intracranial pressure associated with Spinal abscess
focal neurological signs requires urgent
neurosurgical assessment. The differential Spinal abscesses are usually bacterial.
diagnosis includes meningitis or an Infection arises in adjacent bone or by
intracranial tumour. Osteomyelitis due to haematogenous spread. The commonest
frontal sinusitis or middle ear disease may organisms are staphylococcal and
produces localised swelling (Pott puffy streptococcal species. Pus is usually
tumour). confined to extradural space. Subdural and
intramedullary infections are rare.
Investigation
Clinical features
MRI, with and without gadolinium
enhancement, is the investigation of The patient is often systemically unwell and
choice. It is more specific than CT scanning may present with severe thoracic or lumbar
in differentiating a cerebral tumour, back pain at the level of the abscess. The
haematoma and abscess. On contrast pain is worse on movement and associated
enhanced CT scanning, a cerebral abscess with marked muscle spasm and vertebral
appears as radiolucent space occupying tenderness. Radicular signs are often present
lesion with ring enhancement of the capsule. at the level of the lesion. Cord compression
It is often surrounded by considerable results in long tract signs. Thrombophlebitis
cerebral oedema. The position, size and can cause cord vessel thrombosis and
number of abscesses may suggest the cord infarction, presenting with complete
underlying pathology. Lumbar puncture is paralysis, sensory and sphincter loss.
contraindicated as in the presence of raised
Investigation
intracranial pressure it can precipitate
tentorial or tonsillar herniation. Serum white cell count, ESR and CRP are
invariably raised. X-rays are often normal but
334 Chapter 21Neurosurgery
Lacunae Lamellae
Canaliculi
Haversian canal
Osteon
Osteon of
compact bone
Trabeculae of
spongy bone
Haversian canel
Periosteum
Volkmanns canal
336 Chapter 22 Trauma and orthopaedic surgery
Structure of a neurone
Dendrites
Axon terminal
Nucleus
Axon
Presynaptic Synaptic
neurone vesicles
Autoreceptor
Reuptake
transporter
Synaptic cleft
Receptors
Postsynaptic
neurone
This occurs through the action of the enzyme phenylalanine and tyrosine. Tyrosine is
choline acetyltransferase. Neurones that produced in the liver from phenylalanine
synthesise and release ACh are termed through the action of phenylalanine
cholinergic neurones. ACh receptors are hydroxylase. Tyrosine is then transported
ligand-gated cation channels. Two main to catecholamine-secreting neurones. A
classes of ACh receptors have been identified series of reactions convert it to dopamine,
and are known as muscarinic and nicotinic to noradrenaline and finally to adrenaline.
receptors. Both receptor classes are abundant Catecholamines exhibit peripheral nervous
in the human brain. Nicotinic receptors system excitatory and inhibitory effects. They
are further divided into those found at bind to two different classes of receptors
neuromuscular junctions and those found at termed the - and -adrenergic receptors.
neuronal synapses. Numerous compounds The adrenergic receptors are coupled to
have been identified that act as either agonists intracellular G-proteins. Noradrenaline
or antagonists of cholinergic neurones. The released from presynaptic noradrenergic
principal action of cholinergic agonists is the neurones is recycled in the presynaptic
excitation or inhibition of autonomic effector neurone by a reuptake mechanism.
cells. ACh is destroyed by hydrolysis using the
enzyme acetylcholinesterase. The responses of Serotonin
cholinergic neurones can also be enhanced by Serotonin (5-hydroxytryptamine, 5HT)
administration of cholinesterase inhibitors. is formed by the hydroxylation and
decarboxylation of tryptophan. The greatest
Catecholamines concentration of 5HT (90%) is found in the
The principal catecholamines are enterochromaffin cells of the gastrointestinal
noradrenaline, adrenaline and dopamine. tract. Most of the remainder of the bodys
These compounds are formed from 5HT is found in platelets and the central
Applied basic sciences 339
a short delay. A simple twitch usually only appearance of skeletal muscle is due to the
generates about 2030% of the maximum alignment of molecules in bands and lines.
tension and the muscle starts to relax before The most prominent are the A and I bands
the maximum tension is reached. Muscle and the Z line. The unit between two Z lines is
contractions can be added together to called the sarcomere. When muscle contracts
produce more force. If a second stimulus is the sarcomere shortens and the Z lines move
given before a muscle relaxes, the muscle closer together.
will shorten further. This process is known
as summation. If many stimuli are given Actin and myosin
very close together the muscle will go into When muscle contracts, the protein filaments
continuous contraction called tetanus which slide together. Muscle is composed of two
gives a maximum tension several times contractile proteins:
higher than a simple twitch. Another way to Thin filaments actin, is found in both A
increase the force of contraction is to recruit and I bands
more motor units. Muscle produces the Thick filaments myosin, is found in the
greatest isometric tension at intermediate A band
lengths. At rest, many of the bodys muscles
Actin and myosin connect through
are close to their optimum lengths.
crossbridges. The more crossbridges there
Fibre types are, the higher the tension. ATP is required
for both contraction and relaxation of muscle.
Within skeletal muscles, there are different
It is required for the sliding of the filaments,
types of muscle fibres. The relative
accomplished by a bending movement of the
proportions of the different types varies
myosin heads. ATP is also required for the
between muscles and individuals. Type
separation of actin and myosin which relaxes
1 or red fibres have many mitochondria,
the muscle. A sudden inflow of calcium is the
contain myoglobin, contract slowly but resist
trigger for muscle contraction. In the resting
fatigue. Type 2 or white fibres contain few
state, the protein tropomyosin winds around
mitochondria, rely on glycolysis to supply
actin and covers the myosin binding sites. The
energy, contract rapidly but fatigue quickly.
calcium binds to a second protein, troponin.
The sarcomere This causes the tropomyosin to be pulled to
deform, exposing the myosin binding sites.
The basic unit of muscle contraction is
With the sites exposed, the muscle contracts.
the sarcomere (Figure 22.4). The striated
Sarcomere
l band A band
Z line H zone
M line
Applied basic sciences 341
Middle
phalange
Proximal
phalange
3rd
2nd
metacarpal
metacarpal
4th
1st
metacarpal
metacarpal
5th
Capitate
metacarpal
Hamate Trapezoid
Pisiform
Triquetrum Trapezium
Lunate Scaphoid
Ulna Radius
The distal row contains the: are flexion, extension, abduction, adduction,
Trapezium medial and lateral rotation.
Trapezoid
Capitate
The knee
Hamate The knee is a synovial joint but it is not a
simple hinge. It has two component which
Joints of the lower limb are articulations between the femoral and
tibial condyles and the patellofemoral joint. It
The hip is stabilised by the knee ligaments as follows:
The hip is a synovial ball and socket joint.
Anterior cruciate ligament prevents
Articulation occurs between the head of the
anterior translation of the tibia
femur and the acetabulum of the hip bone.
Posterior cruciate ligament prevents
The articular surface is horseshoe-shaped
posterior translation of the tibia
and deficient at the acetabular notch. The
Medial collateral ligament provides valgus
cavity is deepened by a rim of fibrocartilage
stability
knows as the acetabular labrum. The articular
Lateral collateral ligament provides varus
surfaces are covered with hyaline cartilage.
stability
The capsule is strengthened by ligaments as
Posteromedial capsule resists external
follows:
rotation
Iliofemoral ligament Posterolateral capsule resists internal
Pubofemoral ligament rotation
Ischiofemoral ligament
The menisci are semi-lunar shaped
Transverse acetabular ligament
fibrocartilages. They increase the joint
The nerve supply is from the femoral, congruence and distribute the load across
obturator and sciatic nerves. The movements the joint. They are avascular and heal poorly
344 Chapter 22 Trauma and orthopaedic surgery
adjacent structures. Late complications are rupture. It also occurs without injury in
often related to local bone problems. unconscious or paraplegic patients. Pain
is an early symptom. Joint stiffness and a
Delayed union reduced range of movement are late features.
Delayed union is prolongation of the time to In the late stage of the process, a bony
fracture union. No definite timetable to define lump is often palpable. Early x-rays shows
delayed union exists. Delayed union is due to: fluffy calcification. Late x-rays shows bone
Inadequate blood supply formation. Management involves joint rest
Infection in the position of function. Once pain settles,
Incorrect splintage mobilisation can be begun. After several
Intact fellow bone months, consideration should be given to
In delayed union, the fracture site remains excision of the bony mass.
tender. The bones may still move when Avascular necrosis
stressed. On x-ray the fracture remains visible
Avascular necrosis occurs when a fracture
and little callus formation or periosteal
interrupts the blood supply to adjacent bone.
reaction is seen. Management usually
Certain regions are prone to bone ischaemia
involves continuation of the previous fracture
and necrosis including the head of the femur,
management. It may be necessary to replace
the proximal scaphoid and the body of the
casts or reduce traction. Functional bracing
talus. Pain is the main symptom due to fracture
may promote bone union. If union is delayed
non-union. X-ray shows an increase in bone
more than 6 months, then it may be necessary
density. Surgical intervention is required if
to consider internal fixation or bone grafting.
there is a reduction in function. This may
Non-union require an arthrodesis or arthroplasty.
Non-union is failure of the fracture site to
unite. It has many causes including:
Compound fractures
All open fractures must be assumed to be
Bone or soft tissue loss
contaminated. The aim of treatment is to
Soft tissue interposition
prevent them from becoming infected. First
Poor blood supply
aid treatment is the same as for a closed
Infection
fracture. Peripheral neurovascular status
Pathological fracture
should be assessed. In addition, the wound
Poor splintage or fixation
should be covered with a sterile dressing.
Fracture distraction
Wounds should be photographed so that
Clinical assessment shows remaining repeated uncovering is avoided. Antibiotic
movement at the fracture site. Movement is prophylaxis should be given and the tetanus
often relatively painless. Radiologically, the immunisation status should be evaluated.
fracture is still visible and the bone ends on
Open fractures require early operation and
either side of the fracture are sclerosed. Non-
ideally this should be within 6 hours of injury.
union can be either hypertrophic or atrophic
The aims of surgery are to:
depending on the presence or absence of
bone loss. Asymptomatic non-union may not Clean the wound
require active treatment except splintage. For Remove devitalised tissue
hypertrophic non-union, internal or external Stabilise the fracture
fixation may be necessary to achieve union. Small clean wounds can be sutured. Large
For atrophic non-union bone grafting is dirty wounds should be debrided and left
invariably required. open. Debrided wounds can be closed by
delayed primary suture at about 5 days.
Myositis ossificans
Myositis ossificans is due to heterotopic Pathological fractures
ossification with a muscle. The elbow is the A pathologic fracture is one caused by a
commonest joint involved. It is occasionally disease leading to a weakness of the bone
seen following a joint dislocation or muscle (Table 22.3). This process is most commonly
Skeletal fractures 347
due to osteoporosis, but may also be due to used to provide structural support. Both
other pathologies such malignancy, infection, form a scaffold into which osteoblasts and
inherited bone disorders or a bone cyst. osteoclasts can grow. The graft stimulates
The commonest cancers that metastasise to local bone growth by the process of
bone and result in pathological fractures are osteoinduction. Osteoblast differentiation
breast, prostate, kidney, lung and thyroid. A leads to graft resorption. Remodelling occurs
pathological fracture usually occurs during as load is applied to the graft.
normal activities when the underlying disease Bone grafts can be harvested from the
process weakens the bone to the point where iliac crest, proximal tibia and distal radius.
it is unable to perform its normal function. The iliac crest is the most common donor
The aims of surgery for a pathological site but its use is associated with significant
fracture are to provide pain relief and a stable morbidity. Cortico-cancellous grafts are
bone or joint that will allow the patient to harvested as strips. Cancellous bone can
mobilise shortly after surgery and will last be taken from the inner or outer table.
for the remaining life of the patient. Given Segments of bone can be transplanted as free
the frequent large amount of bone loss, the vascularised grafts. Local rotational bone
degree of osteoporosis in the elderly, and the grafts may also be used. The blood supply to
decreased ability of bone to heal at a tumour the graft is maintained. They are technically
site, this is often difficult to achieve. The difficult to perform and the results are
techniques used in these patients differ from unpredictable.
those used in young trauma patients.
Allografts
Principles of bone grafting Allograft bone is more plentiful and can be
Loss of bone can occur in several situations harvested from living donors or cadavers.
including trauma, tumours or following the Donor site morbidity is eliminated. Cadaveric
use of prostheses. The use of bone grafts may bone and femoral heads are stored in tissue
be necessary to fill the resulting defect. Bone banks. Bone is frozen at 20 to 86C. Freeze
grafts can be classified as: drying and storage at room temperature
Autograft Bone from the same individual is occasionally used. Allografts are used in
Allograft Bone from another individual of reconstruction after tumour resection or
the same species revision hip surgery. Infection is the major
Xenograft Bone from another species concern with the used of allografts. Bacterial
contamination may occur, especially
Autografts with cadaveric grafts but this risk can be
Autogenous bone is the ideal graft material eliminated with irradiation of the graft.
but it may only be available in limited Viral contamination with hepatitis or HIV is
amounts. Cancellous bone can be used possible. Bone should be kept in quarantine
to fill cavity defects. Cortical bone can be and living donors tested 90 days after the
348 Chapter 22 Trauma and orthopaedic surgery
bone is harvested. Allograft bone is available Stage 4 complete fracture with significant
as morsellised bone for impaction grafting, displacement
strut grafts to cover cortical bone and massive Intracapsular fractures reduce the blood
allografts to replace significant proportions of supply to the femoral head. They are at
native bone. high-risk of delayed union, non-union or
avascular necrosis. If the femoral head is to be
Bone substitutes preserved they need anatomical reduction.
Interest exists in developing artificial bone Extracapsular fractures do not interfere with
substitutes that would eliminate the supply femoral head blood supply and do not require
and infection problems associated with auto anatomical reduction.
and allografts. Possible bone substitutes
include calcium triphosphate, hydroxyapatite, Management
calcium carbonate and glass-based cements. All patients should be considered for
Unfortunately, most bone substitutes are surgery if fit enough for an operation. Early
brittle and are unable to withstand significant mobilisation is associated with improved
load bearing. long-term prognosis. Ideally surgery
should be performed within 24 hours and
Hip fractures postoperative rehabilitation should be by a
In the UK, approximately 60,000 proximal multidisciplinary team. Multidisciplinary
femoral fractures occur each year. The mean rehabilitation should involve mobilisation
age of patient is 80 years. The incidence strategies, early supported discharge and
increases exponentially above the age of 65 intermediate care.
years and the main risk factors are female
sex and osteoporosis. About 40% of patients Intracapsular fractures
with a hip fracture die within a year and 50% The three treatment options for
of survivors are less independent than before intracapsular fractures are reduction and
the injury. Most morbidity and mortality is internal fixation, femoral head replacement
related to coexisting medical conditions. The or total joint replacement. Internal fixation
cost of managing all hip fractures in the UK is is indicated in undisplaced fractures or
about 2 billion per year. displaced fractures in patients less than
70 years of age. Internal fixation is usually
Clinical features achieved with the use of three cancellous
Proximal femoral fractures usually occur screws. Complications include non-union
following a fall. Patients often have other and avascular necrosis. Femoral head
significant co-morbidity. The main symptom replacement is indicated in displaced and
is hip pain and an inability to weight bear. The pathological fractures. The options available
leg may be shortened and externally rotated. include:
Cemented Thompson prosthesis
Investigation Uncemented Austin Moore prosthesis
The diagnosis confirmed by a anterior- Bipolar prosthesis
posterior and lateral x-ray. However,
Total hip replacements should be
impacted undisplaced fractures may
considered in those with a displaced
present diagnostic difficulty.Fractures
intracapsular fracture who were able to walk
are best separated into intracapsular
independently, are not cognitively impaired
and extracapsular fractures. The Garden
and are medically fit for anaesthesia and the
classification of hip fractures is as follows:
operation. Complications of femoral head
Stage 1 incomplete or impacted fracture and joint replacement include:
Stage 2 complete fracture with no
Dislocation
displacement
Loosening
Stage 3 complete fracture with partial
Peri-prosthetic femoral fracture
displacement
Skeletal fractures 349
Dorsal angulation of the distal fragment occur through the growth plate and therefore
Dorsal displacement of the distal fragment they are unique to children. They are classified
Radial deviation of the hand according to the degree of involvement of
Supination physis, metaphysis and epiphysis:
Proximal impaction Type I Epiphyseal slip no fracture
In severe cases, there may be dislocation of Type II Fracture through the epiphyeal
the distal radio-ulnar joint or fracture of the plate with proximal fragment
styloid process of the ulna. Management Type III Fracture through the epiphysis
depends on the severity of the fracture and extending into the epiphyseal plate
the age of the patient. A minimally displaced Type IV Fracture through both the
fracture may be treated with a cast alone. The epiphysis and shaft crossing the epiphyseal
cast is applied with the distal fragment in plate
palmar flexion and ulnar deviation. A fracture Type V Crush injury causing obliteration
with mild angulation and displacement of the growth plate
may require closed reduction. Significant Classification is important as it determines
angulation and deformity may require an both the treatment and prognosis. Overall,
open reduction and internal fixation or physeal fractures are responsible for about
external fixation. 30% of all long bone fractures in children. In
general, the following statements hold true
Paediatric fractures for Slater and Harris fractures:
About 50% of boys and 25% of girls will
Type I involve the growth plate but growth
sustain a fracture during childhood. Children
is rarely disturbed
tend to develop a specific pattern of fractures.
Type II fractures are the most common
The commonest location of fractures is the
Type III fractures involve the joint and can
upper extremities. The distal radius and
result in chronic morbidity
humerus are the commonest sites of fracture.
Type III fractures often require surgical
Paediatric fractures are fundamentally treatment
different from those seen in adults. Type IV fractures can also result in chronic
The decreased bone mineral density, morbidity
proportionally stronger ligaments and Type V fractures are difficult to diagnose
tendons, increased bone flexibility and and can result in limb shortening
developing growth plates lead to unique
fracture patterns. Greenstick fractures occur Management
when the bone bends and partially breaks Bones in children have a tremendous power
but does not extend through the width of the for remodelling and in their management,
bone. Salter and Harris fractures (Figure 22.7) more angulation or displacement can be
I ll lll lV V
System Manifestation
Syndrome Clinical features
Ocular Keratoconjunctivitis sicca Feltys syndrome Rheumatoid arthritis
Episcleritis Neutropenia
Scleritis Lymphadenopathy
Pulmonary Pulmonary nodules
Splenomegaly
Pleural effusion
Stills disease Rheumatoid arthritis in
Fibrosing alveolitis childhood
Cardiac Pericarditis/pericardial Rash
effusion
Fever
Valvular heart disease
Splenomegaly
Conduction defects
Sjgrens Rheumatoid arthritis
Cutaneous Palmar erythema syndrome Reduced lacrimal and
Rheumatoid nodules salivary secretion
Pyoderma gangrenosum
Vasculitic rashes and leg Table 22.5 Syndromes associated with rheumatoid
ulceration arthritis
Management
Management of rheumatoid arthritis requires
a multidisciplinary approach. Disease
modifying drugs include:
Non-steroidal anti-inflammatory drugs
Methotrexate, sulphasalazine, Figure 22.8 Rheumatoid hands
penicillamine, gold
Corticosteroids
Cytotoxic drugs The timing of surgery is a complex decision
Surgical intervention in patients with and depends on:
rheumatoid arthritis can achieve pain Patients age
relief, deformity correction and functional Stage of disease
improvement. A number of surgical Level of disability
procedures are available including: Site of the involved joints
Myofascial techniques Early surgical intervention may be helpful
Excisions in maintaining a patients functional level.
Reconstructions Deformities of the hand or wrist lead to
Joint fusions loss of the ability to grip, grasp and pinch,
Joint replacements often leaving the patient unable to perform
Degenerative and rheumatoid arthritis 353
the activities of daily living. The surgical Indications for hip replacement surgery
treatments for rheumatoid arthritis of the include:
hand and wrist include: Osteoarthritis
Synovectomy Rheumatoid arthritis
Tenosynovectomy Stills disease
Tendon realignment Ankylosing spondylitis
Arthroplasty Congenital dysplastic or dislocated hips
Arthrodesis Pagets disease
Trauma or avascular necrosis
Hip replacement surgery Septic arthritis
Hip replacement surgery was developed by Contraindications for hip replacement
Sir John Charnley in the 1960s. More than surgery:
50,000 hip replacements are performed each Uncontrolled medical problems
year in the UK and over 2 million hips have Skeletal immaturity
been replaced worldwide. Over 100 different Active infection
types of prosthesis have been used. The Neuropathic joint
gold standard is the Charnley cemented Progressive neurological disease
prosthesis. Muscle weakness
Principle components Surgery
The acetabular component is usually To justify surgery, patients should have
made of high density polyethylene. This significant pain, functional disturbance and
is biocompatible, has a low coefficient of failed conservative therapy. The principle
friction and a low rate of wear. Ceramic aims of surgery are to reduce joint pain
acetabular components have improved and improve joint function. The operative
surface properties but are expensive and have technique requires thorough skin preparation
a tendency to brittle failure. Metal cups are with sterile adhesive plastic drapes. Operating
obsolete due to high friction, loosening and teams should wear two pairs of gloves and
wear. The femoral component is usually made body exhaust suites may be worn. Laminar air
of stainless steel, titanium or cobalt-chrome flow should be provided in the operative field
alloy. It is resistant to corrosion with high and antibiotic prophylaxis should be given.
endurance. Improved longevity is seen with a Specific complications include:
small femoral head.
Neurovascular injuries
Polymethylmethacrylate cement Leg length discrepancy
Polymethylmethacrylate cement acts as a Dislocation
filling agent without adhesive properties. Infection
Macrolocking occurs with cement in drilled Aseptic loosening
holes. Microlocking occurs with cement Implant wear and failure
in the interstices of cancellous bone. It Heterotopic ossification
produces an exothermic reaction during Femoral fractures
preparation. Addition of barium weakens Trochanteric non-union
the cement. Antibiotic impregnation Abductor mechanism weakness
may increase the resistance to infection. The outcome of hip replacement surgery is
Recently uncemented prostheses have affected by many factors including the:
been developed. These require a more Type of implant used
exacting insertion technique. They are Underlying diagnosis
anchored by an interference fit achieved by Sex of patient
a porous surface or hydroxyapatite coating. Cement type
Uncemented prostheses have a tendency to Cementing technique
early failure. Surgical approach
354 Chapter 22 Trauma and orthopaedic surgery
Pathology Investigation
Infection usually occurs in the metaphysis Plain x-rays are usually normal during the
of long bones. Acute inflammation results first 3 to 5 days of the infection. In the second
in raised intraosseous pressure and week, radiological signs include periosteal
intravascular thrombosis. Suppuration new bone formation, patchy rarefaction
produces a subperiosteal abscess that may of the metaphysis and metaphyseal bone
discharge into the soft tissues. Spread of the destruction. In cases of diagnostic doubt,
infection into the epiphysis can result in joint bone scanning or MRI can be helpful. The
infection. Within days of infection, bone diagnosis can be confirmed by aspiration of
death can occur.Fragments of dead bone pus from an abscess or the metaphysis. About
become separated in the medullary canal 50% of patients have positive blood cultures.
(sequestrum). New bone forms deep to the
stripped periosteum (involucrum). If the Management
infection is rapidly controlled, resolution can General supportive measures should include
occur. If the infection is poorly controlled, intravenous fluids and analgesia. The painful
chronic osteomyelitis may develop. limb often requires a splint or skin traction
to relieve symptoms. Aggressive antibiotic
Clinical features therapy should be instituted. If the patient
The patient usually presents with pain, malaise fails to respond to conservative treatment,
and fever and is often unable to weight bear. surgery may be required. A subperiosteal
Early signs of inflammation are often few. The abscess should be drained. Drilling of the
bone is often exquisitely tender with reduced metaphysis is occasionally required. Overall,
joint movement. Late infection presents with about 50% of children require surgery.
soft-tissue swellings or discharging sinus. The
differential diagnosis includes: Septic arthritis
Cellulitis Septic arthritis is an acute inflammatory
Acute suppurative arthritis condition of a joint, usually resulting from
Rheumatic fever bacterial infection. Untreated, it will lead to
Sickle-cell crisis destruction of the articular cartilage. About
Metastatic infection can occur at distant 50% cases occur in children less than 3 years
sites (e.g. brain, lung). Spread into the of age. In infants less than 1 year old, the hip
adjacent joint can result in a septic is the commonest joint involved. In older
arthritis. This complication occurs in children the knee is the commonest joint
young children in whom the growth plate is affected. About 10% of patients have multiple
permeable, bones in which the metaphysis joint involvement.
is intracapsular or when the epiphysis of
the bone is involved by metastatic infection.
Pathology
Involvement of the physis can result in The infecting organism depends on age
altered bone growth. (Table 22.6). Organisms can enter the joint
Children Adults
<3 years old >3 years old <50 years old >50 years old
H. influenzae S. aureus S. aureus S. aureus
S. aureus H. influenzae N. gonorrhoea Gram-negative bacteria
Coliforms Streptococci
Frozen shoulder
A frozen shoulder is due to chronic
inflammation and fibrosis of subsynovial
layer. It often occurs after minor trauma or a
Figure 22.9 An AP x-ray of the shoulder showing period of immobility. It reduces the range of
anterior dislocation active and passive movement, particularly
Disorders of the upper limb 359
loss of external rotation. It is associated with characterised by pain over the medial aspect
severe pain and recovery may be prolonged. of the elbow. Pain is exacerbated by wrist
Treatment options include physiotherapy and flexion. Tenderness is distal to the medial
manipulation under anaesthetic. epicondyle. Management is similar to lateral
epicondylitis.
Calcific tendonitis
Calcific tendonitis is due to deposition of Ulnar nerve entrapment
calcium salts in the supraspinatus tendon. It at the elbow
produces severe pain over the anterolateral The ulnar nerve runs behind the medial
aspect of the shoulder. There is usually a epicondyle at the elbow. It runs in a tunnel
full range of passive movement. Pain is formed by the aponeurosis between the two
aggravated by shoulder movement. Calcium heads of flexor carpi ulnaris. The aponeurosis
deposits on x-ray are diagnostic. Treatment is slack in elbow extension but becomes tight in
options include anti-inflammatory drugs, elbow flexion. Disorders of the elbow joint can
physiotherapy, subacromial injection or result in nerve compression and symptoms are
subacromial decompression and removal of often worse when elbow is flexed.
calcium deposits.
Clinical features
Lateral epicondylitis The main symptoms are pain and
Lateral epicondylitis is often referred to as paraesthesia in the ring and little finger.
tennis elbow. It is due to inflammation at the This may be associated with weakness of
origin of the wrist and finger extensors. It is an grasp and grip and loss of manual dexterity.
enthesopathy of the lateral epicondyle. Wasting of the intrinsic muscles of the hand
can occur.
Clinical features
Lateral epicondylitis usually occurs between Management
30 and 50 years of age. Men and women Night splints to reduce elbow flexion may
are equally affected and 75% experience improve symptoms. Surgical options include:
symptoms in their dominant arm. It causes
Ulnar nerve decompression
pain over the lateral epicondyle radiating to
Medial epicondylectomy
the forearm. Tenderness is usually maximum
Anterior transposition
5mm distal to the insertion of the tendon.
Resisted wrist extension increases the pain. Olecranon bursitis
Plain x-ray may show calcification in the soft Olecranon bursitis is inflammation of the
tissues. bursa overlying the olecranon process at the
elbow (Figure 22.10). Inflammation may
Management
be caused by a variety of mechanisms. It is
Non-surgical management involves anti-
often the result of repetitive trauma but may
inflammatory drugs, rest and steroid
occasionally occur as a result of infection.
injection. Surgical treatment should be
The patient notices a painful lump over the
considered if there is no improvement
olecranon process with painful movement
with 6 months of conservative treatment. It
of the elbow joint. Examination will confirm
involves division and reattachment of the
a swollen bursa. Treatment is with anti-
tendon. About 85% patients notice a dramatic
inflammatory drugs and aspiration if the
improvement in symptoms.
swelling fails to settle.
Medial epicondylitis
Medial epicondylitis is often referred to as Disorders of the hand
golfers elbow. It is less common than lateral
epicondylitis but occurs in the same age
Carpal tunnel syndrome
group. It is an enthesopathy of the pronator The carpal tunnel is formed by the flexor
teres and flexor carpi radialis tendon. It is retinaculum stretching across the carpus.
360 Chapter 22 Trauma and orthopaedic surgery
It forms a tight tunnel through which passes of the flexor retinaculum. This may be
the long flexors to the fingers and thumb and performed endoscopically. About 70%
the median nerve (Figure 22.11). Swelling patients are symptom-free following surgery.
within the tunnel causes nerve compression
and ischaemia. Carpal tunnel syndrome de Quervains disease
affects 3% of women and 2% of men. About de Quervains disease is also known
30% cases are due to an underlying medical as stenosing tenovaginitis. It is due to
condition including: inflammation and thickening of the tendon
Hormonal pregnancy/menopause sheaths of extensor pollicis brevis and
Rheumatoid arthritis abductor pollicis longus. It occurs where both
Hypothyroidism tendons cross the distal radius.
Diabetes
Clinical features
Clinical features It usually presents in middle age. Pain is
Carpal tunnel syndrome usually presents noted over the radial aspect of the wrist and
in middle age. The female:male ratio is often occurs after repetitive activity. The pain
approximately 8:1. Pain and parasthesia is is often worsened by abduction of the thumb
noted in the distribution of the median nerve. against resistance. Passive abduction across
Symptoms are often worse at night and signs the palm often causes the pain (Finkelstein
are few. Tapping over the carpal tunnel can test). The tendon sheath is thickened and
reproduce symptoms (Tinel sign). Flexion tender over the radial styloid.
of the wrist for 60 seconds may precipitate
Management
symptoms (Phalen sign). Thenar wasting
and loss of 2-point discrimination in the Symptoms can often be improved with steroid
distribution of the median nerve are late injections into the tendon sheath. Persistent
features. The diagnosis is confirmed by nerve symptoms require surgery. The tendon sheath
conduction studies which show slowed nerve should be split avoiding the dorsal sensory
conduction across the wrist. branch of radial nerve.
Trapezium
Flexor
retinaculum
Median nerve
Trapezoid
Capitate Hamate
Pathophysiology
Bone undergoes continuous resorption and Metabolic bone disease
formation. About 10% of the adult skeleton Osteomalacia and rickets
is remodeled each year. Bone loss results Both osteomalacia and rickets result from
from an imbalance between resorption and Vitamin D deficiency. The outcome is
formation. The human skeleton comprises incomplete osteoid mineralisation. In
approximately 80% cortical bone and 20% childhood, prior to epiphyseal closure,
trabecular bone. this causes rickets. In adults, it causes
Osteoporotic fractures occur at sites with osteomalacia. Causes of osteomalacia include:
more than 50% trabecular bone such as Vitamin D deficiency
the vertebral bodies, proximal femur and Malabsorption
distal forearm. Bone loss leads to thinning Renal disease familial
of the trabecular plates. This causes a hypophosphataemic rickets
disproportionate loss of bone strength. Peak Anticonvulsant therapy
bone mass is achieved by the age of 30 years. Tumours
After skeletal maturity bone is lost at about
1% per year. Women experience accelerated Clinical features
bone loss after the menopause. Factors Osteomalacia is usually due to dietary
associated with increased bone loss include: deficiency in the elderly or Asian population.
Metabolic bone disease 365
Rickets is usually due to familial signs include characteristic skull and long
hypophosphataemic rickets. Rickets usually bone deformities. Complications causing
presents in early childhood with: symptoms include:
Failure to thrive Pathological fractures complete or
Valgus or varus long bone deformities incomplete
Skull deformities craniotabes Neurological effects
Enlarged costochondral junctions Osteoarthritis
Rickety rosary Sarcomas
Lateral indentation of the chest wall Cardiac failure
Harrisons sulcus
X-ray shows a widened epiphyses and Investigation
cupped distal metaphysis Skeletal x-rays in the osteolytic phase may
Osteomalacia presents in adults with: show osteoporosis circumscripta. Bone
softening can produce bowing, platybasia,
Bone pain and tenderness
protrusion of the acetabuli or greenstick
Proximal myopathy
fractures. In the mixed phase, radiological
True pathological or pseudo-fractures
investigations shows generalised bone
Investigation enlargement. In the sclerotic phase they show
increased bone density with trabecula and
In osteomalacia, the serum calcium and
cortical thickening. The serum calcium and
phosphate are low and alkaline phosphatase
phosphate are usually normal. The serum
is increased. Skeletal x-rays may show
alkaline phosphatase is often increased.
translucent bands in the medial femoral
Serum uric acid levels are increased in about
cortex, pubic ramus or scapula (Loosers
30% of patients.
zones). In familial hypophosphataemic
rickets, the serum calcium is normal and Management
phosphate is low. A bone biopsy is rarely
Anti-inflammatory drugs can be used
required but, if performed, would show
to control bone pain. Biphosphonates
increased unmineralised osteoid.
will reduce bone turnover. Neurological
Management complications and fractures may require
surgical intervention.
Treatment is with Vitamin D replacement
therapy and phosphate supplements in those Pagets sarcomas
with familial hypophosphataemic rickets.
Most osteosarcomas that develop late in life
Pagets disease of bone are associated with Pagets disease. Malignant
change occurs in less than 1% of patients
Pagets disease of bone is named after Sir with Pagets disease. The commonest site is
James Paget who first described osteitis the femur. The prognosis of Pagets sarcomas
deformans in 1877. The aetiology is unknown is poor with a median survival of 1 year and
but it is possibly due to a viral infection. only 5% of patients are alive at 5 years.
Histological features include enlarged
osteoclasts. Increased bone turnover
produces a mosaic pattern of lamellar bone. Locomotor pain
The disease has three phases osteolytic,
mixed and sclerotic.
Low back pain
Lumbar back pain is one of the commonest
Clinical features causes of chronic disability. It is usually due
Pagets disease is often identified as to abnormality of the intervertebral discs at
an incidental finding on an x-ray in an the L4/5 or L5/S1 level. It can occur at any age
asymptomatic patient. If symptomatic, but is most common in previously fit adults
it usually causes bone pain. The clinical between 2045 years.
366 Chapter 22 Trauma and orthopaedic surgery
Cauda equina
Pelvic
brim
L5
L5 root
S2
S2 root
Sacral hiatus
and joint position sense may be reduced. pedicle. The integrity of the disc may indicate
Tendon reflexes are often increased below the diagnosis. Good disc=bad news often
the level of compression, absent at the level indicates malignancy. Bad disc=good news
of compression and normal above. Reflex and may indicate infection. MRI is now the
changes may not coincide with sensory level. investigation of choice to define the extent
Cervical spine disease produces of any soft tissue disease. A bone scan may
quadriplegia. Thoracic spine disease indicate the pattern and extent of bone
produces paraplegia. Lumbar spine disease pathology.
affects L4, L5 and sacral nerve roots.
Sphincter disturbances are late features of
Management
cervical and thoracic cord compression. Acute spinal cord compression is a surgical
Cauda equina compression due to central emergency. In those with malignant disease,
disc prolapse produces: radiotherapy may be the treatment of choice.
In general, tumour, infection and disc
Loss of perianal sensation
disease produces anterior compression and
Root pain in both legs
surgical decompression should be achieved
Painless urinary retention
through an anterior approach. The cervical
Most patients with surgically treatable causes spine can be approached between the larynx
of spinal compression have spinal pain. medially and the carotid sheath laterally. The
Movement-induced pain suggests vertebral thoracic spine can be approached through
fracture or collapse. Exquisite tenderness the chest by a posterior thoracotomy or
suggests an epidural abscess. Low-grade costotransversectomy.
background pain may suggest tumour
infiltration or osteomyelitis.
Bone tumours and
Investigation amputations
Spinal x-rays may show bone or paravertebral
soft tissue disease. Other features which may Primary bone tumours
be seen on a plain x-ray include vertebral Bone and connective tissue cancers account
collapse, lytic lesions and loss of the vertebral for less than 1% of all new cancers diagnosed
Bone tumours and amputations 369
in the UK each year. Primary bone tumours surrounded by dense bone. Local excision is
are rare. Secondary tumours are more curative.
common, especially in the elderly. The
classification of benign and malignant bone Osteochondroma
tumours is shown in Table 22.8. Osteochondromas are the commonest of
the bone tumours. Lesions can be single or
Clinical features and investigation multiple. They usually appear in adolescence
Most primary bone tumours present with as cartilaginous overgrowth at the epiphyseal
bone pain, a limb swelling and localised plate. The tumour grows with the underlying
tenderness. Pain is usually worse following bone. The metaphyses of long bones are the
activity. Pain in an extremity may result commonest sites. They usually present as
in a limp. Rapid growth and associated a painless lump or occasionally joint pain.
erythema are suggestive of malignancy. The Excision should be considered if they cause
tumour may present with a pathological debilitating symptoms.
fracture, but this uncommon. Systemic
symptoms, such as fever and night sweats, Chondroma
are rare. Tumours that spread to the lungs Chondromas are benign tumours of cartilage.
only rarely results in respiratory symptoms The lesions may be single or multiple (Olliers
and this usually indicates extensive lung disease). They usually appear in the tubular
involvement. The diagnosis of a bone or bones of the hands and feet. A plain x-ray will
connective tissue tumour can be confirmed show a well-defined osteopenic area in the
by plain x-ray, CT scan, MRI and a carefully medulla. The lesion can often be excised and
planned biopsy. bone grafted.
Renal cortex
Renal papilla
Major calyx
Renal column
Ureter Renal pyramid
left and right ureters are shown in Table 23.2. with the prostate and the base is related
Three natural constrictions are found along to the rectum, vas deferens and seminal
their course where the: vesicles. In women, the uterus lies against its
posterosuperior surface. The base is related
Renal pelvis joins the ureter to the vagina and cervix. The ureters join the
Ureter crosses the pelvic brim bladder at the upper lateral angles. On the
Ureter enters the bladder interior of the bladder, the ureteric orifices
are joined by the interureteric ridge. With
Anatomy of the lower the urethral orifice this forms a triangular
renal tract area known as the trigone. As the bladder
The bladder distends it strips the peritoneum off the
The bladder is pyramidal in shape and, when anterior abdominal wall. The wall is made of
empty, it is an extraperitoneal structure. Its smooth muscle and is lined by transitional
superior surface is covered by the pelvic epithelium.
peritoneum. Anteriorly, it lies behind the The bladder has two sphincters. The
pubis bone. The apex is attached to the internal sphincter is smooth muscle and
umbilicus by the median umbilical ligament. is found at the bladder neck. The external
This represents the remnant of the fetal sphincter is voluntary muscle distal to the
urachus. The inferolateral surfaces are related internal sphincter. The blood supply is from
to the levator ani and obturator internus the superior and inferior vesical branches
muscles. In men, the bladder neck fuses of the internal iliac arteries. Lymphatic
Bowmans
capsule Key
H2O
Glomerulus Solutes
Filtrate
Cortex Proximal Distal
convoluted convolufed
tubule tubute
Descending
Outer limb
medulla
Ascending
limb
Collecting tubule
Inner
medulla
Loop of Henle
To ureter
Management
Urological trauma Approximately 80% of renal injuries are
Renal trauma minor. Class 1 and 2 injuries can be managed
In the UK, 90% of renal injuries result from conservatively. Early surgical intervention
blunt abdominal trauma. Isolated renal is required for reno-vascular pedicle
trauma is uncommon and approximately injuries, pelviureteric junction disruption
40% of patients have other associated and shock with signs of intraperitoneal or
intra-abdominal injuries. Direct trauma retroperitoneal bleeding. Surgery should be
crushes the kidney against the ribs. Indirect performed through a midline incision and
trauma can result in vascular or pelviureteric a transperitoneal approach. Control of the
disruption. renal pedicle should be obtained before the
retroperitoneal haematoma is opened. The
Clinical features surgical priorities are to save life, remove
The clinical features of a renal injury include: devascularised tissue, preserve renal function
Loin or abdominal abrasions or bruising and repair and drain the collecting system.
Loin tenderness Late complications of renal trauma are:
Loss of loin contour Hypertension
Loin mass Arteriovenous fistula
Macroscopic haematuria and possible clot Hydronephrosis
colic Pseudocyst or calculi formation
A renal pedicle injury is possible in the Chronic pyelonephritis
absence of haematuria. Loss of renal function
378 Chapter 23Urology
Most ureteric calculi less than 5mm in lead to a deterioration in renal function.
diameter will pass spontaneously. If the Acute infection in an obstructed kidney is a
calculus is greater 510mm in diameter and urological emergency. The patient is usually
fails to pass spontaneously consideration will unwell with loin pain, swinging pyrexia
need to be given to intervention dependent of and dysuria. Without drainage, rapid renal
the position of the calculus: destruction may occur. It requires emergency
Upper third of ureter Extracorporeal percutaneous nephrostomy. Overall, less than
shock wave lithotripsy (ESWL) 1% patients with stones require open surgery.
Lower third of ureter Ureteroscopy Bladder calculi
(USC)+lithotripsy
Bladder calculi are uncommon in the Western
Middle third of ureter Either ESWL or
world. They are well-described in ancient
USC
medical literature. Hippocrates wrote about
Lithotripsy is the use of shock waves to break the management of bladder stones and
up stones. It requires an energy source operations to remove stones via the perineum
spark-gap electrode or piezoceramic array, were described in the centuries before Christ.
a coupling device between patient and Suprapubic lithotomy was described in the
electrode water bath or cushion and a 15th century and transurethral lithotomy
method of stone localisation fluoroscopy or became popular in the 18th century.
ultrasound. Lithotripsy was first described in 1822.
If large stones are present in the renal Early surgical attempts at treating bladder
pelvis or upper ureter, consideration should calculi was often associated with significant
be given to percutaneous nephrolithotomy, morbidity and mortality.
particularly if the stone is more than 3cm
in diameter or a staghorn calculus is Pathophysiology
present (Figure 23.4). Chronic infection Bladder calculi are usually associated with
with urease-producing organisms (e.g. urinary stasis. Infection increases the risk of
Proteus) precipitates stone formation. stone formation. Foreign bodies (e.g. suture
Magnesium ammonium phosphate or material) can also act as a nidus for stone
staghorn calculi result. Large staghorn formation. However, bladder calculi can form
calculi may be asymptomatic but they can in a normal bladder. There is no recognised
association with ureteric calculi and most kidney more often than right and 10% cases
bladder calculi form in the bladder per se. are bilateral. The aetiology is often unknown
They vary in size and can be multiple. They but important factors may be aberrant lower
are more common in elderly men. Most pole vessels or persistence of a fetal urothelial
stones in adults are formed of uric acid. fold.
Long-standing untreated bladder stones
are associated with the development of Clinical features
squamous cell carcinoma of the bladder. PUJ obstruction usually presents in
adolescence or early adult life and presents
Clinical features with loin pain, worse after alcohol intake.
Many bladder calculi are asymptomatic. If they In late cases, a renal mass may be palpable.
do cause symptoms they include suprapubic Haematuria is an uncommon feature. About
pain, dysuria and haematuria. Abdominal 10% of patients develop UTIs and 3% have
examination may be normal. Patients may renal colic.
present in acute urinary retention.
Investigation
Investigation The diagnosis can be confirmed by
Historically stones were diagnosed by the ultrasound or abdominal CT scanning.
passage of urethral sounds. Today they Isotope renography allows assessment of the
can be identified on plain abdominal x-ray, percentage of renal function.
ultrasound, abdominal CT and cystoscopy.
Uric acid stones are radiolucent but may have Management
an opaque calcified layer. Any underlying The aims of treatment are to relieve symptoms
bladder abnormality should be sought. and preserve renal function. This can be
achieved by a pyeloplasty. The Anderson
Management Hynes pyeloplasty is the commonest
Indications for surgery for bladder calculi procedure performed (Figure 23.5). If there
include: is severe renal impairment (<20% function)
Recurrent urinary tract infections then nephrectomy may be required.
Acute urinary retention
Frank haematuria Haematuria
Historically the surgical approach involved
cutting for a stone. This was via either a Both microscopic and macroscopic
perineal or suprapubic approach. The three haematuria are abnormal and invariably
common approaches today are: require investigation. Microscopic
haematuria is defined as the presence of
Transurethral cystolitholapaxy five or more RBCs per high-power field
Percutaneous cystolitholapaxy on urine microscopy. The prevalence of
Open suprapubic cystostomy macroscopic and microscopic haematuria
Complications of cystolitholapaxy include: are approximately 1% and 5% respectively.
Infection About 50% of patients with haematuria will
Haemorrhage have an underlying abnormality. Overall, 10%
Bladder perforation and 35% of adult patients with microscopic
Hyponatraemia and macroscopic haematuria respectively will
Extracorporeal shockwave lithotripsy is have a urological malignancy. The causes of
relatively ineffective for bladder calculi. haematuria are shown in Table 23.4.
Causes of haematuria
ultrasound and cystoscopy. If the results of vein and inferior vena cava. Blood-borne
these investigations are normal, then the spread can result in cannon ball pulmonary
patient should be referred for a nephrological metastases.
opinion.
Clinical features
Renal cell carcinoma About 10% of patients present with the
Benign tumours of the kidney are rare and classic triad of haematuria, loin pain and a
all renal neoplasms should be regarded as mass. Other presentations include a pyrexia
potentially malignant. Renal cell cancer of unknown origin and hypertension.
accounts for approximately 3% of all new Polycythaemia can occur due to
cases of cancer diagnosed in men and around erythropoietin production. Hypercalcaemia
2% of all cancers in women. There are about can occur due to production of a PTH-like
8000 new cases per year in the UK. It arises hormone.
from proximal tubule cells. Alternative names
include hypernephroma, clear cell carcinoma Investigation
and Grawitz tumour. The male:female ratio is The diagnosis can often be confirmed by renal
approximately 2:1 and an increased incidence ultrasound. An abdominal CT scan allows
is seen in von HippelLindau syndrome. assessment of renal vein and caval spread.
Pathologically they may extend into the renal Echocardiogram should be considered if
384 Chapter 23Urology
Structural Functional
Figure 23.6 Characteristic
Characteristic uroflowmetry results
uroflowmetry results. 1 = Normal;
2 = Benign prostatic hyperplasia;
Flow rate (mL/s)
3 = Urethral stricture.
30
1
r/
.i
3
s
0 60
s
Time (s)
n
is a
and improve quality of life, relieve prostatic hyperplasia. The bulk of the prostate
bladder outflow obstruction and to treat is reduced endoscopically. The prostate is
r
complications resulting from bladder outflow excided using a wire loop. The bladder is
obstruction. Treatment options can be either irrigated with glycine. The chips of prostatic
e
pharmacological or surgical. Drugs include tissue are washed from the bladder and an
a-adrenergic antagonists, 5a-reductase
p
irrigation catheter is inserted. Obstruction is
.
inhibitors and LHRH antagonists. Surgical reduced and urinary symptoms considerably
options include: improved in over 90% of patients. Absorption
p
of the irrigation fluid can result in acute
iv
Transurethral prostatectomy (TURP)
Transurethral or interstitial thermotherapy hyponatraemia the TUR syndrome. The
possible complications of TURP are shown in
/: /
Interstitial laser prostatectomy
Urethral stents Table 23.6. Postoperative retention occurs in
Open prostatectomy about 5% of patients. Retrograde ejaculation
occurs in about 80% of patients. Post-
tt p
TURP is the gold standard treatment for
prostatectomy incontinence is a transient
bladder outflow obstruction due to benign
phenomenon in many men but becomes a
h
Complications of TURP
/
abnormality. Conservative management Renal failure can occur due to bilateral
r
ureteric obstruction. With locally advanced
.i
improves symptoms in 50% patients.
tumours, the diagnosis can be confirmed by
Prostate carcinoma rectal examination. Features include a hard
s
Prostate cancer is the most common cancer nodule or loss of the central sulcus.
s
in men accounting for nearly a quarter of all
new male cancers. There are about 35,000
Investigation
n
new cases per year in the UK. Although Transrectal ultrasound is the most important
diagnostic investigation. It can confirm
is a
there has been a rise in prostate cancer
incidence over the last 20 years, this has the diagnosis and an ultrasound-guided
not been reflected in mortality rates. It is transrectal biopsy can be performed. Pelvic
CT or MRI is useful in the staging of the
r
more common in northern Europe and
North America and rare in far east Asia. It is disease. PSA is a kallikrein-like protein
e
uncommon before the age of 50 years. It is produced by prostatic epithelial cells. A
serum level of 4ng/mL is the upper limit
p
found at post-mortem in 50% of men older
of normal. A level greater than 10ng/mL is
.
than 80 years. About 510% of operations for
benign disease reveal unsuspected prostate highly suggestive of prostatic carcinoma.
p
cancer. Much of the increased incidence can However, it can be also be raised in BPH.
iv
be attributed to the incidental discovery of Serum PSA is a useful marker for monitoring
prostate cancers following TURP and, more response to treatment. Bone scanning will
/: /
recently, the use of prostate specific antigen detect the presence of metastases. A bone
(PSA) testing. scan is unlikely to be abnormal if the patient
is asymptomatic and the PSA level is less than
tt p
Pathology 10ng/mL.
Prostate cancer is an adenocarcinoma usually
arising in the posterior part of the gland.
Management
More men die with than from prostate
h
About 70%, 20% and 10% arise in peripheral,
transition and central zone, respectively. cancer. Treatment depends on the stage of
Spread occurs through the capsule into the disease, the patients age and his general
perineural spaces, bladder neck, pelvic wall fitness. For local disease the options are
and rectum. Invasion into the seminal vesicles observation, radical radiotherapy or radical
is associated with distant spread. Lymphatic prostatectomy. For locally advanced disease
spread is common. Haematogenous spread the options are radical radiotherapy or
occurs to axial skeleton. hormonal therapy. Hormonal therapy is the
mainstay of treatment for metastatic disease.
Tumours are graded by the Gleason
classification. It is based on the glandular and Radical prostatectomy
cellular pattern of the tumour. It combines Radical prostatectomy involves removal of
the two most common architectural patterns the entire prostate gland. The seminal vesicles
of cancer within the sampled specimen. Each are removed with the prostate gland. Care is
of the two most common patterns is assigned taken to preserve the peri-prostatic plexus
a grade from one to five. A Gleason sum score of nerves. The urethra is anastomosed to the
is reported as the two scores added together. base of the bladder. Radical prostatectomy
388 Chapter 23 Urology
is associated with improvement in mean The gel should be massaged into the posterior
survival compared to simple observation urethra and a catheter not passed for at least
and a 50% reduction in risk of metastatic 5 minutes. A 12 to 16Fr gauge Foley catheter
disease. However, erectile dysfunction occurs (usually with 10mL balloon) is then inserted.
in 50% patients and about 3% develop stress The catheter should pass easily into bladder.
incontinence. The balloon should not be inflated until urine
is seen coming from the catheter. A drainage
Hormonal therapy bag should be attached and the volume of
About 80% of prostate cancers are androgen urine drained recorded. Female catheters
/
dependent for their growth. Hormonal should only be used in women. If the catheter
r
therapy involves androgen depletion and fails to drain a significant volume of urine,
.i
it produces good palliation until tumours reconsider the diagnosis. An attempt at a trial
escape from hormonal control. Androgen without catheter can be made at 48 hours.
s
depletion can be achieved by: If difficulty is encountered in passing the
s
Bilateral subcapsular orchidectomy catheter:
LHRH agonists goseraline Do not use force
n
Anti-androgens cyproterone acetate, Do not inflate the catheter balloon until
flutamide
is a
urine has been seen in the catheter
Oestrogens stilbeostrol Do not use a catheter introducer unless
Complete androgen blockade adequately trained in its use
r
Urinary retention If unable to pass a urethral catheter the use
of a suprapubic puncture is desirable. If an
e
Retention of urine can be acute or chronic.
appropriate technique of catheterisation
Chronic retention can be associated with
p
is used then complications are rare. False
either low or high intravesical pressure.
.
passages and urethral strictures can occur if
Acute retention there is significant trauma to the prostate or
iv p
urethra. Minor degrees of haematuria can
Acute retention usually presents with an
occur but usually clears spontaneously. Post
inability to pass urine for several hours.
obstruction diuresis has been described but is
/: /
It is usually associated with lower abdominal
usually self-limiting. It occasionally requires
pain. The bladder is visible and palpable
intravenous crystalloid volume replacement.
and tender on palpation. Causes of acute
There is no evidence to support gradual
retention include:
tt p
decompression of the bladder.
Bladder outflow obstruction
Faecal impaction Chronic retention
h
Urethral stricture Chronic retention is usually relatively
Acute or chronic prostatitis painless. High intravesical pressure can cause
Blood clot in the bladder hydronephrosis and renal impairment. It can
Retroverted gravid uterus present as late-onset enuresis and may also
Post operation present with hypertension. Low pressure
Spinal anaesthesia chronic retention presents with symptoms
Spinal cord injury of bladder outflow obstruction. Patients with
Urethral rupture chronic retention and renal impairment need
Anal pain urgent urological assessment.
Drug induced anticholinergics,
antidepressants
Pain and swelling in the
Management
scrotum
The immediate management of acute retention
is urethral catheterisation. A catheter is Testicular tumours
passed using a full aseptic technique. Urethral Testicular tumours are one of the commonest
analgesia can be achieved with lignocaine gel. malignancies seen in young men. There are
Pain and swelling in the scrotum 389
about 1500 new cases per year in the UK. The survival is more than 95%. Even in those with
incidence has doubled in the past 25 years. metastatic disease at presentation, cure rates
The two main type of tumour are teratomas of 80% have been reported.
and seminomas. They have a roughly equal
incidence and have a peak age of presentation Clinical features
of 25 and 35 years, respectively. The highest Testicular tumours usually present with a
incidence is seen in caucasians and is five testicular swelling or lump. The amount of pain
times higher than other ethnic groups. Risk is variable, but it is often minimal. Patients
factors for the development of testicular occasionally present with gynaecomastia.
tumours include: Seminomas metastasise to para-aortic nodes.
Cryptorchidism Teratomas metastasise to the liver, lung, bone
Testicular maldescent and brain. Patients may present with symptoms
Klinefelters syndrome of metastatic disease, usually abdominal or
Family history back pain or respiratory symptoms.
The classification of testicular tumours is as Investigation
follows: The diagnosis can often be confirmed
Seminomas by testicular ultrasound. A pathological
Teratoma differentiated diagnosis is made by performing an inguinal
Malignant teratoma intermediate orchidectomy. There is no place for scrotal
Malignant teratoma undifferentiated exploration and a testicular biopsy. The
Malignant teratoma trophoblastic disease can be staged by thoraco-abdominal
Yolk sac tumours CT scanning (Table 23.7). Tumour markers
Treatment for testicular cancer is very are useful in staging and assessing response
effective. Nearly all men are cured by surgery, to treatment, a-fetoprotein (aFP) is produced
chemotherapy and radiotherapy. In those by yolk sac elements and is not produced
with disease localised to testis, the 5-year by seminomas. Beta-human chorionic
Stage Definition
doubt, then the testis should be wrapped epigastric veins. A varicocele consists of
in a warm swab and observed. If the testis dilatation of the veins of the pampiniform
is viable, then both the ipsilateral and plexus.
contralateral side should be fixed within the
scrotum. Clinical features
Approximately 60% of testes are Most varicoceles are detected in adolescence
salvageable. However, if patients are re- or early adult life. About 95% occur on the left
examined at 6 months after surgery, 10% of side and are idiopathic. They are occasionally
testes are found to be atrophic. The outcome associated with left renal tumours. Most are
is best in those operated on less than 6 hours asymptomatic. If they do cause symptoms,
since the onset of symptoms. Beyond 12 it is usually a vague or annoying discomfort.
hours, salvage of the testis is less assured. Examination shows the typical bag of worms
Occasionally, long-term sub-fertility is a which reduces in size in the supine position.
problem possibly due to an auto-immune Varicoceles are occasionally associated with
response affecting both testes. infertility but there is no evidence that surgery
increased semen quality or conception rates.
Epididymitis
Epididymitis is uncommon in adolescents
Management
and one should be wary about making the Varicoceles only need treatment if
diagnosis at this age. Patients usually have a symptomatic. The veins can be ligated via
more prolonged history, the pain may not be either a scrotal or inguinal approach. Recently
severe and urinary symptoms may be present. laparoscopic ligation has been reported.
Examination shows tenderness which is Recurrence can occur due to the collateral
greatest over the epididymis. Treatment is supply via the cremasteric vein.
with antibiotics.
Priapism
Idiopathic scrotal oedema Priapism is a persistent erection of the penis.
Idiopathic scrotal oedema usually occurs in It is uncommon but early diagnosis and
boys less than 10 years old. It presents with treatment is essential. Delayed presentation
scrotal redness and oedema. Pain is slight or treatment results in corporal anoxia and
and the testis feels normal. Management is loss of erectile function.
conservative.
Pathophysiology
Torsion of a testicular appendix Priapism can be either high or low flow. Low-
Torsion of a testicular appendix presents with flow priapism is more common and is due
sudden testicular pain but often not severe. A to venous stasis and ischaemia. Aetiological
hydrocele with a tender appendage (hydatid factors include:
of Morgagni) is often apparent. If discovered Intracavernosal injection
during scrotal exploration, the appendage Pelvic malignancy
should be excised. Blood disorders sickle-cell disease,
leukaemia
Varicocele Trauma spinal cord injury
In the scrotum, the veins from the testis Prolonged sexual activity
form the pampiniform plexus. This reduces Urogenital tract inflammation
to one or two well-defined veins in the Drugs
inguinal canal. One testicular vein is formed High-flow priapism is uncommon and is due
at the deep inguinal ring. The left testicular to the development of an arteriocavernosal
vein drains into the left renal vein. The tight fistula. This can follow blunt or penetrating
testicular vein drains into the inferior vena penile or perineal trauma. Anatomically, it
cava. Some venous drainage also occurs involves the corpora cavernosa only.
via the cremasteric vein into the inferior
392 Chapter 23Urology
10% are bilateral. Cystic teratomas have a celomic epithelium. About 75% are serous
smooth capsule and may grow to 30cm in and 20% are mucinous. Risk factors include:
diameter. They may contain mature elements Advancing age
including bone, hair and teeth (Figure Nulliparity
23.8). Functioning thyroid tissue may cause Family history (BRCA1 and BRCA2)
thyrotoxicosis (struma ovarii). Malignant Possibly fertility drugs
transformation is rare. Treatment is by
ovarian cystectomy. Clinical features
The clinical features of ovarian carcinoma
Ovarian germ cell tumours are often non-specific. Early features include
In adolescents and young women, the urinary frequency and abdominal discomfort.
majority of ovarian neoplasms are germ Later features include distension, early satiety
cell tumours. Approximately 25% of and anorexia. An abdominal mass and ascites
these tumours are malignant. If they are may be present.
functioning they can present with precocious
puberty or early menarche. Tumour markers Investigation
such as CEA, a-fetoprotein or b-hCG may be The diagnosis of ovarian carcinoma can often
increased. CA125 is usually not raised in germ be confirmed by abdominal and pelvic CT.
cell tumours. Types of malignant tumour The serum CA125 may be raised. In patients
include dysgerminoma and embryonal presenting with ascites with no obvious
carcinomas. Treatment is usually by surgical cause, cytology may show characteristic
debulking and chemotherapy. malignant cells. Ovarian carcinoma spreads
by three routes trans-celomic, lymphatic
Ovarian carcinoma and haematogenous. The staging of the
Approximately 6500 women are diagnosed disease is surgical and 2040% of patients
with ovarian cancer in the UK each year are upstaged after surgical intervention. The
making it the second most common International Federation of Gynaecology and
gynaecological cancer and the fifth most Obstetrics staging of ovarian carcinoma is as
common cancer in women. Ovarian follows:
carcinoma arises from either the ovarian or Stage 1 Tumour limited to ovaries
Breast reconstruction, 218 Cardiac risk index, revised, 11 Chest x-ray, 122, 123, 124, 129, 129,
free flaps, 219 Cardiac stab wounds, 123124 138, 138
nipples reconstruction, 219 Cardiogenic support, 53 Child protection, 282
pedicled myocutaneous flaps, Cardiopulmonary bypass, 116, 116 Chlorhexidine, 83
219 Cardiovascular complications Cholangiocarcinoma, 182183
tissue expander, 218 obesity, 12 Cholangitis, acute, 175
Breathing, 90 postoperative, 44 Cholecystitis, acute, 174175
Breslow depth, 316 Cardiovascular disease, 11 Choledochal cysts, 296297
Bronchial carcinoma, 213 Eagle index, 11 Cholinergic receptors, 34
Bronchiectasis, 130131 hypertension, 1112 Chondromas, 369
Bronchodilators, 16 myocardial infarction, 11 Chondrosarcoma, 370
Bronchopleural fistula, 127128 revised cardiac risk index, 11 Christmas disease, see Haemophilia B
BrownSequard syndrome, 329 Cardiovascular support, 53 Chronic health points, 54
Buergers disease, 243 Carotid artery disease, 252 Cimetidine, 213
Bulbar urethra rupture, 378 carotid endarterectomy, 252253 Circumcision, 298
urethrogram, 378 carotid stenting, 253 Cirrhosis, 186, 187, 213
Bupivacaine, 37 Carotid endarterectomy, 252253 Civil Procedure Rules 1998, 6
Burch colposuspension, 396 Carotid stenting, 253 Claw toes, 363
Burn unit, referral criteria, 311 Carpal tunnel, 359 Cleft lip and palate, 283
Burns anatomy of, 361 aetiology, 283284
assessment, 310311 Carpal tunnel syndrome, 359360 clinical features, 284
full-thickness burns, 310 clinical features, 360 embryology, 284
partial-thickness burns, 310 management, 360 management, 284
pathophysiology, 309310 Cartilage, 336 Clinical governance 24, 4
superficial burns, 310 Case-control studies, 68 Clinical trials, 6768
Catecholamines, 113, 338 Clostridium difficile, 79
Catheter Clostridium welchii, 79
C over needle, 41 Clotting cascade, 26, 27
Caecal volvulus, 144145 through needle, 41 Clubfoot, 304305
Caecum, 189 Catheterisation, suprapubic, 65 Coagulase-negative staphylococci,
Calcific tendonitis, 359 Cauda equina, anatomy of, 368 81, 354
Calcification, 73 Cell cycle, 104, 104 Co-analgesia, 107
Cancer Cell proliferation, see also Cancer Coarctation of aorta, 285
colorectal, 191192 genes Codmans triangle, 370
development of, 99 carcinogenesis, 99 Coeliac disease, 168
epidemiology of, 100101 neoplastic, 99 Cohort studies, 68
gastric, see Gastric cancer non-neoplastic, 99 Colles fracture, 349
genes, 99100 Cellulitis, 76 Colloids, 40
genetics, 100 Central cord lesion, 329 Colon, see Large intestine
lung, 126127 Central nervous system (CNS), 33 Colonic infection, see
neoplastic proliferation, 99 infections, 332334 Pseudomembranous colitis
NHS screening programmes, Cerebral palsy 300301 Colonic polyps, benign, 191
101102 Cerebrospinal fluid (CSF), 324 Colonic pseudo-obstruction, 145
non-neoplastic proliferation, 99 Ceruminous glands, 307 Colorectal cancer
oesophageal, 160161 Chalazion, 97 hereditary non-polyposis,
staging of, 102103 Chemical burns, 311 192194, 193
treatment of, 103107 Chemoreceptor trigger zone (CTZ), 38 incidence, 191
tumour markers, 100 afferent and efferent connections liver metastases, 194195
Candida, 41 to, 39 risk factors, 191192
Carbon dioxide equilibrium curve, Chemotherapeutic Colporrhaphy, anterior, 396
115116 Chemotherapy Communication skills, 12
Carbon monoxide, 115 agents, 81 Compact bone, 335
Carcinogenesis, 99 aim of, 104 structure of, 335
Carcinoid tumours, 237 mechanism of action, 104, 104 Compartment syndromes, 9495
appendiceal carcinoid tumours, toxicity, 104105 pressure monitoring, 95
237 use of, 105 Compound fractures, 346
clinical features, 237 Chest drains Confusion, postoperative, 4546
diagnosis of, 237 complications of, 124125, 125 Congenital diaphragmatic hernia,
Carcinoma in situ, 384 components, 124 287
Cardiac cycle, 111112, 112 indications, 124 Congenital heart disease
Cardiac function, 910 occurrence, 124 atrial septal defect, 285
chest x-rays, 10 principles of, 124, 125 classification of, 284285
ECG, 1011 removal, 125 coarctation of the aorta, 286
echocardiography, 11 Chest injuries tetralogy of Fallot, 285286
nuclear medicine, 11 occult, in children, 282 transposition of the great vessels,
Cardiac output, 49 primary, 123 286
and left-sided pressures, 20 secondary, 123 ventricular septal defect, 285
400 Index
Neuromuscular junction, 339 Ogilvies syndrome, see Colonic Paediatric umbilical hernia, 299
excitation-contraction coupling, pseudo-obstruction Pagets disease, 214, 215, 365
339 Olecranon bursa, 360 Pagets sarcomas, 365
muscle contraction, 339 Olecranon bursitis, 359 Pain, 34
Neurones Oncogenes, 99100 bone, 107
and action potential, 336337 Opiate analgesia, 43 co-analgesia, 107
biochemical changes, 337 Opiate sparing effects, 36 dyspnoea, 107
structure of, 336, 336 Opiates, 16, 36 liver capsule, 107
Neuropathic scoliosis, 304 Ossification, 336 morphine, 107
Neurosurgical disorders Osteitis deformans, 365, see also neuropathic, 107
brainstem death, 332 Pagets disease somatic pain, 34
central nervous system infections, Osteoarthritis, 351 WHO analgesia ladder, 106, 106
332333 Osteochondromas, 369 Pain control, postoperative, 35
spinal abscess, 333334 Osteoclastoma, 369370, see also Palliative care, 106, 106 -107
subarachnoid haemorrhage, Giant-cell tumours Pancreas
331332 Osteoid osteomas, 369 anatomy of, 170171, 171
Neurosurgical trauma Osteomalacia, 364365 chronic inflammation of, 185
head injuries, 325327 Osteomyelitis, acute, 354355 gastrinomas, 185
Nicotinic receptors, 34 Osteopathic scoliosis, 304 Pancreatic carcinoma 183184, 184
Nipple discharge, 211212 Osteoporosis, 364 Pancreatic neuroendocrine tumours,
Nipple inversion, 209 Osteosarcomas, 370 184185
Nipples reconstruction, 219 Otitis externa, 270 Pancreatic pseudocyst, 179, 179180
Nitrous oxide, 18 Otorhinolaryngology, 269 Pancreatitis,
Nodes of Ranvier, 337 Ovarian carcinoma, 394395 acute, 176179, 177, 178
Non-absorbable sutures, 43 Ovarian cysts chronic, 185186
Non-cyclical mastalgia, 210 functional cysts, 393, 393 Paralytic ileus, 142143
Non-haemolytic transfusion febrile mature cystic teratoma, 393 Parasympathetic nerve system, 34
reactions, 3031 394 Parathyroid disease
Non-lactational breast sepsis, 211, ovarian germ cell tumours, familial hypocalciuric
211 394 hypercalcaemia, 233
Non-neoplastic salivary gland Ovarian teratoma, abdominal x-ray, hyperparathyroidism, 231
enlargement 394 normocalcaemic hypercalciuria,
acute sialadenitis, 277 Overactive bladder symptom 233
sialolithiasis, 277 syndrome, 395 persistent hyperparathyroidism,
Sjgrens syndrome, 277 Overflow incontinence, 395 232
Non-steroidal anti-inflammatory Overwhelming post-splenectomy recurrent hyperparathyroidism,
agents, 36 infection (OPSI), 134, 262 232
Non-steroids anti-inflammatories, Oxygen dissociation curve, 114115, Parathyroid gland 222223, 223
16 115 Parenteral nutrition, 42
Normal distribution, 69, 70 Oxygen therapeutic agents, 92 central, 42
Nosocomial pneumonia, 44 metabolic complications of, 43
Nottingham Prognostic Index, 216 monitoring, 4243
Null hypothesis, 70 P Parkland formula, 310
Nutritional assessment, 42 Packed cell volume (PCV), 53 Parotid gland, 269270
Nutritional support, 42 Packed red blood cells, 92 Parsonnet score, 15, 117
enteral nutrition, 42 Paediatric fractures, 350 risk changes, 118
parenteral nutrition, 42 management, 350 Pathologic fractures, 346347
Paediatric hernias causes of, 347
inguinal hernia, 298299 Pathophysiology
O irreducible hernia, 299 trauma, 8788
Obesity, 12 umbilical hernia, 299 wound healing, 55, 5556
complications associated, 12 Paediatric stridor, acute, 271 Patient-controlled analgesia (PCA),
Obstruction Paediatric surgery 3637
colonic pseudo, 145 cardiovascular system, 281 Peak flow measurements, 10
large bowel, 143144 renal system, 281 Pedicled myocutaneous flaps, 219
small bowel, 142143 respiratory system, 281 latissimus dorsi (LD) flap, 219
Obstructive jaundice, 172173, 173 thermoregulation, 281 pedicle transverse rectus
management, 173 Paediatric surgical disorders, abdominis (TRAM) flap
Obturator hernia, 153 common Pelvic inflammatory disease (PID), 393
Oesophageal atresia hypertrophic pyloric stenosis, Pelviureteric junction (PUJ)
clinical features, 287288 293 obstruction, 382
management, 288 intussusception, 294 Peptic ulcer disease, 165166, 167
Oesophageal cancer, 160161 necrotising enterocolitis, 294 Percutaneous coronary intervention
Oesophageal perforation, 162 Paediatric trauma, 281 (PCI), 117
Oesophagus airway and breathing, 282 Percutaneous tracheostomy, 272
anatomy of, 156 assessment, 282 Perforated peptic ulcer 137139, 138
disease, 159163 circulation, 282 Pericardial tamponade, 123
Index 405