James notes for surgery

Content:

Basic surgery P.2

Upper GI surgery P.16

Lower GI surgery P.35

Breast surgery P.66

Thyroid surgery P.78

Neck masses P.85

Hepatobiliary surgery P.91

Vascular surgery P.113

Skin and soft tissue P.129

Inguinal hernia P.139

Cardiothoracic surgery P.143

Urological surgery P.163

1
Basic Surgery
========================================
 
Fistula is a permanent abnormal passageway between two organs in the body or between an organ and the
exterior of the body 
 
========================================
 
Diathermy
 
● the use of high frequency electical current to generate heat in a high resistance object
● monopolar diathermy
○ with the patient lying on the return electrode
○ AC current flow through the single probed metal tip, to body of patient, then to the return electrode
○ heat energy concentrated on the site of contact but not the whole body because current rapidly
spread through the body once entering
○ contraindicated in
■ Circumcision - due to the relatively small surface area that limit the rapid spreading of
current, may lead to penile burn
■ Patients with pacemaker in situ
● bipolar diathermy
○ use a metal clip with current flow between them
○ very good in precise microsurgery
 
========================================
 
Sutures
 
Absorbable vs non-absorbable
Monofilament vs polyfilament (braided)
Synthetic vs natural
 
thickness - 3, 2, 1, 0, 2/0, 3/0 ... 11/0
length - estimated by (wound length x 4)
 
Vicryl = absorbable synthetic braided
Ethilon = nonabsorbable synthetic monofilament
Catgut = absorbable natural monofilatment
 
Absorbable sutures
● used in internal organs to allow resorption in 10 days to 8 weeks
● Catgut
○ plain gut - made untreated from sheep or cow
○ chromic gut - tanned with chromium salt to increase persistence
○ fast gut - heat treated for faster resorption
● synthetic polymer fibers
○ superior to intestinal sutures
○ ease of handling, low cost, low tissue reaction, consistent performance and guaranteed non-toxicity
○
polylactic acid, polyglycolic acid
 
Non-absorbable sutures
● used in skin which removal is convenient, less antigenic thus less scarring
● used in dynamic organs like heart and vessels to provide better anchoring
● used in bladder due to the presence of solvent (urine)
● made of natural fibers, silk, nylon, polypropylene
 

2
Monofilament- reduce drag, less infection harboured
Polyfilament (braied)- increase strength, better knotting
 
========================================
 
Needles
 
HEAD - round bodied, blunt, cutting, reverse cutting
SIZE - 63mm (circumference)
CURVATURE - 3/8c (circumference)
Shape - curved, J-shaped, straight
 
========================================
 
Surgical positionings
 
● supine, prone, left or right lateral decubitus
● lithotomy
● trendelenberg (head down legs up) in central line insertion
● reverse trendelenberg (head up legs down) in cholecystectomy
 
========================================  
 
Drains
 
**Tube-french
**Needle- gauge
 
Chest drain
● radioopaque line
● safety triangle= pectoralis major, 4/5 intercostal spaces, mid axillary line
● 3-chamber system= resorvoir, underwater seal, pressure control
 
Sump drain
● closed suction drain
● with two separate channels, one in one out
● avoid suctioning of omentum, which is susceptible to necrosis
 
T-tube
● made of latex to induce fibrosis of the tract, can remove at ~day 10
● inserted after ECBD
● allow T-tube cholangiogram
● allow bile drainage
● allow T-tube choledochoscopy when needed
 
Tissue drain/ Corrugated drain
● open non-suction drain
● directly inserted into tissue to drain accumulated fluid
● capillary effect 
 
Hickmann line
● used for long term venous access, usually for chemotherapy, TPN, dialysis; to reduce infections and to
prevent dislodgement of line
● procedures
○ usually requires GA
○ two incision sites: entrance and exit
○ locate IJV (sometimes, subclavian vein, femoral vein)
○ large bore needle to let guide wire into IJV
○ create a tunnel betweent the two incisions

3
 ○ insert Hickman's line into entrance site and secure position by locating the Dacron cuff
subcutaneously, out from exit site
○ length of hickman line estimated by the distance from sternal notch, then cut
○ advance the line into IVC
○ suturing of incisions
● unit = french (circumference in mm)
○ for Hickman, either 21 or 30
● double lumen or triple lumen
 
Sengstaken blakemore tube
● to control esophageal variceal bleeding
● minessota tube
● 4 lumens
● maximal time 24 hours to prevent pressure necrosis
 
Endotracheal tube
● inflatable cuff to prevent aspiration
● non cuff in paediatric model due to the inverted triangular trachea of infants
 
Tracheostomy tube
●  similar to endotracheal tube 
 
Robinson drain
● non-suction drains
● the type of usual tubal drains used in post-op drainage
 
Foley catheter
● silicone or latex
● inflatable balloon to secure the catheter in situ
 
Angiocatheter
 
Heparin block
● 16G = black
● 18G = green
● 20G = red
● 22G = blue
● 24G = yellow
 
========================================
 
Local anaesthetics
 
Max dose 7mg/kg for lignocaine+adrenaline: offer vasoconstrictive action, reduce systemic circulation, reduce
toxicity, hence higher daily dose allowed
Max dose 3mg/kg for lignocaine
(*lignocaine blocks the voltage-gated fast sodium channel, hence stop action potential)
 
whole day maximal dose (actually refers to a single dose)
 1% ligonocaine= 10mg/ml, similarly 2% = 20mg/ml
eg. For a 60kg man, use 1% lignocaine
● maximal dose= 3x60= 180mg/day= 0.18g/day
● 0.18g 1% lignocaine= 18ml
 
========================================
 
Surgical scar
 
Full laprotomy

4
Upper midline
Lower midline
Right paramedian
Kocher
Roof top
Mercedes Benz/ Chevron
Lanz
Gridiron (oblique)
Pfannelstiel
 
========================================
 
Fluids
 
Basics
● Fluid balance 
○ urine = 1000-1500ml  (0.5-1ml/kg/hour) (post op aim 1ml/kg/hour!)
○ faeces = 250ml
○ insensible loss = 750ml
○ insensible gain (metabolic water) = 300ml
● Electrolytes requirement
○ Na = 1-2 mmol/kg/day
○ K = 0.5-1mmol/kg/day
 
Replacement
1. Deficit
○ Estimated fluid deficit %  x  body weight  x 60%
2. Maintenence fluid
○ 100ml/kg/day for first 10kg
○ 50ml/kg/day for next 10kg
○ 25ml/kg/day for the rest 
3. Ongoing third space loss
○ 10ml/kg/hour for major surgery  (eg Whipple)
○ 5ml/kg/hour for moderate surgery   (eg uncomplicated sigmoidectomy)
○ 2ml/kg/hour for minor surgery   (eg hernia repair)
4. Ongoing blood loss
○ replace with 4 times loss by cyrstalloid
○ replace with equal amount by colloids
 
Post-op fluid balance
● Foley inserted for U/O maintained at 1ml/kg/hour
● NG tube suction, equal volume replaced
● Other drain/stoma output, replace accordingly
● * supplementary potassium may not be neccessary 48 hour post-op, due to:
○ potassium release from cell lysis
○ blood transfusion (20mmol/L excess in each unit)
● * mobilization of perioperative third space loss begins 2-3 days after operation, beware of hypervolemia,
sometime need diuresis!
 
Crystalloids
● Normal saline
○ only 25% of total volume infused remains in intravascular space
○ 9g/(23+35.5) = 154mmol Na in 1 Litre
○ prefered over Ringer's lactate if
■ hypoNa
■ hyperK

5
 ■ hyperCa
■ hypoCl
■ metabolic alkalosis
● Ringer's lactate
○ Na, K, Ca, Mg, Cl, lactate (to bicarb)
● Hypertonic saline
○ eg 7.5% NaCl + 6% dextran
■ immunomodulatory effect >> prevent widespread tissue damage and multiorgan dysfunction
seen after traumatic injury
○ S/E
■ hypernatremia >> central pontine myelinolysis
■ hyperchloremia
■ hyperosmolarity
 
Colloids
● Albumin
○ ~100% stay in intravascular volume!
○ indicated in edematous patient to mobilise interstitial fluid
○ SAFE trial = 4% albumin vs NS >> no significant difference in mortality and organ failure
● Dextran
○ synthetic glucose polymer
○ volume expansion + thromboembolism prophylaxis + promote peripheral perfusion
○ S/E
■ osmotic diuresis
■ renal failure
■ high glucose and lipid
■ coagulopathy
■ interfere crossmatching
 
 
Nutritions
 
Nutritional assessment (esp pre-op)
● History
○ recent weight loss (5% in 1 month, 10% in 6 month)
○ anorexia, nausea, reflux, dysphagia, odynophagia etc
● Physical examination
○  <80% of ideal body weight
○ anthropometric measurement
■ triceps skinfold
■ midarm circumference
● Investigations
○ negative acute phase reactant
■ albumin = half life 20 days
■ prealbumin = half life 3 days
■ transferrin = half life 10 days
○ immune function
■ Delayed hypersensitivity
■ Total lymphocyte count (<1500/mm3)
● Nutritional Screening Tool
○ Malnutrition universal Screening Tool (MUST)
http://www.bapen.org.uk/pdfs/must/must_full.pdf
● Nutritional Assessment Tools

6
 ○ Subjective Global Assessment (SGA)
○ Prognostic Nutritional Index (PNI) - Triceps skin fold, albumin, transferrin, delayed hypersensitivity
○ Hospital Prognostic Indicator (HPI)
 
Estimation of calorie requirement
● Basal energy expenditure (BEE) using Harris-Benedict Equation
○ Men (kcal/day) = 66.4 + [13.7 x kg] + [5 x cm] - [6.8 x age]
○ Women (kcal/day) = 655 + [9.6 x kg] + [1.7 x cm] - [4.7 x age]
○ ** remember to use CURRENT BODY WEIGHT!
● Total energy expenditure (TEE)
○ = BEE  x  stress factors  x  activity factor (Bedbound=1.2; Ambulatory=1.3)
(in stress factor: +13% for every 1 degree increase in temperature!)
● ~35kcal/kg/day.
 
Estimation of protein requirement
● Calorie: nitrogen ratio = 150:1  (calorie: protein ratio = 24:1)
(approx translated to ~1g protein per kg of weight)
● Nitrogen balance
○ nitrogen intake
○ nitrogen loss (g/d) = 1.2 x [24h Urine Urea Nitrogen (g/d)] +2
● Creatinine height index
○ actual 24h urine creatinine/ predicted creatinine excretion
(60-80% = moderate depletion)
(>60% = severe depletion)
 
Enteric nutrition
● Indication
○ for those with functional GIT but unable to sustain adequate oral diet
○ now encourage early enteral feeding, start within 24-48h after surgery, it WOULD NOT affect
anastomotic leak
■ reduce infection
■ no effect on anastomotic dehiscence
■ more vomiting
● Benefit
○ simple and physiological
○ maintain GIT cytoarchitecture and mucosal integrity, absorptive function and flora
○ cheaper
● Feeding tubes
○ nasogastric
○ nasojejunal
○ gastrostomy
■ less aspiration, larger tube less obstruction, less reflux as it not spans over OGJ
■ endoscopic perforation, cardiopulmonary complication
pneunmoperitoneum, gut injury
skin infection, Buried-bumper syndrome (mushroom inserted into gastric wall and
epithelialized), peristomal leakage, gastric ulcer and bleeding
○ jejunal tube
● Feeding products
○ Blenderized tube feeding
■ any food that can be blended
○ Standard enteral diet (nutritionally complete formula)
■ most commonly used
■ standard solution with 1 kcal/mL
■ concentrated solution with >1 kcal/mL, for those with fluid restriction

7
 ○ Elemental diet (chemically defined formula)
■ predigested and readily absorbed, for those with compromised gut function
■ HYPEROSMOLAR >> cramps and diarrhea
○ Modular formulation
■ for specific clinical conditions
● Feeding protocols
○ Bolus feeding
■ for prepyloric tube insertion (nasogastric, gastrostomy)
■ start at 100ml Q4H, 50ml increment until target dose
■ head elevated during and 2h after feed, to avoid pulmonary aspiration
■ measure gastric residue volume before each feed, if >50% of previous bolus, withhold the
next feed
■ flush tube with 30ml of water after each use
○ Continuous infusion
■ for postpyloric tube insertion (nasojejunal, jejunostomy)
■ start at 20ml/h, 20ml/h increment every 4-6 hours
■ stop or slow the feeding if abdominal distention or pain
■ flush tube with 30ml of water every 4 hourly
● Conversion back to oral intake (stop tube feed when >75% calorie from oral intake!)
1. Reduce feeding frequency
2. Decrease feeding volume
3. Withhold daytime feeding
● Drugs that CANNOT be given through enteral feeding
○ gelatinous capsules
○ enteric coated
○ sublingual
○ sustained release
● Complications
○ Tube related
■ Nasal necrosis
■ Tracheobroncial aspiration
■ test glucose in aspirates
■ add methylene blue in feeds
■ Tx: use postpyrloric feeds in high risk patients (eg sedated)
■ Obstruction
■ Q4H flush
■ carbonated soda, cranberry juice, pancreatic enzyme, meat tenderizer
■ tube replacement
■ Malposition, knotting of tube
■ Erosion, ulceration, perforation of GIT
■ Infection, bleeding
○ Metabolic
■ Electrolyte disturbances
■ Hyper/hypoglycemia
■ Trace element deficiency
○ GIT complications (Diarrhea, constipation, cramps, nausea, vomiting)
■ Result from
■ over rapid advancement of feeds
■ use of elemental feeds
■ use of concentrated hyperosmolar feeds
■ components not tolerated (eg lactose)

8
 ■ ddx
■ pseudomembranous colitis
■ medications (metochlorpromide)
 
Total parenteral nutrition
● Indication
○ Temporary: For those patients having non-functioning GI system (severe burns, paralytic ileus,
pancreatic fistula) who cannot sustain adequate nutrition for >5-7days
○ Longterm: short gut syndrome, autonomic dysmotility
● Consideration (Balance ENERGY and VOLUME)
○ eg 2L TPN + 300ml NS/24 hour
○ eg 2.3L PPN
● Types
○ Peripheral parenteral nutrition
■ for adjunct support, usually <2 weeks (~0.7-0.8kcal/ml)
■ via peripheral vein
■ osmolarity limited to 1000mOsm to avoid phlebitis >> it needs a large volume (>2500ml) to
achieve full nutritional requirement!
○ Total parenteral nutrition
■ for full nutritional support (~1 kcal/ml)
■ central line in subclavian or IJV 
PICC (peripherally inserted central catheter), sometimes Hickman line
● Feeding products
○ 3 in 1 mixture of
■ aminoacid
■ dextrose
■ lipid emulsion from soybean or safflower oil
○ Additives
■ Electrolytes
■ Na, K
■ Cl, acetate (balancing cations! Use more acetate if serum bicarb low)
■ calcium, magnesium, phosphate (monitor Ca:PO4 ratio to avoid precipitation)
■ trace elements
■ multivitamins
■ medications
● Feeding protocols
1. Start at 50% the first day
2. Increase gradually over 1-2days
3. No need for additional intravenous fluid
● Monitoring
○ External tubing changed daily
○ Daily
■ weight, I/O
■ CBC
■ RFT, glucose, osmolarity, pH
○ Twice Weekly
■ Ca, Mg, PO4
■ LFT, clotting
○ Biweekly
■ Iron, B12, folate, lactate
■ serum lipid
● Discontinuation

9
 ○ when patient can achieve 75% calories from either orally or enterically
○ infusion rate halved for 1 hour >> halved again in next hour >> stop (to prevent rebound
hypoglycemia)
● Complications
○ Insertion
■ pneumothorax, hemothorax
■ arterial/brachial plexus/thoracic duct injury
○ Catheter related
■ phlebitis
■ sepsis
■ bleeding
■ thrombosis, embolism
■ blockage
○ Metabolic
■ electrolyte disturbance
■ hyperglycemia
■ hyperlipidemia
■ hyperosmolarity
○ fatty liver, cholestatic jaundice, liver failure (cyclic TPN + Omega-3)
○ venous thrombosis, priapism (due to high lipid content)
○ acalculous cholecystitis (unused GIT)
 
 
Percutaneous endoscopic gastrostomy (PEG) feeding
 
Benefit over NGT feeding
● less subjective discomfort
● for longer duration of feeding
● less bleeding, blockage, dislodgement of tube 
 
Indication
● shown to be benefitial only in a subgroup of patients
○ Stroke: reduce mortality and improve nutrition
○ Oropharyngeal CA: improve nutrition
● generally useful in those likely to be nutritionally depleted for 4-6 weeks, who are not suitable for oral
feeding with a functional GIT
 
Contraindications
● Coagulopathy / severe thrombocytopenia
● Not suitable for endoscopy
○ cardiopulmonary compromised
○ sepsis
○ perforated viscus
● Relative
○ acute severe illness
○ previous gastric surgery
○ peritonitis
○ ascites
○ Crohn's disease (fistulation possible)
 
Procedure
● Performed under sedation
● OGD inserted
● Identify optimal site

10
 ○ powerful light source
○ finger indentation
● LA infiltration
● needle inserted through abdominal wall, guide wire inserted
● endoscope grasp the guide wire and retracted
● feeding tube connect with endoscope and enter again
● end of tube retained in stomach by an internal bumper
● external bumper fixed to tube to prevent migration of tube in GIT
 
Complications
● Endoscopy related
○ over sedation (hypotension, respiratory failure)
○ aspiration
○ bleeding and perforation
● Procedure related
○ wound infection
○ wound bleeding
○ pneumoperitoneum
○ ileus
○ injury to liver, bowel or spleen
● Late
○ site of insertion infection/granulation/ulcer
○ tube blockage/ dislodgement
○ buried bumper syndrome (result from excessive tension between the bumpers)
■ pain on feeding
■ leakage of feeds onto skin
■ gastric perforation
○ gastric pressure ulcer
○ gastric outlet obstruction
○ peritonitis
○ gastric fistula after tube-removal
 
========================================
 
Post-op fever
 
Day 1
● Atelectasis
● Persistent infection if surgery is aiming for infection control
● Drug fever/Malignant hyperthermia
● Transfusion reaction
● Thyroid crisis
Day 2-3
● Infection due to indwelling devices (UTI, aspiration pneumonia, drip site)
● Surgical site infection
● Hematoma formation
● Gout/ pseudogout
Day 4-5
● Anastomotic leak
● Intraabdominal abscess or collection
● Acalculous cholecystitis
Day 6-7
● + DVT/ PE (classically 10th day)

11
 
*Infection usually sets in from 3rd day onwards.
  
Approaching a patient with post-op fever
Assess and monitor vitals: BP/P/SaO2/RR
History
● Any active complaint: wound pain, abdopain, chestpain and SOB, sputum, LUTS, leg pain
● Review surgical details: procedure, elective/emergent, duration of catheter placement
● Review recent drug use and transfusion
P/E
● General condition: do patient look septic?
● Examine for drug rash
● Examine wound for discharge, bleeding or dehienscence
● Examine drip site, foley for blockade or infection
● Examine leg for DVT and listen to chest for atelectasis.
● Examine and listen abdomen for tenderness or masses
Ix
● CBC, clottings, blood culture from every drip site
● Urinestix, microscopy, C/ST
● Wound discharge for C/ST
● Sputum for smear, C/ST
● USG doppler leg
● ECG, CXR
● USG or CT (if intraabdominal collection/hematoma/abscess suspected)
 
========================================
 
Wound Failure
 
Definition
● failure of incision to heal and to maintain the normal anatomy of abdominal wall
● Acute = wound dehiscence/ wound infection
○ a partial or complete disruption of any or all layers of surgical wound
○ range from minor breakdown of skin and subcutaneous tissue to to musculoaponeurotic layer to a
complete failure of entire wound with evisceration/ burst abdomen
○ usually we are refering to the detachment of fascial layer
○ most often seen 1 week post-op
● Chronic = incisional hernia
○ 50% occur in 1st year
○ 90% occur in 3rd year
 
Etiology
● Pre-op
○ Age >65
○ male
○ smoking
○ obesity
○ DM
○ malnutrition
○ steroid
○ sepsis
○ anemia
○ uremia
○ malignant, radio, chemo
● Operative

12
 ○ Emergent surgery
○ Re-operation
○ Dirty surgery
○ * Suture type and technique (high tesion, ischemia)
● Post-op
○ * wound site infection
○ chronic increase in abdominal pressure (ascites, CAPD, cough, BPH, constipation)
○ mechanical ventilation
 
Prevention

● Preop
○ avoid unnecessary preop hospital stay
○ optimize nutrition/ DM/ stop immunosuppresives
○ delayed hair removal by clippers or chemical depilatories instead of shaving (microabrasion)
○ shower or bathe with chlorhexidine gluconate (CHG) product in OT
○ bowel preparation
○ prophylactic antibiotic
● Intraop
○ laminated air flow (up to below)
○ Reduce personnel movement
○ adequate hand scrubbing
○ adequate skin prep and drap
■ contact time with skin >2 minutes
■ prepare skin at least 5cm wider that intended wound incision
○ proper sterilization of instruments
● Wound
○ avoid contamination (wound protector)
○ minimize devitalized tissue
○ adeqaute hemostasis
○ for abdominal surgery
■ mass closure for fascia
■ continuous suture to evenly distribute tension across wound
■ monofilament
■ long lasting absorbable (PDS) or non-absorbable suture (Nylon)
■ suture to wound length ratio = 3-4:1 (1cm wide 1cm deep 1cm apart)
○ laproscopic port closed for: midline supra or subumbilical sites, >10mm, stretched (eg taking out
gallbladder)

 
Clinical presentations

● Early post-op
○ serosanguinous fluid discharge from wound, amount varies with abdominal pressure (gush when
cough)
○ subjective feeling of giving away of wound, severe pain after cough or straining
● Around 1 week to 10 days
○ burst abdomen with evisceration after skin suture removed
 
How to manage a minor dehiscence (skin/subcutaneous) with surgical site infection?
● Clinical diagnosis = Fever + local erythema, swelling, heat pain + minor dehisence
● Regular inspection of wound
● Analgesics

13
 ● Antibiotics
● Infected wound opened, explored, drained, irrigated, debrided and dressed
○ Irrigation - normal saline to remove loose dead tissue, exudates and clots
○ Debridement - mechanical (forceps, scalpel, sciscorss) to excise all foriegn bodies or devitalised
tissue. Moist-to-dry packing to help stick to necrotic tissue and remove.
○ Dressing - maintain moisture and warm, impermeable to bacteria, and allow wound to heal by
secondary intention
 
Management of major dehiscene or Burst abdomen
● Call for help

● Resuscitation: ABC
● Keep patient keep in supine and knee flexed
● Cover eviscerated organs with warm sterile saline gauze
● (Do not attempt to reinsert organs)
● Vital signs Q5min
● Analgesics
● Prepare for emergent OT
○ irrigation of wound with NS under GA
○ debridement of wound edge
○ removal of previous suture
○ return of organs
○ Resuturing with Retention suture (for 4-6 weeks)
■ interrupted heavy 1/0 nonabsorbable suture, taking large bites from wound edge >3cm,
including all layers
■ it redistribute tension over wound
■ it prevent cutting through
○ post op ICU care
○ antibiotic
● * If patient have high risk of compromising ventilation or abdominal compartment syndrome
○ consider laparostomy

 
=========================================
 
Incisional hernia
 
Clinical presentation
● Protruding mass with cough impulse
● discomfort, pain
● bowel obstruction, ischemic bowel
 
Physical exam
● Cough and Valsalva manuvre
● Palpate edge of fascial defect + size (to estimate the risk of strangulation)
 
Investigation
● CT scan - modality of choice
● MRI/ USG
 
What is loss of domain?
● Hernia sac contains displaced abdominal content, residing outside abdominal cavity
● With time, there is retraction of normal abdominal muscle
● if significant loss of domain >20%, abrupt forceful return of content risks abdominal compartment
syndrome!
 

14
Suture repair - Mayo repair
● Only for smallest hernia <3-4cm (if large, it has high chance of recurrence)
● Fascial edge with 2cm overlap, closed with interrupted sutures, reinforeced with continuous running suture
 
Open Mesh repair
● old scar and redundant skin excised
● hernia sac opened, adhesion between contents and sac divided, content reduced, sac excised
● Onlay repair - fascial defect closed, mesh placed onto anterior rectus sheath
● Inlay repair - suturing a mesh to fascial edges without closing defect, CORRECT CHOICE of mesh is
important (if ordinary polypropylene used, it will induce severe adhesion intraabdominally and mesh erosion
into bowel), this technique used only when defect cannot be closed with other procedure
● Sublay repair - fascial defect closed, mesh placed onto posterior rectus sheath (or peritoneum if below
arcuate line), a complex technique useful only in midline
 
Laproscopic Mesh repair - intraperitoneal only mesh (IPOM)
● particularly useful in recurrent incisional hernia
● time consuming in the adhesion division part
 
Auxillary techniques (aid in repairing large fascial defect + reduce abdominal compartment syndrome)
● Components separation 
● Relaxing technique
● Progressive pneumoperitoneum 
● Tissue expander
 
=========================================

15
Upper GI Surgery

=========================================
 
CA tongue
 
● Smoking, Spirit, Spices, Sepsis, syphilis, sharp edges of teeth
● Almost always at lateral edge of tongue
● incisional biopsy for diagnosis
○ no safe margin for excision
○ no good would closure possibe in tongue
 
=========================================
 
OGD
 
Indications
● Diagnositic
○ GI bleed (coffee ground vomiting, hematamesis, tarry stool, hematochezia)
○ Epigastric pain
○ GERD symptoms failed PPI
○ Suspicious for CA stomach
● Therapeutic
○ Hemostasis
○ Stricture stenting
○ Foreign body removal
○ PEG insertion
○ Endoscopic CA resection
● What is the 2 indications for emergent OGD?
○ Fresh hematemesis
○ Hemodynamic instability despite resuscitation
 
Contraindications
● Suspected perforation
● Intestinal obstruction
● Unconscious patient
● Unstable cardiopulmonary function
● Oropharyngeal dysphagia
● Bleeding tendency (reverse by vitamin K or FFP, avoid biopsy)
 
Preparation
● NPO for 4-6 hours + IVF
● Crossmatch, CBC, clotting, RFT, LFT
● Consent
 
Procedure
● Sedation by diazemul (an injectable emulsion of diazepam)
○ S/e: Hypotension >> large bore IV cannula and fluid in full rate
○ S/e: Respiratory depression >> O in 15/L
○ antidote as flumazenil
● Topical oropharynx anaesthetic by lignocaine
● Continuous BP/SaO2 monitoring
● Left lateral position
● Mouth guard to prevent patients biting on endoscope

16
 ● Advance through esophagus, stomach, pylorus to D2
● J-manuvre for fundus
● Biopsy or brush cytology taken
● Withdraw
 
Complications
● cardiorespiratory compromise
● aspiration
● bleeding
● perforation
 
=========================================
 
Upper GI bleeding
 
Etiology
● Peptic ulcer
● Esophageal varices
● Mallor Weiss Tear
● Gastric or esophageal CA
● Dieulafoy lesion
 
Management
● ABC + Resuscitation
● NPO + IVF
● Crossmatch, CBC, clottings, LFT, RFT
● Assessment
○ Severity of UGIB
■ Hemodynamic status (Pulse/postural BP)
■ Hb
■ RFT (Urea:Cr)
○ Indication for urgent OGD - need fast or not? Viewing difficulty/aspiration risk.
■ shock
■ massive hematemesis
○ Contraindication to OGD
■ Obstruction (incl oropharyngeal dysphagia >> suspected pharyngeal pouch)
■ Suspected perforation (peritoneal signs, subcutaneous emphysema)
● (iv PPI for all patients) NOT PRACTISED IN PWH
(if suspected variceal bleeding: Vasocactive agents [octreotide/terlipressin] + norfloxacin/ceftriaxone +
FFP/platelets)
● Book endoscopy
○ Peptic ulcer - clips, adrenaline, thermocoagulation, sclerosants
○ Esophageal varices - band ligation, sclerosants, cyanoaacrylate
○ Mallory Weiss - injection therapy
○ Telangiectasia - argon plasma coagulation, thermocoagulation
○ Dieulafoy lesion - argon plasma coagulation, band ligation
● Post-endoscopy
○ NPO, IVF for 3 days
○ Monitor
■ signs of rebleeding (BP/P, symptoms and signs, drop in Hb despite transfusion, Ur:Cr)
■ OGD complications (perforation, aspiration)
○ iv high dose PPI for 72 hours
● Long term management

17
 ○ rescoping
 
The Rockall Score (sum of 5 independent variable, each scored 0-3, predict prognosis after UPPER GIB)
● Age
● Shock
● Co-morbidity
● Diagnosis
● Stigmata of recent hemorrhage
 
=========================================
 
Dysphagia
 
Clarification
● Is it dysphagia, globus or odynophagia
● Is it Oropharyngeal (usually neuromuscular) or esophageal (usually mechanical) dysphagia
○ difficult to initiate   vs   retrosternal holdup
○ choking/aspirating   vs   chest discomfort
○ nasal regurgitation   vs   oral regurgitation
● Is it fluid or solid?
● Is it intermittent or continuous?
 
Causes
● Mechanical
○ Intraluminal - foreign body
○ Luminal - esophageal CA, caustic stricture, Plummer-vinson syndrome
○ Extraluminal - goiter, bronchogenic CA, aortic arch aneurysm, thymic tumor
● Functional
○ Esophageal body - diffuse esophageal spasm, scleroderma, myasthemia gravis, nutcracker eso
○LES - achalasia
 
OGD vs  Barium swallow
2. higher risk of perforation and aspiration
3. more discomfort
4. cannot visualize motility (but good for anatomical)
5. can take biopsy
 
Investigation
2. OGD
3. if visible lesion and passable >> staging work up for malignancy
4. if visible lesion not passable >> barium swallow
5. if no visible lesion >> Barium swallow +- manometry
 
=========================================
 
Achalasia
 
Basics
2. 20-40yo
3. over expressing cholingergic excitatory fibers??
4. absence of ganglions in myenteric plexus
5. high relaxing pressure 8mmHg, intrasphincter pressure can go up to 40mmHg.
 
Presenations
● wax and wanes dysphagia of fluid and liquid
● chest pain

18
 ● regurgitation and heart burn
● weight loss, malnutrition
 
Diagnosis following the dysphagia approach
● OGD = normal +- reflux esophagitis
● Barium swallow = bird beak sign, esophageal dilation, non-peristaltic, aspiration pneumonia
● Manometry
○ Aperistaltic distal esophagus
○ failure of LES relaxation (relaxation pressure >8mmHg) +- increased LES pressure (>26mmHg)
○pressurization of esophagus (exceeds stomach resting pressure)
 
Management
● Pharmacological - CCB, GTN, anticholinergics
● Endoscopic
○ Balloon dilatation - 30,35,40mm, very large ballon aims at a controlled destruction of muscle
fibers
○ Botox injection
● Surgical = Laproscopic Heller's myotomy
○ anterior incision, splitting both longitudinal and circular muscle
○ 10% will develop GERD post-op, so routine partial fundoplication is done
  
=========================================
 
Definition for Barrett's esophagus
● Endoscopically visible columnar epithelium
● Glandular metaplasia under histological examination
 
Esophageal carcinoma
 
Basics
● M:F = 2:1
● SCC
○ most common type in Asia (reverse in caucasian)
○ can occur in all parts, most common at middle esophagus
● AdenoCA
○ lower third
○ almost always associated with barrett's esophagus
 
Risk factors
● Diseases
○ Plummer-Vinson syndrome, achalasia
○ HPV infection, fungal contaminated food - myocotoxin
○ tylosis
○ Barrett's with intestinal metaplasia (*for adenoCA)
● Environmental
○ alcohol, tobacco
○ Corrosive ingestion
○ Vitamin A, C, B1, B2, B6 defiency
○ Molydenum, Zinc defiency
○ Nitrosamine, hot fluid ingestion
 
Clinical presention (usually LATE)
● Local
○ Painless progressive dysphagia (may indicate muscle invasive disease)
○ Upper GI bleeding, anemia

19
 ○ Choking, hemoptypsis (tracheoesophageal fisula or aspiration)
○ Hoarseness of voice, stridor (recurrent laryngeal nerve involvement)
● Systemic
○ constitutional symptoms
 
Investigation
● Diagnosis
○ OGD + biopsy
● Staging
○ CXR
○ CT thorax + abdomen - for distant metastasis and regional invasion (T3/4)
○ EUS - discriminate intramural (T1/2) or transmural (T3) tumor or invasion of adjacent structures
(T4); also helps in assessing lymph node status
○ PET scan & Bone scan
○ Laparoscopy - if significant infradiaphragmatic component is presence, to see peritoneal seed
○ Bronchoscopy - if EUS shows equivocal TOF
● Assess patient's FITNESS
○ pulmonary function test (FEV1>1.5L), ABG
○ ECG, echocardiogram, exercise tolerance test (>2FOS)
 
Management Outline
● Curative
○ Endoscopic (EMR/ESD)
○ Esophagectomy +- neoadjuvant chemoRT
○ Primary chemoRT
● Palliative
○ endoscopic
○ chemoRT
○ surgical
● Choices depends on
○ Tumor factor: TNM staging, local invasion of adjacent organs (aortic arch, trachea, bronchus)
○ Patient factor: cardiopulmonary function, comorbidity
○ Organ factor: esophagus replacement
 
Curative Management
● Endoscopic
○ for early T1 tumor with mucosal (m1,2,3) or superficial submucosal (sm1) involvement
○ Endoscopic mucosal resection (EMR)
○ Endoscopic submucosal dissection (ESD)
○ * In real life, very few patients present this early to allow endoscopic curative surgery, but if done,
excellent prognosis comparing to esophagectomy
● Esophagectomy +- neoadjuvant chemoRT
○ for Stage II/III patients (no adjacent organ involvement) + good pre-op function
○ Complete resection
■ complete tumor excision
■ adequate proximal and distal margin (*esophageal CA classically spread longitudinally in
submucosal lymphatics)
■ adequate adventitial margin
■ radical lymphadenectomy
○ Types of esophagectomy
■ 2-stage: Ivor-Lewis (for CA in mid/lower third esophagus)
■ Thoracic (left lateral) phase: mobilization of esophagus
■ Abdominal (supine) phase: gastric mobilization

20
 ■ lower risk of leak but high risk of mediastinitis
■ 3-stage: McKeown (for CA in upper third esophagus)
■ Thoracic phase
■ Abdominal phase
■ Cervical phase: esophageal resection and anastomosis
■ higher risk of leak but lower risk of mediastinitis
■ Transhiatal
■ transhiatal esophagectomy with reconstruction - for lower 1/3
■ transhiatal total gastrectomy with Roux-en-Y jejunal resconstruction - for OGJ
■ esophagus dissected bluntly so, avoid thoracotomy
■ but it lacks lymphadenectomy
○ Things to know about esophagectomy
■ Left lateral position in abdominal phase - right thoracotomy, so that whole esophagus is in
view (in contrast to left thoracotomy performed in repair in Boerhaave syndrome, where only
lower esophagus is involved
■ Thoracic duct needs to be clipped, to prevent chylothorax (50% mortality)
■ Artery pedicle to preserve = right gastric & right gastroomental artery
■ Conduit choices = stomach, colon, small bowel
■ Route of mobilization = subcutaneous (for those with caustic esophagitis), substernal,
mediastinal
■ Pyloroplasty/ pyloromyotomy as vagal nerve is transected routinely, beyond the carina,
to avoid disrupting upper airway sensation which predisposes to aspiration
■ EARLY Complications
■ pneumonia
■ bleeding
■ conduit ischemia
■ anastomotic leak (TPN, conservative, diversion esophagostomy)
■ chylothorax (early reexploration with ligation of thoracic duct)
■ LATE complications
■ anastomotic stricture (endoscopic dilation)
■ bilous reflux
■ chronic pain (from thoracotomy)
■ delayed gastric emptying if pyloroplasty poorly done
○ Lymphadenectomy
■ currently two-field = abdominal & mediastinal nodes
■ Japanese proposed the radiacl three-field lymphadenectomy = + cervical nodal basin
○ After resection (most important prognostic factor)
■ R0 = removal of all macroscopic and microscopic tumor
■ R1 = microscopic disease left
■ R2 = macroscopic disease left
○ Neo-adjuvant chemoRT
■ 1 RCT showed improved survival
○ Adjuvant chemoRT
■ not useful
● Primary chemoRT
○ cisplatin + 5FU  & high dose RT
○ similar 2 year survival and recurrence, long term result unknown
 
Palliative Management
● Endoscopic
○ Stenting
■ Self-expandable metal stent

21
 ■ used BELOW cricopharygeus muscle to avoid continuous sensation and aspiration
■ Complications
■ Early
■ perforation
■ misplacement (too high to cricopharyngeus, too low causing
reflux) + PPI
■ Late
■ migration
■ tumor ingrowth
○ Dilation
○ Local ablation (laser, argon plasma coagulation, alcohol injection, photodynamic therapy)
○ Feeding tube/ Percutaneous Endoscopic Gastrostomy (PEG)
● Chemotherapy
○ usually poor response
○ ECT regime (epirubicin, cisplatin, 5-fluorouracil)
 
=========================================
 
Stenting in esophagus
● Types
○ metallic - good anchoring and long lasting, but difficult to remove when needed
○ plastic - good for removal, but easier to dislodge
● Complications for stenting
○ Early - infection, bleeding, perforation
○ Late - dislodgement, displacement, tumor invasion, erosion into tissues
○ Specfic to sites - if near OGJ then it causes easy REFLUX
 
=========================================
 
Boerhaave syndrome
 
● longitudinal transmural tear (RUPTURE) of distal esophagus.
● usually due to severe retching and associated with alcoholism, or due to instrumentation
● Classically presented with Mackler's triads of vomiting, lower thoracic pain, and subcutaneous
emphysema
● Complicated by pneumomediastinum, mediastinitis, pleural effusion, empyema and septicaemia
 
=========================================
 
Esophageal varices
 
Management
● Resuscitation
○ endotracheal intubation to protect the airway from aspiration and later endoscopy
○ vascular access via short large bore peripheral lines secured + volume resuscitation
○ recombinant activated factor VII to correct lengthened prothrombin time
● Drugs
○ iv octerotide or vasopressin given on admission
○ short term prophylactic antibiotics (ciprofloxacin or ceftriaxone)
○ correct coagulopathy (FFP, Vit K)
○ iv thiamine if alcoholic
● Endoscopic treatment
○ endoscopic band ligation
○ sclerotherapy : STD, ethanolamine oleate, absolute ETOH, histoscrylic glue
○ cyanoacrylate glue injection

22
 ● Balloon tamponade
○ Sengstaken-blakemore tube
○ Minnesota tube
○ gastric balloon inflation under radiological guidiance to prevent the misplacement in esophagus,
inflat with 200-250cc water with blue dye or contrast
○ esophageal ballon at 40mmHg
○ <24 hours to prevent pressure necrosis
● Transjugular intrahepatic portal shunt
○ PTFE stent (polytetrafluroethylene)
○ as a salvage therapy in patients failing the above, but early placement in 24-48 hours can provide
survival improvement in HIGH RISK patients (eg child C cirrhosis)
● Surgical treatments
○ transgastric variceal plication
○ Johnston's method
■ esophageal transaction with circular stapler
○ Sugimura procedure
■ devascularization of esophagogastric area
○ Emergent shunting
■ non selective or selective
■ carries the risk of sudden deterioration of hepatic encephalopathy
■ with ascites: mesocaval shunt
■
without ascites: distal splenorenal shunt (Warren's)
 
=========================================
 
Gastric varices
 
● Causes
○ as a complication of portal hypertesion, as with that in esophageal varices
○ splenic vein thrombosis (short gastric vein patent)
● Sarin classification

 
○ Treatment as that in esophageal varices
○ use of Linton Nicholas tube (larger gastric balloon without esophageal part)
 
=========================================
 
Dieulafoy's lesion

23
 
● an arteriovenous malformation characterized by a dilated aneurysmal submucosal vessel
● usually found in stomach (70%), located at lesser curve within 6cm from OGJ
● presented as massive bleeding
 
=========================================
 
Hiatus hernia
 
Classification
Type I - sliding hernia
Type II - paraesophageal hernia, usually anterior and lateral to esophagus
Type III - combination of the above two, more common than a pure type II
Type IV - abdominal organs other than or in addition ot stomach herniated thru hiatus
 
Clinical presentation
● Type I will show symptoms of reflux
● Type II-IV present as postprandial pain or bloating, early satiety, breathlessness with meals and mild
dysphagia
● herniated pouch complicated by volvulus, obstruction and infarction, ischemic longitudinal ulcers called
Cameron ulcers
 
========================================  
 
Gastroesophageal reflux disease
 
========================================  
 
Helicobacter pylori infection
 
========================================  
 
Peptic ulcer diseases
 
Etiology
● H. pylori infection
● NSAID related
● Others
○ Cushing's (increase in intracranial pressure, thus irritate the vagal nuclei, which in turn stimulate the
stomach to overproduce acid)
○ Curling's (ulcers found after severe burns, due to hypoperfusion of mucosa)
○ Hypercalcemia
○ Zollinger Ellison Syndrome
○ G-cell hyperplasia, Gastrinoma
○ Crohn's disease
  
Location
● Gastric - lesser curvature
● Duodenum - bulb
● *If found in distal duodenum, consider
○ Crohn's disease
○ Ishchemia
○ Zollinger-Ellison syndrome
 
Clinical presentations
● Dyspepsia (food bad in GU; food good in DU)
● Upper GIB - coffee ground vomiting, hematemesis, tarry stool, fresh PR bleed, anemia
● Perforation - sudden onset of pain, toxic looking, rigidity
● Gastric outlet obstruction - wax and wanes pain, repeated projectile vomiting

24
 
Managements of dyspepsia
● Smoking cessation
● Risk stratification
○ If uncomplicated >> test and treat (see above) >> PPI trial >> OGD
○ If complicated or old age >> OGD
● If Test and treat-FAILURE, think
○ Compliance
○ H pylori resistance
○ NSAID
○ CA stomach, Crohn's, ZES
● Elective surgery as last resort:
○ Duodenal ulcer
■ truncal vagotomy with pyloroplasty
■ truncal vagotomy with Billroth I (GDstomy) or Billroth II (GJstomy) antrectomy
■ highly selective vagotomy
○ Gastric ulcer
■ wedge resection
■ antrectomy
 
Management of bleeding
● Resuscitation  &  correct coagulopathy  &  close monitoring  &  Crossmatch
(NEJM 2008 Lau: the use of omeprazole before endoscopy in ALL patients with upper GIB, can reduce the
need for endoscopic treatment, reduce hospital stay, and reduce actively bleeding ulcers)
● Localisation by OGD + biopsy
○ Forrest's classification 
 Forrest ○  Type of lesion: ○  Risk of rebleeding if untreated:
class: Arterial spurting bleeding 90%
IA Arterial oozing bleeding 50%
IB Non-bleeding visible vessel 30%
IIA Adherent clot 20% 
IIB Pigmented flat spot  <5%
IIC No stigmata of hemorrhage <5%
III
● Hemostasis (NOW favour COMBINED endoscopic treatment, it reduces rebleeding)
○ Mechanical clips
■ difficult for flat, difficult positioned or multiple ulcers
■ better for visible vessels
■ (not rubberband ligation as the ulcer cannot be sucked up)
○ Adrenaline injection (1:10000) (0.5-1ml up to 10ml)
■ local tamponade
■ vasoconstriction
■ platelet aggregation
○ Sclerosant injection
■ ethanol, ethanolamine, STD, fibrin glue, thrombin
■ now rarely used as it may induce necrosis and result in bigger ulcers
○ Thermocoagulation
■ heater probe or bipolar coagulation probe
■ may be difficult if vessel to large
○ (Laser coagulation)
● Post-endoscope high dose iv PPI infusion for 72 hours
● Monitor BP/P, U/O
● Consider second look endoscopy(all GU?) in high risk patients
● HP eradication after all acute management

25
 
Rebleeding
● High risk group
○ shock on admission
○ high rank forrest class
○ ulcer >2cm
● Reduction of this risk
○ combined endoscopic treatment
○ high dose PPI infusion for 72 hours (stablise coagulation, less platelet disaggregation in higher pH)
○ second look endoscopy
○ ** no role for HP eradiction at acute stage!
● Choice of treatment
○ Repear endoscopy and endotherapy
○ Angiographic embolisation
○ Salvage surgery
 
Salvage surgery
● Indications
○ Failed primary endoscopic hemostasis
○ Rebleeding in hospital +- angiographic embolisation failure
○ Ongoing transfusion >8 units
● Choices
○ Small ulcer
■ plication of vessel
■ exclusion of ulcer
○ Large ulcer
■ Distal = distal partial gastrectomy
■ Proximal = ulcer excision + vagotomy
■ Unstable = ulcer excision
 
Management of Gastric outlet obstruction
● Resuscitation
● NPO with IVF
● NGT inserted
● Investigations
○ crossmatch, CBC, RFT (hypoK) , chloride, ABG (hypochloremic metabolic acidosis)
○ urine pH
○ water soluble constrast
- 1st part obstruction = GOO
- 2nd part obstruction = periampullary CA
- 3rd part obstruction = SMA compression / food bolus
● Replace K
● OGD + biopsy
● Surgery
○ endoscopic - balloon dilatation, 50% recur, reserved for poor risk patients
○ surgical - gastrojejunostomy + vagotomy (prevent ulcer at anastomosis)
● HP eradication after all acute management
     
=======================================
 
Perforated peptic ulcer
 
Clinical presentation

26
 ● Sudden epigastric pain +- peritonism
(pain might be inobvious due to local sealing by omentum OR NSAIDs)
(lower abdomen pain may occur due to gastric fluid tracking down paracolic gutter)
● Toxic, tachy, hypotensive
● Board like rigidity
 
Most common site
● Anterior duodenum
 
Investigation
● Erect CXR for free gas under diaphragm (70%)
● Contrasted CT abdomen
●Amylase
 
Boey's score to predict mortality
● Time since perforation >24h
● SBP on admission <100
● Systemic illness comorbid
1 = 0%
2 = 10-46%
3 = 100%
 
Management of perforated peptic ulcer
● Resuscitation
● NPO
● IVF
● NGT to BSB
● Foley to BSB
● BP/P/UO Q1H
● Chart I/O
● Urgent erect CXR (If unsure: Decubitus film/ CT abdomen)
● AXR
● Blood x CBC d/c, clotting, RFT, T/S, LFT, amylase
● IV tramadol 50mg Q8H prn
● IV cefuroxime 750mg Q8H
● IV metronidazole 500mg Q6
● IV PPI
● Book urgent laproscopy +- laparotomy + mesh repair + peritoneal lavage
○ Laparoscopic omental patch repair + peritoneal lavage (>6L warm NS)
○ Laparotomy: if ulcer too large >1cm
● HP eradication after all acute management
 
=======================================
 
Sydney classification of gastritis

Endoscopic criteria of gastritis Classification according to etiology

1. erythematous/exudative gastritis 1. Autoimmungastritis (type A)

2. superficially erosive gastritis 2. Bacteria related gastritis (type B)
3. polypoid gastritis with erosions 3. gastritis induced by Chemotoxic agents (type C)
4. atrophic gastritis 4. distinct forms of gastritis
5. hemorrhagic gastritis
6. bile gastritis
7. giant folds gastritis

Classification according to localisation Grading

27
 1. Pangastritis normal, low-, middle-, high- grade
2. gastritis of the body
3. antral gastritis

Histomorphologic criteria

1. acute
2. chronic
3. chronically-active
 
========================================  
 
Gastric tumors
 
Benign:
● Gastric polyps (hyperplastic, fundic gland, adenomatous polyp)
○ only adenomatous polyp has malignant potential to turn in to adenocarcinoma
● Gastrointestinal stromal tumor
●Hemangioma/ leiyomyoma
 
Malignant:
● Adenocarcinoma
● lymphoma
● malignant stromal tumors
○ GIST
○ leimyosarcoma
● Carcinoid
 
========================================  
 
Gastric adenocarcinoma
 

Risk factors (*ONLY FOR INTESTINAL TYPE ADENOCARCINOMA)

● Disease factors:
○ H. pylori infection (x2-3 fold) **
○ Chronic gastritis with intestinal metaplasia
○ Pernicious anemia
○ Partial-gastrectomy
○ 1% chronic peptic ulcer
○ Gastric adenoma
● Genetic factors
○ HNPCC,FAP,PJS
○ blood GpA
○ positive family history
○ Japanese and korean
● Environmental factors:
○ Smoking and alcohol (not a direct causative agent, but lead to precancerous states including
gastritis)
○ Nitrites
○ Little veges
○ low vitamin C or carotene intake
● *no established risk factors for diffuse type carcinoma, proposed the E-cadherin mutation may take a role

Pathogenesis for H. pylori induced gastric cancer

28
 ● Free radical mode - a local production of free radical by HP thus an increased rate of DNA mutation
● Perigenetic mode - the inflammation caused by HP infection will lead to a increase in local TNF or IL-6,
they alter gastric cellular adhesion

Classifications
● Macroscopic classification for Early gastric tumors EGC (limited to mucosal and submucosal, regardless of
lymph node status)
○ I: protruded
○ IIa: superficially elevated
○ IIb: superficially flat
○ IIc: superficially depressed
○ III: excavated 

● Macroscopic classification for late tumors (Bormann's):

○ Type 1 = polypoidal
○ Type 2 = ulcerated with raised margins
○ Type 3 = ulcerated with inflitrating margins
○ Type 4 = diffusely infiltrative (linitis plastica)
● Microscopic classification (Lauren's):
○ Intestinal: glandular pattern resembles colonic adenocarcinomas
○ Diffuse: signet ring cells, tend to be poorly differentiated
■ linitis plastica - a leather bottle stomach, small thickened contracted stomach due to
submucosal infiltration without ulceration (bleeding infrequent)
 

Sites
● 50-60% antrum, 25% cardia
● 75% lesser curvature
● thus the favoured location is the lesser curvature of the antropyloric region
● * recent years there is a trend of promixmal migration of gastric cancer, ?GERD related, OGD tumor
classification
○ Type 1 = true esophageal cancer, associated with Barrett esophagus
○ Type 2 = true carcinoma of cardia
○ Type 3 = subcardinal gastric cancer spreading above
 

Spread
● Local contagious invasion: esophagus, duodenum, pancreas, transverse colon, liver
● Hematogenous: liver, adrenal, lung, bones
● Lymphatics: perigastic (greater and lesser curve nodes), Virchow's node (troisier's sign)
● Trancoelomic: pertioneal seedings (Krukenberg tumors in bilateral ovaries), typically from diffuse type
signet ring cell gastric cancer

S/S (early cancer is asymptomatic, often incidental)

● General constitutional symptoms
○ weight loss and anorexia
● Local features
○ epigastic pain and discomfort
○ hematomesis/coffee ground vomiting/melena/anemia
○ antral tumor - obstructive symptoms with vomitting
○ cardiac tumor - dysphagia (pseudoachalasia)

29
 ● Metastatic features
○ jaundice, ascites
● Paraneoplastic features
○ acanthosis nigricans
○ migratory thrombophlebitis 
○ Leser-Trelat sign (multiple seborrheic keratoses)
○ Sister Mary Joseph sign (periumbilical mass)
○ Blummer's shelf (soild peritoneal deposit anterior to rectum, palpable on DRE)
○ Trousseau sign of malignancy (hypercoagulability from adenoCA causing DIC)
○ membranous glomerulonephritis

Staging (2010 AJCC/UICC TNM)

● Tumor
○ T1 - invade muscosa and submucosa
○ T2 - invade muscularis propria
○ T3 - invade subserosal connective tissue
○ T4 - invade surrounding structures
● Nodes
○ N1 - 1-2
○ N2 - 3-6
○ N3 - >7
 
Investigations
● Diagnosis:
○ OGD with muiltiple biopsy +- brush cytology
● Staging:
○ Contrasted CT abdomen (iv contrast + po water for stomach distention)
○ endoscopic USG
○ MRI, PET, bone scan
○ laparoscopy
● Patient assessment:
○ Nutritional status
○ CXR, lung function test, ABG
○ resting ECG
○ CBC, RFT, LFT
 
Contraindiaction for curative surgery
● Locally advanced disease (extensive nodal involvement with encasement of major arteries eg left gastric or
splenic)
● Distant metastasis
○ multiple liver metastasis
○ ascites, peritoneal nodule
○ pelvic deposit
○ SCF nodes

Curative Managements who to subject?

● Endoscopic (for early gastic cancer)
○ Endoscopic mucosal resection (saline injected to raise it, removed by polypectomy snare)
■ T1a - mucosal* only (submucosal with nodal metastasis rate ~15-20%!)
■ <2cm

30
 ■ not ulcerative/excavating type
■ not diffuse histology
○ Endoscopic submucosal dissection
● Surgical
○ Adequate resection margin
■ proximal minimum 6cm
■ distal down to D1/2
○ Resection
■ Distal subtotal (75%) gastrectomy for antral tumors (Billroth II)
■ Total gastrectomy for midbody and proximal tumors (Roux-en-Y)
■ Transhiatal esophagogastrectomy for OGJ tumors
○ Lymphadenectomy (ideally one station beyond involvement)
■ D1 (first tier) = limited lymph nodes dissection (perigastric nodes)
■ D2 (second tier) = extended lymph nodes dissection (nodes on hepatic/splenic/left gastric)
■ D2 + PAND= paraaortic lymph nodes dissection
■ *Trials comparing D1 vs D2, and  +-PAND
■ the early Japanese trials showed survival benefit in D2
■ Dutch and UK MRC trials showed similar survival but increased perioperative
mortality in D2 resection...BUT were criticised for LOW VOLUME hospital+ inadequate
training
■ subsquent Italy trial confirmed survival advantage! 日本人果然勁!
■ NEJM 2008, no additional benefit from PAND on D2
○ Adjuvant chem/chemoRT/target therapy - slight benefit
■ Chemo = NNT of 25 for early mortality
■ S1 - 5FU prodrug (oral fluoropyrimidine) - 10% increase in survival
■ ChemoRT - trials shown to be benefitial, but critics with poor D2 surgery done, so not in HK
■ Herceptin - 20% gastric cancer with her2 mutation, 1 RCT show benefit
○ Neoadjuvant chemo
■ can downstage T/N stage and improve operability and overall survival
 
Resection outcome
● R0 = no residue disease
● R1 = microscopic disease
● R2 = macroscopic disease
 
Palliative Management
● Endoscopic
○ hemostasis with ETOH injection
○ stenting (only liquid diet afterwards)
● Surgical
○ Palliative surgical resection
○ gastric by pass by gastrojejunostomy
○ Devine exclusion
○ Le Veen shunt - peritoneal venous shunt connecting peritonuem to SVC/internal jugular vein for
malignant ascites
● Chemoradiation
 
Complications of gastic surgery
● Early
○ Chest infection(from upper midline incision)
○ Anastomotic leak, duodenal stump leak >> adequate drainage, TPN or enteral feeding beyond it,
good skin care
○ Bleeding (reactionary, secondary to infections high mortality) >> angiographic embolisation

31
 ● Long term
○ Post-gastrectomy syndrome
○ Tumor recurrence
 
Prognosis
● TNM
● Microscopic peritoneal disease
● Tumor differentiation
● Adjvant therapy

 
========================================  
 
Gastric MALToma
● Mucosal associated lymphoid tumor
● low grade B-cell lymphoma, slow progressive
● STRONG association with HP (80%)
● Treatment
○ HP eradication (regress in 75-85%) + endoscopic surveillance
○ Gastrectomy or Chemotherapy for
1. HP +ve not responding to eradication
2. HP -ve
3. high grade component
4. histology suggesting transformation
 
Gastrointestinal stromal tumor 
● Originate from nerve of Cajal
● usually at gastric fundus, with submucosal mass
● CD 34 and CD 117 immunostaining
● mutation in the c-kit tyrosine kinase gene
● Classified into:
○ smooth muscle cell differentiation
○ neural differentiation (Gastrointestinal autonomic nerve tumor)
○ dual differentiation
○ no differentiation
● Malignant if
○ > 5cm
○ High mitotic index (>5 dividing cells in 50 High Power Field)
○ tumor necrosis
○ distant metastasis
● Treatment
○ Surgical:En bloc excision WITHOUT lymphadenectomy (LN met in GIST is rare)
■ avoid damaging pseudocapsule
■ if high risk >> Imatinib (sunitinib)
■ if R1 disease >> Imatinib (sunitinib)
○ Non-resectable cancer >> Imatinib (sunitinib)
 
=======================================
 
Zollinger Ellison syndrome
 
● A gastrin-producing tumor usually in pancreas, also in duodenum
● the gastrinoma triangle
○ junction of cystic duct and CBD

32
 ○ junction of pancreatic head and neck
○ junction of 2nd and 3rd part of duodenum
● 50% malignant
● 25% associated with MEN-1, plus pituitary tumor and parathyroid tumor
● greatly increase gastric acid production hence present with:
○ Non HP non NSAID ulcers
○ multiple ulcers
○ recurrent ulcers
○ atypical ulcer site (eg 3rd part of duodenum/jejunum)
● Diagnostic tests
○ fasting gastrin level (also high in: G-cell hyperplasia, atrophic gastritis, Acid suppression therapy)
■ >1000pg/l is diagnostic
■ <1000pg/l : go for secretin stimulation test
○ Antral acidity test < 2.5
● Management
○ PPI and H2 blocker for symptom control
○ Surgical resection or chemotherapy for primary tumor
○ Octreotide to suppress gastrin release
  
======================================= 
 
Carcinoid tumor
● Classification
○ Type I: asso with autoimmune atrophic gastritis
○ Type II: asso with MEN1 and gastrinoma
○ Type III: sporadic
● Endocrine cell origin that secrete a variety of hormones
● for carcinoid syndrome to manifest, the co-defect of liver function is required (possibly from liver
metastasis), because serotonin is readily degraded in liver
● check urinary 5-HIAA
 
=======================================
 
Complications
● Early: chest infection, bleeding, anastomotic leakk
● Late: Post-gastrectomy, recurrence
 
 
Post gastrectomy syndrome
 
Mechanical
● Small stomach syndrome (early satiety, reflux >> eat little meals)
● Intestinal obstruction from adhesion or food bolus
● Afferent loop syndrome
○ pancreatic enzyme stasis leading to pain radiating to back
○ relieved by vomiting
● Roux status syndrome
○ bacterial stasis in the afferent stump , present with steatorrhea with malabsorption of fat soluble
vitamins and B12
 
Functional
● Bilious reflux
○ esp in Billroth II gastrectomy
○ pain, nausea, bilious vomitting not associated with food intake
○ treat by frequent meals or a roux-en-Y reconstruction

33
 ● Dumping syndrome
○ Early dumping
■ in 30 minutes
■ relative hypovolemia with sympathetic discharge: nausea, explosive diarrhea, dizziness,
palpitation, diaphoresis
■ due to hyperosmolar intestinal load
○ Late dumping
■ in 1-4 hours
■ reactive hypoglycemia
■ due to the high simple carbohydrate loads
● Diarrhea from intestinal denervation, vagotomy
 
Nutritional disturbance
● Decrease overall intake
● Iron deficiency anemia (absence of HCL make iron into less absorbable form)
● B12 deficiency anemia (lack of intrinsic factor)
● Osteoporosis
 
Other
● Gallstone (hypokinesia from denervation, bile stasis)
● CA in gastic remant (from chronic bile reflux and hypoacidity)
 
=======================================
 
GI anastomosis
 
Good anastomosis
● GI factor
○ Discrepancy of bowel caliber
○ blood supply
○ tension
○ persistent GI disease
○ infection around anastomosis
● Surgeon factor
○ sero-submucosal
○ good apposition of layers
○ single layer anastomosis
● Patient factor
○ Malnutrition
○ Obesity
○ Immunosuppression
○ Chemotherapy/ Radiotherapy
○ Malignancy
○ Connective tissue disease
○ Renal failure
 
Anastomotic leak S/S
● Post-op fever Day 5-6  (if day-1, it has to be technical failure)
● Tachycardia, hypotension
● Abdominal pain
● Bile or faceal drain
● Lung collapse
● high WCC
 

34
Management
● Resuscitation
● iv broad spectrum antibiotics
● Water soluble contrast study
● CT with po and iv contrast
○ subphrenic, subhepatic, intraloop, pelvic collection
● USG guide drainage +- pigtail insertion
● Operation for revealed leakage
○ Consideration
1. Site of anastomosis (lower GI)
2. Patients' condition (critically ill)
3. Likelihood of severe abdominal contamination (eg fecal, gastric content)
○ Procedure
■ take down anastomosis + bring out stoma, OR
■ diversion loop ileostomy or colostomy without taking down anastomosis
■ peritoneal lavage
● Conservative for concealed leakage (promote enterocutaneous fistula)
○ adequate drainage
○ iv antibiotics
○ nutritional support (TPN or elemental EN)
○ local skin care (stomal bag)
 
Factors for persistence of fistula
1. Persistent foreign body
2. Epithelialization
3. Malignant infiltration
4. Local collection
5. Diseased GIT (eg Crohn's, TB, Actinomycosis)
6. Distal obstruction
 
Treatment
● Resection of fistula
● GI reconstruction
● skin reconstruction
● Treat underlying disease
 
 ==========================================
 

35
Lower GI Surgery

=======================================  
 
Carcinoembryonic Antigen
 
Positive in 60-70% CRC recurrence, may precede symptoms by 6 months!
 
False positive in:
● Breast, lung, pancreas, kidney, CA
● Alcoholic cirrhosis, gastritis, diverticulitis
● diabetes mellitis
● smoking, emphysema
 
=======================================  
 
Faecal occult blood test
● Chemical test
○ guiaic test for heme
○ False positive: ingestion of undercooked meat
○ False negative: vitamin C supplements 
● Immunological test
○ test for globulin
○ +ve result mean LOWER GIB
 
=======================================
 
Colonoscopy
 
Indications
● Diagnostic
○ gastrointestinal hemorrhage
○ change of bowel habit
○ Unexplained anemia
○ any positive fecal occult blood test
○ streptococcus bovis endocarditis
● Screening
○ family history of early onset GI malignancy
○ family history of familial inherited cancer syndrome
○ ? old age male >50 years old
 
Preparation
● low fiber diet three days prior
● admit one night before or at same morning
● mechanical bowel preparation
○ Polyethylene glycol
■ isosmolar compound dissolved into 4L of water, drink withi 4 hours
■ inert, nonabsorbable, nonfermentable agent
■ wash bowel by volume effect (whole bowel irrigation)
■ slightly more effective than phosphosoda
■ patient discomfort and non adherence (bad taste, large volume)
○ phosphosoda
■ osmotic agents
■ 45ml drink with 8 cups of water for two times (oral laxative) 10-12 hour apart

36
 ■ more well tolerated
■ contraindicated in patients with
■ chronic renal failure (phosphate retention)
■ congestive heart failure, liver disease (fluid compartment shifts)
■ hyperphosphate, hyperNa, hypoK, hypoCa
● set up intravenous assess
○ Pethidine: injectable form of opioid analgesics
○ Diazemuls: injectable emulsion of diazepam, as sedative
○ (Midazolam can be an alternative to diazemuls)
 
Procedures
● start by DRE
● Caecum is reach in 85-90% (considered full colonoscopy)
○ obstructive lesion
○ difficult anatomy
■ redundant sigmoid or transverse
■ previous abdominal surgery or infection
■ previous pelvic irradiation with narrowed rectum or sigmoid
● Looping of endoscope
○ tight turns and redundancy in areas of the colon that are not "fixed"
○ advancement of the endoscope creates a "bowing" effect that causes the tip to actually retract
○ result in discomfort due to stretching of the colon
○ Treatment:
■ pulling the endoscope backwards while torquing the instrument
■ change body position
■ abdominal support from external hand pressure
● withdrawal time at least ~20min for better diagnosis
 
Complications
● Bowel Preparation
○ fluid and electrolytes disturbance (enema and vomitting)
○ intestinal obstruction from bowel prep
○ vomitting
● Sedation
○ hypotension and bradycardia
○ reduction of oxygen saturation
● Procedural
○ bleeding by bowel wall injury
○ extraluminal bleeding (seromucosal tear, mesenteric tear, liver and spleen rupture)
○ perforation (1 in 1000) esp after polypectomy (with full thickness necrosis)
 
Colonoscopy vs DCBE
● Good
○ therapeutic
○ more sensitive and specific in diagnosis (esp small lesion)
● Bad
○ higher chance of perforation (1 in 1000 vs 1 in 25000)
○ operator dependent
 
=======================================
 
Lower GI bleed
 

37
Etiology
2. Diverticular disease
3. Angiodysplasia
4. Colorectal cancer
5. Inflammatory bowel disease
6. Drugs (anticoagulants, NSAIDs)
7. Meckel's diverticulum
8. Endometriosis
 
Management
6. Assess vital signs, degree of bleeding and resuscitate when needed
7. Take a history for suspicious bleeding
○ age >50
○ altered blood
○ blood mixes with stool
○ mucus in stool
○ change in bowel habit
○ tenesmus
○ abdominal pain
○ constitutional
○ anemic
○ personal history, family history
○ chronic inflammatory bowel
8. P/E and proctosigmoidoscopy
○ Inspection (fissure, fistula, prolapsed hemorrhoids)
○ Sphincter tone (if loose, cannot go for DCBE)
○ DRE (palpable tumors, pouch of douglas, blood on glove)
○ proctosigmoidoscopy
 
Minor GI bleed
● Distinguish the outlet type bleeding or suspicious bleeding
○ outlet type : Proctosigmoidoscopy; if negative then proceed
○ suspicious bleeding : straight to DCBE/ colonoscopy
● DCBE
○ performed in the radiological department
○ need bowel preparation
○ with rectal ballon in situ, instill liquid barium + air
○ low sensitivity in rectum (no contrast) 
○ not sensitive in showing small polyps or angiodysplasia
○ high mortality if barium peritonitis (1 in 25000)
● Colonoscopy
○ needs bowel preparation with or without sedation
○ lowest sensitivity at splenic flexure (acute angulation)
○ complications include bleeding and perforation (1 in 1000)
 
Massive GI bleed
● age related
○ young age - meckel's diverticulum/ inflammatory bowel diseases
○ adult - diverticulosis, angiodysplasia, CA
● Acute stage management
○ Resuscitated first
○ monitor vitals

38
 ○ correct coagulopathy if any
○ check CBC, clottings and cross match
● proctosigmoidoscopy with nasogastric aspiration to look for outlet or upper GI bleeding sources
○ the absence of blood + presence of bile in NG tube only make the possibility of lower GIB UNLIKELY,
does not rule it out!
● OGD as upper tract bleeding is possible
● if massive bleeding ceased (80-85%), procede to colonoscopy after urgent purge
● if ongoing bleeding, perform angiography/ RBC scan/ intraoperative locatlization studies
● Angiography
○ from femoral artery, both diagnositic and therapeutic
○ detects bleeding rate of 0.5-1ml/min
○ Complications
■ contrast allergy or constrast nephropathy
■ bleeding from arterial puncture
■ embolism from dislodged thrombus
■ mesenteric infarct with ischemic colitis from therapeutic embolisation
● RBC scan
○ Technetium-99m labelled red cell, remain in circulation fro 24 hours
○ detects bleeding rate of 0.1-0.5ml/min
○ useful for active and INTERMITTENT bleeding
○ HIGH FALSE LOCALIZATION RATE
■ overlapping bowel loops
■ migration of the red cells
 
Obscure GI bleed
● occult or massive GI bleed despite initial investigations performed
● manifests as postitive FOBT, iron-deficiency anemia
● CT enteroclysis
● Capsule endoscopy
● Meckel's scan
● Small bowel enema (enteroclysis)
○ intubated to DJ flexure
○ instill barium, methycellulose and water
○ POOR for obscure GI bleed (yield~ 15%)
○ GOOD for small bowel neoplasms (yield~ 95%)
● Enteroscopy
○ push type
○ pull type (sonde)
○ wireless capsule enteroscopy
■ 7-8hours
■ 2 image per second
■ single use
○ double balloon enteroscopy
■ need GA and IV sedation
■ both diagnostic and therapeutic
■ from oral or per anal route
■ can visualiz the entire GI tract
 
Indications for surgery in lower GIB
● immediate life threatening bleeding
● hypotension
● need transfusion >4-6u in 24 hours or >10u in total

39
 ● rebleeding in the same episode
 
=======================================
 
Hirschsprung disease
 
● 1 in 5000-8000
● male predominance
● failure of neural crest cells migration, arrested somepoint not arriving anus
● lack of neural tissues (both meissner and auerbach plexuses) in mucosa
● functional obstruction resulted in proximal megacolon to diameter of 15-20cm
● stercoral ulcers also found on mucosa due to fecal impaction
● S/S
○ delayed passage of meconium
○ vomitting in 48-72 hours after birth
○ risk of superimposed enterocolitis with risk of perforation
● ** Acquired megacolon
○ toxic megacolon in inflammatory bowel diseases
○ chagas disease (direct invasion by trypanosomes)
○ organic obstruction by a mass
 
=======================================
 
Ischemic bowel disease
 
Etiology and classification
● Transmural infarction
○ from acute obstruction of vessels
○ if chronic, the rich anastomosis will be able to compensate
○ Arterial thrombosis: severe atherosclerosis, systemic vasculitis
○ Arterial embolism: recent MI, cardiac vegetations, angiographic procedures
○ Venous thrombosis: post-op, hypercoagulable state
● Mural or mucosal infarction
○ from acute hypoperfusion of the vessels
○
localized anatomic defects
 
Pathology
● dark red hemorrhagic appearance
● marked edema, interstitial hemorrhage, necrosis and sloughing of the mucosa
● typically at the WATERSHED AREA due to the most distal blood supply which render it vulnerable to
ischemia
 
S/S
● sudden onset of abdominal pain OUTPORTIONED the physical signs
● possible bloody diarrhea
● high degree of suspicion is required for prompt dianogsis, and it is important to elicit the risk factors for
bowel ischemia to occur
 
Ix:
● Mesenteric angiography
● elevated WBC, lactic acid, amylase, potassium
●
severe METABOLIC ACIDOSIS
 
=======================================
 
Appendicitis

40
 
Basics 
● exact etiology is unknown, but probably contributed by obstruction (faecolith, lymphoid hyperplasia) at
appendiceal orifice, with secondary bacterial infection
● greater omentum and small bowels adhere to inflammed appendix and localise the sepsis
 
Clinical presentations 
● Periumbilical vague pain (visceral mid-gut) followed by shifting to sharp RLQ pain (parietal peritoneum)
● Anorexia, nausea, vomiting
● affected by age: young children and elderly have an underdeveloped or small omentum, thus higher
perforation rate, also in elderly are often afebrile with normal WCC
● affected by appendix position:
○ Retrocaecal = absent peritonism, right hip flexed due to psoas spasm, passive extension of right hip
gives rise to abdominal pain (Psoas stretch sign)
○ Post-ileal/ pelvice = diarrhea, urinary frequency and mild pyuria and hematuria, passive internal
rotation of hip gives rise to abdominal pain (Obturator sign)
 
Physical examination 
● low grade fever
● flushed with dry tongue
● foetor oris
● tachycardia
● GTR +
● McBurney's sign
● Rovsing's sign = palpation of left iliac fossa cause pain in right iliac fossa
 
Investigation (diagnosis mostly clinical)
● Pregnancy test
● CBC, urinalysis
● Abdominal ultrasound
● AXR - 50% <2yo appendicitis with faecolith seen
● Laparoscopy - mostly used in female, so that adnexa can be visualized too
 
Management
● NPO + IVF
● cefuroxime + metronidazole
● Surgery
○ Open appendicectomy
■ Gridiron/ Lanz incision
■ Skin
■ Subcutaneous fat
■ Scarpa's fascia
■ External oblique
■ Internal oblique
■ Transversalis muscle
■ Transversalis fascia
■ Preperitoneal fat
■ Peritoneum
■ caecum and appendix identified (follow taenia coli) +- mobilisation of caecum if retrocecal
■ appendiceal mesentry divided and vessels ligated
■ warm NS lavage on peritoneum
■ tube drain considered if large purulent fluid in retrocaecal space or pelvis
○ Laparoscopic appendicetomy
■ used in female, if appendix looks normal, look for:

41
 ■ Meckel's diverticulum
■ Chron's disease
■ intussussception
■ gynaecological diseases
■ adenopathy
■ less wound infection, less pain, shorter stay and earlier recovery
■
but, HIGHER incidence of post-op intraabdominal abscess
 
Complications 
● Appendiceal mass
○ when delayed presentation
○ mass consists of inflammed or perforated appendix surrounded by greater omentum, caecum or
small bowel loops
○ Conservative management
■ NPO
■ close monitoring
■ antibiotics
○ the mass will resolve by itself
○ ?need of elective appendicectomy due to variable recurrence rate  
● Appendiceal abscess
○ high swinging fever with tachycardia
○ need drainage by USG or open procedure
○ ?need of elective appendicectomy due to variable recurrence rate
 
=======================================
 
Intestinal obstruction
 
Etiology  
● Small
○ luminal: bezoar, foreign body, gallstone, peduculated tumor
○ mural: CA, strictures, atresia, intussusception
○ extramural: adhesions, strangulated hernia, volvulus, abdominal or pelvic tumors
● Large
○ luminal: fecal impaction
○ mural: CA, strictures (eg from diverticulitis, radiation)
○ extramural: volvulus, abdominal or pelvic tumors
 
Clinical presentations  
● SBO = colicky pain + vomiting
● LBO = absolute constipation + distention
 
Physical exam
● BP/P, hydration and volumeic status
● Abdominal scars
● TGR + left low quadrant tenderness
● Masses
● Hernia
● DRE: tumor, faeces, blood
   
Investigations
● CBC, crossmatch, RFT, clottings, Ca, PO4
● ABG for metabolic alkalosis
● AXR (supine and erect)for absent rectal air and identify site of obstruction

42
 ● CXR for gas under diaphragm
● Water soluble contrast enema
○ Thinner, less likely to exacerbate impeding obstruction and avoid barium peritonitis
○ To differentiate mechanical or functional obstruction
○ Complications
■ Complete obstruction
■ Perforation
■ Aspiration (ARDS) - need overnight NGT decompression
○ IF failed to get to large bowel in 6 hours = high grade obstruction
● Contrast enema
○ ddx mechanical from functional LBO
● CT scan
 
Management for Small bowel obstruction
● Conservative first, at 2/3 will resolve in 72 hours
○ NPO
○ NS 500ml FR x1, then Q1H x1
○ IVF: 3D2S Q5H/500ml
○ NGT to BSB
○ Foley to BSB
○ BP/P, U/O Q1H
○ CBP, LFT, RFT, clottings, Ca, PO4, x-match
○ AXR S-E, CXR E
○ Pethidine 50mg im Q6H prn
● Consider surgery if (lower threshold if virgin abdomen):
○  Features of strangulation or perforation
■ fever, chills, rigors
■ tachycardia, persistent oliguria, persistent high/fecal NG output
■ increasing analgesic requirement
■ increasing abdominal pain, peritonism
■ high WCC
○ Primary disease that warrants surgery
○ Failing conservative management
● Surgery
○ adhesiolysis for adhesion
○ repair of hernia
○ intraluminal mass milked proximally and taken out
○ * decide if a strangulated loop is viable
■ sheen remaining on serosal surface
■ normal pink color
■ peristalsis seen
■ mesenteric pulsation seen
○ resect the nonviable bowel then either primarily anastomose them, or bring out as a double-barrel
ileostomy for observation

 
Management of left colonic CA caused IO  
● Endoscopic stenting
○ good for sites in rectosigmoid or descending colon
○ enable good optimization for later surgery + proper bowel prep + proper staging
○ increase later chance for successful anastomosis
● Surgical procedure

43
 ○ Three stage procedure:
■ proximal loop transverse colonstomy to stablize patient and relieve bowel obstruction,
optimize condition for surgery
■ excise tumor bearing segment with anastomosis
■ reverse of stoma
■ rarely done now 
■ for patients whose condition is very critical and not suitable for long-time surgical procedure
○ Two stage procedure:
■ Hartmann's procedure with tumor excision
■ Reverse of stoma
■ No condition would a double-barrel stoma needed, because obstruction in ascending colon
will always proceed for a 1-stage procedure
○ One stage procedure:
■ direct cut and anastomose wth ON TABLE LAVAGE (patient condition must be relatively
stable!)
 
Management of right colonic CA caused IO  
● *No need to create stoma!(ileocecal anastomosis relatively safe with better blood supply )
● *No need for on table lavage!(no faeces in ileum)
 
WHY SURGERY IS SO DIFFICULT TO PERFORM IN CASE OF IO?
● patient factors
○ dehydration - third space loss into bowel lumen
○ electrolytes imbalance - secretion from bowel wall + vomitting
○ respiratory distress - distended abdomen pushing diaphragm upwards
● bowel factors
○ reduced blood supply from dehydration
○ caliber discrepancy
○ edematous
○ no bowel preparation
 
=======================================
 
Factors affecting bowel anastomosis
 
Local factors
● blood supply
● bowel wall tension
● degree of edema
● surgical technique
 
Systemic factors
● nutrition
● immue status
● overall morbidity
● age
 
=======================================
 
Volvulus
 
Definition
● twisting of a loop of bowel around its mesenteric axis
 
Complications
● intestinal obstruction, mostly close-loop

44
 ● occlusion of main vessels at the base of involved mesentery, results in strangulation hence intestinal
gangrene
 
Sites
● most commonly sigmoid, caecum
● small intestine
● stomach, gallbladder
 
Precipitating factors
● abnormally mobile intestinal loop (redundancy)
● abnormally loaded intestinal loop
● a loop fixed at its apex by adhesion
● a loop with narrow mesenteric attachment
 
Sigmoid volvulus
● elderly, institutionalized, constipated patients
● M:F = 4:1
● loop of colon twisted ANTICLOCKWISELY
● CXR
○ dilated oval gas on left side
● Treatment
○ a long soft rectal tube passed through a sigmoidoscope and advanced into sigmoid colon, untwisting
an early volvolus
○ untwisted by laporotomy
○ Paul-Mikulic procedure
■ for gangrened bowel loop segment
■ bring up for a double barrel colostomy
 
Caecal volvulus
● usually associated with a congenital malrotation
● Treatment
○ volvulus is untwisted by laporotomy
 
=======================================
 
Paralytic ileus
 
Clinical presentations
● absolute constipation
● nausea and vomitting
● abdominal distention
● * absence of colic and bowel sounds
 
Differentiating between ileus and mechanical obstruction
● usually last not longer than 3-4days
● absent colicky pain
● absent bowel sound
● presence of rectal gas
● contrast follow through/ contrast enema
● colonoscopy
 
 
CAUSES
 
Colonic pseudoobstruction
● idiopathic pseudoobstruction

45
 ● acute neurological disease (stroke/ SAH)
● pneumonia
● tricyclic antidepressants
 
Paralytic ileus
● Post operative
● Mesenteric ischemia
● Intraabdominal infection/bleeding
● Retroperitoneal irritation (bleeding, pancreatitis, spinal injury)
● Hypokalemia
● Drugs (anticholinergic, opioids)
 
Post-op ileus
● occurs after every laporotomy
● etiology
○ sympathetic over-action
○ amnipulation of bowel
○ potassium depletion (eg pre-op vomitting)
○ peritoneal irritation from bloo
● considered as prolonged paralytic ileus if >48 hours
○ rule out post op hematoma or collection due to anastomotic leak, presenting as a persistence ileus
○ check Hb and electrolytes
○ imaging with contrast CT
 
Reflex paralytic ileus
● interference with autonomic nerve supple of gut
● etiology
○ fractured spine or pelvis
○ retroperitoneal hemorrhage/ surgery
○ intestinal ischemia
○ ureteric colic
○ parturition
 
Peritonitis ileus
● toxic paralysis of intrinsic nerve plexuses
● often a component of mechanical obstruction by fibrous adhesion
 
Metabolic ileus
● severe hypokalemia
● uremia
● diabetic coma
 
Drugs induced ileus
● anticholinergics
● antiparkinsonian drugs
   
Management
● Conservative (see above*)
● Treat underlying cause (electrolytes, remove drugs, treat infection)
● Decompression
○ Flatus tube inserted for 48hours
○ Decompression colonoscopy with cautious insufflation
● iv neostigmine (NOT RECOMMENDED, high risk of bradycardia, given with atropine near by)
● Surgery

46
 ○ if conservative treatment failed, peritonism, or caecum >12cm
 
=======================================
 
Diverticulosis
 
Etiology
● outpouch of mucosa through a weak point of colon by high intraluminal pressure
● at where the nutrient arteries enter the intestine
● associated with aging, chronic constipation (low fiber diet), family history, connective tissue disease
● usually sigmoid colon, but right side common in orientals
 
Clinical presentations
● usually asymptomatic
● when vasa recta ruptures, it gives massive bleeding! (note: most diverticular bleeding originates from
diverticuLOSIS, not diverticuLITIS
○ 15% patients bleed at some time in life
○ 38% 2nd rebleeding
○ 50% 3rd rebleeding
 
 
Diverticulitis
● Etiology: inflammation due to impaction of diverticulosis by a faecolith
● Complications
○ Perforation thus peritonitis
○ Pericolic abscess (local perforation walled off)
○ Fistula (eg. colovesical)
○ Obstruction (acutely due to inflammation or absces compression, or chronicly due to strictures)
● Hinchey classification of diverticulitis
Stage 1: Pericolic or mesenteric abscess
Stage 2: Pelvic or retroperitoneal abscess
Stage 3: Purulent peritonitis
Stage 4: Fecal peritonitis
* stage 1 and 2 need only conservative treatment with serial imaging >> elective colectomy
* stage 3 and 4 warrant surgical operation
**Hinchey is not quite suitable for orientals, it is set for western diverticula
● S/S
○ lower central abdominal pain then migrate to the site of diverticulitis (eg LLF)
○ fever
○ nausea and vomitting
○ local guarding
● Ix:
○ erect CXR + AXR - for gas under diaphragm and rule out IO
○ Contrasted (iv, po, pr) CT scan is the ix of choice in acute inflammation, to prevent possible
perforation by colonoscopy or barium enema
○ Colonoscopy
● Management
○ Conservative for uncomplicated cases - 70% responsive
■ NPO + IVF
■ Analgesics
■ Antibiotics given with serial imagings
○ For abscess
■ if small and stable, try conservative
■ Percutaneous drainage if there is pericolic abscess (under USG or CT guidance)
■ Surgical resection (Hartmann's, OR primary anastomosis +- defunctioning ileostomy)

47
 ■ Consider primary anastomosis if:
■ Pre-op = full resuscitation, good nutrition, little comorbidity
■ Intra-op = limited contamination, good blood supply, tension free
■ Post-op = high level of monitoring available
○ For perforation
■ resuscitation and emergent laparotomy
■ Surgical resection (Hartmann's, OR primary anastomosis +- defunctioning ileostomy)
Consider primary anastomosis if:
■ Pre-op = full resuscitation, good nutrition, little comorbidity
■ Intra-op = limited contamination, good blood supply, tension free
■ Post-op = high level of monitoring available
○ For fistula
■ exclude radiation, cancer, IBD if possible
■ contrasted CT/ enema
■ Choices
■ Defunctioning colostomy
■ single stage resection with fistula closure
● Recurrent attacks
○ now, only 10% respond to conservative treatments1
○ ELECTIVE 1-stage colonic resection operation if >2 recurrent attacksj!
 
=======================================
 
Meckel's diverticulum
 
Pathology
● most common congenital anomaly of the gastrointestinal tract
● failure of the vitelline duct to obliterate by the sixth week of fetal development
● true diverticulum
○ contains all layers of the bowel wall
● located on the antimesenteric border of the ileum
● Half contain heterotopic gastrointestinal mucosa, usually gastric, sometimes pancreatic
● “rule of two” 
○ incidence is 2%
○ the male/female ratio is 2:1
○ typically present before the age of 2 years
○ location is 2 ft from the ileocecal valve
○ base is typically 2 inch in width
○ often contains two types of mucosa
 
Clinical presentations
● usually asymptomatic
● mostly presents as bleeding, painful and episodic
● may present as obstruction (volvulus and intersussception)
● 20% as Meckel diverticulitis
○ due to mucosal erosion from ectopic gastric mucosa
○ mimics acute appendicitis
○ ddx: appendicitis, colonic diverticulitis, Chron's disease  
 
Treatments
● Diverticulotomy for cases of obstruction
● Segmental resection for cases of:
○ acute diverticulitis

48
 ○ wide base diverticulum
○ ischemic volvulus
○ bleeding
● Interval srugery is not indicated for asymptomatic patients
 
=======================================
 
Solitary Rectal ulcer syndrome
 
● young adult presents at around 35 years old with PR bleed with mucus and change in bowel habit
● granulatioin tissue, fibrosis, hypertrophic muscularis mucosae
  
=======================================
 
Colonic polyp
 
Types
● Non-neoplastic
○ Hyperplastic (more in distal colon, generally small)
○ Harmartomatous (juvenile, Peutz Jeghers)
○ Lymphoid
○ Inflammatory
● Neoplastic
○ adenoma
 
Concerning colorectal adenomas (* confined to mucosa)
● Basics
○ 70% of all polyps
○ 70% left colon
○ 70% solitary
○ 70% small (<1cm)
○ 7% severe dysplasia
○ 3-5% invasive cancer
● Types
○ tubular (>75%)
○ villous - usually sessile, more malignant  (>75%)
○ tubulovillous
○ sessile serrated adenoma
● Degree of dysplasia (mild, moderate, severe)
● Pre-malignant potential factors
○ Maximum diameter > 2cm
○ Total numbers
○ Sessile
○ Villous type
○ Severe dysplasia
● ** adenoma-carcinoma sequence
 
Management
● If pedunculated: Endoscopic polypectomy
● If sessile:
○ try endoscopic polypectomy first, sometimes piecemeal
○ endoscopic submucosal dissection
○ transanal local excision
○ transanal endoscopic microsurgery (TEMS)

49
 ○ surgery
 
Haggit's level (for polypoid malignant polyp, T1 disease = submucosa)
● 0 = Carcinoma in situ
● 1 = Invasion to submucosa but confined to head of polyp
● 2 = Invasion extending to neck of polyp
● 3 = Invasion extending to stalk of polyp
● 4 = Invasion extending beyond stalk, but not to muscularis propria
 
Approach to a malignant polyp
● Unfavorable conditions where surgery is warranted
○ Unclear resection margin
○ Piecemeal resection
○ Pathology report shows lymphovascular invasion
○ Pathology report shows poorly differentiated grading
● If all of the above NEGATIVE
○ the chance of existing lymph node metastasis <5%
○ follow up in 3-6 months then every 3 yearly
 
Surveillance after polypectomy
● 5 years
○ 1-2 adenomas <1cm
● 3 years
○ 3-10 adenomas
○ >1cm
○ severe dysplasia
○ villious histology
● <3 years
○ >10 adenoma
● 2-6 months
○ sessile adenoma removed piecemeal
 
=======================================
 
Familial polyposis syndromes
 
● Familial adenomatous polyposis
○ 1% of all CRC, 100% lifetime risk for CRC
○ Genetics
■ Autosomal dominant with 100% penetrance
■ 85% APC gene mutation, a gatekeeper gene (because the gene have 3000exon, different
mutations give rise to some extra-intestinal manifestation)
■ 15% beta-catenin gene mutation
○ Attenutated FAP (AFAP)
■ <100 adenoma
■ late age onset
■ more right side predominance >> support Ileo-rectal anastomosis
○ >100 polyps (usually tubular polyps)
○ Other cancers
■ Duodenal or periampullary 5-10%
■ Pancreatic 2%
■ Thyroid 2%
■ Gastric 0.5%

50
 ○ Extraintestinal manifestation
■ CHRPE (Congenital hypertrophy of the retinal pigmented epithelium)
■ Gardner's syndrome
■ Osteomas + Epidermoid cysts + Desmoid tumors (tumors of musculoaponeurotic
sheath) + Fibromatosis 
■ Turcot's syndrome
■ FAP/ HNPCC+ medulloblastoma+ malignant glioma
○ Screening
■ Genetic
■ Annual flexible sigmoidoscopy from age 10 to 40, 3-5 years thereafter
■ OGD every 1-3 years
○ Tx - Prophylactic (procto)colectomy done when large number of polyps OR symptomatic
■ Total proctocolectomy with ileostomy
■ Restorative proctocolectomy with ileopouch anal anastomosis
■ Total colectomy with ileorectal anastomosis (ONLY for AFAP)
○ Tx - Sulindac and Celecoxib
■ Temporizing treatment awaiting surgery
■ Control pouch and rectal polyposis after surgery
 
● Familial juvenile polyposis
○ autosomal dominant
○ SMAD4 gene
○ multiple juvenile polyps >> 50% risk of CRC
 
● Peutz Jeghers syndrome
○ STK11
○ hamartomatous polyps in GIT (jejunum> ileum> stomach)
○ patches of hyperpigmentation in the mouth and on the hands and feet
○ increased risk for CRC
○ increased risk for breast and ovarian cancer in female
○ Tx: removal of polyps if complicated or >1.5cm
 
● Cowden syndrome
○ hamartomatous polyps in GIT
○ CA thyroid, breast, uterus, skin
 
● Cronkhite–Canada disease
○ SPORADIC, not inherited
○ hamartomatous polyps in GIT
○ anomalies of ectodermal tissues - alopecia, nail loss, hyperpigmentation
○
malabsorption, weight loss, loss of electrolytes and PROTEINS
 
 
HNPCC
 
Basics
● 2-5% of all CRC
● mutation of 1 out of 5 DNA repair gene, lead to microsatellite instability
● Autosomal dominant with 70% penetrance
● a caretaker gene - accelerated polyp transformation
 
Subtypes
● Lynch I: familial colorectal CA

51
 ● Lynch II: familial colorectal CA with extra GI cancers
○ endometrium  43%
○ stomach  19%
○ biliary tract  18%
○ urinary tract  10%
○ ovarian  10%
● Muir-Torre syndrome= HNPCC+ keratoacanthoma
 
Amsterdam criteria
● One patient should be a first degree relative of the other two
● At least two successive generations should be affected
● At least one tumour should be diagnosed <50 years of age
● FAP should be excluded in the colorectal cancer case (if any)
● Tumours should be verified by histopathologic examination
* Amsterdam criteria II: At least 3 relatives with an HNPCC-associated cancer: colorectal cancer, or cancer of
the endometrium, small intestine, ureter or renal pelvis.  
 
Bethesda criteria
● Individuals with cancer in families meeting the Amsterdam criteria
● Individuals with two HNPCC-related cancers, including synchronous and metachronous colorectal cancers or
associated extracolonic cancers
● an individual and a first-degree relative with:
○ either colorectal 
○ and/or HNPCC-related extracolonic cancer
○ and/or a colorectal adenoma
**One of the cancers diagnosed at age <45 years, and the adenoma diagnosed at age <40 years
● Individuals with colorectal cancer or endometrial diagnosed at age <45 years.
● Individuals with right-sided colorectal cancer with an undifferentiated pattern (solid/cribiform) on
histopathology diagnosed at age <45 years
● Individuals with signet-ring-cell-type colorectal diagnosed at age <45 years.
● Individuals with adenomas diagnosed at age <40 years.
  
Screening
● Colonoscopy 2 years until 40 years old, then annually
○ from age 20
○ 5y younger that earliest diagnosis of CRC
● TVS & Endometrial sampling yearly from 25 years old
 
=======================================
 
Colorectal carcinoma
 
Basics
● 95% sporadic, 5% hereditary
● 2/3 in left colon
 
Screening
● For >50 years
○ 1-2 adenoma <1cm  = 5 year
○ 1-2 ademoma >1cm = 3 year until 2 -ve
○ 3-4 adenoma <1cm  = 3 year until 2 -ve
○ >3 adenoma >1cm = 1 year until out, step down
○ >5 adenoma <1cm = 1 year until out, step down
● For 1 first degree relative with CRC <60
○ colonoscopy from 40yo OR 10 years younger than youngest affected relative

52
 ○ every 3-5 year
● For 2 first degree relative with CRC
○ colonoscopy from 40yo OR 10 years younger than youngest affected relative
○ every 3-5 year
● For personal history of cancer
○ 1st colonoscopy at 1 year
■ normal > 3 year
■ abnormal > 1 year
○ 5 year thereafter
● For ulcerative colitis
○ start 8 years after pancolitis OR 15 years after left colitis
○ colonoscopy every 1-3 year
 
Risk factors
● Non-modifiable
○ *Old age
○ male
○ family history (both in sporadic and familial; even higher risk in young age onset and more
members)
○ personal history of polyps or CRC
○ inflammatory bowel diseases
● Modifiable
○ smoking
○ high fat, low fiber, red meal
 
Pathogenesis
● Adenoma carcinoma sequence
○ APC/beta-catenin gene >> K-ras >> p53
○ with precursor lesions of adenoma
○ mostly left sided
○ evidented by FAP
● Microsatellite instability
○ mutations in the 5 DNA repair genes
○ no precursor lesions
○ mostly right sided
○ evidented by HNPCC
● Morphology
○ proximal tumors: polypoid exophytic masses
○ distal tumors: circumferential constricting lesions (napkin ring)
 
Clinical presentation (depends on site of tumors)
● Local = GIB, mucus, change in bowel habit, change in caliber, tenesmus
● General = weight loss, anorexia, malaise;  anemic symptoms
● Metastatic = liver, lung, bone, abdomen, brain
● Paraneoplastic
● Complications =  massive bleeding, obstruction, perforation, fistulation
 
Investigation
● CBP, iron profile
● CEA
● Colonoscopy + biopsy
○ for diagnosis confirmation with histological evidence
○ localization of tumors

53
 ○ identification of synchronized lesions
■ synchronised tumors ~ 3-5%
■ synchronised polyps ~30-50%
○ if endoscope fails to ascend through the obstructing tumor
■ procede to fine cut CT-scan
■ barium enema
● CXR
● MRI> CT
● PET (better for detecting metastasis)
● Endorectal USG
● Other baseline investigations
 
Staging
● Duke's criteria
○ Dukes A: Invasion into but not through the bowel wall
○ Dukes B: Invasion through the bowel wall but not involving lymph nodes
○ Dukes C: Involvement of lymph nodes
● Modified Duke's (Astler-coller criteria)
○ Stage A: Limited to mucosa
○ Stage B1: Extending into muscularis propria but not penetrating through it; nodes not involved
○ Stage B2: Penetrating through muscularis propria; nodes not involved
○ Stage C1: Extending into muscularis propria but not penetrating through it. Nodes involved
○ Stage C2: Penetrating through muscularis propria. Nodes involved
○ Stage D: Distant metastatic spread
● TNM staging
○ N1= 1-3 nodes involved
○ N2= >3 nodes involved
○ ** to achieve adequate N-staging, a minimum of 12 nodes have to be resected in surgery
 
Prognostic factors
● Stage
● Histology: worse if lymphovascular invasion, poorly differentiated
● Pre-op CEA: worse if >10ng/ml
● Young age
● Male sex
 
Pre-op preparation
7. Consent
8. Decide which type and which method (open or lap) of surgery to perform
9. Stoma nurse
10. Medical comorbidities optimized
11. Bowel preparation
○ recent metaanalysis found that mechanical bowel prep offers no effects on post-operative
complications! Becoming used less in colorectal surgery!
12. Antibiotic prophylaxis
13. DVT prophylaxis
○ (pre-op herapin or LMWH)
○ compression stockings
○ pneumatic cuffs
○ early mobilisation
 
Colon surgery
● Vascular supply

54
 ○ SMA >> ileocolic, right colic, middle colic
○ IMA >> left colic, left lower colic, sigmoid, superior rectal
● Types
○ Right Hemicolectomy
■ ileocolic + right colic + right branch of middle colic*
■ for tumors in caecum/ ascending colon/ hepatic flexure
■ middle colic artery is often the major supply to right colon, as right colic artery is often non-
dominant or even absent in patients
○ Extended right hemicolectomy
■ ileocolic + right colic + middle colic
■ for tumors in transverse colon or splenic flexure
○ Left hemicolectomy
■ left colic
■ for tumors in descending colon
○ Sigmoidectomy
■ sigmoid
■ for tumors in sigmoid colon
 
Rectal surgery
● Why rectal surgery are more difficult to perform:
○ deep location
○ prone to invasion to adjacent structure
○ short distance from anal sphinter
○ proximity to autonomic nerves 
● Local excision - *for very early rectal CA, require accurate pre-operative staging!
○ Transanal excision
○ Transanal endoscopic microsurgery
○ Transphinteric excision
○ Transcoccygeal excision`
● Radical excision
○ Anterior resection (primary descending colo-rectal anastomosis + defunctioning ileostomy)
○ Low anterior resection (primary descending colo-rectal anastomosis + defunctioning ileostomy)
■ +- Colonic J-pouch
■ +- Coloplasty: longitudinal cut made and closed transversely
○ Abdominoperineal resection
○ Pelvic exenteration
● How to choose? Divide rectum in 3 parts.
○ upper 1/3 : 11-15cm = AR/LAR
○ middle 1/3 : 7-11cm = LAR/APR
■ safe distal margin
■ size and histology of tumor
■ pelvic size
■ stapling device
○ lower 1/3: <7cm = APR
● Total Mesorectal excision (TME)
○ lymphovascular, fatty and neural tissue surrounding rectum
○ posterior part of superior rectum, posterior and lateral part of mid-rectum, entire part of lower
rectum
○ peri-mesorectal "holyplane" sharp dissection under direct vision
○ aim to get an intact mesorectum + preserve autonomic nerves
 
Postoperative Care

55
 ● NPO + IVF
● Monitor BP/P/Temp Q4H
● foley catheter and I/O chart
● Robinson drain
● Chest physiotherapy (Triflow)
● DVT prophylaxis
● Patient controlled analgesia
 
Adjuvant therapy
● "Administration of chemotherapy or radiotherapy after SURGERY OF CURATIVE INTENT aim to reduce
number of micrometastasis"
● Colon Cancer
○ better surgical margins hence less local recurrence, usually distant metastasis
○ Post-op chemotherapy, NO NEED FOR post-op radiotherapy
○ All Stage III patients  +  high risk Stage II patients with:
■ T4 tumor
■ signet ring/ mucinous histology
■ poor differentiation
■ lymphvascular invasion
■ obstruction/ perforation
○ Post-op chemotherapy
■ 5-FU + folinic acid (+ oxaliplatin)
■ capecitabine
● Rectal Cancer
○ narrow surgical margin thus higher local pelvic recurrence + distant metastasis
○ All Stage III patients  +  high risk Stage II patients with:
■ T4 tumor
■ signet ring/ mucinous histology
■ poor differentiation
■ lymphvascular invasion
■ obstruction/ perforation
○ Pre-op radiotherapy
1. SCPRT (Short course preoperative RT)
■ for those with circumferencial resectable margin, to reduce risk of local recurrence
■ 25Gy, 5 daily fraction for 1 week >> surgery in the following week
■ no recognisable shrinkage
2. CRT (chemoradiothearpy)
■ for reducing size of irresectable tumors for surgery, OR
■ for reducing size of low lying rectal cancer, hence go for sphinter-preserving surgery
■ 45-50Gy, 25 daily fraction for 5 weeks >> surgery 1-2 months later
○ Post-op radiotherapy
■ current practice in HK
■ smaller benefit on local recurrence than pre-op RT
■ routine use not recommended, but acceptable for those without pre-op RT (maximal dose
limit) and with involved circumference resection margin
○ Post-op chemotherapy
■ current practice in HK
■ 5-FU + folinic acid (+ oxaliplatin)
■ capecitabine
 
Chemotherapy for advanced CRC
● FOLFOX = 5-fluorouracil  +  low dose folinic acid (leucovorin) +- oxaliplatin for 6 months

56
 ● FOLFIRI = 5-fluorouracil + low dose folinic acid + irinotecan
● Capecitabine (oral 5-FU prodrugs) as effective
● + Bevacizumab - vascular endothelial growth factor
● + Cetuximab - epidermal growth factor receptor
 
Follow up
● Aim:
○ to detect recurrence (40% after primary surgery)
○ to detect metachronous tumors
● Clinic visit (History, P/E, rigid sigmoidoscopy, CEA, LFT, )
○ Q3month until 2 years >> Q6month until 5 year >> yearly
(* you can use CEA even the pre-op level is normal! As CEA is produced less in those
undifferentiated tumor, and their level may be masked by the first pass effect through liver. But
when there is distant metastasis, the CEA can enter systemic circulation, bypassing the liver)
● Colonoscopy
○ if preop colonoscopy incomplete >> 3-6months
○ if preop colonoscopy complete >> 1 year
○ then every 3-5 years
● If suspected recurrence:
○ Colonoscopy
○ CXR
○ CT/MRI
○ USG
○ bone scan
○ PET
 
=======================================
 
Surgery for Ulcerative colitis
 
Colonoscopy surveillance for cancer
● High risk group
○ early age of diagnosis (<15yo)
○ pancolitis
○ long duration of disease (>10year)
○ primary sclerosing cholangitis
● Biopsy take in 4 quadrants every 10cm
● If high grade dysplase or DALM (dysplasia associated lesion/mass) >> prophylactic colectomy
 
Indications
● Elective surgery
○ failure of maintenance medical therapy
○ intractable extraintestinal manifestation (pyoderma gangrenosum, monoarthropathy, uveitis)
○ prophylactic surgery for cancer
● Emergent surgery
○ fulminant colitis failed medical remission induction
○ toxic megacolon
○ perforation
○ massive hemorrhage
 
Fulminant colitis
1. Use the Truelove and Witts Criteria for severity stratification, severe if
○ Bowel opening >6/24 hours
○ Large rectal bleeding

57
 ○ Fever >37.8
○ Tachacardia >90
○ Anemia <10.5g/dL
○ ESR >30mm/h
2. Medical stabilization (fluids, antibiotics, iv steroids, close monitoring)
○ If clinical deterioration >> emergent surgery
○ If no improvement in 5-7 days >> iv cyclosporin/infliximab >> surgery
 
Toxic megacolon
1. Diagnosed by >6cm + acute colitis + systemic toxicity
2. Medical stabilization (fluids, antibiotics, iv steroids, close monitoring)
○ If no improvement in 2-3 days/ deterioration/ perforation/ massive hemorrhage >> surgery
 
Surgical Choices
● EMERGENT
○ Total colectomy + end ileostomy (allow subseqeunt restorative surgery, avoid anastomosis and deep
pelvic dissection)
○ Total colectomy + IRA (single operation BUT high risk of leakage from patient's ill condition +
inflamed bowel + pre-op high dose steroid, NOT RECOMMENDED)
● ELECTIVE
○ Protocolectomy + end ileostomy (for poor sphinter function/ distal CA involving sphinter)
○ Protocolectomy + Koch pouch ileostomy (for severe incontinence after IPAA)
○ Protocolectomy + IleoPouch-anal anastomosis IPAA (good sphincter function is a must!)
 
IPAA
● Remember to assess sphincter function before operation
● S-pouch (evacuation problem), J-pouch (fecal frequency), W-pouch (difficult to fit in pelvis)
● Do we need a defunctioning stoma after IPAA surgery?
○ consider patient (steroid, nutrition) and operation (air leak, incomplete dounut) factors
○ may use a pouch drain instead
● Pouch-failure
○ Early = ischemia, anastomotic leak, small bowel obstruction at stoma site
○ Intermediate = pelvic sepsis/abscess, fistula
○ Late = pouchitis (fever, diarrhea, blood, arthropathy), outlet obstruction
■ metronidazole/ciprofloxacin
■ probiotics (acidophilus)
■ steroids
● Incontinence
○ 80% daytime
○ 50% nocturnal
○ pouch frequency may be reduced by medication like loperamide
 
 
Surgery for Crohn's Disease
 
Basics
● most patients will require at least on esurgery in theri lifetime 70% (cf 30% in UC)
● most patients will recur after first surgery an drequire repeated surgery
● surgery is not curative but for palliation only
● surgery shold be conservaive in order to preseve bowel fucntion 
 
Indications
● Failure of medical therapy >> problem of endoscopic or clinical recurrence after surgery*
● Complications

58
 ○ Stricture and Intestinal obstruction
○ Fistula
○ Abdominal mass and abscess
○ Perianal diseases
○ Massive GIB/ perforation
 
Medical
1. 5-ASA, budesonide, antibiotics
2. ASA/6MP, systemic steriods, methotrexate
3. cyclosporin, infliximab
 
Surgery
● Inflammatory disease failing medical therapy OR complication >> Resection surgery
● Fibrostenotic disease (stricture or IO) >> surgery/ endoscopic dilation
● Abscess or fistula >> drainage + medical +- surgery
 
Severe inflammtory disease
● Segmental disease
○ segmental resection- few symptoms and diarrhea, better anorectal functions
○ total colectomy + IRA
● Total colonic disease
○ Total colectomy + IRA  (if rectal sparing & minimal perianal disease)
○
Proctocoloectomy + end ileostomy
 
Stricture
● Strictureplasty
○ Contraindication
■ perforation
■ fistula near stricture site
■ multiple fistula in same region
■ colonic fistula (potentially cancerous)
○ Types
■ Heineke-Mikulicz strictureplasty <10cm
■ Finney strictureplasty 10-20cm
■ Side-to-side isoperistaltic strictureplasty >20cm
● Bypass
 
Fistula
● Indications
○ embarrasment (enterocutaneous)
○ connection to genitourinary (enterovaginal, enterovesical)
○ bypass with malabsoption or diarrhea (duodenocolonic, enterosigmoid)
● Consideration for perianal fistula - HIGH RISK OF INCONTINENCE if surgery done
○ prolonged diarrhea
○ perianal Crohn's on sphinter
○ reduced rectal compliance from proctitis
● Choice of surgery
○ Simple fistulotomy + medical
○ Aggressive medical + judicious surgery if
■ high and complex fistula
■ multiple external opening
■ rectovaginal fistula
■ perianal abscess

59
 ■ anorectal stricture
■ rectal inflammation
 
=======================================
 
Hemorrhoids
 
Risk factors - pregnancy, straining, portal hypertension, chronic constipation
Sites: 3,7,11 o'clock
 
Grading
● first degree - no prolapse
● second degree - spontaneously reducible prolapse
● third degree - prolapse required manual reduction
● fourth degree - permenant irreducible prolapse
 
Clinical presentations
● bleeding
● prolapse
● pruritis ani
● pain when thrombosed
 
Treatments
● Conservative treatments
○ high fiber diet with adequate fluid intake
○ avoid straining at stool
○ bulk laxatives
● Medical
○ Daflon (phlebotropic agent)
● Fixation
○ Rubber band ligation
■ local obliteration of submucosal vessels and fix the pile by fibrosis
■ postprocedural pain >> REMOVE he band immediately
■ postprocedural bleed >> self limiting >>local pressure, adrenaline, single stitch 
○ Sclerotherapy
■ for 1st or 2nd degree piles
■ only for piles above the dentate line (if thrombose the external pile >> painful)
■ injecting phenol and almond oil,  to cause fibrosis at submucosal tissue thus shrinking the
piles
○ Thermal methods
■ infrared, laser, diathermy, cryotherapy
■ infrared energy converted to heat and coagulate vessels at piles, time is 1.5-2s, depth as
2mm
■ each hemorrhoid should have at least 3 applications
○ Stapled hemorrhoidopexy
■ also called the Procedure for Prolaspe and Hemorrhoids
■ remove mucosa above the prolapsed pile and bring them up and reduce bleeding
■ less pain, shorter OT time, shorter hospital stay, faster recovery
● Excision
○ Hemorrhoidectomy
■ Open hemorrhoidectomy= Milligan Morgan hemorrhoidectomy
■ Early compx: urinary retention, reactional bleeding
■ Intermediate compx: faecal impaction, bleeding
■ Late compx: ectropion, stenosis, incontinence

60
 ● Destruction of hemorroidal arteries
○ Doppler guided hemorrhoidal artery ligation
■ identification and ligation of terminal branches of SRA
■ day procedure and less pain
○ Laser photocoagulation
 
=======================================
 
Fistula in ano
 
Causes
● The Cryptoglandular Hypothesis
○ obstruction of anal gland ducts, which connect to crypts of Morgagni
○ infection sets in, leading to an abscess
○ the abscess discharges along the path of lowest resistance
● Others
○ Crohn's disease
○ CA rectum
○ TB, actinomycosis, AIDs
○ Radiation
● features suggeting an underlying crohn's (10-15% first presentations)
○ unusual location
○ deep fistula
○ multiple fistula
○ ano-vaginal fistula
○ anal stricture
 
Classification (Park's)
● superficial - submucous, subcutaneous
● low anal - intersphinteric, transsphinteric
● high anal - suprasphinteric, extrasphinteric
● Goodsall's law (* practically only accurate for posterior fistulas)
○ fistulas described either anterior or posterior to the transverse anal plane (a coronal section cutting
through the mid anus)
○ anterior fistulas will have a direct radial course and openning in anal canal
○ posterior fistulas will have a curved track with internal openning in posterior midline
○ EXCEPTION: when an anterior openning is associated with a horseshoe that opens posteriorly
 
Clinical presentation
● perianal painful lump with fluctuation (perianal abscess)
● purulent/bloody discharge
● symptoms of inflammatory bowel disease
 
P/E
● external openning
● palpate for redness, swelling, hot, tenderness, fluctuating mass (abscess)
● DRE for internal openning, induration suggestive of a tract
 
Assessment
1. Location of external openning (inspection)
2. Location of internal openning (DRE, protoscope, rigid sigmoidoscope)
3. Course of primary tract (MRI, endoanal USG, CT, fistulogram)
4. Course of secondary tract (MRI, endoanal USG, CT, fistulogram)

61
 5. Underlying disease (+- GI endoscope)
 
Investigation
● MRI - the best modality
● Endoanal USG - as complemetary to MRI
○ use of hydrogen peroxide + high resolution probe
○ three dimensional ultrasound
● (Fistulography - injection of contrast, cannot show relation to sphinter)
 
Treatment (Goal: to cure the fistula with lowest possible recurrence rate and keep continence
● Drain any perianal abscess
○ under GA
○ swab taken - if come back to be gut flora = fistula in ano (not skin infection)
● Examination under anesthesia
○ internal opening seen using an Eisenhammer retractor
■ pressure on external opening >> bead of pus
■ injection of H2O2 (low pressure as air embolism), methylene blue, milk
○ Probing: path of track detected by a Lockhart-mummery or lachrymal probe
■ Low tract = 30 degree; High tract = 80 degree
● Low tracts
○ fistulotomy: specimen sent to exclude Crohn's or CA
○ fistulectomy
● High tracts
○ Tight/Cutting seton insertion
■ Function as a drain + fibrosis inducer +- antiinflammatory (chemical)
■ skin lay open down to muscle >> seton inserted with tight knot >> as it cuts along, it
induces fibrosis so that the sphinter do not spring apart
■ changed for several times as it cuts through
■ contraindicated in perianal Crohn's
○ Loose seton
■ suture tied loosely, acting as a drain
■ it heals without cutting through sphincter in 44%
○ Other surgical procedures
■ Advancement flap
■ fistulotomy with sphinter repair (3 stage: colostomy > repair > reverse colostomy)
■ Fibrin glue - autologous or commercial sealant, good shortterm but poor longterm result
■ Anal fistula plug
  
 
Anal fissure
 
Anal anatomy
● 4-5cm long
● dentate line marks the junction between endoderm and ectoderm
● Upper canal
○ autonomic nerve
○ portal drainage
○ abdominal nodes
● Lower canal
○ somatic nerve
○ systemic drainage
○ inguinal nodes
● Resting pressure of anus is important in maintaining continence

62
 ○ 55% from internal anal sphincter
○ 30% from external anal sphincter
○15% from anal cushions and mucosa
 
Definition
● >90% acute fissure heal by itself
● if not healing in 6 weeks >> chronic fissure
 
Etiology
● Passage of hard stool
● associated with increased anal resting pressure, leading to hypoperfusion; viscious after fissure pain!
○ increase risk of damage
○ poor healing
● Most common site lies in the midline (100% posterior in men, 90% posterior 10% anterior in women)
○ watershed area of blood supply in these regions
● If not in midline, think about other causes:
○ trauma and childbirth
○ Crohn's disease
○ TB, syphilis
○ cancer
 
Diagnosis
● Typical history (sudden sharp to tearing pain after passage of a hard stool)
● Examination under LA
○ Features of chronicity
- Proximal hypertrophied anal papilla
- Distal sentinel tag
- Fibrotic edge
● Excluding other ulcers due to AIDS, syphilis, TB or Crohn's disease
 
Management of acute fissures (90% heal spontaneously!) >> conservative treatment
● high fiber diet + adequate water intake
● stool softener
● warm sitz bath
● lignocaine gel
 
Management of chronic fissures >> aim to break the viscous cycle of spasm and pain
● Pharmacological
○ topical nitrates 0.2% bd/tds for 8 weeks
■ NO donor
■ reversibly relax internal sphinter
■ S/E: headache and recur
○ topical diltiazem/nifedipine 2% bd for 8 weeks
○ botulinum toxin injection
■ inhibit acetylcholine release at NMJ
■ reversible paralysis of sphinter (may cause transient faecal incontinence)
● Surgical = sphinterotomy
○ lateral internal anal sphincterotomy
○ V-Y anoplasty with advancement flap
  
=======================================
 
5 things to look for in DRE in trauma patients
1. anal tone - for spinal cord injury
2. bony spicules - for pelvic fractures

63
 3. high rising prostate - for urinary tract damage
4. rectal mucosal continuity - for tears
5. blood per rectum - internal intestinal injury
 
=======================================
 
Stoma
 
Large intestines - Solid faeces, left sided, larger, no sprouts, no villi with haustra
Small intestines - Liquid faeces, right sided, smaller, sprouts present (prevent skin excoriation)
   
Two major functions
1. Fecal diversion/decompression
2. Exteriorization of feces as site of excretion
 
Sites selections
● Easily assessable by patients
● Avoid skin creases/scars/dip (prone to infection and poor anchor)
● Avoid bony prominence (poor anchor)
● Avoid belt line
● Within rectus
 
Assessing stoma viability
● Reddish fresh mucosa
● Water vapor seen on bag
 
How to reduce complications
● Pre op: good siting
● Intra op:
○ Adequate mobilization to avoid tension
○ Good blood supply assured
○ Correct aperture size
○ Through rectus
○ Adequate sprouting
● Post op
○ Good stomal care
○ Dietary advice
 
Complications:
● General: GA, bleeding, infection  
● Early complications
○ Ischemic necrosis (poor blood supply, high tension, small aperture)
■ Full thickness = immediate reversion
■ Partial thickness = conservative, watch out for later stenosis
○ Retraction (obesity, high tension) *poorly tolerable in ileostomy!
○ Peristomal abscess
● Intermediate complications
○ Stenosis
■ due to fibrotic scarring/retraction/ischemia
■ stool softener, stomal dilator, surgery
○ Fistulations
■ esp in ileostomy /Crohn's /iatrogenic full-thickness stitch /infection
○ Effluent dermatitis
■ creases or dips in skin, poor stoma care, incorrect fitting of appliance
■ protect skin, education of care

64
 ○ Contact dermatitis (allergic to the stomal appliances)
○ Granuloma
■ repeated frictional trauma >> bleed easily
■ need biopsy for tumor recurrence
■ silver nitrate, excision
● Late complications
○ Parastomal hernia
■ more common in end-stoma, 20%
■ high intra-ab pressure, stoma outside rectus, oversized fascial defect, emergent surgery (IO
wit edematous bowel)
■ Mx: abdominal truss, weight reduction, surgery
○ Prolapse
■ more common in loop, esp transverse colostomy >> active proximal limb peristalsis
■ at risk of trauma and necrosis
■ Mx: larger stomal appliance, baby oil inside pouch, surgery
○ Parastomal varix
■ associated with portal hypertension
■ risk of bleeding
■ Mx: direct suture ligation, sclerotherapy, reversion
○ Lateral space herniation
■ internal herniation into the potential space between colon and lateral abdominal wall, leading
to small bowel obstruction
■ diagnosed by CT scan
■ prevented by obliteriating lateral space in stoma surgery!
○ Lifestyle and psychosocial complications
 
 
Ileostomy
● End ileostomy
○ patients undergone proctocolectomy (eg in FAP/ ulcerative colitis)
● Covering loop ileostomy
○ in patients performed lower anterior resection + total mesorectal excision
○ blood supply at anastomosis site is very restricted
○ temporary faecal diversion for better wound healing
○ *no supporting-ROD is needed for loop ileostomy!
■ ileum is more mobile (intraperitoneal) with less tension
■ ileum is lighter
○ *proximal everted sprout for protection
● Ileostomy output (normally 1.5-2L fluid enters colon)
○ day1-day3: progressive increase in output; bilious fluids
○ day3-day5: output stabilized
○ till 6-8weeks: output gradually declines, to around 300-500ml/day
○ HIGH OUTPUT ILEOSTOMY
■ >1L/day
■ post-op: vigorious fluid and electrolytes replacement
■later: dietary modification and anti-motility drugs
 
Colostomy
● End colostomy
○ patients undergone abdominal perineal resection/ hartmann's procedure >> check anus
● Loop colostomy
○ in sigmoid or transverse (mobile intraperitoneally)

65
 ○ for temporary/permenant faecal diversion (eg 3-stage procedure, or distal fistulas)
○ the colostomy rod can be removed on post-op day7
● Double barrel colostomy 
1. Intestinal ischemia
■ after resecting the infarcted part of bowel
■ to assess the viability of the anastomic ends, because sometimes the mesenteric ischemia
may progress
■ make sure good subsequent anastomotic outcome
2. Complete diversion of faeces
■ eg. distal colovesical fistula
■ to maximally divert bowel content (including mucus) for better fistula healing
3. To make next operation more feasible
● Colostomy output
○ Volume varies depends on site of colostomy (transverse vs sigmoid)
○ Initial output is liquid >> viscus from D10 onwards >> solid stool
● **Colonoscopy in patients with stoma
○ endoscope through the stoma
○ endoscope through rectal stump (if present)
 
 
Examining a stoma
Inspection
● General: cachexic, thin
● Surgical scar
● Cough impulse
● Site
● Content
● Appearance: lumen number, caliber, spout
● Complications: ischemia, necrosis, parastomal hernia, prolapse/retraction
Ask to remove bag
● dermatitis
● digital examination for stenosis +- palpate for fascial defect
Examine perineum
● Look for anus
● Digital rectal examination
If hernia
● Chest, abdomen, prostate
 
1. End ileostomy
The general condition of the patient is stable. For proper exposure, I would like to expose him from nipple to mid
thigh. On inspection, there is a upper/lower midline scar and a stoma located in the right iliac fossa (RIF), without
any visible and palpable cough impulse. There is a single lumen which is small in caliber. There is a 2 to 3 cm
spout and there is greenish fluid content without blood or mucus. The mucosa lining is well nourished without sign
of ischemia. I would like to remove the stoma bag in order to observe any skin changes surrounding the stoma and
perform the digital examination to check for the patency of the stoma.
 
In conclusion, this is an end ileostomy fashioned in the RIF, which is most commonly performed after
panprotocolectomy. I would like to examine this patient's perineum for an anal orifice or a perianal scar, in order to
differentiate whether it is a temporary or permanent ileostomy respectively.
 
2. Loop ileostomy
The general condition of this patient is stable. For proper exposure, I would like to expose him from nipple to mid
thigh. On inspection, there is a upper/lower midline scar and a stoma located in the right iliac fossa, without any
visible and palpable cough impulse. The stoma is connected to a transparent stoma bag, which contains greenish
fluid with no blood or mucus. The stoma has two lumens and has a relatively small caliber. One of the limb is
longer with a spout present, which should indicate the proximal limb. The stoma mucosal lining is well nourished

66
without signs of ischemia. I would like to remove the stoma bag in order to observe any skin changes surrounding
the stoma, and perform digital examination to check for its patency.
 
In conlcusion, this patient has a loop ileostomy fashioned in the RIF, which is most commonly performed for
temporary fecal diversion for distal anastomosis or intestinal fistulas.
 
3. End colostomy + parastomal hernia
The general condition of this patient is stable. For proper exposure, I would like to expose him from nipple to mid
thigh. On inspection, there is a upper/lower midline scar and a stoma located in the left iliac fossa. There is no
visible or palpable cough impulses on the scar. I would like to focus on the stoma first. It is now connected to a
transparent stoma bag, which contains browish solid faeces. The stoma has a single lumen and a relatively large
caliber. There is no spouting seen. The stoma mucosal looks well nourished without signs of ischemia. However,
upon coughing, there is a visible and palpable cough impulse over the left side of stoma, which suggests a
parastomal hernia. I would like to remove the stoma bag to examine for any skin changes, and a digital
examination esp to assess the fascial defect.
 
In conclusion, this patient has an end colostomy fashioned in LIF, which is most commonly performed in either a
Hartmann's operation or an abdominal perineal resection, where I would like to examine his perineum for anal
orifice or scar to differentiate. Currently, the stoma is complicated by a parastomal hernia, where I would like to
examine his chest for reasons for chronic cough, palpate carefully the abdomen for intraabdominal mass or ascites,
and DRE for enlarged prostate.
 
=======================================
 
Imaging modalities in staging tumors
 
● PET-scan
○ standard uptake value
○ use radiolabelled glucose and assess hotspots with high metabolic rates
○ not useful to assess brain metastasis
○ Pros
■ sensitive for small tumors (functional image!)
■ whole body surveillance
○ Cons
■ not readily available
■ expensive
■ not enough for assessing local invasion (eg SMA encasing in pancreatic CA)
■ false positive in infection or inflammation
● CT-scan
○ good localisation, good resolution
○
high radiation dose
 
=======================================
 
 

67
Breast Surgery

Glossary
 

Cooper's ligament - Suspensory breast ligament connecting pectoral fascia to skin dermis
- hold the breast contour, also the reason for skin dimpling in cancer
Rotter's node The groups of nodes between pectoralis major and minor, not often removed unless
suspicious
Tail of Spence Axillary tail
Long thoracic nerve - runs along serratus anterior, supply it
Thoracodorsal nerve - runs along latissimus dorsi, supply it
Medial pectoral nerve - runs lateral/through pectoralis minor, supply pectoralis major & minor
Lateral pectoral nerve - runs medial to pectoralis minor, supply pectoralis major
Intercostobrachial - the second intercostal nerve, supply sensation of upper medioposterior arm
nerve
Mammotome Mammogram guided (computerised) stereotactic biopsy
Peau d'orange Dermal edema in inflammatory carcinoma of breast, like orange skin
Paget's disease Eczematous changes of nipple caused by skin invasion
Mondor's disease Thrombophlebitis of superficial breast veins
Hemithyroidectomy Lobe + Isthmus
Subtotal Leaving behind some thyroid tissue
thyroidectomy
Pyramidal lobe 50% have it
Thyroid ima artery from aorta/ brachiocephalic trunk, 3% have it
Delphian lymph node Around pyramidal lobe, prelaryngeal node
Berry ligament Ligament berry
Tubercle of Most posterior extension of thyroid lobe, anatomically significant as closely related to
Zuckerkandl inferior thyroid artery and recurrent laryngeal nerve
Plummer's disease Toxic MNG
 
============================================= 
 
Breast pathology
 
Ask for chaperon
 
Inspection
● Symmetry of breast contour
● Swelling on ____  breast, in 5 o'clock direction, __cm from nipple
● Scars, radiation marks, skin changes, p'eau d'orange
● *Hand high: skin tethering
 
Palpation at 45 degree
● Start from normal side (*Arthur Li) >> abnormal side >> axillary tail
○ Palpable mass in 5 o'clock direction, __cm from nipple
○ Tenderness, consistency, border, surface, skin attachment
○ *Press on waist feel the difference: muscle attachment
● Nodes
○ anterior, posterior, lateral, central, apical

68
 ● Back
○ supraclavicular nodes
○ percuss the back
○ percuss for effusion
 
I would also like to
● Examine abdomen for hepatomegaly
● Examine abdomen for ascites
 
In summary, this lady has a left sided solitary mass clinically suspicious of malignancy, as supported by... With a
clinical staging of T,N,M.
 
Further investigations
● Imaging: USG/mammogram with cutting age at 35
● Pathology: FNAC/core biopsy/excision depends on clinical suspicion for malignancy (*Arthur Li: excision for
all)
 
============================================= 
 
Benign breast pathology
 
Rationale = Aberration in Normal Developement and Involution
● A spectrum of breast condition: Normal >> disorders >> diseases
● benign breast disorders and diseases are related to the normal processes of reproductive life and to
involution
 

Table 17-3 ANDI Classification of Benign Breast Disorders

  Normal Disorder Disease

Early reproductive years Lobular development Fibroadenoma Giant fibroadenoma

(age 15–25 y)  
  Stromal development Adolescent hypertrophy Gigantomastia
  Nipple eversion Nipple inversion Subareolar abscess
      Mammary duct fistula
Later reproductive years Cyclical changes of Cyclical mastalgia Incapacitating
(age 25–40 y)   menstruation mastalgia
    Fibrocystic disease/ Nodularity  
  Epithelial hyperplasia Bloody nipple discharge (from  
of pregnancy nipple projections)
Involution (age 35–55 y)   Lobular involution Macrocysts —
    Sclerosing lesions  
  Duct involution    
    Dilatation Duct ectasia Periductal mastitis
    Sclerosis Nipple retraction —
  Epithelial turnover Epithelial hyperplasia (ductal Epithelial hyperplasia
and lobular) with atypia
(ductal and lobular)
Intraduct papilloma
 
 

69
 Table 17-5 Classification of Benign Breast Disorders

Nonproliferative disorders of the breast  

  Cysts
  Duct ectasia (dilated subareolar ducts with thick secretions)
  Calcifications (from inflammation/trauma, NOT the microcalcification which vary in shape/density and <0.5mm)
  Fibroadenoma (hormonal dependent) and related lesions (eg tubular/lactating adenoma, harmartoma)
Proliferative breast disorders without atypia  
  Sclerosing adenosis (Proliferative:ductal proliferation + Involution: stromal fibrosis)
  Radial scars (<1cm) and complex sclerosing lesions (>1cm)
  Ductal epithelial hyperplasia (arise from minor ducts; mild=3-4layers, moderate=>5layers, florid=>70%lumen)
  Intraductal papillomas (arise from major ducts, serous/bloody nipple discharge; NO malignant potential)
Atypical proliferative lesions  
  Atypical lobular hyperplasia
  Atypical ductal hyperplasia
 
 
Management of selective benign breast disorders
Fibrocystic disease
● Two cardinal rules:
○ Mass must not present after aspiration >> if so: biopsy
○ Aspirate must no be blood stained >> if so: cytology
● Other management
○ stop caffiene
○ analgesics
○ vitamin E, primrose oil
Fibroadenoma
● USG features + Core needle biopsy
● Choices:
○ Reassurance for shrinkage in post-menopausal period
○ Surgical excision if patient prefer
○ ?Cyroablation
Phallodes tumor
● Mesenchymal tumor from lobular tissue
● Variable biological behaviour - benign, intermediate, malignant
○ ~50% benign, 20% malignant (tend to lung spread)
○ Clinically rapid increase in size
○ Degree of atypias
○ Mitotic figures
○ Infiltrative vs circumscribed
○ Presence of stromal growth
● Treatment:
○ Benign = wide local excision with 1cm margin, recurrence high if inadequate
○ Malignant = simple mastectomy
(*no need for node clearance, nodal metastasis rare even in malignant cases)
Sclerosing lesions (Sclerosing adenosis/radial scars/complex sclerosing lesions)
● A palpable mass
● *They mimics malignancy both clinically and radiologically, sometimes even on gross specimens!
● If very sure of diagnosis >> Reassurance

70
 ● Otherwise >> Localised excisional biopsy for histology
Intraduct papilloma
● Arise from SUBAREOLAR ducts, presenting usually as nipple discharge
● Tx: microdochectomy
 
Breast mass
● Breast cysts
● Fibroadenoma
● Phallodes tumor
● Sclerosing lesions, radial scar
● Fat necrosis
● CA breast (ductal, lobular)
 
Nipple discharge
Etiology
● Multi-duct
○ Physiological
○ Galactorrhea (hyperprolactinemia, pregnancy)
● Single-duct
○ Intraduct papilloma
○ Duct ectasia
○ Periductal mastitis
○DCIS/ Ductal CA
Approach
● Differentiate physiological and pathological

Physiological ● Pathological

Elicited ● Spontaneous

Risk factors for CA absent ● Risk factors for CA present

Bilateral ● Unilateral

Multiductal ● Uniductal

Thick, negative blood ● Watery, test for blood +

Intermittent ● Persistent

Non-troublesome ● Troublesome
● Investigation
○ USG/Mammogram
○ Biopsy for suspicious lesions
● Treatment
○ Lesion found: Treat accordingly
○ No lesion found
■ Multiductal
- Distressing symptoms: total duct excision
- Mild/No symptoms: Reassurance
■ Uniductal
- Suspicious for CA: Further workup/Surgery
- Distressing symptoms not suspicious for CA: Microdotectomy
- Mild/No symptoms not suspicious for CA: Reassurrance
 
Nipple change
5. Developmental inversion
6. Acquired nipple retraction: duct ectasia, periductal mastitis

71
 7. Eczema
8. Paget's disease
 
Breast pain
Etiology
9. Mastalgia
○ Cyclical
○ Non-cylical
10. Infection
○ Lactational
11. Non-lactational
- Central: Periductal mastitis
- Peripheral: DM, RA, trauma, steroid
- Other: TB
Treatment
6. Avoid fat/methylxanthine/OCP/HRT
7. Supportive garments
8. Drugs
○ Evening primrose oil
○ Danazol/ Goserelin
○ Tamoxifen
 
============================================= 
 
Breast malignancy
Noninvasive
● ductal carcinoma in situ
● lobular carcinoma in situ
Invasive
● invasive ductal carcinoma = scirrhous carcinoma
● invasive lobular carcinoma
● inflammatory carcinoma (very poor prognosis)
○ peau d' orange
○ cancer en cuirasse
● medullary carcinoma
● colloid carcinoma
● tubular carcinoma
 
DCIS
● Cancer cells in duct without invasion to basement membrane
● No symptoms
● Mammogram: microcalcification
● *Increased risk of invasive ductal cancer for THAT breast
● Treatment
○ BCS + Radiotherapy
○ Simple mastectomy (>1cm tumor, diffuse breast involvement, contra to radiation)
○ *Adjuvant Tamoxifen
 
LCIS
● Cancer cells in lobule without invasion to basement membrane
● No symptoms
● Mammogram: normal (so often detected incidentally by biopsy)
● *Increased risk of invasvie lobular/ductal cancer for BOTH breasts
● Treatment
○ Close observation

72
 ○ Bilateral simple mastectomy
 
Paget's disease of the nipple
● presents as eczema-like lesion of the nipple, spreading outward to the areola epithelium
● associated with ductal carcinoma in situ (or an underlying invasive carcinoma)
● Etiology:
○ Paget cells (small darkly stained nuclei, clear cells) break off from the tumor within the breast and
migrated along the mamillary ducts to the nipple
○ Paget cells form spontaneously on the nipple epithelium
● confirmed by biopsy
● Treatment depends on the underlying breast pathology - total mastectomy or BCS
● its presence does not worsen the prognosis of the underlying cancer
 
Inflammatory carcinoma of breast
● 1-5% of breast cancer
● Cancer cells blocking lymphatics, leading to a peau d'orange appearance
○ Redness
○ Swelling
○ Warmth
○ Tenderness
○ *Often without a discrete lump
● Immediate jump to T4d >> stage IIIA
● Treatment
○ Neoadjuvant chemotherapy
○ Locoregional surgery
○ Postoperative radiotherapy
 
=============================================
 
Breast Cancer
 
Epidemiology
● Western population peaked at age 50
● HK population peaked age 40
○ 1:22 female
○ 1:106 mortality
● 90% is Invasive ductal carcinoma
 
Pathology 
● Normal cell >> ductal hyperplasia >> atypical ductal hyperplasia >> DCIS >> ductal CA
 
Clinical presentations
● Breast/axillary mass
● Nipple discharge
● Skin tethering
● Bone pain
 
Risk factors
● Patients factors:
○ Family history, BRCA1 (also for ovarian cancer), BRCA2
○ Female
○ Age> 40
○ Obesity
○ Increased estrogen exposure
■ menarche age <12

73
 ■ menopause age >55
■ >35 first birth
■ nulliparous without breast feeding
○ History of benign breast diseases
■ intraductal papilloma, sclerosing adenosis (x1.5)
■ moderate or florid hyperplasia without atypias (x2)
■ atypical hyperplasia (x5)
○ History of malignant breast diseases 
■ DCIS, LCIS
■ 3% synchronous contralateral tumor
● Environmental factors
○ HRT or OCP
○ Smoking, Alcohol
○ Breast radiation
 
Triple Assessment
● Clinical examination
● Imaging
○ Mammogram (10% cancer are mammogram occult, particularly lobular cancer)
■ Age >35, Nonpregnant patient
■ Craniocaudal + mediolateral oblique view
■ Features
■ Solid spiculated mass
■ Clustered microcalcifications
■ BIRADS scoring system
■ Normal
■ Benign
■ Probably benign (<2%) (shortterm followup for 6 months)
■ Suspicious
4a - mildly suspicious (<30%)
4b - suspicious (>30%)
■ Highly suggestive of malignancy (>90%)
○ Ultrasound
■ for younger patients (dense breast tissue)
■ for differentiating solid vs cystic
■ ?for axillary USG, allow FNAC or core biopsy for preop nodal staging
○ Ductography
■ for patients with nipple discharge
■ A single filling defect >> intraduct papilloma
■ Muitple filling defect >> ?CA breast
● Pathology
○ FNAC - for low clinical suspicion
■ relatively high false negative rate
■ CANNOT differentiate in situ from invasive disease
■ CANNOT assess hormone receptor status
○ Core biopsy - for high clinical suspicion
■ 14G trucut biopsy
■ Stereotactic mammotome (on prone table by vacuum suction)
○ Excisional biopsy
■ when triple assessment FAILED to confirm precise nature of a lesion
■ localised preoperatively by hook-wire, ?margin
■ **SPECIMEN MAMMOGRAM for microcalcification to confirm correct biopsy

74
 ● Other Staging investigations
○ Contralateral breast mammogram
○ CXR
○ CT scan
○ PET scan
○ Calcium, LFT
 
Poor ronogstic indicators
● Size >1cm
● Lymph node involvements (both numbers and stages)
● Distant metastasis
● Tumor grading
● Type of carcinoma (worse in invasive ductal carcinoma=no special type)
● absence of ER or PR
● presence of HER2/NEU has a poorer prognosis
● * Nottingham prgnostic index = 0.2 x diameter + grade + nodal status
 
Staging
● Tumor
○ T1
■ 1mic <0.1cm
■ 1a <0.5cm
■ 1b <1cm
■ 1c <2cm
○ T2 2-5cm
○ T3 >5cm
○ T4
■ 4a spread to chest wall
■ 4b spread to skin
■ 4c spread to both chest wall and skin
■ 4d inflammatory CA
● Node
○ N0 = no regional node
○ N1 = axillary nodes
○ N2
■ 2a = matted/fixed axillary nodes
■ 2b = internal mammary nodes + NO axillary nodes
○ N3
■ 3a = infraclavicular nodes
■ 3b = internal mammary nodes + axillary nodes
■ 3c = supraclavicular nodes
● Metastasis
○ M0 = no metastasis
○ M1 = metastasis
 
Management outline
● Locoregional control
○ Total mastectomy (=simple??) (+-reconstruction)  vs  BCS+radiotherapy
○ Sentinel node biopsy >> axillary node dissection
● Adjuvant radiotherapy
● Adjuvant chemotherapy
● Adjuvant hormonal therapy

75
 ● Adjuvant biologic therapy
 
Local surgery
● Modified radical mastectomy = Simple mastectomy (incl nipple areola complex) + Axillary dissection to
level I/II LN +- ???pect minor
○ Indication
■ Tumor >4cm
■ Multifocal cancers
■ Local recurrence following BCS
■ those who wish to avoid radiotherapy
■ male breast cancer
○ Procedure
■ Transverse elliptical incision (with linear axillary extension) encompassing the tumor and
nipple areolar complex, ensure no skin redundancy with adequate skin for closure. But if
breast reconstruction planned: make a "Skin-sparing incision" to preserve skin for
flap/prosthesis
■ Raise the skin flaps for separating breast tissue
■ Clavicle superiorly
■ Edge of breast disc medially
■ Anterior edge of latissimus dorsi laterally
■ Rectus sheath inferiorly
■ Fascia over pectoralis major muscle dissected together with the en bloc breast tissue
■ * beware of perforator vessels from internal thoracic artery to breast from 2nd - 4th ICS
■ Axillary dissection
■ Closed suction drains inserted
■ One above pec major
■ One below pec major to axilla (if dissection done)
○ Complications
■ GA, hemorrhage, infection
■ Nerve damage with parasthesia or weakness
■ Axillary vessels damage (so LIGATION is prefered over electrocautery in bleeder control)
■ Lymphedema of arm
■ Shoulder stiffness
■ Skin flap necrosis
■ Phantom breast syndrome
○ Post-op management
■ Remove skin sutures in day 3-5
■ Remove drains in day 3-5 if output <30ml
■ Encourage normal use of arm +- strengthening exercise
● Breast conservative surgery (BCS) = Wide local excision (1cm margin) + Radiotherapy
○ Indication
■ single lesion <4cm
■ tumor-breast volume ratio <15% (for better cosmetic result)
○ Contraindication
■ Pregnancy
■ Connective tissue disease
■ Extensive DCIS
■ Previous radiation to chest
○ Procedure
■ if tumor impalpable, guide wire inserted prior to surgery
■ incision oriented in skin creases if possible

76
 ■ complete excision (tissue margin of ~2cm in DCIS, ??? for invasive cancer) down to pectoral
fascia
■ Titanium clips placed onto pectoral fascia at base of excision, allow accurate postop
radiotherapy planning
■ post-excision volume defect reconstituted by local parenchyma
■ 3D orientation of excised specimen with clips or sutures for better pathological evaluation
○ Oncoplastic technique
■ with the addition of plastic surgery technique to achieve EVEN BETTER cosmetic results!
■ eg vertical scar + periareolar technique

  
 
Axillary surgery
● (Preoperative axillary ultrasound scan + FNAC of lymph nodes is now increasely popular)
● Axillary Node Clearance
○ Indication
■ Positive sentinel lymph node
■ Confirmed metastasized lymphnode preoperatively (clinical, radiological, pathological)
○ Boundary of axilla identified (axillary vein, pectoralis major and latissimus dorsi), all tissue below
axillary vein is cleared
○ No muscle paralysis during dissection: need to stimulate nerve for identification
○ Nerves to be aware of:
■ Long thoracic nerve (c5-c7) - on serratus anterior and supply it
■ Thoracodorsal nerve (c6-c8) - lateral to long thoracic nerve, supply latissimus dorsi
■ Medial pectoral nerve (c8-t1) - lateral or through pectoralis minor (named with reference to
brachial plexus origin!) , supply pect major and minor
■ Lateral pectoral nerve (c5-c7) - medial to medial pectoral nerve, supply pect major
■ * Try: Intercostobrachial nerve where axillary tail is situated

77
 ● Sentinel Lymph Node Biopsy
○ Rationale: if first draining lymph node is positive, axillary dissection is needed
○ For EVERYONE unless pre-operative clinical/radiological/pathological evidence of involved axillary
nodes
○ *Periareolar INTRADERMAL injection of technetium labelled nanocolloid detected by handheld
Geiger counter
○ *Periareolar SUBCUTANEOUS injection of Patent V blue dye detected by eye
○ Pitfall
■ Axilla receives only 75% of lymphatic drainage, other to internal mammary chain of nodes
■ Tumor spread does not always sequentially, skip metastases may occur
● Axillary Node Sampling
○ remove >4 lymph node at random
○ rarely done nowadays 
 
Breast reconstruction surgery
● Timing
○ Immediate (with skin-sparing mastectomy)
■ One procedure, more efficient
■ better result as SSM can be done, it provides good envelope to shape the flap, sensate and
avoid color mismatch
○ Delayed
■ less expectation thus more satisfied
● Autologous
○ Pedicled flap (Latissimus dorsi flap, Tranverse rectus abdominis myocutaneous (TRAM) flap)
○ Free flap (DIEP - deep inferior epigastric perforator, SGAP, IGAP) with vessel anastomosis
(plastic surgeon needed)
■ superior in cosmesis
■ risk of complete flap loss, require mircovascular surgical technique
○ Disadvantage = risk of flap necrosis or infection, donor scar, longer and more technical procedure
● Prosthesis
○ Silicone (silicon-carbon based polymer)
■ no association between silicone and CA/autoimmune disease (though anti-silicone Ab found)
○ Expander stage may be needed for submuscular placement (no more gland for subglandular!)
■ placed underneath the pectoralis major, and fluid added to strech skin (resected at surgery)
and muscle
■ contraindicated if patients have performed postop radiotherapy where skin fibrosed and tight
○ Disadvantage = risk of infection, capsular contracture esp after radiotherapy, rupture, interfere with
mammogram intepretation
 
Nipple-areolar reconstruction
● Timing
○ done 6-month after reconstruction and adjuvant radiotherapy
○ less tissue edema + let gravitational force added on reconstructed breast
● Nipple done by a graft from contralateral side or local flaps
● Areola done by staged tattooing
 
Radiotherapy
● RT to breast
○ following Breast Conservative Surgery
○ following high grade DCIS or intermediate grade DCIS >2cm after wide local excision
● RT to chest wall
○ Tumor >5cm
○ >4 involved axillary nodes

78
 ○ extensive lymphovascular invasion
○ positive resection margin
● RT to supraclavicular fossa
○ >4 involved axilary nodes
● RT to axilla (generally not recommended due to high chance of lymphedema)
○ if no axillary dissection done
 
Chemotherapy
● Indications
○ POSITIVE nodes
○ Negative nodes plus
■ young age
■ high grade
■ >2cm
■ HR -ve
■ HER-2 +ve
● Anthracycline based (FEC - 5FU, epirubicin, cyclophosphamide)
● Docetaxel containing regime (FEC followed by docetaxel) - only in those with excellent condition
● S/E
○ alopecia, nausea, vomiting
○ myelosuppression
○ mucositis
○ ovarian failure
○ long term cardiac toxicity by anthracycline
 
Hormonal therapy
● Recommended for all ER-positive patients
● Pre-menopausal
○ Tamoxifen, a selective estrogen receptor modulator for >5 YEARS
■ estrogenic agonist/partial agonist/antagonistic effect depending on target tissue; Breast -,
Endometrium +
■ protective for osteoporosis and cardiovascular diseases
■ S/E: Endometrial cancer x3, thromboembolic risk, mood swing, vaginal discharge, flushing
○ Ovarian function supression (oophorectomy/ radiation to ovaries/ goserelin)
■ used if tamoxifen contraindicated (eg history of endometrial pathology/ thromboembolism)
■ once achieved, can consider treating with an aromatase inhibitor
● Post-menopausal
○ HIGH/INTERMEDIATE RISK: Aromatase inhibitor (anastrazole, letrozole, exemestane)
■ under the rationale that estrogen is continually produced by peripheral fat aromatization
■ S/E: musculoskeletal discomfort, osteoporosis
○ LOW RISK: Tamoxifen
 
 Biological therapy
● Recommended for all HER2-positive patients
● Trastuzumab (Herceptin)
○ Human epidermal growth factor receptor inhibitor
○ should NOT be offered in patients with poor ejection fraction
○ S/E: cardiac dysfunction, reversible cardiomyopathy
● ?Bevacizumab
  
===================================
 

79
Thyroid Surgery
 
Anatomy
● Structure
○ Pretracheal fascia
○ Traceha
○ Strap muscles
● Artery
○ Superior thyroid (external carotid) *LIGATE AWAY: superior laryngeal nerve
○ Inferior thyroid (thyrocervical trunk) *LIGATE CLOSE: recurrent laryngeal nerve
○ Thyroid ima artery (aorta, brachiocephalic trunk) *BEWARE OF VARIABLE COURSE
● Vein
○ Superior thyroid (Internal jugular)
○ Middle thyroid (Internal jugular)
○ Inferior thyroid (Brachiocephalic vein)
 
DDx of anterior neck mass
● Cutaneous (sebaceous cyst)
● Subcutaneous (lipoma, dermoid cyst)
● Lymphnode
● Submandibular gland mass
● Thyroid
● Thyroglossal cyst
● Brachial cyst
● Carotid body tumor
 
Assessment
● Anatomical: clinical, USG, CT, MRI, thyroid scan>> diffuse, solitary nodule, MNG
● Functional: TFT>> euthyroid, thyrotoxic
● Pathological: FNAC, core biopsy (may induce needle seeding lead to cutaneous, for lymphoma or anaplastic
CA) >> benign, indeterminate, malignant
○ FNAC has 5% false positive and negative rate!
 
CT scan
● Check for retrosternal extension, not detected by USG
● Staging for thyroid cancer, to check for local invasion
 
Thyroid scan
● only indicated when nodules present, to differentiate toxic nodule from toxic gland
● choices of total or subtotal
 

80
Features suggestive of CA:
● History
○ Very old or young
○ Male gender
○ Family history of thyroid CA
○ Previous neck irradiation
○ Rapid increase in size
● Physical exam
○ Hard, irregular fixed mass
○ Pressure symptoms (dysphagia, stridor)
○ Hoarseness of voice
○ Lymph nodes
● USG
○ Irregular solid component
○ Hypoechoic nodule
○ Loss of perinodular halo
○ *Punctate microcalcification
○ *Doppler: chaotic intranodular vascularity
     
Differentiating pathology
Diffuse MNG Solitary nodule
Hyperthyroid Graves' disease Toxic MNG Toxic adenoma
Euthyroid Colloid goiter MNG Benign: Cyst, colloid nodule
- physiological Malignant: Thyroid cancer
- iodine deficiency
- goitrous agents
Hypothyroid Thyroiditis Thyroiditis Thyroiditis
 
Indications for FNAC
● Solitary nodule
● Dominant nodule in MNG
 
Result of FNAC
● Insufficient
○ Repeat USG guided FNAC
- Direct visualization of needle placement, avoid vital neck structure
- Target suspicious nodule
- Target solid area in suspicious nodule
● Benign (Thyroid cyst, hemorrhagic cyst, colloid nodule)
○ Expectant management to monitor size change
○ Surgery if cosmetic/compression
● Indeterminate
○ = Follicular lesion/Hurthle cell lesion
○ benign (85%) or malignant (15%)determined only by histopathologic evidence of capsular or
vascular invasion
○ Diagnostic hemithyroidectomy >> completion total thyroidectomy after incisional biopsy
(No role for intra-op frozen section: low meaningful yield but increase operative time)
● Suspicious/Malignant
○ Papillary
○ Medullary
○ Lymphoma
 
Epithelial thyroid cancers
● Papillary carcinoma  85%

81
 ○ Childrens and young adult
○ lymphatic spread, but occurs late
● Follicular carcinoma  10%
○ Hematogenous spread to lung, liver, bone
○ Capsular or vascular invasion is vital for ddx from other benign follicular lesions, FNAC is insufficient
○ Hurthle cell CA
■ variant of follicular
■ behaves more aggressively
■ cannot concentrate RAI so unresponsive
■ recommnend total thyroidectomy
 
Non-epithelial thyroid cancers
● Medullary carcinoma
○ Sporadic or familial (MEN2A, MEN2B, Familial medullary thyroid carcinoma)
○ from thyroid C-cell secreting calcitonin
■ profuse diarrhea
■ episodic flushing
■ tumor calcification on neck X-ray
■ elevated plasma level
○ some secreting ectopic CRH causing Cushing's syndrome
○ Metastasize readily via bloodstream and lymphatics
○ associated with MEN-2A and 2B: test for pheochromocytoma before surgery to avoid crisis!
○ check the RET protooncogene
● Anaplastic carcinoma  1-2%
○ Elderly
○ extremely poor prognosis
○ present with severe local compressive or infiltrative symptoms
● Primary lymphoma
○ usually Non-Hodgkins B cell lymphoma 
○ associated with longstanding Hashimoto thyroiditis
 
Pre-op workup
● Baseline tests
● CT neck for retrosternal extension
● Laryngoscope
 
Operation for thyroid cancer
● Papillary CA
○ Total vs Hemi-thyroidectomy

Total thyroidectomy ○ Hemi-thyroidectomy

- papillary CA tends to be multiple

- prevent local recurrence

- prevent progression into undifferentiated type ○ - uncommon

- postop thyroglobulin surveillance

- postop adjuvant RAI ○ - not needed in most cases

- similar complication rate

○ Criteria for Hemi-thyroidectomy

■ <1cm

82
 ■ Absence of multifocal involvement
■ Absence of capsular/vascular/extrathyroidal invasion
■ Absence of lymphnode or distal metastasis
*If histopatholgy findings violates any of the above: completion total thyroidectomy in 8
weeks
○ Central compartment (level 6) lymphnode dissection
○ Ipsilateral modified radical node dissection (functional neck dissection) if node involvement
■ preserve SCM, spinal accessory nerve, IJV
■ For papillary with involved nodes or medullary CA (lymphatic spread)
● Follicular CA
○ Diagnostic hemithyroidectomy, for excisional histopathology
○ Completion total thyroidectomy in 8 weeks if malignancy confirmed
● Medullary CA
○ Preop workup
■ Baseline cacitonin
■ Assess familial trait
■ Family history
■ Calcium level
■ 24 hour urine catecholamine
■ RET oncogene study
○ Total thyroidectomy
○ Central compartment lymphnode dissection
○ Ipsilateral modified radical node dissection
○ Contralateral modified radial node dissection if preop or intraop frozen section node involvement
● Anaplastic CA
○ Palliative management
● Lymphoma
○ >> Core biopsy for confirming diagnosis
○ Chemoradiation

 
Post-op management
● Adjuvant
○ Suppressive T4
■ a suppression dose is used, to TSH<0.1mu/l without clinical hyperthyroism
○ Radioiodine
■ ablate residual thyroid tissue to prevent local recurence
■ need to stop T4 replacement for 4 week, so as to achieve a high sTSH to enhance the
radioiodine uptake
○ External beam RT
■ for those with extrathyroidal extension or residual lesion
● Monitoring
○ BP/P/Temp
○ Airway (bilateral nerve palsy or laryngeal edema from reactive hemorrhage)
○ Drain output
○ TSH, Thyroglobulin
○ Calcium level
  
Procedure in thyroidectomy
● Preoperative assessment
○ Control thyroid status
○ Vocal cord check
○ Consent

83
 ● Procedure (http://www.youtube.com/watch?v=WTjvPWEV2gw)
○ 2cm transverse suprasternal incision (Kocher's scar)
○ Upper flap to upper thyroid cartilage + lower flap to sternal notch
○ Vertical midline incision between strap muscles through pretracheal fascia
○ Identify the followings:
■ Superior thyroid vessels - transfix and ligate NEAR to gland, avoid damaging external nerve
■ Middle thyroid viein
■ Inferior thyroid vessels - transfix and ligate FAR from the gland, avoid damage to recurrent
■ Parathyroids - dissect and free from thyroid
○ Suction drain inserted
○ Incisions closed
 
Specific complications of thyroidectomy (infection is not one of them as it is a CLEAN surgery!)
● Reactionary hemorrhage
○ from torn middle thyroid vein, slipped tie on superior pedicle
○ leads to laryngeal edema >> airway obstruction
● External branch of superior laryngeal nerve injury
○ during ligation of superior thyroid vascular pedicle, not close enough
○ only affect those who needs to shout or sing
● Recurrent laryngeal nerve (right side more common due to its more medial position)
○ Unilateral = hoarseness of voice
○ Bilateral = cords in cadeveric position leading to aphonia and breathing difficulty >> tracheostomy
● Tracehal or esophageal damage
● Tracheomalacia
● PTH injury
○ Transient hypocalcemia 24-48hour after surgery
○ Permenant hypoPTH
● Permamant hypothyroidism
● Scar hypertrophy/Keloid
 
Specific complications of functional neck dissection
● Spinal accessory nerve damage
● Vagus nerve damage
● Phrenic nerve damage
● Sympathetic trunk damage
● Brachial plexus damage
● Posterior auricular nerve damage
● Internal jugular vein
● Chylothorax or chylofistula
● Pneumothorax

 
===================================
 
Approach to Non-toxic multinodular goiter
 
Biopsy the dominant nodule
● Insufficient >> USG guided biopsy
● Benign
● Indeterminate >> Diagnostic hemithyroidectomy
● Suspicious/Malignant >> Surgery
 

84
Benign
● Recommendation:
○ RAI / Surgery for compressive symptoms or cosmetic concern
○ Expectant management for others
● Expectant management
○ Slow thyroid growth rate in clinically small thyroid
○ Repeat USG in 1 year
1. Static >> expectant
2. Growth >> FNAC
- Benign = Try thyroixine/ surgery
- Malignant = Surgery
● RAI
○ Effectiveness: 40-80% reduce in size (60% volume in 5 years)
○ Is addition of recombinant TSH useful?
■ based on TSH dependent iodine uptake
■ an addition 15-20% volume reduction
■ S/E: transient hyperthyroidism, acute thyroid swelling (~10ml) leading to compression
■ * Now only used before thyroid scan/ thyroid cancer
● Thyroxine
○ based inducing a subclinical hypethyroidism on the negative feedback to suppress TSH-dependent
MNG growth
○ Effectiveness: only 20% reduce insize (50% volume), because most nodules are independent of TSH
for growth, thyroxine can only reduce the perinodular normal tissue
○ S/E: Osteoporosis, ischemic heart disease
● Surgery

*Total thyroidectomy Subtotal thyroidectomy +- thyroxine (no

use)
0% MNG recurrence 10% MNG recurrence
Complication similar except for temporary hypoparathyroidism ++  
+
Treating incidental cancer (up to 10%)
 
A word on toxic adenoma or MNG
● Toxic adenoma = Hemithyroidectomy
● Toxic MNG = Total thyroidectomy
 
===================================
 
Parathyroid
 
Anatomy
● 2 pairs of parathyroid glands - superior and inferior
● Superior glands derived from 4th branchial pouch
○ consistently located above the inferior thyroid artery
● Inferior glands derived from 3rd branchial pouch, descend with thymus, have a more variable position
○ usually within 1 cm of thyroid lower border
○ some are pretracheal or mediastinal
● Usually both supplied by inferior thyroid artery, though some superior glands are supplied by superior
thyroid artery instead
 
Etiology of primary hyperPTH (from high Ca, high/normal PTH, normal RFT)
● 85% single adenoma
● 10% multiglandular hyperplasia

85
 ● 5% multiple adenomas / carcinoma
 
Clinical presentations
● polyuria, polydipsia
● anorexia, vomiting, constipation, abdominal pain, peptic ulcer, pancreatitis
● bone pain
● kidney stones, poor renal function
● depression
● hypertension, LVH
 
 Indication for surgery
● Calcium >2.8mmol/l
● Urine calcium >10mmol/l
● Symptomatic
● Asymptomatic with: young age, impaired RFT, low bone mass, stone
 
Management protocol
● 99m-Tc-sestamibi scan + USG neck (but both thyroid and parathyroid enhanced!)
○ 123 iodine subtraction - to create a thyroid-only enhancement, and subtract with the sestamibi scan
○ Delayed image (3-4h) - different washout time: thyroid >> parathyroid >> adenoma
○ * detects ~60% adenomas (FN in small adenoma, clear cell adenoma, ectopic adenomas)
○ * some FP if there is a small functional thyroid nodules
● If positive, go for Minimally invasive open parathyroidectomy
○ lateral incision
○ unilateral neck exploration with focused parathyroidectomy
○ intraoperative PTH measurement to confirm removal of hyperfunctioning gland (>50% drop
10min postresection)
■ it excludes possibility of double adenomas
■ it excludes possibility of multiglandular hyperplasia
○ * this technique has FEWER complications, SHORTER surgery time and hospitalisation, potential day
surgery!
● If negative, go for Bilateral neck exploration (the classical method)
○ Kocher incision
○ manual exploration of all four glands
○ frozen sections needed to confirm correct excision
 
Total parathyroidectomy + heterotopic parathyroid autotransplantation
● Indications
○ secondary or tertiary hyperPTH
○ four gland hyperplasia that all require resection
● site of autotransplantation = SCM / brachioradialis, so that if the hyperplasia recur, it can be readily
reduced in a small office procedure
  
====================================
 

86
Neck masses

Anterior triangle
● Moves with swallow
○ Thyroid gland
○ Thyroglossal cyst
● Dont move with swallow
○ Lymphnode
○ Salivary gland (parotid, submandibular)
○ Branchial cyst
○ Dermoid cyst
○ Carotid body tumor
Posterior triangle
● Lymphnode
● Cystic hygroma
● Subclavian aneurysm
● Pharyngeal pouch
 
 
Thyroglossal cyst
 

87
 
Definition
● Patent thyroglossal duct during descent of thyroid gland from foramen caecum at base of tongue
Clinical presentation
● 20yo women
● painless midline lump
● Complications
○ Infection - painful, tender and enlarged
○ Thyroglossal sinus - sinus openning with drainage
○ Papillary carcinoma (from the ectopic thyroid tissue)
Treatment
● Surgical excision
○ Preop
■ USG for cyst + define thyroglossal duct + for normal thyroid tissue (some only have ectopic
at base of tongue!)
■ TFT for normal thyroid function
○ transverse incision over cyst and dissect cyst out
○ look for downward and upward tract and excise, including middle 1/3 of hyoid bone
 
On inspection, there is a prominent mass over the anterior neck above the thyroid cartilage. There is no overlying
surgical scars or skin changes, and no sinus openning could be seen. The mass does not move with swallowing, but
it moves upward with tongue tug test, suggesting its attachment to hyoid bone.
On palpation, the mass is circular in shape, firm and nontender, sized around 3cm in diameter. It has a smooth
surface and distinct border. It does not attach to overlying skin or surrounding structures. It is not fluctuant or
pulsatile, and does no transilluminate with light. There is no associated cervical lymphadenopathy. Base of tongue
shows no ectopic thyroid tissue.
This is likely to be a thyroglossal cyst. Differential diagnoses include congenital dermoid cyst, enlarged lymph node,
the pyramidal lobe of thyroid or a solitary thyroid nodule.
 
 
Cervical lymphadenopathy
Differential diagnosis
● Metastastic deposits
● Lymphoma
● Reactive lymphadenopathy (URIT, tonsillitis)
● Tuberculous lymphadenitis
What to do if I suspect malignant nodes?
● Detailed history
○ sore ulcer on tongue/buccal mucosa
○ Hoarse voice, tinnitus, nosebleed
○ Cough, sputum, hemoptysis, SOB
○ Abdominal pain

88
 ○ Weight loss, malaise, anorexia
● Physical examination
○ Head, scalp, face, ears, neck
○ Look into nose
○ Look into mouth at tongue, gums, mucosa, tonsils
○ Parotid, submandibular glands
○ Thyroid gland
○ Examine chest, breasts, abdomen, testes
● Investigations
○ Full ENT examination (sinus, oropharynx, nasopharynx, buccal cavity)
○ CXR/mammogram/CTscan
○ ?Biopsy
 
On inspection, there is a group of swellings over the right anterolateral region of neck. There is no overlying skin
changes or surgical scars, and they do not move with swallowing.
On palpation, the masses are stony hard and non-tender, sized around 2-5cm in diatmeter each, with the largest
lesion located at the mid-jugular region with a diameter of 5cm. The masses seem to be matted together, they
have an irregular surface and border, and do not attach to skin or underlying structures. Otherwise, they do no
fluctuate, pulsate or transilluminate.
This is a group of enlarged lymph nodes in the upper and mid jugular chain. I would like to exclude malignancy by
taking a detailed history, examine for a primary lesion, and arrange some urgent investigations which would
include a full ENT examination. Other differential diagnoses include lymphoma and reactionary nodes - but still
they should be considered only after diligent work in ruling out malignancy.
 
On inspection, there is a group of swellings over the right posterior triangle of neck. There is no overlying skin
changes or srugical scars, and they do not move with swallowing.
On palpation, the masses are firm and rubbery, they are non tender, sized around 2-4cm indiameter with the most
prominent one located at lateral border of SCM. The masses have a smooth surface and distinct border, and they
are not matted together. Otherwise they do not fluctuate, pulsate or transilluminate. There is no similar lesions on
the contralateral side of neck.
This is a group of enlarged lymph nodes in the right posterior triangle of neck. In view of his age, my top
differential diagnosis would be a primary lymphoma. I would like to further examine other lymph nodes in axillary
and inguinal region, also palpate the abdomen for enlarged liver or spleen.
 
 
Branchial cyst
 

 
Definition
● Remnant of branchial cleft (2nd)
● *Preauricular sinus = remnant of first branchial arch
Pathology
● as the 2nd branchial cleft grows into neck, it leaves a temporary space lined with squamous epithelium
● it may persist and distend with cholesterol containing fluid
Clinical presentations
● around 20yo as a painless swelling
● Complications
○ Infection - pain and swelling
○ Branchial fistula - tract connecting oropharynx just behind tonsils to external skin (lower third of
SCM)
○ Branchial sinus - similar to fistula but internal openning obliterated
Treatment
● Treat infection with antibiotics >> Surgical excision
 
On inspection, there is a prominent mass in the left anterior triangle of neck located at medial border of SCM, there
is no overlying surgical scars or skin changes, there is no external sinus openning at lower neck. It does no move
with swallowing.

89
On palpation, the mass is soft/firm and non-tender in ovoid shape, it sized around 6cm x 8cm. It has a smooth
surface and distinct border, and does not attach to skin but is fixed to deep structures. It is not fluctuant and non-
pulsatile. It does not tranilluminate. There is no associated cervical lymphadenopathy.
It is likely to be a branchial cyst. Differential diagnoses include enlarged lymph node, parotid lesion or carotid body
tumor.
 
 
Carotid body tumor
 

 
Definition
● Rare tumor from chemoreceptors of carotid body (usually benign, but with malignany potential)
Clinical presentations
● Age 40-60yo
● Painless pulsatile lump on upper anterior triangle
● Transient ischemic attack from carotid artery compression
Investigation
● Ultrasound
● Carotid angiography
Treatment
● Surgical excision +- bypass/grafting/shunting
 
On inspection, there is a prominent mass in left anterior triangle of neck, located at medial upper border of SCM.
There is no overlying surgical scars or skin changes, and it does not move with swallowing or tongue tug.
On palpation, the mass is firm, non-tender and ovoid in shape. It sized around 3cm in diameter, and has a smooth
surface and indistinct border. It does no attach to overlying skin, and appears to be deeply attached. The mass is
pulsatile in nature, but it is not fluctuant and does not transillumninate. There is no associated cervical
lymphadenopathy. Auscultation reveals bruit over it.
It is likely to be a carotid body tumor.
 
 
 
Pharyngeal pouch (Zenker's diverticulum)
 

 
Definition
● Pulsion diverticulum of pharynx (gap between horizontal and olique fibers of interior constrictor muscle)
● from Killian's dehiscence
Clinical presentions
● Old age man
● Halitosis and recurrent sore throat
● Regurgitation of undigested food at any time >> aspiration, choking, coughing, pneumonia, lung abscess
● Dysphagia (compressing on adjacent esophagus)
● Posterior triangle neck mass
Investigations
● Barium swallow
● Careful Endoscopy
Treatment
● Surgical excision + Cricopharyngeal myotomy
○ Pouch packed with gauze to aid identification
○ Incision along inferior SCM
○ Dissect out pouch, clamp and excise
○ Send histology for CA
○ Cricomyotomy to release pressure
● Dohlman's procedure (for high risk patient)
○ endoscopic resection: simple inversion and oversewing of pouch
● Endoscopic stapling

90
 
On inspection, there is a prominent mass in right posterior triangle of neck, located at lateral upper border of SCM
at level of thyroid cartilage. There is no overlying surgical scars or skin changes. It does not move with swallowing.
On palpation, the mass is soft, non-tender and ovoid in shape. It sized around 6cm in diameter, and has a smooth
surface and indistinct border. It does not attach to overlying skin, and appears to be deeply attached. The mass is
not pulsatile or fluctuant and does not transilluminate. There is no associated cervical lymphadenopathy.
It is likely to be a pharyngeal pouch, differential diagnoses include cystic hygroma and isolated enlarged cervical
node.
 
 
Cystic hygroma
 

 
Definition
● A lymphagnioma usually present at birth (some aggrevated by infection and present in adult)
Clinical presentation
● Large posterior triangle mass
● Infection with pain, red and swelling
Treatment
● Watch and wait until 4-5yo (they may regress)
● Aspiration/ Sclerosant injection
● Sugical excision
 
On inspection, there is a prominent mass in left posterior triangle of neck, occupying almost the entire lateral neck
area. There is no surgical scars or overlying skin changes.
On palpation, the mass has an indistinct shap and is soft and non-tender, sized around 10cm in diameter. It has a
smooth border and indistinct edges, it is fluctuant and transilluminate brilliantly, emphasising its superficial nature
and its clear fluid content. There is no enlarged lymph nodes.
It is likely to be a cystic hygroma.
 
===================================
 
Salivary gland pathology
Anatomy of parotid gland
● Structures within the parotid gland:
○ 5 terminal branches of facial nerve (temporal, zygomatic, buccal, marginal mandibular, cervical)
○ Retromandibular vein (and its tributaries: superficial temporal, maxillary)
○ External carotid artery (and its branches: superficial temporal, maxillary)
○ Lymphnodes
○ Parotid duct - midway between zygomatic arch and angle of jaw

91
 ● Pre-op investigations
○ ?Ultrasound and FNA
○ CT scan
○ *NO CUT INTO A PAROTID LUMP, so no trucut or excision biopsy, it increases risk of recurrence!
● Parotidectomy
○ Clinically benign: Superfical parotidectomy
■ if found malignant followed by watchful waiting
■ if found malignant followed by radiotherapy
■ if found malignant followed by further radical excision
○ Clinically malignant: Total parotidectomy (conservative vs radical: facial nerve sacrificed)
○ S/E:
■ Hemorrhage
■ Sloughing of skin flap
■ Parotid duct fistula
■ Facial nerve palsy/ Frey's syndrome
■ Damage to external carotid artery and retromandibular vein
Tumor
● Parotid: 90% benign
○ 2/3 pleomorphic - 10% recur after surgery, malignant transformation can occur
○ 1/3 monomorphic - eg Warthin's tumor = adenolymphoma [inferior, soft, fluctuate, bilateral])
● Sublingual/Submandibular: 50% benign
Calculi and sialadenitis
● more in submandibular and sublingual - mucus rather than serous content
Examination
● Adenoma (pleomorphic, warthin)
● Carcinoma
● Parotitis
● Calculi
* always request a bimanual examination, check attachment to masseter, examine facial nerve
 
There is a swollen mass just anterior and superior to angle of jaw on the right side. There is no overlying surgical
scar or skin changes.
On palpation, the mass is firm and nontender, hemispherical in shape and sized around 3cm in diameter. It has a
smooth surface and distinct edge, skin can be moved freely above it, and it does not attach to underlying masseter
muscle. The mass is not pulsative, not fluctuant and does not transilluminate. The rest of the gland and the
contralateral gland are normal, there is no associated cervical lymphadenopathy.
On bimanual examination, the mass is palpable. The facial nerve examniation is unremarkable.
This is likely to be a tumor of parotid origin, based on the physical exam findings, it is likely to be a benign tumor
(eg pleomorphic adenoma, Warthin's tumor).
 
There is a swollen mass just over the angle of jaw of the right. The overlying skin is erythematous without any
surigcal scars.
On palpation, skin is relatively hot. The mass is hard and nontender in a irregular shape. It sized around 3cm in
diameter. It has an irregular surface and indistinct border. It seems to tether to overlying skin, and deeply fixed to
masseter muscle. Otherwise the mass is not pulsatile, fluctuant or transilluminate. The rest of and the contralateral
gland are normal. On neck examination, multiple cervical lymph nodes are palpable in the submandular and upper
jugular regions. They are all hard and nontender, with the largest sized around 2cm in diameter.
On bimanual examination, the mass is palpable. Facial nerve examination reveal a right sided lower motor neuron
lesion, with loss of nasolabial fold, inability to close eye against resistance, and obvious facial asymmetry.
This is likely to be a malignant tumor arising from the right parotid gland.
 
===================================
 

92
Hepatobiliary Surgery

=======================================
 
Jaundice
 
Bilirubin metabolism
● Hemoglobin 80%, ineffective erythropoiesis 15%, heme protein (myogloblin, catalase) 5%
● RES
○ heme to biliverdin by heme oxygenase
○ biliverdin to bilirubin by biliverdin reductase
● Plasma transport
○ bilirubin bound reversibly to albumin
● Liver
○ ligandin Y/Z transport bilirubin to SER
○ conjugation by UDP-glucoronyl transferase
○ excreted into bile canaliculi by an export pump (rate limiting)
● Bile
○ conjugated bilirubin hydrolysed by intestinal bacterial B-glucuronidase to unconjugated bilirubin
○ unconjugated bilirubin reduced to urobilinogen
■ 80% further to urobilin or stercobilin
■ 20% reabsorbed and circulated to liver forming enterohepatic circulation
 
Etiology
● Hemolysis
○ Extravascular
■ spherocytosis, eliptocytosis
■ autoimmune hemolytic anemia
■ hypersplenism
○ Intravascular
■ G6PD, pyruvate kinase deficiency
■ DIC, TTP, HUS, mechanical heart valve
● Hepatocellular injury
○ Hepatitis
■ viral hepatitis
■ alcoholic hepatitis
■ drug induce hepatitis
■ NASH
■ autoimmune hepatitis
■ wilson's, hemochromatosis, a1 antitrypsin deficiency
○ Hereditary
■ Gilbert's syndrome
■ Criggler Najjar syndrome
○ Cirrhosis
● Cholestatic or obstructive
○ Obstruction - see below
○ Drugs - anabolic steroids, OCP, augmentin, flucloxacillin, erythromycin
○ Hereditary
■ Rotor's syndrome (defective storage of bilirubin in hepatocytes)
■ Dubin Johnson syndrome (defect in transporter to bile canaliculi)
 
History

93
 ● SOCRATES
● Tea urine, pale stool, pruritis
● Abdominal pain, fever, confusion, dizziness
● Anemic symptoms
● Constitutional symptoms
● Previous biliary surgery 
 
=======================================
 
Gallstones
Prevalence = 10-15% of adults
 
Risk factors
● Fat
● Fertile
● Female
● Forty
 
Formation
● Pigmented stone - black (hemolysis), brown (biliary infection)
● Cholesterol stone
● *Mixed stone
 
Presentations
● Asymptomatic
○ ?risk future complications = 1-4% per year
○ ?risk of gallbladder cancer = very low incidence
● Biliary colic
○ impaction of stone to gallbladder neck
○ sudden postprandial RUQ pain, constant in severity for hours, radiating to scapula or shoulder,
patient inability to assume a comfortable position to lessen the pain
● Acute cholecystitis
● Chronic cholecystitis
○ chronic inflammation and fibrosis of gallbladder
○ postprandial fullness, belching and nausea; RUQ discomfort
○ USG shows contracted gallbladder with stones in site
● Cholangitis
● Biliary pancreatitis
● Gallstone ileus
 
=======================================
 
Acute cholecystitis
 
Pathology
● prolonged obstruction of stone at neck, lead to concentration of bile thus chemical cholecystitis, this
further lead to distension of gallbladder wall and worse until secondary bacterial infeciton sets in
● 95% calculous, 5% acalculous (usually ICU, TPN)
 
Clinical presentations
● Fever
● RUQ pain, may radiate to shoulder 
 
Complications (High swinging fever, worsening pain, tachycardia, sky high WCC with left shift)
● Empyema
● Gangrene

94
 ● Perforation
 
Investigations
● USG gallbladder
○ Stone in gallbladder neck casting an acoustic shadow
○ Distended gallbladder >4x10cm with thickened wall >3mm
○ Pericholecystic fluid
○ Ultrasonic Murphy's sign: arrest of breathing while hand placed in RUQ, with absence of pain on left
side
● Crossmatch, CBC, RFT, LFT, amylase, clottings, blood culture
 
What if clinical and investigation findings equivocal?
12. Observe: time will tell - rising pulse, high fever, septic
13. Further Ix: repeat USG/ EHIDA/ *CT scan (can also look for extrabiliary pathology!)
 
Management
9. NPO + IVF
10. NGT if heavy vomiting
11. Monitor vitals, chart I/O
12. Crossmatch, CBC, RFT, LFT, amylase
13. Iv ampicillin + cefuroxime + metronidazole (Evidence not strong, but still use!)
14. NSAIDs/Opioids
15. Early (same hospital admission) laparoscopic cholecystectomy
○ Comparing with interval cholecystectomy, it offers:
■ a shorter hospital stay
■ reduce the incidence of defaulting surgery
■ avoid failure to conservative management (IVF, analgesics, antibiotics)
■ NO DIFFERENCE in complication/conversion rate
● Interval (6-8 week) laparoscopic cholecystectomy for:
○ delayed presentation/late diagnosis (>72hours)
○ refusing OT
● Conservative +- Percutaneous cholecystostomy for:
○ unfit for surgery
○ multiple comorbidities
● Endoscopic transpapillary gallbladder drainage
○ for non-surgical candidate + failed percutaneous drainage (eg. inappropriate anatomy)
 
=======================================
 
Obstructive jaundice
 
Surgical jaundice = obstructive jaundice
● Intraluminal - stones, parasites, clots, tumor embolus
● Mural
○ Benign - stricture (postinflammatory, ischemia, PSC, PBC), congenital atresia
○ Malignant - cholangiocarcinoma
● Extramural
○ Benign - liver cysts, liver abscess, mirrizi syndrome, chronic pancreatitis
○ Malignant - periampullary CA (2cm from ampulla eg. CA pancreas, CA ampulla of Vater, CA
duodenum, cholangiocarcinoma), porta hepatis nodes,  CA gallbladder
 
Investigation:
● CBC, CRP, blood culture, LFT, RFT, clottings, amylase

95
 ● Imaging (Normal diameter of CBD is around 6-7mm, whilst in patient who has undergone
cholecystectomy, CBD will dilated due to physiological accumulation of bile within. Compare with width of
endoscopy ~1-1.2cm)
○ USG (for size of CBD, obstruction level, cause of obstruction)
■ Distal obstruction = CBD stone, periampullary CA
■ Proximal obstruction = Klatskin tumor, porta nodes, Mirizzi syndrome, gallbladder tumor
■ Dilated CBD only = minor CBD stone, cirrhotic non-distendable bile ducts,
postcholecystectomy
■ No biliary dilation = intrahepatic cholestasis
○ AXR for 10% stones and chronic pancreatitis
○ MRCP - for low risk cases from USG
■ non contrasted technique, T2 weighted imaging
■ sensitivity comparalbe to ERCP, more sensitive in diagnosing intraheptic stones
■ avoid contrast injection, non-invasive, less operative dependent
■ purely diangostic, costly, miss stones <3mm
○ EUS
■ endoscopic visualization with high frequency USG
■ sensitive >90% common bile duct stones
○ ERCP - for high risk cases from USG
○ PTC (Percutaneous transhepatic cholangiography)
○ ECBD
   
 
Cholangitis
 
Clinical presentations
● Charcot's triad = Fever + RUQ pain + jaundice
● Raynaud's pentad = Fever + RUQ pain + jaundice + confusion + low BP
● Painful obstruction= benign disease
Painless obstuction= malignant causes
 
Management
● NPO + IVF
● NGT if vomiting
● Monitor Temp/BP/P
● Chart I/O
● CBC, CRP, LFT, RFT, amylase, clottings, bloodculture
● USG
● iv Ampicillin, Cefuroxime, Metronidazole
● iv Vitamin K
● oral 500g paracetamol qid prn
● Prepare for ERCP
○ consent
○ correct coagulopathy
 
Surgical Management options
● ERCP >> Interval Laproscopic cholecystectomy
● Open IOC >> ECBD + cholecystectomy
(This option reserves for patients contraindicated or difficult for ERCP, eg post-Billroth II or post
hepatojejunostomy)
● Laproscopic IOC >>
○ Lap ECBD (technically demanding) + lap cholecystectomy
■ Transcystic exploration - access CBD via cystic duct, easy closure, but high failure rate
30%

96
 ■ Choledochotomy
○ Intraop ERCP + lap cholecystectomy
○ lap cholecystectomy + postop ERCP (only 95% canulation rate, so 5% cannot remove stone and
need to go in for surgery again!)
 
* Single-stage ECBD and cholecystectomy  vs  Pre-op indentification clearance + interval cholecystectomy (2-
stage) 
● idenitical efficacy for stone removal, similar morbidity and mortality
● GOOD: cost effective, one admission
● BAD: expertise needed, OT setup, OT time, consumables
 
PWH
● Non invasive investigation (USG) to determine need of ERCP
● Preop identification and clearance of CBD stone
○ Expertise and facility of ECRP is easily available
○ Lap transcystic ECBD is not always feasible
○ Avoid morbidity of lap ECBD
 
===================================
 
Indications for Cholecystectomy
[Symptomatic / Complications - Rationale: high risk of recurrence, potential mortality if recur]
● Pain which affect quality of life (including pass stones)
● Cholecystitis
● Cholangitis
● Biliary pancreatitis
● Gallstone ileus
● Porcelain gallbladder
● Gallbladder CA
● Hepadectomy
 
Laparoscopic cholecystectomy
 
● <5% conversion rate
● Comparing with open cholecystectomy, it offers:
○ reduced pain
○ early mobilisation
○ shorter hospital stay
○ early resumption to work
○ reduce complications (wound/chest infection, ileus, stress response)
○ better cosmestic result
● Comparing with open cholecystectomy, it may be worse in:
○ more biliary tree injury
○ cardiopulmonary compromise by pneumoperitoneum
● Techniques
○ 4 ports (10mm camera, 10mm operating, 5mm dynamic retraction, 5mm static retraction)
○ Calot's triangle - cystic duct, CHD, liver edge
○ Critical View of Safety Technique
■ clear up everything including fat and connective tissue of calot's triangle
■ to achieve adequate exposure of cystic artery
● Contraindications
○ Multiple abdominal surgery
○ Pregnancy
○ Suspected CA gallbaldder

97
 ○ Coagulopathy
● Complications
○ General: GA, incision wound infection, hemorrhage, keloid
○ Specific: convert to open, damage to biliary tree/duodenum, cholangitis, cystic stump formation
● New modified techniques:
○ Needlescopic cholecystectomy: small operating ports 5,3,2mm (less pain)
○ Single port laparoscopy
○ NOTES: Natural orifice transluminal endoscopic surgery! (2007 JUNE: first transgastric
cholecystectomy)
- potentially transvaginal/transcolon/transvesical too.
 
====================================
 
 
PTC (Percutaneous transhepatic cholangiography) +- PTBD (into intrahepatic ducts)
● pros
○ indicated when ECRCP unsuccessful or not feasible (after GI surgery) owing to altered anatomy
○ good for malignant causes of obstruction, as it prevents contamination of biliary tree from gut flora,
increase the later surgical successful rate
○ good for known hilar stricture
○ can help delineate the upper border of obstruction
○ easy output monitoring (chart the output volume)
● cons
○ fluid and electrolytes loss
○ may not completely relieve jaundice, unless multiple tubes inserted
○ inconvenience from bed side bags
● * internal-external drainage (internalization of PTBD) -
try to pass the PTBD catheter down the site of obruction, so that the bile is now drained internally, with the
external tubing spicotted, it improves the quality of life. When output monitoring is needed, the external
drain can be used
 
 
ERCP
● Diagnositic (stones and strictures, brush biopsy)
● Therapeutic (papillotomy, balloon, basket, stents, papillotomy)
○ Temopory treatment
■ biliary stenting (minimize risk of biliary spesis, no need for sphinterectomy)
■ nasobiliary drainage (cholangiogram can be done,
● pros
○ usually complete drainage with more interventional modality
○ better quality of life without BSB
● cons
○ restenosis rate quite high for malignancy
○ difficule to assess output, usually present only by jaundice or cholangitis
● Reasons for failing ERCP
○ Billroth II reconstruction
○ duodenal stricture/ diverticulum
○ ampullary stenosis
○ bile duct tortuosit
○ biliary stricture
○ stone impaction
○ multiple stone
○ stone >15mm

98
 ○ intrahepatic stones
 
● Complications
○ General: perforation, bleeding, aspiration
○ Specific: pancreatitis, biliary tree damage, cholangitis, duodenal perforation in papillotomy
○ if duodenum perforated, as it is RETROPERITONEAL, low peritonitis risk, treat it conservativelyby
close monitoring, keep fast with TPN
 
ECBD (Exploration of common bile duct)
● possible for t-tube insertion
● t-tube made of latex which can induce fibrosis and form a fibrous tract
● allow further t-tube cholangiogram
● allow percutaneous drainage of bile
 
=======================================
 
Recurrent pyogenic cholangitis
 
Pathology
● malnutrition caused reduced enzymatic inhibitors of deconjugation of bilirubin and promote level of
unconjugated bilirubin, this the calcium bilirubinate act as a nidus for stone formation
● chronic infection by parasites (Ascaris lumbricoides, clonorchis sinesis, opisthorchis viverrini) and bacteria
promote intrahepatic ductal stones
 
CT scan
● intraheptic (left hepatic segment) stones
● liver segmental atrophy
 
Management
● Modality
○ Hepatectomy +- drainage (HJ/HCJ/CD) - atrophic liver segment, segemnt of lobe-dominant disease,
suspected cholangioCA
○ ECBD +- drainage
○ Pecutaneous chledochoscopic lithotripsy
○ Laesr lithotripsy, ESWL
 
=======================================
 
Mirrizi's syndrome
 
Stone lodged at the Hartmann's pouch (always pathologically formed by repeated impaction and disimpaction of
stones) and compress onto CHD, with four types:
 
Classification
Type I: no fistula
Type II: fistula width 1/3 of CBD
Type III: fistula width 2/3 of CBD
Type IV: fistula width of CBD
 
=====================================
 
Gallbladder polyp
 
Basics
● 5% of healthy individuals
● Natural history
○ 50% same size
○ 25% increase size
○ 25% decrease size

99
 
Risk factors
● Old age
● Coexisting stone (85% in CA)
● Polyp size >10mm
● Polyp rapidly increasing in size
● Solitary polyp
 
Investigation
● USG (~90% sen and spec)
● CT scan
 
Management
● Malignancy unlikely = Observe by USG
● Malignancy probable = Lap cholecystectomy
● Malignancy likely = Open cholecystectomy + frozen section* +- liver segment 4b/5 resection +- porta node
dissection
● Malignancy confirmed = Radical cholecystectomy + enbloc liver semgent 4b/5 resection + porta node
dissection
 
=====================================
 
Acute Pancreatitis
 

 
Basics
● Head, neck, body, tail
● level of L2
● Arterial supply
○ celiac trunk (gastroduodenal artery >> superior pancreaticoduodenal artery)
○ superior mesenteric artery (inferior pancreaticoduodenal artery)
● Venous supply
○ pancreaticoduodenal veins >> portal vein
● duct of Wirsung
● duct of Santorini
 
Pathogenesis
● Spectrum: interstitial odematous pancreatitis >> necrotizing hemorrhagic pancreatitis
● Pancreatic acinar damage with autodigestion by trypsin, perpetuate the cycle
● Recruitment of inflammatory cell mediators >> systemic inflammatory response
● Biliary pancreatitis [3 hypothesis]
○ gallstones passing the ampulla of Vater and damage the sphinter, thus allow a duodenobiliary reflux,
the enterokinase can then cleave trypsinogen into trypsin, kick off the autodigestion cycle
○ gallstones stuck in CBD, irritate pancreas
○ CBD stone causing biliary reflux into pancreas
● Death
○ EARLY: multiple organ failure
○
AFTER 1 WK: septic complications
 
Etiology
● Idiopathic
● Gallstones
● Ethanol
● Trauma
● Steroids

100
 ● Mumps, coxackie
● Autoimmune (PAN)
● Scorpion/snake venom
● Hypercalcemia, hypertriglyceridemia, hypothermia
● ERCP
● Drugs (isoniazid, thiazide, frusemide, sulfonamides, tetracycline, azathioprine, HAART)
● pancreatic divisum, choledochocysts
● pancreatic duct obstruction (eg tumor)
 
Clinical presentations
● Severe epigastric pain radiating to the back, reaching max in minutes
● nausea and vomitting
● Symptoms of organ failure (eg. SOB, oliguria, jaundice)
 
Physical signs
● Low grade fever
● Greyturner's and Cullen's sign: signify hemorrhagic pancreatitis with retroperitoneal blood track
● Tachycardia, hypotension
○ third space sequestration due to systemic inflammatory response with increase capillary
permeability thus fluid accumulates in connective tissues and other potential spaces like the
peritoneal cavity and pleural cavity
● Abdominal distention
● Paraylytic ileus
 
Blood tests
● CBC, CRP (* if >150mg/L, poor prognosis)
● Calcium, glucose, lipid profile
● LFT (if ALT x3 elevated is specific for gallstone pancreatitis)
● RFT
● Clottings, ABG, LDH
● Serum amylase
2. rise in 12 hours, >1000IU/ml is diagnostic
3. return to normal over 2-5 days; elevation longer than 10 days indicate complications (pseudocyst)
4. False positive
5. False negative (lipemic serum, in very severe case where most pancreas is destroyed)
● Amylase clearance
○ to correct false positive from renal impairment
● Urine amylase
○ elevation persists days after normalization of serum amylase (4x)
○ for patients with delayed presentation
● Urine trypsin activated peptide
○ elevated in 12 hours
○ 96% sensitive
○ 95% specific
● Serum lipase
○ 95% sensitive
○ 55-95% specific
○ NOT available in PWH
 
Imaging
● USG
○ first line investigation, for presence of choledocholithiasis or dilated biliary tree
○ for pancreatitis but 40% may obscured by distented bowel gases

101
 ● AXR
○ loss of psoas shadow (retroperitoneal fluid)
○ sentinel loop (distended jejunum)
○ generalised ileus
○ pleural effusion
● Constrasted CT scan
○ Indications
■ Inconclusive diagnosis
■ Suspected necrosis (Fail to improve/deteriorate upon conservative management)
○ Features of pancreatitis
■ parenchymal enlargement
■ parenchymal edema
■ blurring of fat plane
■ thickening of fascial plances
■ peripancreatic fluid collection
■ bowel distention
■ mesenteric edema
■ pleural effusion
○ Detection of pancreatic necrosis
■ iodinated contrast failed to enhance
■ IF INFECTED: gas bubbles seen
● ERCP
○ Indications
■ Biliary pancreatitis
■ Preoperative evaluation in traumatic patients (determine whether pancreatic duct is
disrupted)
○ biliary decompression done within 72 hours to confer benefit in mortality/morbidity reduction
● EUS
○ most accurate for diagnosing gallstone pancreatitis
○ guide ERCP
 
Prognosis
● Ranson's criteria
○ GA LAW
■ Glucose >11.2mmol/l
■ Age >55
■ LDH >350IU/l
■ AST >250FU/dl
■ WCC > 16 
○ C Hobbs
■ Calcium <2mmol/l
■ Hematocrit drop >10%
■ O2 <8kPa
■ BUN urea rise >1.8umol/l
■ Base excess <-4mEq/L
■ Sequestration >6L
○ 0-2= 1%
3-4= 20%
5-6= 50%
7-8= 90%
○ particularly for alcohol induced pancreatitis
● Modified Glasgow score

102
 ○ PaO2 <8.0kPa
○ Age >55
○ Neutrophil count (WCC >16)
○ Calcium <2mmol/l
○ Urea >16mmol/l
○ LDH>600/ AST>200
○ Albumin >32g/l
○ Glucose >10mmol/l
○ ** >3 positive factors in 48 hours should be transferred to ICU for close monitoring
● APACHE II - Acute Physiology And Chronic Health Evaluation II
○ can start assessment at admission and update the score daily as monitoring
○ not specific to the use in acute pancreatitis but other critical illness
● C-reactive protein
○ at 24 and 48 hour
○ if high than 150mg/dl >> predict severe acute pancreatitis
● CTSI - CT severity index
○ based on CT findings like peripancreatic fluid collection
○ A: Normal
○ B: gland enlargement , small intrapancreatic fluid collection
○ C: <30% necrosis
○ D: 30-50% necrosis
○ E: >50% necrosis
 
Systemic complications
● Acute respiratory distress syndrome
● Systemic inflammatory response syndrome
● Disseminated intravascular coagulation
● Heart failure
● Renal failure
● Hypocalcemia
● Hyperglycemia
● Pancreatic effusion or ascites
 
Local complications
● Necrotizing pancreatitis (10-20%)
○ diagnosed by contrasted CT
○ NO NEED for surgical intervention
● Infected pancreatic necrosis (5-10%)
○ very high mortality
○ occurs after 1 week
○ increasing abdominal pain, rising fever and WCC, SIRS, MODS
○ CT: air bubble at necrotic areas
○ CT/USG guided FNA for smear and culture is gold standard
○ need surgical intervention
● Acute pancreatic pseudocysts (25% acute fluid retention)
● Pancreatic abscess (3%)
○ persistent high swinging fever
○ percutaneous drainage + antibiotics
● Visceral pseudoaneurysm (4-10%)
○ exposure of visceral arteries with pancreatic enzymes
○ splenic and left gastic artery
○ diagnosed by angiography

103
 ● Visceral vein thrombosis (24%)
○ splenic, portal, SMV
○ some are temporary
○ long term may lead to esophageal varice (cf cirrhosis)
● Diabetes mellitis from pancreatic burn out
 
General managements
● Mild
○ Resuscitation
○ NPO + generous IVF
○ NGT insertion
○ Monitor BP/P, Temp, SaO2
○ Chart I/O
○ CBC D/C, CRP, RFT, LFT, LDH, ABG, clottings, Calcium, glucose, lipid profile
○ Abdominal USG, AXR
○ Analgesic
■ pethidine
■ morphine may cause sphincter spasm
○ Find the underlying cause
■ elevated ALTx3  or  USG  >> gallstone
■ hyperCa, hypertriglycerides
● Severe (with local or systemic complications)
○ Admit ICU
○ Oxygen supplement
○ Monitor CVP, PWP
○ Prophylactic antibiotics (sepsis only sets in after 1 week) in necrotizing pancreatitis
■ imipenem
■ still controversial
○ Nutritional support
■ indicated in patients not expected to eat for 1 week or more
■ enteral feeding beyond ampulla of Vater is preferred, but NOT for ileus patient
■ total parenteral nutrition in paralytc ileus/duodenal obstruction
○ Treat systemic complication
○ Treat local complication
 
Surgical managements
● Indications
○ Diagnosis in doubt (eg cannot ddx from mesenteric infarct)
○ Failed medical management
○ Life threatening complications (infected necrosis, hemorrhage, abscess, pseudocysts)
○ Biliary pancreatitis (laparoscopic cholecystectomy within same admission)
● Choices
○ Percutaneous drainage
■ only when the necrosis is well demarcated and liquefied
■ pancreatic abscess
○ *Necrosectomy (indicated in infected necrosis only! Delayed to >2 weeks can improve survival!)
■ wide debridement + peritoneal lavage
■ relaparotomy, zip closure, laparostomy (dont close)
■ with either open packing or closed drainage
○ Pancreatic resection
■ high mortality or morbidity
● Elective cholecystectomy for biliary pancreatitis 

104
 
=====================================
 
Acute pancreatic pseudocysts
 
Poorly defined cystic wall lined by granulation tissue (not epithelium) in lesser sac
● < 4 weeks = acute fluid retention
● > 4 weeks = pseudocysts
○ no true epithelial lining
○ collection of pancreatic juice encloased in a wall of fibrous or granulation tissue
 
Clinical presentations
● Continuous epigastric pain +- palpable mass
● nausea, vomitting, anorexia
 
Investigations
● Persistently elevated amylase
● CT scan
○ < 4cm cysts tend to resolve spontaneously
○ > 6cm requires surgery
○ wall calcifications and thick walls tend NOT to resolve spontaneously
● Cyst fluid analysis/ cyst wall biopsy**
○ only important in distinguishing various kind of true cysts (malignancy)
 

 
Complications
● Infection = 10%, require external drainage
● Hemorrhage due to vessels erosion
● Obstruction of gastric outlet, duodenum, colon, biliary systems, ureters
● Peritoneal rupture
 
Treatments
● Indication
○ >6cm and >4-6week
○ thick walled or calcified
○ or symptomatic
● If small and asymptomatic then serial CT or USG to monitor
● External drainage (may lead to pancreaticocutaneous fistula)
○ Infected
○ Ruptured
○ Thin friable cyst wall where we cannot suture to perform internal drainage

105
 ● Internal drainage (prefered, but need to exclude cystic neoplasm first)
○ Retrogastic = posterior cystogastrostomy
○ Head of pancreas = cystoduodenostomy
○ Anterior cyst = Roux-en-Y cystojejunostomy
○ Tail of pancreas = distal pancreatectomy + cyst excision + splenectomy
 
=====================================
 
Ddx for increased amylase
 
Acute abdomen
● pancreatitis
● perforated peptic ulcer
● gangrenous cholecystitis
● mesenteric infarct (*most difficult to differentiate, operative)
● ruptured AAA
● ruptured ectopic pregnancy
Medical causes
● macroamylasemia
● renal failure
● ketoacidosis
● acute alcoholic intoxication
● morphine administration
 
Salivary gland diseases
● stones, parotitis
 
=====================================
 
Chronic pancreatitis
 
Definition
● a continuous, prolonged, inflammatory process of pancreas
● with irreversible morphological changes of fibrosis, stricture, calcification and stone formation
● resulting in pancreatic exocrine and endocrine insufficiency
 
Etiology
● Major:
○ Alcoholism
○ Idiopathic
● Minor:
○ Tropical
○ Hereditary pancreatitis
○ Hyperlipidemia, hypercalcemia
○ Obstruction (stone, stricture, tumor, pseudocysts, divisum)
 
Pathogenesis
● 4 current theories:
○ Toxic-metabolic - direct effect of chronic alcoholism
○ Oxidative stress - overactivity in hepatic detoxification enzymes, generating free radical that
enters bile, and refluxed to pancreas
○ Ductal obstruction and stone formation - hypersecretion of protein with plug formation, and
increase in ductal permeability to calcium resulting in intraductal calcium deposition
○ Necrosis-fibrosis - recurrent acute insult leading to chronic fibrotic inflammatory response
● Cells involved:
○ T-cells - chronic inflammation + pain

106
 ○ Satellite cells - transform into myofibroblasts and resulted in fibrosis
● Pain from:
○ Increased pressure in main precreatic duct
○ Parenchymal edema with compartment syndrome
○ Neuronal inflammatory mediator increase signals of pain sensitive neurons
● * acute pancreatitis does not lead to chronic pancreatitis!
 
Clinical presentations
● Epigastric pain
○ radiating to back (95%)
○ exacerbated by food >> weight loss
○ relieved by sitting upright, drawing up to jackknife position
○ chronic with acute attacks
● Exocrine insufficiency = malabsorption, steatorrhea
● Endocrine insufficiency = DM
 
Physical signs
● Weight loss, malnutrition
● Erythema ab igne
● stigmata of chronic liver diseases
 
Investigations
● Biochemical (*amylase NOT elevated!)
○ CBC (thrombocytopenia may mean splenic vein thrombosis)
○ LFT (biliary obstruction)
○ Faecal elastase ,  Pancreatic secretin stimulation test, Daily fecal fat content (72hours)
○ Fasting glucose, OGTT, HbA1c
○ Genetic sequencing
● Radiological
○ AXR  - pancreatic calcification 70%
○ USG - pancreas atrophy/enlargement, duct dilation or stone, pseudocysts
○ Contrasted CT - pancreatic atrophy, pancreatic duct dilation/stone, calcification, fluid collection
○ MRCP/ ERCP
■ a must for ductal assessment: dilation, narrowing, filling defect
■ ERCP used only when therapeutic procedure needed (eg stone removal, stent, stricture
dilation)
○ Endoscopic USG
■ extremely sensitive for early pathology!
■ parenchymal - gland atrophy, hyperechoic foci, cysts, lobularity
■ ductual - narrowing, dilation, irregularity, stone
■ can have FNAC, help to exclude pancreatic cancer
 
Complications
● CBD obstruction  15%
○ Parenchymal fibrosis with distal duct obstruction
○ Pseudocyst obstruction
● Pseudocyst
● Biliary/Duodenal obstruction
● Visceral pseudoaneurysm
● Venous thrombosis
● Pancreatic ductal adenoCA (x20)
 
Medical managment

107
 ● Treat underlying cause
● Analgesic
○ Opiates
○ pancreatic enzyme can help
○ nerve block
● Pancreatic enzyme supplement
○ enteric coated
○ take with meals + PPI
● OHA + insulin
○ hypoglycemia is of high risk as the patient also lacks glucagon
● Treat local complications
 
Surgical management
● Indication
○ severe intractable pain
○ multiple relapses
○ inability to rule out CA
○ complications
● Endoscopic
○ biliary stent , pancreatic stent, stone removal, ESWL
● Drainage only
○ Puestow procedure
■ Longitudinal side-to-side pancreaticojejunostomy
■ for functionally significant strictures along duct (chains of lake)
■ duct at least 8mm diameter
● Combined drainage-resection
○ Whipple procedure
■ pancreaticoduodenocholecystectomy
■ when head of pancreas disproportionally affected OR cancer cant be rule out
■ pyloric preserving techique
○ Beger procedure
■ duodenum preserving pancreatic head resection
■ pancreatic tissue removed at head + transected at pancreatic neck + roux-en-Y jejunal loop
with 1 pancreaticojejunostomy + 1 jejunojejunostomy
○ Frey procedure
■ pancreatic head parenchyma cored out + lateral pancreaticojujunostomy
● Resection
○ Distal subtotal pancreatectomy - if disease confined to tail
○ Total pancreatectomy
● Celiac plexus block
○ for pain relief only
 

108
 
=====================================
 
Pancreatic cancer
 
Basics
● An almost invincible cancer with high mortality
● 60% head, 20% body, 20% tail
● Exocrine tumor
○ SOLID: Ductal adenocarcinoma 80%, Acinar cell adenocarcinoma 5%, Undifferentiated 5%
○ CYSTIC: Serous, Mucinous, Intraductal papillary mucinous tumor (IPMT)
● Endocrine tumor (from Islets of langerhans)
○ 1/3 malignant
○ 1/3 multiple
○ Associated with MEN-1, with pituitary and parathyroid tumor
○ Insulinoma, Gastrinoma, Glucagonoma, Somatostatinoma, Nonfunctional
 
Risk factors
● Smoking
● VHL, FAP, Gardner's syndrome
● Chronic pancreatitis
 
Clinical presentations
● *mostly non-specific
● heavy constituitional symptoms
● mild epigastric pain/discomfort
● painless prgoressive jaundice (for head)
 
Signs
● Cachexia, Jaundice
● Supraclavicular lymphnodes
● Courvoisiers's law - palpable gallbladder in the setting of jaundice
● Trousseau's sign - migratory thrombophlebitis
 
Investigations (for staging, to assess resectability & suitability for major surgery)
● Blood tests
○ CA19.9, CEA
○ CBC, RFT, LFT, clottings

109
 ● Imaging
○ CXR
○ USG
○ CT
■ hypoattenuating distinct mass in pancreas
■ preserved fat palnt between the mass and SMV/PV
■ absence of tumor encasement of hepatic/celiac or SMA
○ EUS/ERCP/MRCP
○ Staging laparoscopy
■ extent of local invasion
■ laparoscopic USG for liver metastasis
■ peritoneal deposits
● Ix for comorbidities
 
Management outline [balance the risk-benefit ratio in surgery]
● Curative resection (~5% resectable)
● Palliative treatment
 
Curative management
● Pre-op
○ Top up patient's nutritional status
○ Correct any existing electrolytes or acid-base abnormality
○ Biliary drainage (this is merely for logistic reasons, studies have show that this results in slight drop
in surigical morbidity and later infections)
● Whipple's procedure
○ pancreaticoduodenectomy + pancreaticojujunal + gastrojejunal + hepaticojejunal anastomosis
○ Determine operability
■ Exploration of pancreas by reflecting peritoneum at pancreatic tail and spleen
■ Kocher's manuver
■ Assess root of tranverse mesocolon
○ Standard Whipple vs PPPD??
■ Similar oncological clearance
■ offter no additional benefit
○ Pancreatic-enteric anastomosis: End-to-side or Duct-to-mucosa?
■ Similar outcome
○ Is the Cut-back technique good?
■ Yes. By ensuring adequate blood supply at pancreatic cut surface + meticulous mircoscopic
suture placement, it almost eliminates the risk of anastomotic failure in pancreaticojejunal
junction.
○ Any role for Extended-lymphadenectomy (celiac, SMA, iliac birfurcation, PV)
■ No. No survival benefit.
■ Increased morbidity.
● Post-op
○ May need ICU
○ NGT out until <200ml
○ Abdominal drain out until low amylase level
○ Antibiotics shortcourse
○ Adjuvant somatostatin
○ Adjuvant chemoRT (gemcitabine)
 
Palliative mangement
● Pain
○ Adequate analgesia

110
 ○ Nerve block
● Jaundice
○ Endoscopic stenting
○ Surgical bypass (hepaticojejunostomy, cholecystojejunostomy)
● Gastric outlet obstruction
○ Ednoscopic stenting
○ Surgical bypass
 
=====================================
 
Hemangioma
 
Clinical presentation
● <5cm mass usually asymptomatic and found on unrelated imaging
● >5cm mass with vague discomfort, almost always asymptomatic
● intermittent symptoms from necrosis, infarction or thrombosis of the tumor
● Very rarely hemorrhage
● Kasabach Merritt syndrome
○ a consumptive coagulopathy from platelet sequestration within the tumor
 
Dianogsis
● ultrasonography
● multiphasic CT scan
○ peripheral enhancement in early phase
○ gradual central enhancement
○ uniform in delayed phase
 
Treatment
● mostly observation
● resection if complicated or inability to exclude malignancy
 
=====================================
 
Focal nodular hyperplasia
 
Pathology
● nonneoplastic hyperplasic response to a congenital vascular lesion
● associate with oral contraceptive pills, but to a lesser extent as hepatic adenoma
● predominantly FEMALE
● macroscopic
○ well circuscribe but without capsule
○ central stellate scar radiating outwards dividing tumor into nodules
○ ** distinguish it from the fibrolamellar HCC!
 
Clinical presentation
● rarely symptomatic
● no malignant degeneration
 
=====================================
 
Hepatic adenoma
 
Pathology
● strong association with oral contraceptive pills
● usually solitary with a pseudocapsule
● trabecular pattern WITHOUT BILE DUCTALS

111
 ● premalignant
 
Clinical presentation
● vague abdominal symptoms
● tendency for spontaneous rupture and hemorrhage as intraperitoneal bleeding
○ esp in pregnancy due to the rapid expansion as the estrogen rises
 
Management
● cessatioin of OCP
● surgical resection if
○ >5cm mass
○ tumor not shrinking after stopping OCP
○ patients not possible to stop OCP
○ patients planning for pregnancy
 
=====================================
 
Hepatocellular carcinoma
 
Basic
● M:F = 3:1
● Old age
● 3rd most common cancer
● 2nd cancer mortality
● right hemiliver more common
 
Risk factors
● Any cause of Cirrhosis
● aflatoxins
● hepatic adenoma
 
Pathology
● solitary, multifocal, diffuse
● Histology
○ malignant hepatocytes in broad trabaculae >3 cells
○ foci of hemorrhage and necrosis
○ pattern: trabuculae, pseudoglandular, solid, scirrhosis
○ Edmondson & Steiner grading
● microscopic giant cells seen
 
Clinical manifestation
14. weight loss and weakness
15. abdominal discomfort
16. acute pain when it ruptures and bleeds
 
Screening?
● For high risk groups - known HBV/HCV infection
● 6 monthly AFP/USG
● * Not fully supported by RCT: only the questionable Shanghai trail in 1999
 
Diagnosis
● Modality used
○ Multiphasic CT scan (arterial enhancement + washout in portovenous phase + hypodense in delayed
phase)
○ Contrast USG
○ Contrast MRI

112
 ○ AFP level
○ Biopsy (only when it alters management)
● Protocol
○ Lesion <1cm =  follow by USG 3-6 month
■ if no growth up to 2 years >> return to surveillance
■ if growth >> go to part two
○ Lesion 1-2cm = 2 dynamic studies (CT scan/ contrast USG/ contrast MRI)
■ both typical >> HCC
■ one typical >> biopsy
■ both atypical >> biopsy
○ Lesion >2cm = 1 dynamic study + AFP
■ typical >> HCC
■ AFP 200 >> HCC
■ atypical >> biopsy
○ Biopsy
■ diagnostic >> HCC
■ nondiagnostic >> repeat biopsy or imaging >> until disappear/typical
 
Other investigations
● Baseline blood: CBC, RFT, LFT, clottings
● Tumor markers: AFP, CEA
● Liver reserve: Volume estimation, Indocyanide green clearance
 
Management consideration
● Tumor factor - Size, Number, Location, Encasing major vessels
(Not resectable if: bilobar involvement, extrahepatic disease, major vessles involvement)
● Organ factor - Child Pugh Grading, Indocyanide green clearance
● Patient factor - Age, comorbidities, Performance status (Karnofsky performance status)
 
Staging
● HCC is a special case, as staging can not merely consider pathological findings, but also the underlying liver
function
● The Barcelona-Clinic-Liver-Center staging system (BCLC)
○ includes variables:
■ tumor stage (TNM) (local vascular invasion)
■ liver functional status (Child Pugh)
■ physical status (Performance status grades)
○ link staging with treatment modality with estimation of life expectancy
○ * if Child's C cirrhosis = jump to terminal stage, only for supportive management
 
Curative Treatments
● Surgical resection
○ Child's A
○ <3cm
○ normal bilirubin
○ normal hepatic vein pressure gradient <10mmHg
● Orthotopic liver transplant
○ Milan criteria
■ single tumor < 5cm
■ <3 tumors, with the largest <3cm
● Local ablation
○ for patients not suitable for OT or OLT + solitary tumor <5cm
○ can help to down stage the tumor hence procede to OLT

113
 ■ Percutaneous ethanol injection
■ good for tumor <2cm/ risk of RFA (eg. near major biliary tree/ intestinal loop)
■ as HCC is generally softer, it permits injection of large amount of ethanol without
being absorbed by peripheral harder fibrosed liver tissue
■ USG guided 95% ethanol, usually MULTIPLE sessions
■ Radiofrequency ablation
■ good for tumor <2cm (but up to 5cm), more effective and predictable necrosis than
PEI esp >2cm
■ NOT for tumor with close proximity to vascular pedicle
■ Image guided percutaneous ablation OR laparoscopic ablation
■ needle electrode to tumor center, heat to 60-100 degree for coagulation necrosis
■ Complications
■ Peritoneal bleeding
■ Tumor seedling
■ Hepatic abscess/peritonitis
■ Transient liver failure
■ Bile duct damage
■
GI perforation
 
Palliative treatments
●  Transarterial chemoembolization
○ Palliative measurement
○ based on dual blood supply
3. HCC >> hepatic artery
4. Liver >> portal vein (75%)
○ intraarterial administration of chemotherapeutics (lipiodol, cisplatin/doxorubicin) followed by
gelfoam embolisation of the artery
○ Contraindicated in
2. Most Child's B, All Child's C
3. Vascular invasion
4. Biliary obstruction (high chance of postprocedural abscess)
○ Complications
2. Post-embolisation syndrome - fever, abdominal pain within 49-72h
3. Liver failure
4. Liver abscess
5. Bile duct injury
6. Gastrointestinal bleeding (chemo shunted to GIT by collateral veins)
● Radiotherapy
○ Selective internal radiation therapy (SIRT)
■ Iodine 131 labelled lipiodol, Yttrium-90 tagged glass, Resin microspheres
■ deliever focal irradiation
■ Not for patients with
■ Lung shunting
■ Low tumor to normal uptake ratio
○ External beam radiation currently no use, under investigation
● Chemotherapy
○ HCC is generally a chemoresistant tumor, with MDR gene product, that gives it the ability to efflux
chemoagents from cells
○ Targetted therapy
■ Sorafenib - a multikinase inhibitors with both antiproliferative and antiangiogenic effect,
phase III trial showed survival benefit over placebo, but $38000/month!
○ Can try Conventional Chemo:

114
 ■ Doxorubicin 10-20% response rate
■ Intensive chemo (PIAF = cisplatin, doxorubicin, 5-flurouracil, aIFN) - high response rate but
no additional overall survival benefit due to drug toxicity
 
Liver anatomy
● Hemiliver: cut by a line joining gallbladder and IVC
● Sections:
○ Right = anterior, posterior
○ Left = medial, lateral
● Segments: I-VIII
 

 
Liver operations
● Pre-op
○ liver volume measurement
○ idiocyanide green clearance
● Pre-op portal vein occlusion: atrophy of HCC segment/lobe, and hypertrophy of residue normal liver
● Chevron incision (roof top with upper midline extension)
● Minimize insult to liver remnant + precise transection plane with adequate margin
○ intraop USG
● Minimize blood loss
○ Trendelenberg position
○ CVP kept <5cm H2O
○ Pringle manuover = intermittent vascular control (NOT IN PWH!)
○ CUSA (Cavitron Ultrasonic Surgical Aspirator) and TissueLink (RF with fluid which avoid charring and
burning, can coagulate up to 6-8mm thick of tissue), large vessel ligated
○ Tissue glue on paranchymal surface
● Avoid biliary complications
○ meticulous bile duct dissection within parenchyma
○ preresection intra-op cholangiogram
○ postresection methylene blue test
● Avoid air embolism
○ PEEP 5cm H2O
 
Complications
2. Intraabdominal abscess
3. Bile leaks (from liver cut surface OR damaged biliary ducts)
4. Liver failure
5. Persistent ascite
6. Wound dehisance
 
=====================================
   
Fibrolamellar HCC
 
Basics
2. variant of HCC
3. usually without cirrhotic background
4. younger patients
5. normal AFP
6. better prognosis
** differentiate it with FOCAL NODULAR HYPERPLASIA!!
 
=====================================

115
116
Vascular Surgery

===========================================
 
Peripheral vascular disease
 
Chronic limb ischemia (mostly from atherosclerosis)
 
Risk factors
● Male, old age, smoker
● HT, DM, hyperlipidemia
 
Why more in lower limb?
● longer artery
● more exercise demand
● more tubulent flow
 
The two major problem
● Loss of limb
● High overall CV risk
 
Fontaine classification
● Asymptomatic
● Intermittent claudication >> muscle ache with a reproducible claudication distance, release by rest!
○ aortoiliac disease = thigh/buttock
*Leriche's syndrome is thigh/buttock claudication + erectile dysfunction with internal iliac disease
○ femoral or popliteal disease = calf
○ infrapopliteal disease = rest pain
● Rest pain
● Ulcer/gangrene
* Critical limb ischemia:
- severe persistent rest pain for >2weeks with need of analgesic
- Ulcer / Gangrene
- + ankle systolic pressure <50mmHg / Toe systolic pressure <30mmHg (DM/CRF  patients with calcified
vessels)
 
Physical examination
● Inspection
○ Scars (axillofemoral, axillobifemoral, aortobifermoral, iliofemoral, femorofemoral, femoropopliteal)
○ Muscle wasting
○ Trophic changes
■ hair loss
■ shiny skin
■ nail dystrophy
■ flattened pulp
○ Ulceration
○ Gangrene
- Wet: ill defined edge with advancing border, superimposed infection with pus and smell
- Dry: well dermecated edge indicating non-viable tissue
● Palpation
○ temperature
○ capillary refill
○ peripheral pulses
● Buerger's test (look for Buerger's angle and dependent rubor)
● Auscultation

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 ○ femoral
○ carotid
○ renal
○ (carotid)
● I would like to finish by:
○ palpating abdomen for AAA
○ neurological exam of lower limb
○ cardiac exam (focusing on thromboembolic risk)
○ measure BP
○ doppler for ABI
○ urine for glucose
 
On inspection, there are no surgical scars over bilateral lower limbs. Comparing to the left side, the skin is shiny
over the left calf area, together with absence of hairs, nail dystrophic changes and flattening of pulps. These
suggest the present of underlying arterial insufficiency. There is also a prominent ulcer located at the base of right
big toe. It is punched out in nature, with a regular edge and clean base. It is sized around 1cm in diameter and is
tender. Otherwise there is no other skin lesions in the interdigital spaces.
On palpation, the rigth calf is relatively cooler than the left couterpart, it has a sluggish capillary refill of 4 seconds.
Bilateral fermoral pulses are palpable, with a weakened right popliteal pulse and absent posterior tibial and dorsalis
pedis pulse.
Auscultation reveals no bruit at femoral, abdominal aorta, renal or carotid arteries.
Now I would like to proceed to Buerger's test. Upon elevation of leg, the right leg turned pale at a Buerger's angle
of around 50 degree. Dependent rubor is also noted when legs are hanged at bededge. Buerger's test is positive,
and it suggests arterial insufficiency.
To finish my examination, I would like to examine the abdomen for AAA, perform a full cardiovascular examination
with blood pressure measurement, examine the lower limb nerurological system, and also to perform a bedside
doppler USG to measure ankle-brachial index.
 
Assessement goal
● Severity of disease
○ Asymptomatic
○ Intermittent claudication
○ Critical limb ischemia (poor prognosis: 50% die in 5 years)
● Localisation of diseased segment
● Find out the overall cardiovascular risk + disease
 
Investigation
● Tests for cardiovascular risks or comorbidities
○ CBC, fasting glucose and lipids
○ ECG. echocardiogram
● Doppler USG for ankle-brachial index
○ Ankle systolic pressure/ Brachial systolic pressure
○ normally 0.9-1.0
○ intermittent claudication 0.6-0.9
○ critical limb ischemia >0.5
○ *In DM/CRF, arteries often calcified, value spuriously high
● Duplex ultrasound/Non invasive vascular laboratory
○ for segmental arterial pressure
○ for waveform analysis (normally triphasic, is stenosis presence it becomes bi- or mono-)
● CTA/MRA
○ modality of choice
○ CTA: image interfered by calcified plagues
○ MRA: contraindicated in patients with implants
● Digital subtraction arteriography
○ Risks: radiation, contrast allergy or nephropathy, bleeding, distal embolism

118
 ○ require intraarterial iodinated contrast
○ now rarely used as diagnostic purpose, but in angioplasty/stenting/embolisation
 
Management goal
● Control symptom
● Save limb
● Reduce CV risk
 
Management
● Risk factor control and lifestyle modification (for Class 1234)
○ Smoking cessation
○ Treat DM, HT, hyperlipidemia
○ Supervised exercise program (show to lengthen painfree/maximum walking distance)
○ Foot care
○ Buerger's position
● Medical treatment (for Class 234)
○ Low dose aspirin, ticlopidine or clopidogrel
(no proven benefit with double-antiplatelet or +warfarin)
○ Cilastazol - PDE3 inhibitor that increase intracellular cAMP;  antiplatelet + vasodilation
○ Naftidrofuryl - serotonin receptor blockade, reduce platelet RBC aggregation
○ Pentoxifylline - PDE3 inhibitor, reduce viscosity
○ Prostaglandins
○ Vasodilators
● Interventional managment (for Class 34)
○ Percutaenous endovascular revascularization: Angioplasty +- stenting [generally reserved
for failed angioplasty/ residual stenosis >50%/ procedure related arterial dissection]
■ for symptomatic intermittent claudication despite medical therapy
■ for critical limb ischemia
○ Vascular reconstruction
■ usually for those with critial limb ischemia
■ Comparing with Angioplasty
■ similar amputation-free survival
■ longer stay + $$
■ less likely to need reoperation
■ Types:
■ Surgical bypass
- anatomical  vs  extraanatomical
- saphenous vein graft (higher patency rate)  vs  synthetic
■ Endarterectomy - remove the artherosclerotic plaque in carotids
■ Profundoplasty - widen the narrowed produndus artery by sutures
○ Primary amputation
■ For those with uncontructable disease/ extense tissue loss/ already immobile
■ recommended if the probablity of saving a useful limb at 1 year is <25%; this is based on
that a failed reconstruction often results in amputation at a higher level and worse quality of
life
○ Lumbar sympathectomy
■ division of sympathetic nerves to divert blood flow to skin by releasing the tonic
vasoconstriction of artery(more oxygen, more nutrition)
 
 
 
Acute limb ischemia
 
Definition

119
 ● Previously stable limb with sudden deterioration of artery supply, resulted in rest pain and/or severe
ischemia of <2 weeks
● A surgical emergency!
 
Etiology
● Thrombosis (watch for features of CHRONIC LIMB ISCHEMIA!)
● Embolism (watch for EMBOLIC SOURCE!)
● Dissection  (*super important to differentiate, as the use of anticoagulation will...)
● External compression
● Vasculitis
 
Clincal presentations
● Pain
● Pulselessness
● Parathesia
● Paralysis
● Pallor
● Perishly cold
  
Management
● Acute stage
○ Oxygen + Hydration
○ Control the underlying cause if any (eg AF)
○ Pain relief (no IM injection!)
○ Urgent imaging, usually contrasted CT scan to confirm diagnosis and to rule out dissection
○ Aspirin
○ Anticoagulation by Heparin if sure NOT dissection
● Definitive
○ Embolectomy
■ retieved by a Fogarty tube
○ Intra-arterial thrombolysis  (Urokinase, streptokinase, Tissue plasminogen activator)
■ Contraindications
■ recent major bleeding
■ recent surgery
■ recent TIA (2wk) or stroke (6wk)
■ recent head trauma
■ cerebral neoplasm
■ esophageal varicess
■ suspected dissection
■ severe hypertension
■ severe liver disease
■ acute pancreatitis
■ Complications
■ allergic reaction
■ major bleeding
■ stroke
■ reperfusion injury
■ distal embolisation
○ Angioplasty/bypass grafting
○
Primary amputation: if leg no longer salvagable
 
============================================
 

120
Varicose veins
 
Definition
● Varicose vein = torturous dilated elongated superifcial veins (defined as superficial to deep fascia)
● Reticular vein = prominent subdermal vein <4mm
● Telangiectasia = dilated intradermal venule <1mm
● Chronic venous insufficiency =  Impairment in venous return (superficial/deep)
 
Anatomy
● Tributaries of long saphenous vein
- Superficial circumflex iliac vein
- Superficial epigastric vein
- Superficial external pudendal vein
- Anterolateral vein of thigh
- Posteromedial vein of thigh

121
 ●
 
Etiology
● Idiopathic
○ Familial, female
● Accquired
○ Venous obstruction (eg DVT)
○ Raised venous pressure
■ abdominal/pelvic masses (including fetus)
■ congenital venous malormation
■ Klipple-Trenaunay syndrome
(VV + lower limb hypertrophy + extensive cutaneous hemangiomas)
■ arteriovenous fistula
■ severe tricuspid incompetence
 
Pathophysiology
● Incompetent valves in superficial system & perforators (primary/secondary)
● Ambulatory venous hypertension
● More valvular defects (superficial >> perforators >> deep)
● Chronic venous insufficiency (from reflux/obstruction)
 
Clinical presentations
● Asymptomatics
● Unsightful veins
● itchiness, aching, swelling
● restlessness, cramping, tingling
 
Complications
● Bleeding
● Thrombophlebitis (Tx: compression stockings and NSAIDs)
● Venous insufficiency skin changes

122
 
Examinations
● Inspection
○ Site of varicose vein (long or short saphenous system)
○ Evidence of venous insufficiency (esp in Gaiter's area) including pigmentation (hemosiderosis),
eczematous changes, lipodermatosclerosis (inverted champagne bottle), venous ulcers
Lipodermatosclerosis = chronic venous hypertension with extravasation of RBC with hemosiderin
causing pigmentation + extravasation of WBC which release enzyme causing fat necrosis together
with fibrin cuft formation, that impede oxygenation to tissue leading to ulcerations
○ look for the saphena varix
○ Previous surgical scars
● Palpate for hardness (thrombosis) or tenderness (phlebitis)
● Palpate for edema
● Palpate the cough thrill on the saphena varix
● Trendelenberg test
○ Empty vein when patient is lying down
○ Use FINGER to press on SFJ
○ Stand to see refilling
● Tourniquet test
○ empty the vein when patient is lying down
○ apply a tourniquet on upper thigh, above knee and below knee
○ ask the patient to stand and observe for venous refilling
○ Complete, partial, incomplete control
○ 50% sensitivity only
● Perthes' test
○ same as above, but ask the patient to stand up and down on toes for few times
○ if painful/ paradoxical engorgement of superfical veins = deep venous obstruction; cannot procede
to surgery because the superficial vein could be the only pathway for venous drainage
● Hand-held doppler US
○ useful for assessing venous reflux at sphenofemoral and saphenopopliteal junctions
Put tranaducer at site, compress calf muscles >> listen for audiable reflux
 
On inspection, there is prominent dilated tortous elongated veins on right lower limb, compatible with varicose
veins.
They locate in the long saphenous vein distribution, which starts from the dorsal venous arch, anterior to medial
malleolus, and ascend along the anteromedial thigh to the groin area.
And as for the groin, there a blue-tinge swelling with a visible cough impulse, compatible with saphena varix.
Further on, there is also heavy skin pigmentation with ezcematous changes, most prominent around the medial
malleolus, also known as the Gaiter's area. The right calf is also mildly swollen (with distal taperring in an inverted
champnge bottle appearance). Otherwise there is no ulcer seen.
On palpation, the calf is non tender, with pitting edema up to knee. The skin is hardened, and together with the
pigmentation, it is compatible with lipodermatosclerosis.
Now, to delineate the level of incompetent perforator, I would like to perform the Tourniquet test.
The distended veins empty spontaneously upon elevation of leg, the tourniquet is applied below the
saphenofermoral junction.
- Long sphenous system is completely controlled by tourniquet test, which indicates the SFJ is the only
incompetent perforator
- Long sphenous system is partially controlled by tourniquest test, which indicates the SFJ is one of the
incompetent perforators, with other being in the lower thigh or leg.
- Long sphenous system is not controlled by tourniquest test, which indicates the SFJ is not incompetent, but
others in the lower thigh or leg.
I would like to finish my examination by look for abdominal masses or ascites, and perform a DRE for an enlarged
prostate gland. If possible, I would also like to use a hand-held dopple USG to look for venous reflux.
 
Assessment (CEAP)
● CEAP classification
○ Clinical
■ 0 = no sign of venous disease

123
 ■ 1 = telangectasia/ reticular veins
■ 2 = varicose veins
■ 3 = edema
■ 4 = pigmentation, lipodermatosclerosis, eczema
■ 5 = healed ulceration
■ 6 = active ulceration
○ Etiology
■ congenital
■ primary
■ secondary (post-thrombotic, post-traumatic)
○ Anatomy
○ Pathogenesis
■ obstruction
■ reflux
■ combination
● Venous clinical severity score (VCSS)
○ Ten clinical descriptors
■ pain
■ varicose veins
■ venous edema
■ pigmentation
■ inflammation
■ induration
■ numbers of active ulcers
■ duration of active ulcers
■ size of active ulcers
■ compressive therapy use
○ total score = 0-27
 
Investigations
● Duplex US
○ Functions
■ accurate determination of incompetence sites
■ demonstrate venous reflux
■ look for deep venous obstruction
● Air plethysmography/ Photoplethysmography/ venous pressure measurement
○ look for deep venous obstruction (measure the Maximum venous outflow [MVO] - the speed at
which blood can flow out a maximally congested lower leg when tourniquet suddenlt removed)
● Venography
○ apply tourniquet just above ankle to occlude superficial veins
○ inject contrast on dorsum and it thus enters the deep veins
○ serial X-ray will identify the perforator
 
Treatments of venous ulcers
● Local wound care with wet-to-dry dressing
● oral antibiotics if signs of infection
● compression bandaging
● if large ulcers, consider fenestrated split thickness skin graft
 
Treatment outline of varicose veins
● Non-surgical
● Endoluminal treatment

124
 ● Surgical
Contraindications:
- presence of venous outflow obstruction, because the VVs are important bypass pathway
- patients who cannot remain active enough to reduce post-op DVT
 
Non-surgical management
● Pressure stockings
○ graduation pressure (25-35mmHg at ankle, 10-15mmHg at thigh)
○ effective in healing ulcers, but can take months to good results
○ uncomfortable, so compliance is a problem
○ S/E: skin necrosis (particular patient with DM/PVD-ABI index<0.9 is a contra/poor sensation)
● Layered compression bandaging
○ labour intensive, change 1-2/week
○ effective in healing ulcers, but can take months to good results
○ worse outcome in large lcers, previous DVT and arterial insufficiency
● Venoactive drugs
○ improve edema
○ but no effect on varicose vein progression
○ Micronized diosmin - a venotonic agent
 
Endoluminal Treatment
● Sclerotherapy
○ effective for telangiectasia, reticular veins and SMALL varicose veins
○ Procedure
■ Under LA, if done under GA = high DVT risk
■ Reverse trendelenberg for easy cannulation + Trendelenberg to empty vein when administer
■ Sodium tetradecyl sulphate (STS), polidocanol, 23.4% hypertonic saline (painful) to induce
thrombophlebitis with vein closure
■ postprocedural compression for 2 weeks helps to compress vein wall to prevent
recanalization
○ Complications
■ Anaphylaxis
■ Thrombophlebitis (Tx: aspiration of thrombus), DVT
■ Extravasation necrosis/ulceration, pigmentation*
○ Foam sclerotherapy
■ liquid sclerosant made into foam with ratio of 1 part to 4 part of air/CO2
■ ability to displace blood from vein + increase contact time of sclerosant to vein wall
■ potential complication of neurological event and tight chest with cough, due to migration of
microbubbles to pulmonary and cerebral circulation
● Endovenous laser ablation (EVLA)
○ Vein cannulated under USG, probe inserted 2cm below SFJ or SPJ
○ Performed under tumescent LA
(injection a volume of very diluted lignocaine and 1:200000 adrenaline)
■ Insulation of surrounding tissues from thermal injury
■ Improve contact time of catheter and vein wall by compression
■ Pain relief
○ slowly withdrwal the laser fiber to achieve thermal ablation
○ Complications
■ Bruising, phlebitis
■ Cutaneous nerve injury
■ DVT
■ Skin burns
● Radiofrequency ablation

125
 ○ Vein cannulated under USG, probe inserted 2cm below SFJ or SPJ
○ performed under tumescent LA
○ bipolar endovenous catheter generates temperature of ~100 at vein wall, causing heat damage
hence collapse of vein
○ PROS:
■ better cosmesis
■ avoid groin wound complication/ thigh hematoma
■ less pain
■ early resumption of activity
○ CONS:
■ expensive
■ limited to long saphenous vein disease
○ Complications
■ Bruising, Phlebitis
■ Cutaneous nerve injury
■ DVT
■ Skin burns

■
 
Surgical management
● Which systems to work on?
○ Depend on findings: more deep more effective but more S/E
○ Eradication of main stem saphenous reflux corrects incompetent perforating veins (IPV) in most
cases, BUT when there is coexist deep venous reflux, saphenous surgery alone fails to correct IPV
○ SEPS can reduce IPV + better ulcer healing
● Superfical system
○ Saphenofemoral ligation + stripping + stab avulsions
○ Saphenopopliteal ligation + stab avulsions
○ Stab avulsion

126
 ■ SF/SP (flush with femoral vein) ligated with all tributaries (to prevent recanalization hence
recurrence of disease!!)
■ patient's varicose vein marked pre-op while standing
■ incision made next to markings, vein pulled out by small vein hook, pull tauted and avulsed,
forceps can be passed subcutaneously to retrieve nearby veins to minimize incisions made
○ Stripping
■ SF ligated (flush with femoral vein) with all tributaries
■ stripper inserted with proximal end tied to vein, comes out from the other end (usually at
knee level), then pulled smoothly and firmly to tear off all tributaries and perforators
■ compressive bandages applied to reduce hematoma, with compressive stockings for weeks
■ Why not stripping the calf?
■ reduce damage to saphenous nerve
■ allow vein used for arterial bypass in future
● Perforator
○ Open surgical subfascial ligation (Linton procedure)
■ fading out of fashion, as it requires incision through diseased skin, and extensive
subcutaneous dissection
○ Subfasical endoscopic perforating vein surgery (SEPS)
■ gaining recognition as it reduced open perforator surgery mortality
■ small port incisions in UNAFFECTED SKIN and fascia of posterior superficial compartment
■ CO2 insufflation with endoscope inserted
○ Perforator mapping and ligation
● Deep system
○ Valvuloplasty
■ open (venotomy) or close (angioscope inserted) technique
■ cusp sutured to vein OR transfer a valved segment with end to end anastomosis
 
============================================
 
Buerger's disease
 
Acute inflammation and thrombosis of arteries and veins of the extremeties, strongly associated with tobacco
consumption.
 
Olin criteria
● Age younger than 45 years
● Current (or recent) history of tobacco use
● Presence of distal extremity ischemia (indicated by claudication, rest pain, ischemic ulcers or gangrene)
documented by noninvasive vascular testing such as ultrasound
● Exclusion of other autoimmune diseases, hypercoagulable states, and diabetes mellitus by laboratory tests.
● Exclusion of a proximal source of emboli by echocardiography and arteriography
● Consistent arteriographic findings in the clinically involved and noninvolved limbs. 
 
Clinical presentation
● pain in the affected area
● complicated by gengrene and ulceration
● need amputation and is life shortening 
 
============================================
 
Aortic dissection
 
Classification
● Debakey classification
○ Type I: Originates in ascending aorta and propagates beyond the aortic arch
○ Type II: Originates in and is confined to the ascending aorta

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 ○ Type III: Originates in descending aorta, rarely extends proximally
● Stanford classification
○ Type A = Type I and II DeBakey
○ Type B = Type III DeBakey
Pathology
● *partial thickness tearing of intima and inner media
● Ascending aortic dissection = associated with hypertension, cystic medial necrosis, Marfan's, Ehler-danlos
syndrome
● Descending aortic dissection = hypertension and atherosclerosis
● a double lumen may be produced due to re-entry of dissecting blood into the aorta
● if dissected proximally
○ aortic regurgitation (aortic root dilatation)
○ cardiac tamponade (pericardium)
○ acute myocardial infarction (coronary ostium)
○ syncope (carotid artery)
● if dissected distally
○ renal failure (renal arteries)
○ leg ischemia (femoral arteries)
○ mesenteric ischemia (intestinal arteries)
 
Clinical presentations
● Severe anterior/posterior tearing chest pain, maximal at onset
● Acute AR = dyspnea
● Tamponade = heart failure and syncope, pulsus paradoxus, pericardial rub
● Renal ischemia = anuria, hematuria
● Limb ischemia = absence of pulses, pain, weakness, unequeal BP in two arms
● Mesenteric ischemia = PR bleed, severe abdominal pain outportion of signs
 
Investigations
● ECG, cardiac enzymes (* rule out the common causes first!)
● Chest X-ray
○ widen mediastinum
○ calcium sign: calcified intimal flip seen
● Contrasted CT-scan
● Transesophageal echocardiography: also for screening secondary AR
 
Management
● NPO, IVF
● Complete bed rest
● Oxygen
● Morphine
● Close monitoring
○ BP/P +- A-line insertion
○ I/O chart
○ Complications
● iv labetalol, aim systolic BP 100-120
● Type A >> urgent cardiothoracic surgery
● Type B >> conservative medical management, unless complications (persistent pain, renal failure, limb
ischemia, mesenteric infarct)
 
Surgical management
● Median sternotomy
● Cardiopulmonary bypass

128
 ○ femoral vessels
○ IVC, SVC
○ cardioplegia
● Replacement of ascending aorta
○ clamp aortic root
○ clamp proximal to brachiocephalic trunk
○ split layers of aorta re-approximated (injecting glue into false lumen)
● Replacement of aortic valve
○ composite prosthesis (aorta + valves) OR resuspending the native valves in graft
○ coronary arteries detached from dissected native sinuses
● Deep hypothermic circulatory arrest
○ for replacement of aortic arch, and minimise neurological injury to cerbral ischemia
○ reducing temperature of outflow from CPB to 18 degree (can hold for 25min)
○ carbon dioxide needs to be added to counteract the alkalotic hypocapnic blood when cooled, it also
helps in cerebral vasodilation
○ S/E: coagulopathy, diffuse brain injury, renal compromise
○ Selective antegrade cerebral perfusion
■ second canula into arch branches to supply brain
■ burden of microemboli increaseed
■ can prolong to 40min or more
○ Retrograde cerebral perfusion
■ give blood via jugular system, but only <10% of flow reaches cerebral capillary beds to
deliver oxygen, majority shunting via dural collaterals
 
============================================
  
Abdominal aortic aneurysm
 
Definition
● Size >3cm(?2cm in female)  OR  >1.5times of normal diameter
 
Basics
● 95% infrarenal
● 10% with concomittant popliteal aneurysm
● fusiform vs saccular
● true vs pseudo
● *50% rupture survive to hospital, of which 50% die on table
 
Etiology
● Degenerative/Atherosclerotic
● Connective tissue disease  eg. Marfan's syndrome
● Traumatic
● Infective  eg. Staph Aureus, salmonella, syphilis
 
Clinical presentations
● Asymptomatic or Incidental  75%
● Painless pulsatile abdominal mass ABOVE umbilicus
● Complications
○ Rupture: pain+shock
○ Thromboembolic event
○ Obstruction (duodenal or ureteric)
○ Fistulation 
■ aortoduodenal 4th part - GIB
■ aortocaval - machinery murmur, pulsatile VV, high output heart failure, hematuria

129
 
Physical examination
● Inspection
○ Midline pulsating mass
○ Circular
○ Transverse diameter
● Palpation
○ Expansile mass
○ Get above? Infrarenal.
○ Get below umbilicus? Iliac involvement (also comment on the side).
● Auscultation
○ Bruit
On Inspection over the abdomen, there is no surgical scars, but a large pulsating mass is located at midline. On
palpation, the mass is soft, non-tender with illdefined edges. It sized around 4cm in transverse diameter. It is also
expansile with outward movement. This is an abdominal aortic aneurysm. As I can get above it, it is consistent
with an infrarenal aneurysm, and as there is no infraumbilical part, there is no iliac involvement.
Asuculation reveals a loud vascular bruit over the mass.
In summary, there is an expansile midline abdominal mass sized 4cm in diameter consistent with an infrarenal
abdominal aortic aneurysm without iliac involvement. The cardiovascular condition is stable.
I would like to finish my examination by performing a peripheral vascular and cardiovascular exam, and to listen
for bruit in other areas.
 
Risk of rupture (Classical triad = pain, mass, shock)
● Diameter of AAA
● Fast rate of expansion >0.5cm in 6 month
● Hypertension (esp Wide pulse pressure)
● Smoking
● COAD
● Family history
 
Investigation
● CXR/AXR - calcification
● USG - monitor progression of diameter
● Contrasted CT
 
Management outline = Weighing: risk of rupture  VS  risk of surgery (~5-10% for elective ones)
● Risk factor control + medical (betablocker)
● Endovascular surgery
● Open surgery
 
Indication for surgery
● Symptomatic/Complication: operate
● Size (*1% per year mortality for <5.5cm)
○ <4cm: control risk factors
○ 4-5.5cm
○ >5.5: operate
 
Pre-op
● Contrast CT for exact location and anatomy
● Cardiac reserve: ECG, echo
● Pulmonary reserve: lung function test
● Renal reserve: RFT
● Crossmatch, FFP, platelet
 
Open Surgery (WHY the graft will not block the IMA/spinal arteries?)
● Open artificial graft replacement

130
 ○ GA
○ antibiotics prophylaxis
○ division of posterior peritoneum to expose aneurysm
○ bolus of heparin
○ aortic or iliac clamps applied
○ open aneurysmal sac + thrombus removal
○ prosthetic graft anastomoses
○ limbs reperfused sequentially (beware of sudden hypotension and release of toxins)
○ sac closed
● Laparoscopic artificial graft replacement
○ Contraindications
■ previous abdominal surgery
■ bilateral diffuse iliac disease
■ extensive calcification
■ severe cardiac/pulmonary insufficiency
● Complications
○ Death >5%
○ General
■ GA
■ Bleeding
■ Infection - wound/graft
○ Specific
■ Myocardial infarction (increased afterload with aorta clamped, metabolic waste from
reperfusion)
■ Renal failure (reperfusion hypotension, cholesterol emboli, clamping of aorta for suprarenal)
■ Leg/colonic/spinal cord ischemia
■ DVT (hypercoagulable state)
■ Stroke
 
Endovascular Aneurysm Repair (EVAR) - a stent grafting operation
● First done in 1991
● Is it better than open surgery?
○ 30-day mortality <2%   vs   5% in open
(reduction in longterm aneurysm related deaths, but NOT all-cause mortality...)
○ can avoid abdominal scar and aortic crossclamping
○ longterm durability is yet to be known
● The stents
○ stainless steel or nitinol framework + impermeable fabric covering
○ proximal uncovered external barbs/hooks for suprarenal fixation to aortic wall
○ most stents are modular in design (connecting pieces)
○ usually bifurcated, or aorto-uni-iliac with femorofemoral crossover graft
● Contraindications
○ *Morphology of aneurymal neck (segment between lowest renal artery and sac)
■ short <1cm
■ conical
■ severely angulated
○ Young age (<60 years) - just because of the unknown durability
○ Significant mural thrombus
○ Severe iliac disease with extensive strictures or tortuosity
● Preop
○ Precise aortic imaging by CT, for
■ Suitability of EVAR

131
 ■ Stent sizing
● Procedure
○ LA, regional, GA
○ Surgically expose both common iliac arteries
○ Insert main body, with barbs/hooks just suprarenally, so that top of covered portion lies
immediately below renal ostia
○ iliac limbs inserted just above internal iliac ostias
○ angiography to confirm in-place and absence of leakage
● Complications
○ GA/bleeding/wound infection
○ Renal failure
■ coverage of renal artery ostia
■ constrast nephropathy
■ cholesterol embolism
○ Endoleak
■ communication between ciruclation and the aneurysmal sac
■ most common is type II (but benign)

○
○ Stent graft infection/migration
○ Post-implantation syndrome (fever + leukocytosis + ESR/CRP rise)
● Follow up
○ Annual contrasted CT - endoleaks, occlsions, enlarging aneurysmal sac
○ Annual plain radiograph - mechanical complications (fractures/migration/distortion)
 
============================================

132
Skin and Soft tissue

===============================================  
 
A word on wound closure...

Primary closure
● clean laceration or incision closed directly by sutures/tissue adhesives
● Heal in DAYS with good cosmesis
Secondary closure
● wound left open to heal by granulation+contraction+epithelization
● Heal in WEEKS/MONTHS with massive scarring
Delayed primary closure
● combination of both
● for wounds not clean enough for primary closure, left open for 5-10 days, closed by sutures when deemed
clean enough
 
===============================================  
 
SKIN LAYERS
 
lateral abdominal wall
● skin
● subcutaneous tissue and fat
● Camper's fascia
● Scarpa's fascia
● external,internal, transverse oblique
● transversalis fasciae
● preperitoneal fat
● peritoneum
 
anterior abdominal wall
● skin
● subcutaneous tissue and fat
● Camper's fascia
● Scarpa's fascia
● anterior rectus sheath
● rectus muscle
● posterior rectus sheath
● peritoneum
 
Skin ulcers
 
Examinations
● nature of ulcer
○ site, size, shape
○ pain or tenderness
○ depth, ulcer base, discharge
○ border (sloping, punchout, undermined, rolled, everted)
○ surrounding tissues (pigmentation, cellulitis)
○ lymph nodes status
● check arterial supply
○ temperature
○ loss of hair
○ capillary refill

133
 ○ peripheral pulses
○ Buerger's test
○ (ankle-brachial index)
● check venous drainage
○ varicose veins, pigmentation, lipodermatosclerosis, inverted champagne bottle
○ trendelenberg test
○ perthes test
● check sensation
 
Differential diagnosis
● COMMON: veinous, arterial, DM neuropathy, neoplastic
● UNCOMMON: infective, trauma, insect bite, topical allergy
● RARE: vasculitis, SLE/PAN/CREST, bood dyscrasis
 
===============================================  
 
The Reconstructive ladder
● Healing by secondary intention
● Primary closure
● Split thickness skin graft
● Full thickness skin graft
● Local flap (+- tissue expansion)
● Pedicled flap
● Free flap
 
===============================================  
 
BURNS
 
 
Basics
● Types: Thermal, radiation, electrical, chemical  
 
Jackson's burn model
 

      
● Zone of coagulation:
○ represents the zone of severe damage caused by primary injury, these tissue will not recover and
will slough out in due course of time.
● Zone of stasis:
○ comprises of less damaged tissue in which inflammation occurs and vascularity is impaired. Tissue in
this zone have the potential to recover under correct conditions
● Zone of hyperaemia:

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 ○ tissue with intense vasodilation and increased blood flow. In favourable conditions the margin of the
central zone remains static and the zone of stasis shrinks as it is replaced by the zone of
hyperaemia. 
 
Key management pearls:
● Primary damage (by burn itself) - little can be done to limit the injury
● Secondary damage (eg loss of fluid, infection) - Stongly influenced by management, WHAT WE AIM TO
PREVENT
 
Pre-hospital management
● Stop the burning process
○ Electrical: source switched off, removed by insulating material
○ Flame/Scald: remove or extinguish source
○ Chemical: Clothings removed ASAP
○ Copious irrigation with cool water (reduce pain, and reduce burn depth)
*Not with cold ice, it results in vasoconstriction with worsen injury and risk of hypothermia
● Primary survey
○ Airway & Breathing
■ 100% oxygen
■ tracheostomy or intubation if needed
○ Circulation
■ Vigorous fluid resuscitation if no pulse
○ Cervical spine immobilisation by neck collar
● Secondary survey
○ Other injuries
○ Burn wound
■ wrap in clean non-antimicrobial draping (not necessarily sterile) - reduce pain
■ iv morphine
○ Synthesize a concise summary for communication
■ Age, sex
■ Type, time, extent of burn
■ Associated injury
■ General status
 
A/E management
● Primary survery
○ A - Airway
■ Assess for Inhalational injury, leading to upper airway edema (usually >30min)
- Closed environment
- Perioral/oral burns, burnt nasal hair, drooling, carbon sputum, dyspnea, hoarness, stridor
■ Look for constricting neck schar
■ Tx: Intubation by senior anaesthetist
○ B - Breathing
■ Edema/Sputum plug/Collapse from smoke inhalation or chemical injury
■ Tx: Intubation (>8mm diameter for bronchoscope to pass) & Ventilation, Bronchscopy +-
endobronchial toileting with dilute bicarbonate
○ C - Circulation
■ Hypovolemia from capillary leak
● Depth of burn
○ Partial thickness (superficial, deep)  vs  Full thickness

○ ○
Color ○
Bli Cap○ ○
Sensat Recov
sters refill ion ery

135
 Superfical partial ○ Pink○ ○
+/ + ○ ○
Painful Full
-

Deep partial ○ ○
Red/ ○
+/ - ○ +/- ○ +-
Pale -

Full thickness ○ Pale○ -○ - ○ - ○ Scari

ng
○  
Descriptive ○ Anatomical ○ Degree

Very superficial ○ Epidermis only ○ First Degree

Rapid healing without scar

Superficial Partial ○ Epidermis to papillary dermis ○ Superficial

Thickness Good potential for healing second degree

Deep Partial ○ Epidermis to reticular dermis ○ Deep second

Thickness Re-epithelialization allowed degree

Full Thickness ○ Entire thickness of skin destroyed (eschar)○ Third degree

No potential for healing → contracture

Very deep ○ Deep structures destroyed e.g. muscles, ○ Fourth degree

tendons

● Area of burn
○ Palm method - closed palm (finger inclusive) of victim is around 1% of BSA
○ Wallace Rule of 9% - tend to overestimate, not for paedi
○ Lund and Browder chart - suitable esp for infant, doesnt fit the 9% rule
● Resuscitation
○ Supplementary oxygen
○ Fluid resuscitation (start for >15%BSA in adults; >10%BSA in children)
■ Parkland's Formula: 2-4ml x kg x %BSA
■ Hartmann's solution for adults
■ Hartmann's/D5 for children
■ give half in first 8 hours (*with delayed admission time subtracted), another half in
next 16 hours
■ aim U/O 0.5-1ml/kg/hour
■ Fluid maintenence:
■ 100ml/kg/24 hours for first 10kg body weight
■ 50ml/kg/24 hours for next 10kg body weight
■ 25ml/kg/24 hours for the remaining body weight
● Secondary survery
○ History
■ Cause of burn (chemical involved? Electrical injury? Type of current?)
■ Time of burn
■ Smoke inhalation
■ Associated injury
■ Other PMH and allergy
○ P/E
■ Other signs of trauma
■ Circumferencial full thickness burns
■ Inhalation burn
■ Facial injury: ectropion (lower eyelid outward) if eye lid injuried >> corneal ulceration

136
 ■ Joint flexures: warrants high priority skin grafting, due to the possible permenant movement
impairment
■ Perineum: Prone to infection
● Decompression surgery/Escharotomy
[Circumferenential burns (loss of skin plasticity) + Capillary leak + Vigorus fluid = high compartment
pressure]
○ Limb (tense skin/loss of distal pulses)) - ischemia
○ Chest (ventilatory pressure) - compromise excursion
○ Abdomen (bladder pressure) - abdominal compartment syndrome
● After stabilization
○ Keep NPO
○ Continuous fluid replacement
○ NGT insertion if nauseated, distended (decompress stressed stomach/ morphine usage)
○ Foley insertion
○ Close monitoring of Vitals, Chart I/O
○ Wound
■ Cling films (no wet gauze >> hypothermia)
■ Clean surgical drapes
○ Pain relief
○ Tetanus toxoid +- Tatanus immunoglobulins (if previous status unknown)
○ Triage
■ To specialized hospitalized burns care?
■ To Burns units?
Adult >10% BSA
Paedi >5% BSA
Special areas: face, hands, feet genitalia, perineum, major joints
Full thickness >5%
Electrical burns
Chemical burns
Inhalational injury
Circumferential burns
Extremes of age/ Comorbidity
 
Management in Burns Unit - Prevent complications
● Fluid management
○ *Interstitial fluid shifts does not occur in the burns shock phase
○ Colloid (0.5ml/kg/BSA 5% albumin) starts in 2nd 24hours
● Nutritional support
○ *Important for wound healing and resistant to infection
○ BEE x 1.5-1.75
○ Enteral nutrition preserves gut function and lower the risk of bacterial translocation
● Poisoning management
○ Carbon monoxide
■ check serum carboxyhemoglobin (x200 affinity to O2)
■ Tx: high flow O2 via non-rebreathing mask
○ Hydrogen cyanide
■ combustion of nitrogenous material
■ headache, vomiting, convulsion, coma, high anion gap acidosis
● Daily dressing + regular swabs
● Continuous monitoring
○ BP/P
○ Temperature (prone to hypothermia by fluid resus, also loss of regulation)
○ SaO2
○ CVP

137
 ○ PCWP
○ ECG
● Intermittent monitoring
○ Hemoglobin & Hematocrit
○ Renal function
○ Electrolytes
○ Coagulation
○ CXR
● Surgical skin grafting
○ Primary vs secondary
○ Auto, allo, iso, xeno
○ Full-thickness vs Split thickness

Full thickness ○ Split thickness

- Epidermis + entire dermis ○ - Epidermis + variable amount

of dermis

- more durable

- more cosmetically acceptable

- less contraction

- less dry as sweat gland present

○ - Less likely to fail (good passive

supply)

- Donor site cannot regenerate, need primary closure (so ○ - Donor site can regenerate,
sites limited: neck, behind ears) or split thickness graft theoretically indefinite graft available

- for face, hands ○ - for others

○ For split thickness grafts: Meshing/ fenestrated (by knife) may be needed to increase surface area +
allow exudates to escape + better conformation; but unsighty
 
Dressings
● *Flammacerum - silver sulfadiazine + cerium nitrate; deep partial thickness burn, will form a silver eschar
● *Duoderm - for very superfical burns only
● *Jelonet - paraffin coated; 1 layer + heptadine gauze + dry gauze
● Grassolind - paraffin coated; 1 layer + heptadine gauze + dry gauze
● Bactrigras - paraffin/chlorhexidine coated; tulle
● *Allevyn Ag - silver containing; bactericidal, monitor RFT
● Aquacel Ag -  silver containing; bactericidal, monitor RFT
● Seasorb Ag - silver + calcium alginate containing; bactericidal, monitor RFT
● Algisite M - calcium alginate containing; absorb exudates; CaNa exchange to Na alginate to stop bleeding
● Fucidin Intertulle - Antipseudomonal, not too long, need regular wound swab
● *Iruxol mono - clostriopeptidase and protease; for debriding wounds and enhance sloughing
● Maxogel - hydrogel dressing, make sure patient has passed exudative phase
● Omniderm - very thin for superfical face burn in paedi
 
Scar management
● Scar massage with emollient
● Pressure garments
● Silicone gel
● Surgical reconstruction
● Psychological counselling

138
  
===============================================
 
Basal cell carcinoma
 
Basics
● Most common skin cancer in whites
● M:F = 2:1
● from pluipotent epidermal stem cells (NOT BASAL CELLS!)
● 90% occurs in a line joining angle of mouth to the external auditory meatus
● 80% BCC in Chinese population is pigmented
● Low metastatic potential, but can be locally invasive
● Gorlin's syndrome
○ autosomal dominant genetic disease
○ multiple BCC + mandible cysts + skeletal abnormalities
 
Risk factors
● Ultraviolet light, ionizing radiation
● Arsenic
● Immunosuppression
● Xerdoderma pigmentosum
 
Clinical presentations
● Nodular 60%
- Flesh colored papule
- Pearly translucent telangiectic
- "Rodent Ulcers" with rolled edges
 
● Superfical 30%
- more on trunk
- slightly scaly papule or plaque that is red color
- may be rimmed by fine translucent micropapules
 
● Morpheaform 10%
- atrophic, smooth, very lightly erythematous papule
- AGGRESSIVE FORM of BCC

 
Investigations
● Incisional or punch biopsy may be needed for large lesions
 
What suggests high risk tumor?
● Histological
○ Morpheaform, sclerosing, infiltrative, micronodular
○ Perineural invasion
○ Basosquamous features
● Clinical
○ Central faces, eyelid, eyebrow, lips
○ Indistinct margin
○ Size>10mm
○ Recurrent lesion
○ Previous radiation site
 
Treatment
● Low risk tumors
○ Topical chemotherapy (5-FU, Imiquimod - an immune response modulator, enhance cytokine
release)

139
 ○ Electrodessication, Currettage
○ Cryotherapy
○ Photodynamic therapy (laser + photoactivated chemical)
● High risk tumors
○ Excision  [adequate margin (2-5mm depend on distinctness) followed by intraoperative frozen
sections]
○ Mohs micrographic surgery (cosmetically sensitive area/ complex lesions for better tumor clearance)
○Radiation (poor surgical candidate)
 
===============================================
 
Squamous cell carcinoma
 
Basics
● Bowen’s disease = SCC in situ
● Marjolin’s ulcer = SCC in sites of chronic inflammation (esp burn scar)
● DDX: Keratoacanthoma - a fast growing lesion that usually involutes in months
 
Risk factor
● Ultraviolet light, ionising radiation
● Chronic inflammation/wounds
● Immunosuppression
● HPV16 transformation
 
Clinical presentations
● Ulcerating nodular lesion with everted edge/ red scaly thickened patches
 

Treatment
● Low risk tumors
○ Topical chemotherapy (5-FU, Imiquimod - an immune response modulator, enhance cytokine
release)
○ Electrodessication, Currettage
○ Cryotherapy
○ Photodynamic therapy (laser + photoactivated chemical)
● High risk tumors
○ Excision  [adequate margin (2-5mm depend on distinctness) followed by intraoperative frozen
sections]
○ Mohs micrographic surgery (cosmetically sensitive area/ complex lesions for better tumor clearance)
○ Radiation (poor surgical candidate)
 
===============================================
 
Melanoma
 
Risk factors:
● male
● blistering sunburns, UV light exposure
●white patients with blonde or red hair, green or blue eyes
 
Common sites
● Skin, eye, anus
● male tends to develop on trunk (back), female on extremities (legs)
● mucosa of vulva or vagina, anorectum, esophagus, choroids
 
S/S

140
 ● Asymmetry
● Border irregularity
● Color variation
● Diameter >6mm + Dark
● Elevation
 
Types
● Superficial spreading  70%e
● Lentigo maligna 10%
○ most benign
○ Hutchinson’s freckle: melanoma in radial growth phase without vertical invasion
● Acral lentiginous
○ common in Asians
● Nodular
● Amelanotic
 
Clark's classification
      I – epidermis
      II- papillary dermis
      III- intersection of papillary and reticular dermis
      IV- reticular dermis
      V- subcutaneous fat
 
Breslow classification
      <0.76mm thickness – more than 90% cure
      >4mm thickness – 80% risk of local recurrence or metastasis in 5 years 
 
===============================================
 
Keloid scar***
 

Onset Natural history Extent Microscopic

Keloid can be progress beyond limits of Disorganised bundles of large irregular
delayed, original wound collagen fibers with reduced crosslinking
months
after
surgery
Hypertrophic Soon after Regress stays within Wavy loose collagen bundles
scar injury spontaneously limits
 
Basics
● Distribution:earlobes, neck, chest, chin
● Patient factor: more in Black, Hispanic people
● Surgery factor: tension, midline incision
● Disease factor: trauma, burns, infections
 
Clinical presentations
● Unsighty scar
● Itch
● Prone to infection
 
Treatment
● Non surgical
○ Mechanical pressure therapy day and night for a whole year
○ Topical Silicone gel sheets
○ Steroids (intralesional/topical)

141
 ○ ?IFN, 5FU, bleomycin
● surgical
○ revision of scar with closure by direct suturing, local Z-plasty or skin grafting
○ Excision (surgery/CO2 laser, cyrosurgery)
○
Radiotherapy
 
===============================================

 
Lipoma***
 
On inspection there is a prominent mass over the dorsal forearm, there is no overlying skin changes or surgical
scars.
On palpation the mass is soft, non-tender, hemispherical, sized around 3cm in diameter. It has a lobulated surface
and ill-defined border, but does not tether to overlying skin or muscles underneath. It has normal temperature and
is non-pulsatile.
It is a lipoma, and I would like to ask if the patient has notices other similar lesions.
 
● Soft: fat in semi-fluid state in body temperature
● Lobulated: fat cell hyperplasia and hypertrophy in the presence of Cooper’s ligament
● lll defined border: lipomas originate from surrounding similar tissues
● Dercum's disease
○ multiple painful lipomata over body
○ usually in obese postmenopausal women
○ associated with significant fatique and obesity (proposed to be the RESULT of the disease!)
 
===============================================
 
Ganglion***
● degenerative lesion of the synovial membrane, pouching out and contains fluid
● typically at dorsum of hand
● Local excision with GA recommended, surgery needs tourniquet to slow down bleeding, and close excision
to bone needed thus stability is important
● Classical treatment is by direct strong hit 
 
===============================================
 
Pharyngeal pouch *
Definition
 Herniation of pharyngeal mucosa at Killian’s dehiscence

Presentation
 Symptom free period followed by dysphagia and hoarseness
 Weight loss
 Halitosis due to regurgitated food
 Most common in elderly
 A cystic swelling at posterial triangle of the neck
 A squelching sound due to free fluid in the pouch

Complication
 Aspiration pneumonia
Ix
 Ba swallow, usually diagnostic
 Rigid endoscopy if CA suspected
Tx
 Nonsurgical: Dohlman’s procedure/ endoscopic stapling
 Surgical: diverticulopexy/ diverticulectomy

142
Inguinal hernia
 
DDx of groin mass
● inguinal/femoral hernia
● enlarged lymph nodes (Cloquet's node - the most superior inguinal node)
● saphena varix
● femoral artery aneurysm
● psoas abscess
● undescended testis
● lipoma/hydrocele of cord

 
Definition
● Hernia is the protrusion of an organ or part of an organ through the wall of cavity that normally contains it
 
Etiology
● Defect in the Myopectineal orifice
○ only laid with a layer of transversalis fascia
○ Boundaries
■ superior = conjoint ligament
■ infereior = cooper's ligament
■ lateral = iliopsoas
■ medial = rectus
○ Indirect inguinal - deep inguinal ring (sometimes with patent processus vaginalis)
○ Direct inguinal - traversalis fascia at Hasselbach's triangle (inferior epigastric vessels, rectus,
inguinal ligament)
○ Femoral - the femoral canal
● increase in intraabdominal pressure
6. chronic cough
7. constipation
8. urinary obstruction

143
 9. pregnancy
10. ascites
 
Anatomy of inguinal canal:
● Anatomy
○ 4cm long canal from internal inguinal ring to external inguinal ring
○ Anterior = external oblique aponeurosis
○ Posterior = conjoint tendon (aponeurosis internal oblique and transversus abdominis fused)
○ Superior = fibers of internal oblique and transversus abdominis muscle
○ Inferior = inguinal ligament
● Contents
○ Spermatic cord/ Round ligament
○ Ilioinguinal nerve
○ Blood and lymphatics
 
Clinical presentation
● bulging mass in groin area, worsen by prolonged standing
● if incarcerated: intestinal obstruction
● if strangulated: severe sudden onset of pain, gangrene and perforation
 

indirect inguinal hernia  direct inguinal hernia

lateral to inferior epigastric vessels medial to inferior epigastric vessels
congenital or acquired acquired
may extend down to scrotum not extend down to scrotum
commonly strangulate rarely strangulate
oblique pathway of reduction straight pathway of reduction
 
Examination
● Is it a hernia?
○ stand and inspect for visible mass
○ inspect for cough impulse (cough)
○ feel for cough impulse (cough)
○ palpate SCROTUM - demostrate cannot get above the mass + presence of testes
● Is it reducible?
○ ask patient to lie on bed, reduce it
● Is it a inguinal or femoral hernia?
○ find pubic tubercle and cough to see relation (cough)
■ medial and above = inguinal
■ lateral and below = femoral
● Is it a direct or indirect hernia?
○ press on mid-point-of-inguinal-ligament
○ control the hernia (cough)
● complete the examination by
○ examining the other side
○ abdominal exam for ascites and masses
○ chest for COPD
○ PR examination for BPH
● This patient has a right-sided inguinoscrotal/inguinal/scrotal mass, there is no overlying surgical scars or
associated skin changes, a cough impulse is visible. On palpation the mass is soft and non-tender, and i
cannot get above it, a cough impulse is palpable. Both testes are present and they can be separated from
the mass. This is a hernia.

144
 Upon lying on bed, the hernia is reducible upon manual manipulation.
As it locates medial and above the pubic tubercle, and it can be controlled by the deep ring compression
test, it is an indirect inguinal hernia.
In summary this patient has a first episode of right sided reducible indirect inguinal hernia.
 
Indications for surgery
● Symptomatic: dragging, pain, discomfort
● Complication: IO, incarceration, strangulation

Incarcerated hernia: by definition, a chronically irreducible hernia which is not strangulated.

**this term easily mixed up with acutely irreducible hernia. In patients as emergencies at AED, it is safer to
assume such a hernia is strangulated until proven otherwise. Some patients give episodes of hernia temporarily
irreducible, occasionally IO symptoms/local painurgent operation within 4 hrs
 
Management
● Conservative watchful waiting +- Abdominal truss - only for asymptomatic hernia!
● (Open suture repair, no longer used, due to high recurrence compared with mesh repair)
● Open herniorrhaphy - tension-free Lichtenstein repair
○ external oblique aponeurosis opened in direction of fibers to form two leaves (avoid damaging
ilioinguinal nerve)
○ upper leaf cleared from underlying internal oblique to identify iliohypogastric nerve
○ spermatic cord gently freed
○ hernia reduced
○ mesh (polypropylene) placed
■ first nonabsorbable suture above and medial to pubic tubercle
■ lower mesh continuous sutures to inguinal ligament
■ upper mesh sutured to internal oblique musle with loose absorbable sutures
● Laproscopic herniorrhaphy
○ Types
■ Transabdominal preperitoneal (TAPP) approach
http://www.youtube.com/watch?v=ClCc2QL33vs&feature=related
■ enter abdominal cavity
■ hernia reduced, neck of hernia sac excised allowing entry to preperitoneal plane
■ a pocket created for mesh insertion, mesh stapled or sutured in place
■ created peritoneal defect closed meticulously to avoid internal herniation with small
bowel obstuction
■ Totally extraperitoneal (TEP) approach
■ insufflation +- balloon dilatation device, repair and mesh placement done in
preperitoneal plane without entering abdominal cavity
■ technically demanding
■ prevent adhesion formation/ ileus/ internal hernia
■ if failed >> converted to TAPP
○ Advantages
■ faster recovery time
■ less pain
■ can inspect and reinforce femoral ring
■ good for bilateral or recurrent hernias
○ Disadvantages
■ need general anaesthesia
■ technically more demanding
■ longer operation time
■ expensive
■ specific complications (see below)
● Complication of open surgery

145
 ○ Wound problem (infection, hematoma, seroma [Conservative obs for 2 weeks +- percutaneous
drainage)
○ Nerve damage
■ ilioinguinal = medial thigh and groin
■ femoral branch of genitofemoral = middle upper thigh
■ lateral cutaneous nerve of thigh = entire lateral thigh
○ Scrotal problem (scrotal edema, ischemic orchitis/testicular atrophy due to venous congestion)
○ Chronic pain (adductor strain, osteitis pubis, neuralgia)
■ Avoid by prophylactic neurectomy + laparoscopic hernioplasty
■ Tx: analgesics, surgery for neurectomy and mesh removal
○ Foreign body sensation
○ Mesh-related: shrinkage, fistula, migration, infection
○ Recurrence 1% (usually medial)
● Complication of laproscopic surgery
○ ALL THE ABOVE
○ General anaesthesia risk
○ * bowel, bladder, vascular injury from pneumoperitoneum (only in TAPP!)
○ * internal herniation in peritoneal defect, with small bowel obstruction (only ln TAPP!)
○ * formation of intraabdominal adhesions (only in TAPP!)
 
Other interesting hernias:

● Pantaloon's hernia = a combined direct and indirect hernia

● Sliding heria = retroperitoneal organs (colon) slides down posterior abdominal wall and herniates directly
OUTSIDE peritoneal sac
● Littre's hernia = hernia sac involves the Merkel's diverticulum
● Richter's hernia = hernia involving antimesenteric border of bowel, late diagnosis of ischemia/infarct
● Maydl's hernia = 2 loops of bowel within sac
● Amyand's hernia = hernia containing ruptured appendix
● Cooper's hernia = a femoral hernia with two sacs, the first being in the femoral canal, and the second
passing through a defect in the superficial fascia and appearing immediately beneath the skin, may
protrude into scrotum or labia majora
● Spigelian hernia = herniation through fascial defect in linea semilunaris at lateral rectus border
● Epigastric hernia = herniation through defect in linea alba, 4x in male
● Umbilical hernia = common in children
● Paraumbilical hernia = with a crease visble either above or below hernia
● Sciatic hernia = rarest, suprapyramidal/ subpyramidal hernia
● Diastasis Recti = widened band of noncontractile fascia ot tendon between rectus, not a hernia!
 
===============================================
 
Femoral hernia
 
Anatomy of femoral canal (2cm in length)
● anterior - inguinal ligament
● posterior - pectineal ligament
● medial - lacunar part of inguinal ligament
● lateral - femoral vein
● contains a plug of fat and lymph node (node of Cloquet)
 
Clinical presentation
● globular swelling below and lateral to pubic tubercle
● as it enlarges, it may protrude out from the saphenous opening in deep fascia, turns upwards and project
above the inguinal ligament (mimic inguinal hernia)

146
 ● 20% chance of strangulation!!
 
Surgical management
● Lockwood (low approach)
○ elective under LA
○ skin crease incision
○ dissection of sac to femoral ring >> reduction or excision
○ suture or mesh plug repair
● McEvedy (high approach)
○ Emergency under GA
 
===============================================
 
Parotid mass
 
● physical examination
○ mass exam
○ bimanual palpation
○ inspect the parotid duct opening
○ contract messeter and SCM for deep attachment
○ regional lymphnodes
○ facial nerves
● differential diagnoses
○ lymph nodes - but usually mulitple, not palpated manually
○ carotid body tumor
○
masseter or SCM tumor
 
===============================================

147
Cardiothoracic Surgery

============================================

Prosthetic valvular replacement

Basics
● Size
○ 19-29mm for aortic
○ 25-33mm for mitral
● An ideal valve
○ Long term durability
○ Good hemodynamics (low tranvalvular gradient)
○ Not thrombogenic
○ Not infective
○ Easy to implant

Types
● Mechanical
○ Caged-ball
■ Starr-Edwards caged-ball valve first commercially available valve
■ very durable with minimal mechanical failure
■ suboptimal hemodynamics
■ used in third world countries only, cheap.
○  Tilting-disc single leaflet
■ Bjork-Shiley convexo-concave disc valve with documented strut failure, withdrawn.
■ Medtronic Hall tilting dic valve is still used currently
○  Bileaflet
■ most frequently used valve
■ made of tungsen-impregnated graphite, mounted to a sewing cuff maded of Dacron
● Biological
○ Stented
■ harvested porcine aortic valves OR made of porcine pericardium
■ mounted to a sewing cuff to support the valve structurally
○ Stentless
■ aortic replacement
■ autograft vs homograft vs heterograft
■ increase effective orifice area, closest hemodynamic profile to native valves, slower
degeration compared to stented counterparts

How to choose? *need to be individualized, balancing the risk-benefit ratio in various choices
● Patient factor
○ Old age - bioprosthesis
○ Contraindicated to anticoagulation - bioprosthesis
○ Childbearing age
■ *bioprosthesis: subject to accelerated structural deterioration
■ mechanical: teratogenicity of warfarin (need hospitalization for heparin), risk of hemorrhage
leading to miscarriage or antenatal hemorrhage, hypercoagulable state with thrombotic risk
○ Renal disease
■ accelerated calcification in ?bioprosthesis
■ risk of anticoagulation
● Prosthesis factor
● Environmental factor

148
Indications
● Aortic stenosis
○ Symptoms (angina, syncope, failure)
○ EF <50%
○ Gradient >50mmHg
○ Other need for open heart surgery
● Aortic regurgitation
○ Symptoms (reduced ET, failure)
○ EF <50%
○ Dilated LV (ES>55mm, ED>75mm)
○ Other need for open heart surgery
● Mitral stenosis
○ Percutaneous Mitral Balloon Valvotomy
■ MVA<1.5cm2 + PA pressure >50mmHg
■ exclude left atrial clot
■ exclude severe MR
○ Valvular replacement
■ Symptomatic not for PMBV
● Mitral regurgitation
○ Symptoms
○ EF <60%
○ Dilated LV (ES>40mm)
 
Procedure
● GA + ventilation
● Aseptic field
● Median sternotomy
● Heparin 300IU/kg (aim activated clotting time >480s)
● Incise pericardium
● Insert aortic canula
● Insert IVC/SVC canula
● Insert cardioplegic canula
● Aortic crossclamp
● Cardioplegia
● Aortic incision
● Valve replacement (mitral >> aortic)
● Close aortic incision
● Wean off pump
○ Reduce IVC/SVC cannula output + ventilate
○ Release gas from cardioplegic cannula
○ Confirm no gas by TEE
○ Release crossclamp
○ Further reduce IVC/SVC ouput + Slowdown pump to aorta
● Temporary pacing wire attached
● Mediastinal drain +- chest drain inserted
● Protamine
● FFP/platelet
● Wound closed

Post-op management
● Pain relief
● Chest physio + triflow

149
 ● Monitor ECG, CXR, drain output +- echocardiogram
 
Short term complications
● General
○ GA
○ Bleeding
○ Infection (surgical site, mediatinitis, chest, UTI)
● Bypass
○ Systemic inflammatory response
○ Capillary leak syndrome
○ Postperfusion syndrome (pumphead)
○ Hemolysis
○ Consumptive coagulopathy
○ Hemodilution
○ Electrolytes (K, Mg) and ABG derrangement
● Specific
○ Arrhythmia
○ Pericardial effusion
 
Long term Complications
6. Thromboembolism
○ Mechanical valve
■ 1-2% per year
■ more common in MVR
■ need anticoagulation aiming INR 2.5-3.5
○ Bioprosthesis - rare
7. Bleeding
○ associated with anticoagulation, 1-2% per year
8. Structural deterioration
○ Mechanical valve - extremely rare
○ Bioprosthesis
■ younger the time of implantation (?imposing more hemodynamic stress)
■ starts earlier and deteriorates quicker in MVR (5yr cf 8yr in AVR)
9. Prosthetic valve endocarditis
○ rare 0.5% per year, but high mortality 20-50%
○ Antibiotic prophylaxis in perioperative period and invasive procedures
○ often need re-operation if failed antibiotic treatment
10. Paravalvular leak & hemolysis
○ from endocarditis or from technical error in implantation
○ mechanical hemolysis
============================================
 
Coronary artery bypass grafting
 
Basic
● both symptomatic and prognostic value
● Benefit dated back to THREE key trials (VA, ECSS, CASS) comparig with medical therapy done in 1970s:
high risk patients benefits more from CABG
 
Indications
● Angina failed medical treatment
● High risk anatomy
○ left main stem disease >50%

150
 ○ triple vessel disease + poor LV function
○ proximal high grade LAD stenosis
● Early after MI/IHD (usually as elective case after post-MI because of lower surgical risk, rarely as primary
reperfusion strategy, but EARLY in following cases)
○ Complication of PCI
○ Severe persistent symptoms
○ Mechanical complications
○ Cardiogenic shock
○ Life threatening ventricular arrhythmias
 
Pre-op preparation
● Assess operative risk
○ CXR, ECG
○ CBC, RFT, LFT, clotting, *Cold agglutinin
○ Lung function test
○ HbsAg
○ EuroSCORE
■ use 18 identifiable risk factors
■ Standard score: bedside use
■ Logistic score: more accurate calculation
● Prepare operation
○ Crossmatch
○ Platelet, FFP x6
○ Withhold aspirin/warfarin
○ Consent + Education booklet
● Reduce post-op complication
○ Pre-op chest physio + smoking cessation
○ MRSA screen (nasal and groin [for retrograde blood in aortic dissection surgery] swab)
Intranasal mupirocin ointment tds for 5 days
○ DKI drip for DM
○ Shaving (chest, groin +- arm/leg)
Shower x3
○ Antibiotic prophylaxis
 
Procedure
● GA + ventilation
● Aseptic field
● Median sternotomy
● Harvest conduits
○ long saphenous vein
○ IMA to down to level of xiphoid process
● Heparin 300IU/kg (aim activated clotting time >480s)
● Incise pericardium
● Insert aortic canula
● Insert IVC/SVC canula
● Insert cardioplegic canula
● Aortic crossclamp
● Cardioplegia
● Distal coronary anastomosis + crossclamp release
● Proximal coronary anastomosis
● Wean off pump
○ Reduce IVC/SVC cannula output + ventilate

151
 ○ Release gas from cardioplegic cannula
○ Confirm no gas by TEE
○ Release crossclamp
○ Further reduce IVC/SVC ouput + Slowdown pump to aorta
● (Temporary pacing wire attached)
● Mediastinal drain +- chest drain inserted
● Protamine
● FFP/platelet
● Wound closed
 
Choice of conduit
● Saphenous vein
○ long length available for many grafts, easy to harvest and use
○ only 50% 10yr patency rate due to attrition with graft atherosclerosis
● Internal mammary artery
○ usually LIMA, graft for LAD
○ good with 95% 10yr patency as it is a pedicled graft
● Radial artery
○ usually used for younger age, less optimal if used in female/DM
○ initial result disappointing as many develop graft failure due to diffuse stenosis (string sign), now
best if used in >80% stenosis (reduce failure from competitive flow)
○ Allen's test +- radial artery USG to confirm flow and adequate ulnar supply
● Gastroepiploic artery
● Inferior epigastric artery
 
Cardiopulmonary bypass
● Aim: create a bloodless surgical field
● Component
○ Connecting tubings (silicone or PVC)
○ Vacular cannulae
■ IVC/SVC/RA out
■ aortic root in
■ cardioplegic canula
○ Venous oxygen sensor
○ Resouvir with gas release
○ Pump (where flow determines the cardiac output)
■ usually kept mean pressue ~55-60mmHg, only aim to keep organs alive
■ too much flow will damage blood products
○ Heat exchanger
■ 36C for CABG
■ 32C for valve
■ 18C for aorta
○ Oxygenator
○ Gas detector (up to 0.003mm bubble)
● Complications
○ Systemic inflammatory response
○ Capillary leak syndrome
○ Postperfusion syndrome (pumphead)
○ Hemolysis
○ Consumptive coagulopathy
○ Hemodilution
○ Electrolytes (K, Mg) and ABG derrangement

152
 
Cardioplegia
● Aim: create a still surgical field + reduce myocyte oxygen demand (hold for 30min)
● Procedure
○ Cardioplegic cannulae
- Anterograde: aortic root proximal to cross clamped aorta (*if for AR: need direct canulation to
ostium!)
- Retrograde: coronary sinus (difficult to locate, need to limit flow to avoid rupture)
○ Cardioplegic solution (Cold vs warm , crystalloid vs blood)
■ Cold
- 4C for valvular surgery, at least 70min for single valve
- better cardioprotection
■ Warm
- for CABG, usually 40-55min
- quicker recovery from cardioplegia, less arrhymias
■ St. Thomas solution (20ml with 1000ml Ringer's lactate)
- Ca2+ = 1.2mmol/l low to maintain membrane integrity, but minimize calcium parodox in
reperfusion
- Mg2+ = 16mmol/l stabilize myocardial membrane
- K+ = 16mmol/l immediate cardiac arrest to preserve ATP
- HCO3- = 10mmol/l slight alkanity neutralize ischemic acidosis
- Procaine 16mmol/l = cardioprotection
- Overall hyperosmolarity for preventing ischemic edema
■ Blood
- 200ml Ringer's lactate (20mmol K+) + 800ml Blood (4mmol K+)
- theoretically reduce ischemic damage with natural buffer and oxygen supply
Complications
● General
○ GA
○ Bleeding - consumption + anticoagulation! (need exploration if severe: >400,300,200,100ml in
1,2,3,4h)
○ Infection (Wound/chest/urinary tract)
● Bypass
○ Systemic inflammatory response
○ Capillary leak syndrome
○ Postperfusion syndrome (pumphead)
○ Hemolysis
○ Consumptive coagulopathy
○ hemodilution
○ Electrolytes (K, Mg) and ABG derrangement
● Operation Specific
○ Myocardial infarction 2%
○ Stroke 2% (4% if previous stroke)
■ Postperfusion syndrome (pumphead): neurological deficit from debris or gasbubbles released
into brain from CPB
■ ICH from heparinization
■ Calcific plaque dislodgement
○ Renal failure (1% dialysis risk)
○ Atrial fibrillation 30%
■ old age
■ poor myocardial protection in cardioplegia
■ hypoK, hypoMg, acidosis
■ hypoxia
○ Graft failure
■ Early = poor surgical handling, thrombosis (*Better conduit handling + high dose aspirin
within 6h to 1yr post-op)

153
 ■ Late = intimal hyperplasia and atherosclerosis (*Cardiovascular risk factors control)
 
Offpump Coronary Artery Bypass (OPCAB)
● No CPB, No cardioplegia
● Additional aids
○ Mechanical stabilizer + Suction stabiliser
○ Intracoronary shunt (maintain coronary perfusion)
○ Blower (mist of NS and air blowed to help visualize anatomical sites)
● Who might benefit?
○ >70yr, reoperation
○ poor LV function
○ PVD, CVD, CRF, COPD, liver dysfunction, bleeding tendency, calcified aorta
 
Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)
● No CPB, No cardioplegia, No sternotomy
● assess through anterior mini-thoracotomy at 4th/5th intercostal space
● for single LIMA to LAD graft
  
============================================
 
Intraaortic ballon pump
 
Basics
● Set up
○ Balloon catheter (34cm3, 40cm3) with helium inside with low density which allow rapid flation
○ Drive console (ECG sensing - deflate in Q-peak, inflate in T-peak/ Pressure sensing)
○ Frequency of augmentation (change when tachyarrhymias, weaning patient from IABP)
● Mechanisms
○ Diastolic counterpulsation
■ Inflate in diastole: augment diastolic pressure >> improve coronary blood flow
■ Deflate in systole: reduce forward flow impedence >> reduce myocardial oxygen demand
 
Insertion
● Seldinger technique via femoral artery
● Tip of balloon just distal to left subclavian artery
○ Too advance will impede cerebral blood flow
○ Too inferior will impede renal or mesenteric blood flow
 
Indications
● Prophylactic for high risk patients undergoing PCI
● Cardiogenic shock from AMI
● Mechanical complications from AMI
● Weaning patients from CPB
● Bridge to heart transplant
 
Contraindications
● Aortic dissection/ Aortic aneurysm
● Aortic regurgitation (acute left ventricular dilatation)
● Severe peripheral vascular disease
 
Complications
● Wound site bleeding or infection
● Aortic dissection
● Limb ischemia (we need to check pulse daily!)
● Renal or mesenteric artery ischemia

154
 ● Thromboembolic shower (usually start heparin if IABP in situ for >2 days)i
● Balloon rupture/entrapment
 
============================================
 
Pneumothorax
 
Classification
● Spontanous
○ Primary (young men with ruptured congenital apical blebs)
○ Secondary (COPD, cancer, infection, Marfan)
*Smoking is a major risk factor x10 for pnuemothoraces: elastase with bled formation + obstruction
with high intraalveolar pressure
● Traumatic
● Iatrogenic
 
Estimating volume of pneumothorax
● 1 - (Average lung diameter^3 / Average hemithorax diameter^3)
 
Management (ALL given oxygen supplement)
● Conservative monitoring (<1cm) - Resoprtion rate = 1.5% of hemithorax per day
● Percutaneous needle aspiration (1-2cm)
● Chest drainage
○ Indications
■ significant lung collapse >20% (>2cm)
■ increasing in size
■ secondary pneumothorax (except those non-breathless + <1cm)
● Pleurodesis
 
Management of tension pneumothorax
● Large bore needle (at least 19G) at 2nd intercostal space mid clavicular line at side of lesion
● Insert chest drain after patient become stable
 
============================================
 
Chest drain
 
Three bottle system
● Collection bottle
○ allow precise output assessment
○ avoid contaminating the system
● Underwaterseal (2cm water)
○ as a one way valve to avoid backleak
○ the depth of tube inserted into water (~2cmH2O) determine the minimum intrapleural pressure
needed for successful drainage
○ look for absence of swinging when off suction (tell by clinical status)
■ lung fully expanded
■ blockage
○ look for air leak (tell by clamping)
■ still air inside lung to be drained
■ system leakage
○
○
Swinging

○ ○ indicates drainage from not-yet reexpanded lungs (greater the swing and bubbling,

155
YES greater the extent of collapsed lung)

○ ○ indicates either:
NO - resolution of pneumothorax with lung reexpansion
- tube obstruction

○ ○ indicates system airleak

NO

○
YES
●  Suction control
○ limit suction force, depth of tube inserted into water control the maximum suction force applied
○ should always bubble if suction is on
○ amount of suction can only be determined when suction is off
 
*Two bottle system - Collection bottle + Underwater seal
*One bottle system - Underwater seal
 
Indications
● Pneumothorax
○ Primary - >2cm
○ Secondary - all, except those non-breathless+<1cm pneumothorax
● Pleural effusion, hemothorax, empyema
● Post-thoracic surgery
 
Procedure
● Connect to SaO2 monitor
● Choose chest drain size (24F pneumo, 36F thick empyema)
● IM pethidine 50mg
● Lateral position affected side up, hand on top of head
● Aseptic field
● LA infiltrate to skin, periosteum, pleura
● Needle aspiration to confirm air/fluid present before inserting drain
● 2cm incision above and parallel to upper rib border at Safety Triangle (4th/5th intercostal space, anterior
and mid axillary line)
● Blunt dissection through muscles and pleura
● Insert drain, apical for gas and basal for fluid
● Connect to underwater seal
(*to Heimlich flutter valve if outpatient management or transfer is needed)
● Anchoring suture
● Confirm drain position with CXR
 
Complications
● Bleeding
● Infection (incision site, pleural space)
● Subcutaneous emphysema
● Injury to long thoracic and thoracodorsal nerve, diaphragm, spleen, liver
● Re-expansion pulmonary edema
 
Post-procedural management
● Pain relief
● Vigourous chest physiotherapy, Triflow
● Monitor SaO2
● Chest drain
○ chart output (if >2L output, clamp)

156
 ○ notice airleak and swinging
● CXR daily for improvement and in situ
 
Chestdrain removal
● Aseptic field
● Off suction
● Release anchoring stitch
● Inhale as deep as possible, exhale with mouth (pull drain out as quick as possible)
● Compress wound firmly
● Close wound with stitches
● Confirm CXR that no pneumonthorax reaccumulated
 
This patient has a chest drain in situ, examine
● General status (dyspnea, tachypnea)
● Location (safety triangle) - thoracodorsal, long thoracic
● Complication
○ infection
○ subcutaneous emphysema
○ securing suture tight enough
● Tube patency
● Collection bottle
○ content
○ volume
○ active drainage
● Underwateral seal
○ Swinging
○ Bubbling
○ Air Leakmeter
● Suction control
○ suction force
 
============================================ 
 
Pleurodesis
 
Indications
● Pneumothorax
○ Recurrent pneumothorax
○ Bilateral pneumothorax
○ Tension pneumothorax
○ Persistent airleak
○ Hemothorax
○ Special occupation
● Pleural effusion
○ Recurrent symptomatic malignant pleural effusions
○ Chylothorax not resolving on conservative management
● Post-operative
○ after pericardial window surgery for malignant pericardial effusion (it will not block the pericardial
window: patient should have died, it may help to seal the pericardium as well!)
○ prophylactically on discovery of pleural metastasis
○ post-op persistent air leak
 
Chemical pleurodesis
● Indications (*lower success rate compared with mechanical pleurodesis)

157
 ○ Malignant pleural effusions
○ Patients unfit for surgery
● Choices
○ Talc (Magnesium silicate hydroxide)
○ Tetracycline, bleomycin
○ Silver nitrate
○ Blood
● Procedures
○ Chest drain inserted to ensure full lung expansion
○ Give sclerosing agents, hold in several positions
○ LA also given for pain relief
● Complications
○ Pain
○ Fever
○ Empyema
○ 1% ARDS, acute pneumonitis (esp in low GC elderly)
○ Long term: restrictive lung disease from ?pulmonary calcification
 
Mechanical pleurodesis
● Procedure
○ GA
○ Set up port sites
○ Bleb identified, stapled and resected (typically at apex of each lobes)
○ Mechanical abrasion to induce inflammation to parietal pleura
○ Chest drain inserted with suction
● Complications
○ Pain
○ Bleeding
○ Infection (surgical site, pleural space)
○ Recurrence 3%
○ Hinder further thoracic operations
● Post-op management
○ Pain relief (*no NSAIDs: we are aiming for inflammation induction!)
○ Vigorous chest physio + triflow
○ Monitor
■ CXR for fill expansion
■ Chest drain for output (<150-200ml)
■ Chest drain for airleak (any is abnormal!)
○ Off drain after 2 days if all okay
○ STOP SMOKING! (to avoid future lung surgery)
 
============================================
 
Video assisted thoracic surgery
 
Procedure
● One lung ventilation with double lumen endotracheal tube
● lateral decubitus position
● Operating table flexed 30 degree
● Three ports
- Midway between shoulder and ASIS (may adjust according to prefered chest chain insertion site)
- 2cm anterior to scapula
- other point to form an equilateral triangle

158
 ● No CO2 insufflation
● LA applied to wounds on closing
 
Uses
● Diagnostic
○ Lung/mediastinal/pleural biopsy
○ Operative staging of CA lung
● Therapeutic
○ Mechanical pleurodesis and bleb excision
○ Drainage and decortication for empyema/loculated effusion
○ Drainage and clot evacuation for hemothorax
○ Sympathectomy for PVD and palmar hyperhidrosis
○ Bullectomy + Lung volume reduction surgery
○ Resection of all masses
○ Pericardial window surgery
 
Contraindication
● Excessive pleural adhesions
● Inability to tolerate one lung ventilation
● Poor interlobar fissures in lobectomy
 
============================================

Lung cancer
 
Etiology
● Smoking (active and passive)
● Environmental or occupational (asbestos, arsenic, nickel, chromium, cadmium)
● Diet (vitamin E and betacarotene deficiency)
● Genetic
 
Types
● Adenocarcinoma
○ peripheral (ddx from secondarys difficult)
○ lymph node metastasis common
○ a subtype being bronchioalveolar CA: grows along alveolar space, synchronous, multifocal lesions
● Squamous cell
○ centrally near hilum or bronchi, local invasion likely >> likely picked up by sputum cytology
○ paraneoplastic (PTH)
○ history of heavy smoking
● Undifferentiated large cell
○ peripheral, often cavitates, early spread to distant sites
○ poor prognosis
● Small cell
○ central large infiltrative tumor, with bulky mediastinal lymphadenopathy
○ disseminate early
○ paraneoplastic syndrome (ADH, CRP)
○ history of heavy smoking
 
Clinical presentations
● Constitutional
○ weight loss, anorexia, malaise
● Local
○ Cough

159
 ○ SOB (airway obstruction, collapse)
○ Wheeze/ stridor
○ Hemotypsis
○ Recurrent unresolving infections
● Regional invasion
○ Pleural effusion (pleura)
○ Chest wall pain (chest wall)
○ Hoarseness of voice (left recurrent laryngeal nerve)
○ Dysphagia (esophagus)
○ Pancoast syndrome
■ Horner's syndrome = ptosis, miosis, anhydrosis, enophthalmos (stellate sympathetic
ganglion)
■ Pain and atrophy of hand small muscles (brachial plexus)
■ Pain in shoulder arm or neck (ribs and chest wall)
○ SVCO = facial edema, headache, dizziness, cyanosis, SOB, dilated veins
● Metastatic
○ bone (hypertrophic osteodystrophy)
○ liver
○ brain
○ adrenal
● Paraneoplastic
○ Cushing's syndrome (CRH)
○ SIADH (ADH)
○ Humoral hypercalcemia of malignancy (PTHrP)
○ Cerebellar syndrome
○ Dermatomyositis
○ Eaton lambert syndrome
 
Investigation
● Staging (non-invasive)
○ CXR
■ parenchymal mass
■ hilar or mediastinal lymphadenopthy
■ pleural effusion, collapse
■ phrenic nerve palsy (raised hemidiaphragm)
■ osteolytic bone lesions
○ CT thorax
■ assess local invasion
■ evaluate mediastinum (>1cm diameter SUSPICIOUS!)
○ CT Brain
■ for SCLC only
○ Bone scan
■ if suspecting bone metastasis, like an increased ALP
○ PET scan/ PETCT
■ good for detecting mediastinal and metastatic disease
■ but difficult to distinguish hilar from mediastinal nodes, because it is a functional scan, no
precise ANATOMY could be shown. This distinction is important, because mediastinal nodes
involvement (N2) is inoperable
● Staging (invasive)
○ Flexible fibreoptic Bronchoscopy
■ can get up to third degree bronchi
■ biopsy/ brush or saline lavage cytology/ transbronchial needle biopsy for paratracheal nodes

160
 ○ Image guided percutaneous needle biopsy
■ useful in the high risk surgical candidate
○ Transesophageal needle biopsy
○ Mediastinoscopy
■ the GOLD STANDARD for lung cancer staging!
■ allow access to paratracheal and subcarinal mediastinal nodes
■ under GA
■ small incision in suprasternal notch, dissect beneath pretracheal fascia, direct visualization of
mediastinum
○ Left Anterior Mediastinotomy
■ for AP window lymph node sampling (not easily done by mediastinoscopy)
■ GA, incision in left 2nd intercostal space
○ Video assisted thoracoscopy exploration (operative staging)
■ allow access to peripheral lung nodules for biopsy
■ allow sampling nodes in aortopulmonary window
■ allow examination of pleural space for seeding
● Assessing patient's operability
○ Nutritional status
○ Performance status
○ Pulmonary function
■ Spirometry (FEV1 >1.5L for lobectomy; >2L for pneumonectomy)
■ ABG
■ if in doubts/bordline, go for more sophisticated tests (eg. DLCO absolute minimum 20%, VQ
scan, cardiopulmonary exercise function test etc)
○ Cardiac status
■ resing ECG
■ if needed, echocardiogram
○ Other medical comorbidity
 
Staging (2009 IASLC)
● Tumor
○ T1a <2cm
○ T1b <3cm
○ T2a <5cm
○ T2b <7cm
○ T3
■ >7cm
■ chest wall, diaphragm, phrenic nerve, mediastinal pleura, parietal pericardium
■ tumor in main bronchus <2cm distal to carina
■ atelectasis or obstructive pneumonitis of entire lung
■ separate nodules in same lobe
○ T4
■ heart, great vessels, trachea, recurrent laryngeal nerve, esophagus, vertebrae, carina
■ separate nodules in another ipsilateral lobe
● Node
○ N1 = ipsilateral intrapulmonary/peribronichial/hilar nodes
○ N2 = ipsilateral mediastinal/subcarinal nodes
○ N3 = contralateral hilar/mediastinal nodes OR any scalene/supraclavicular nodes
● Metastasis
○ M1a = pleura involvement, malignant pleural/pericardial effusion, nodules in contralateral lobes
○ M1b = distant metastatic disease
● Stage

161
 ○ Any M = IV
○ Any N3 = IIIb
○ Any N2
- T123 = IIIa
- T4 = IIIb
○ Any N1
- T12a = IIa
- T2b = IIb
- T34 = IIIa
○ Any N0
- T1 = Ia
- T2a = Ib
- T2b = IIa
- T3 = IIb
- T4 = IIIa
 
Management outline
● Stage I-II = Surgery +- adjuvant chemotherapy (*offer 10% extra median survival)
● Stage IIIa = Chemoradiotherapy followed by surgery
● Stage IIIb-IV
○ EGFR mutation+ve =  EGFR tyrosine kinase inhibitor +- Bevacizumab??
○ EGFR mutation-ve = Palliative chemotherapy +- Bevacizumab
 
Curative management
● Basics of lung resection surgery
○ Lateal decubitus position (affected side up) + Table-broken to spread rib spaces
○ Insertion of double lumen endotracheal (Robertsaw) tube
■ allow independent access to either lung
■ allow one or two lung ventilation and suction
○ Posterolateral thoracotomy/ VATS ports
○ Dissection and division of pulmonary veins, artery branches and bronchi
○ Mediastinal Lymphnode sampling (not dissection) >> post-op adjuvant chemoradiotherapy
○ Chest drain inserted finally
● The VATS Lung resection - a current standard
○ shorter hospital stay
○ less pain, less analgesic requirement
○ early mobilization
○ less wound complications
○ better cosmesis
○ * BUT, it is technically difficult, and port site recurrence reported
● Pneumonectomy
○ for tumors that CROSS FISSURE or INVADE hilar structures
○ technically easier, but risk of post-op respiratory insufficiency exist
○ remember no suction on post-op drain >> it will suck on mediastinum
○ ~5-10% mortality (R>L) ?due to larger right lung mass
● Lobectomy
○ for tumors that dont cross fissure
○ allow complete resection of hilar (N1) nodes
○ relatively preserved lung function
○ ~2% mortality
● Segmentectomy
○ only for patients with peripheral tumors and impaired pulmonary function
○ higher rates of recurrence
● Bronchoplastic/Sleeve resection

162
 ○ an alternate to pneumonectomy to spare lung tissue
○ resect endobronchial lesions near carina to preserve distal tissue
● Extended resections
○ en bloc resection of contiguous intrathoracic structures
○ Chest wall resection with flap reconstruction
○SVC resection with reconstruction
 
Palliative
● Chemotherapy
○ Cisplatin + paclitaxel
○ Cisplatin + gemcitabine
○ Cisplatin + docetaxel
○ Carboplatin + paclitaxel
● Targetted therapy
○ Anti-VEGF
■ Bevacizumab
■ recognises all major isoforms of human VEGF
■ increased median survival for 2 months
○ EGFR tyrosine kinase inhibitors
■ Erlotinib, Gefitinib
■ targeting the EGRF mutations, which is found only in a subgroup of patient, so use them only
if tissue testing found positive! If used in -ve patient, it results in shorter survival.
■ Who are more likely to have the mutation?
■ Asian
■ Female
■ Never smoker
■
Adenocarcinoma
 
SVCO - an oncological emergency
Causes
● Bronchogenic lung cancer
● Lymphoma
● Others
○ Aortic aneurysm
○ Large goiter
○ Mediastinal fibrosis
 
Clinical manifestations
● Facial edema
● Headache, dizziness
● SOB (only when edema affects the airway)
 
Signs
● Engorged neck veins and chest collateral veins
● Pamberton sign
● Clubbing, tar stain, hypertrophic osteoarthropathy, collapse
 
Investigations
● CXR: medial upper lobe tumor
● CT thorax
 
Management
● This is a medical emergency, warrants immediate care.
● Treatment

163
 ○ iv Furosemide
○ Dexamethasone
○ Local radiotherapy
○ Chemotherapy for SCLC or lymphoma
○ SVC stenting: only if patient is fit
 
============================================
 
Surgery on emphysema
 
Pathology
● Loss of elastic tissue with increased compliance
● Functional obstruction >> airtrapping (increased residue volume) + hyperinflation (increased total volume)
● Impaired chest wall/ diaphragm mechanics
 
Choices
● Bullectomy
○ Procedure
■ VATS controlled deflation of affected bulla + staple the puncture site
■ Excision of deflated bulla
○ Patients who will benefit: (deVries-Wolfe classification)
■ Stage I: single giant bulla
■ Stage II: multiple giant bulla
■ * NOT those with homogenous distribution
● Lung Volume Reduction Surgery
○ Procedure
■ VATS/Open
■ Staple resection of peripheral lung tissues
○ Patients who will benefit:
■ Upper lobe distribution of bullae
■ Low pre-op exercise capacity
● Endobronchial Valve placement
○ Endobronchial placement of one-way valves
○ Prevent further airtrapping and induce atelectasis + allow continuous flow of mucus
● Airway Bypass
○ Endobronchially connects bullae to segmental bronchus to deflat the hyperinflated segment (using
concept of "collateral ventilation")
○ short term result controversial
 
============================================
 
Massive hemoptysis
 
Basics
● Potentially fatal from asphyxiation
● definition depends on local threshold: generally 600ml in 24hour (200ml in 24 hour in PWH with good
backup)
 
Etiology
● Rule out upper respiratory tract or GI tract sources first!
● Bronchiectasis (chronic inflammation with dilated and tortous bronchial artery)
● TB (chronic inflammation, ruptured Rasmussen aneurysm, erosion of calcified lymph nodes)
● Lung abscess
● Lung cancer
● Systemic bleeding tendency

164
 ● Trauma
● Pulmonary embolism
● Autoimmune disease (SLE, Goodpasture, Wegener's)
 
Investigation
● Etiology and severity
○ CBC, RFT, LFT, Clottings
○ Crossmatch, ABG
○ Sputum smear and culture
● Localise
○ CXR (for laterality +- clues of underlying etiology)
○ CT thorax (quick but need to leave ICU)
○ Bronchoscopy
○ Bronchial angiography
 
Management principle
● Protect other not affected lung
● Assess
○ clinical status
○ amount, rate of bleed
○ underlying pulmonary reserve
 
Management
● Admit to ICU
● Resuscitation
○ Airway for asphyxia
○ Breathing O2
○ Circulation
● Protect airway
○ Sit up patient to limit bleed to lower lobe, or lying the patient on lesion side
○ Endotracheal intubation - Pulmonary separation technique
■ Selective endobronchial intubation with single lumen ET tube +- endobronchial block
- tubing left main bronchus: technical difficult
- tubing right main bronchus: may block upper lobe bronchus
■ Double lumen ET tube insertion
- requires muscle relaxant and experienced anaesthetists
● Hemostasis 
○ Comparing Medical vs surgical
■ similar effectiveness
■ medical - higher recurrence rate
■ surgical - high mortality 20% at acute setting, only after stabilisation and proper lung
function test
○ Flexible/rigid Bronchoscopy
■ Pulmonary toileting
■ Cold saline/ Diluted adrenaline/ Vasopressin irrigation
■ Fogarty balloon catheter - direct pressure to bleeder for 24-36h (avoid pressure necrosis)
■ Laser/ electrocautery to bleeder
○ Bronchial artery embolisation
■ high success rate 80-90%, but 10% recurrence in 6 months
■ Consent
■ Indication: diagnostic and therapeutic for massive hemoptypsis
■ Procedure
■ Expected outcome: hemostasis

165
 ■ Complication: Failure and convert to surgery, rebleeding, puncture/dissect artery,
spinal cord artery embolization
■ Alternative and risk:
- repeat bronchoscopy (success rate 50-70%)
- do nothing (high mortality)
- surgery (mortality 20%)
○ Surgery
■ lobectomy/pneumonectomy/bronchial artery ligation
■ very high mortality 20% at acute stage
■ reserved for those failing medical management

============================================
 
Aortic dissection
 
Classification
● Debakey classification
○ Type I: Originates in ascending aorta and propagates beyond the aortic arch, 1% mortality/yr
○ Type II: Originates in and is confined to the ascending aorta
○ Type III: Originates in descending aorta, rarely extends proximally
● Stanford classification
○ Type A = Type I and II DeBakey
○ Type B = Type III DeBakey
Pathology
● *partial thickness tearing of intima and inner media
● Etiology
○ Ascending aortic dissection = associated with hypertension, cystic medial necrosis, Connective tissue
disease
○ Descending aortic dissection = hypertension and atherosclerosis
○ Trauma
○ Iatrogenic
● a double lumen may be produced due to re-entry of dissecting blood into the aorta
● if dissected proximally
○ aortic regurgitation (aortic root dilatation)
○ cardiac tamponade (pericardium)
○ acute myocardial infarction (coronary ostium)
○ syncope (carotid artery)
● if dissected distally
○ renal failure (renal arteries)
○ leg ischemia (femoral arteries)
○ mesenteric ischemia (intestinal arteries)
 
Clinical presentations
● Severe anterior/posterior tearing chest pain, maximal at onset
● Acute AR = dyspnea
● Tamponade = heart failure and syncope, pulsus paradoxus, pericardial rub
● Renal ischemia = anuria, hematuria
● Limb ischemia = absence of pulses, pain, weakness, unequeal BP in two arms
● Mesenteric ischemia = PR bleed, severe abdominal pain outportion of signs
 
P/E!!
● BP in both arms
● AR murmur
● Muffled heart sounds
 

166
Investigations
● ECG, cardiac enzymes (* rule out the common causes first!)
● Chest X-ray
○ widen mediastinum
○ calcium sign: calcified intimal flip seen
● Contrasted CT-scan
● Transesophageal echocardiography: also for screening secondary AR/ LV dysfunction from AMI

 
Management
● NPO, IVF
● Complete bed rest
● Oxygen
● Morphine
● Close monitoring
○ BP/P +- A-line insertion
○ I/O chart
○ Complications
● iv labetalol, aim systolic BP 100-120, + sodium nitroprusside if not controlled (dont use it alone as it
will lead to reflex tachycardia that increase dissection shear stress)
● Type A >> urgent cardiothoracic surgery
● Type B >> conservative medical management, unless complications (prxomial progression, persistent pain,
renal failure, limb ischemia, mesenteric infarct)
 
Surgical management of Type A dissection
● Median sternotomy
● Cardiopulmonary bypass
○ femoral vessels
○ IVC, SVC
○ cardioplegia
● Replacement of ascending aorta
○ clamp aortic root
○ clamp proximal to brachiocephalic trunk
○ split layers of aorta re-approximated (injecting glue into false lumen)
● Replacement of aortic valve
○ composite prosthesis (aorta + valves) OR resuspending the native valves in graft
○ coronary arteries detached from dissected native sinuses
● Deep hypothermic circulatory arrest
○ for replacement of aortic arch, and minimise neurological injury to cerbral ischemia
○ reducing temperature of outflow from CPB to 18 degree (can hold for 25min)
○ carbon dioxide needs to be added to counteract the alkalotic hypocapnic blood when cooled, it also
helps in cerebral vasodilation
○ S/E: coagulopathy, diffuse brain injury, renal compromise
○ Selective antegrade cerebral perfusion
■ second canula into arch branches to supply brain
■ burden of microemboli increased
■ can prolong to 40min or more
○ Retrograde cerebral perfusion
■ give blood via jugular system, but only <10% of flow reaches cerebral capillary beds to
deliver oxygen, majority shunting via dural collaterals
 
Surgical management of Type B dissection (usually conservative unless complicated)

167
 ● Posterolateral thoracotomy
● Partial left heart bypass
○ Drain from left atrium
○ Pour into distal aorta
○ Significant risk of paraplegia (from interupted intercostal supply to spinal artery)
● Choices
○ Descending aorta replaced by a Dacron graft
○ False lumen fenestration
○ Endovascular stent-grafting
■ right femoral artery
■ self expanding metal frame affixed to PTFE membrane

============================================= 
 
Carotid artery stenosis
 
Symptomatic carotid disease (sudden onset focal neurological symptoms in carotid distribution)
● Definition
○ transient ischemic attack / stroke
○ monocular blindness (amaurosis fugax)
○ NOT VERTIGO/SYNCOPE
● Recommendation
○ 70-99% stenosis + life expectancy >5years - Carotid endarterectomy / Carotid artery stenting
■ pre-procedural Stroke/death assessment for CEA: if >6%, it offsets the benefit of CEA (but
clinically difficult to make such an accurate assessment)
■ CEA if:
■ Surgically accessable artery
■ + low anaesthetic risk
■ + no previous ipsilateral endarterectomy
■ CAS if:
■ Surgically inaccessable artery
■ high anaesthetic risk
■ Restenosis after endarterectomy
■ Radiation induced stenosis
○ 50-69% stenosis + life expectancy >5years
■ CEA for men
■ Medical management for women
○ <50% stenosis
■ Medical management
● Timing for CEA/CAS = ASAP, preferably within 2 weeks
 
Asymptomatic carotid disease
● Recommendation
○ Medical management
○ CEA can be done (for long term prevention of stroke, delay to benefit in 5yrs) if:
■ >60% stenosis
■ pre-procedureal stroke/death risk <3%
○ CAS has similar effacacy, but more periprocedural stroke or death, recommended only to perform if
recruited in a trial
 
=============================================
Urological Surgery

168
What is the difference between overactive bladder syndrome and detrusor instability?
 
Renal mass
LUTS
AROU
Hematuria
IVU filling defect
Urodynamic study results
 
Renal stone
BPH
Prostate cancer
Bladder cancer
Renal cell carcinoma
 
====================================================================
 
Renal mass (often incidental from imaging)
 
Cystic
● Simple cyst - very common as one ages
● Complicated cyst - solid component, thickened wall, septa, calcifications
Solid
● Renal cell carcinoma (*85% of all solid renal mass!)
● Benign lesions = Abscess, hemangioma, angiomyolipoma, adenoma
● Malignant lesions = TCC, oncocytoma, sarcoma, lymphoma, metastatic tumors
 
Bosniak classification of renal cysts
● Category I = simple cyst
● Category II = thin smooth speta or linear calcification
● Category IIF = multiple smooth thin walled septa
● Category III = indeterminate lesion
● Category IV = high probablity of cystic malignancy
 
IVU filling defect
● Stone
● Tumor
● Clot
● Fungal ball
● Dislodged papilla
 
 
Lower urinary tract symptoms
 
Voiding symptoms (hesitancy, poor stream, intermitency, straining, incomplete emptying)
● Outflow obstruction
○ Urethral stricture (STD, longterm cath, phimosis)
○ BPH, Prostatic cancer
○ Bladder stone/clot/cancer
● Hypocontractile bladder
○ Neurogenic bladder (Stroke, spinal cord lesion, Pelvic surgery, DM neuropathy)
○ Detrusor muscle hypocontractility
 
Storage symptoms (Urgency, frequency, nocturia)
● Local
○ Anatomical capacity reduction (radiotherapy, TB)
○ Functional capacity reduction (overactive bladder, detrusor instability)
○ Local irritation (UTI, stone, tumor)

169
 ● Regional
○ Neurogenic bladder
● Systemic
○ High fluid intake
○ High urine output (DM, DI, primary polydipsia)
P/E
● Abdomen - distended bladder, scars
● Penis - phimosis, discharge
● Back - spina bifida, tenderness
● DRE - anal tone, prostate (size, nodularity)
●Dipstix
 
Nocturia
● ICS definition: waking up at least once per night due to urinary urge
● True nocturia (without daytime frequency)
○ Impaired nocturnal ADH secretion
○ Dependent edema
○
Obstructive sleep apnea
 
Hematuria
Glomerular
● Glomerulonephritis (with proteinuira, red cell cast, dysmorphic red cells, hypertension)
Non-glomerular
● UTI
● Stone
● Tumor
● Trauma
● BPH
● Renal cysts
● Systemic bleeding tendency
History
● PV, LGIB?
● Part of stream
● Severity: clots? anemic symptoms?
● Associated symptoms
○ fever, loin pain, dysuria, pyuria
○ Colic, passage of stone
○ LUTS + retention
○ systemic bleeding tendency, anticoagulants, antiplatelets
○ constitutional symptoms, bone pain, hypercalcemic symptoms
○ frothy urine, hypertension, known renal disease
P/E
● DRE
● Abdominal examination for enlarged kidneys/ masses (RCC, polycystic kidneys, Bladder cancer)
● Loin tenderness, temp chart
● Arthritis, skin rash, uremic complexion, BP
● * Anemic symptoms
Ix:
● Dipstix/ M+CS
● Urine cytology
● Cystoscopy
●Upper tract imaging (US/IVU/CT urogram >> ureterorenoscopy)
Other secondary line Ix:

170
 ● EMU for AFB x3
● Retrograde pyelogram
● Ureterorenoscopy
● renal angiography
 
 
 
Acute retention of urine
Urethra
● UTI
● Stricture
● Trauma
Prostate
● BPH
● Prostate cancer
● Prostatitis
Bladder
● Retention clot
● Constipation
● Pelvic mass
Functional
● Acute nerve injury
● Drugs (eg. anticholinergics, alpha agonists)
Steps
● Insert foley to release urine
● Close monitor output for post-obstructive diuresis & hematuria
● History: LUTS, hematuria, dysuria, fever, BO, history of trauma/catheterisation/drugs
● DRE: fecal impaction/ BPH/ CA prostate
 
Elevated PSA
Prostate pathology
9. Prostatic cancer
10. BPH
11. Acute prostatitis
12. AROU
Prostate manipulation
14. Vigorous DRE
15. Prostatic massage
16. Recent catheterization
17. Recent biopsy
 
Scrotal mass
16. Inguinal: Indirect inguinal hernia
17. Spermatic cord: Varicocele, Hydrocele, cord lipoma
18. Epididymus: Cysts, Infection
19. Tunica vaginalis: Hydrocele, Hematocele
20. Testis: Cancer
 
Acute scrotum
11. Testicular torsion
12. Torsion of testicular appendage
13. Epididymo-orchitis
14. Strangulated inguinal hernia 
 
====================================================================

171
 
Congenital renal abnormalities
   
9. Pelvic kidney - failure of cranial migration
10. Horseshoe kidney
○ fusion of metanephric masses across the midline
○ level of L4/L5 in front of AA
11. Duplex system
○ metanephric bud duplication
○ double pelvis draining into one ureter, or bifid ureters merging together, or two separate ureter
entering bladder
○ lower pole ureter in normal position
○ upper pole ureter enters bladder medial and below the lower pole ureter
12. Congenital absence of kidney
13. Polycystic kidneys
○ PKD1 and PKD2, on 4 and 16 chromosomes, AD
○ multiple cysts in liver 80%, lungs, spleen, pancreas 10%
○ intracranial berry aneurysms
○ S/S: mass, hematuria, recurrent UTI, renal failure, hypertension, intracranial bleed
○ Ix: USG (very sensitive), U/E (to show renal failure), IVU (spidery calyces)
○ Tx: medical control on hypertension and renal failure, nephrectomy when needed
14. Congenital hydronephrosis - neuromuscular incoordination at the pelvi-ureteric junction
15. Aberrant renal arteries - one or more arteries supplying upper or lower poles or kidneys
16. Medullary sponge kidneys
○ usually asymptomatic picked up in routine KUB
○ congenital cystic dilation of collecting ducts
○ flower-like appearance
 
* metanephric mesenchyme = mature  glomeruli and proximal renal duct system
* ureteric bud = ureter, renal pelvis, calyces and distal ducts
 
========================================  
 
Recurrent UTI:
● >2 episodes in half year
● >3 episodes in one year
● give three days antibiotics course in uncomplicated UTI
● 2 weeks repeated culture
○ if positive with same culture: bacterial persistence
○ if positive with different culture: reinfection
○if negative: unresolved infection  
 
======================================== 
 
Hydronephrosis
● Causes:
○ luminal obstruction: stone, blood clot
○ mural obstruction: transtional cell tumor, congenital hydronephrosis (see above)
○ extramural obstruction: retroperitoneal fibrosis, extrinsic tumors
○ vesicoureteric reflux
○ aberrant renal vessels
● S/S: symptomless, dull aching pain at loin with acute attacks, if bilateral>> uremia
● Complications: infection, stone formation in stagnant urine, hypertension, renal failure, traumatic rupture of
pelvis

172
 ● Ix:
○ USG, CT, IVU
● Tx:
○ remove any amendable underlying causes
○insertion of a JJ stent (24-30cm) vs PCN 
 
========================================
  
Urinary tract calculi
 
Causes for renal stones
● Inadequate drainage (eg stagnated urine in hydronephrosis), dehydration
● Excess normal constituents:
○ high calcium: hyperPTH, malignancy, milk-alkaline, FHH, renal tubular acidosis I
○ high urate: gout, postchemo
○ high oxalate: strawberries, rhubarb, leafy veges
● Lack of inhibitors of stone formation:
○ low citrate
○ low Mg
● Abnormal constituents:
○ UTI - epithelial sloughs, high pH (for calcium phosphate)
○ Foreign bodies
○ Vitamin A defi - hyperkeratosis of urinary epithelium
○ Cystinuria
 
Causes for bladder stones
● Voiding dysfunction
● Foreign bodies (longterm cath, suprapubic cath)
 
Stone types
● Calcium oxalate: sharp spiky, traumatizes epithelium causing bleeding; dark brown
● Triple phosphate (struvite): calcium, ammonium, magnesium; infected urine; staghorn stones; coffin-lid
rectangular shape in microscopy
● Urate: smooth surface, radiolucent
● Cysteine: hexagonal in microscopy
● Melanine cyanurate: formed in low pH, soft and radiolucent, Tx only require hydration
 
Pathology
● Staghorn stones
○ formed by urea-spliting organisms like proteus that infect the renal pelvis, they produce ammonia
within the urinary tract
○ pyelonephritis may superimpose so all staghorn stones need to be treated
○ either PCNL or open surgery
 
Clinical presentation
● Renal colic (sudden onset intense continuous pain radiate from loin to groin lasting for few hours)
○ two components: colicky pain from ureteric spasm + constant pain from stretched kidney capsule
○ exacerbated by drinking
○ associated with restlessness, nausea and vomiting
○ relieved best by NSAIDs (painkilling effect + reduction in renal plasma flow hence GFR)
● Hematuria
● Passage of stone
● Complications
○ Recurrent UTI

173
 ○ Obstructive uropathy
 
Common sites for stone lodging
● <5mm stone can pass spontaneously
● >5mm stone
○ pelviureteric junction
○ pelvic brim
○ ureterovesical junction
● Ddx for small calcifications in KUB
○ Pelvic/prostatic calcification, pheboliths, faecoliths, calcified lymph nodes, nephrocalcinosis,
renal cyst wall, medullary sponge kidneys, gallstones
○ pheboliths - round, heterogenous with central lucency, below and lateral to ischial spine lying close
to bones 
 
Diagnostic investigations
● Dipstix - hematuria; pH (acidic - urate; alkaline - infection)
● Microscopy, C/St 
● KUB (90% stones)
● Non contrasted CT
○ very sensitive in picking up stones, replacing IVU as first line imaging
○ Additional info:
■ for ruling out other extrarenal pathology that leads to the pain
■ cortical thinning indicating dereased renal function
■ visualize radioLUCENT stones
○ 1.5-2x radiation than IVU
○ *best taken with KUB, so that if KUB found radioopaque stone, KUB can be used as followup, or else
CT would be needed
● IVU
○ Features: dense nephrogram / lack of contrast entering collecting system
○ Cons
■ image obscured by fecal loaded gut/ bowel gas/ bony structures
■ quality reduced in poor renal functions
■ Contrast allergy/nephropathy
 
Etiological investigations
● Serum calcium/ phosphate/ urate
● Urine microscopy for crystals
● 24 urine for calcium/ oxalate
● Stone analysis
 
 
Acute managements
● Painkillers (pr diclofenac or pethidine)
● If in urosepsis:
○ Resuscitation & close monitoring
○ IV antibiotics
○ Emergent drainage
■ Percutaneous nephrostomy (need prone position):
■ Can be done in bedside (cf JJ-stent may be difficult to pass through obstruction, also
need SA and OT room)
■ Allow accurate monitor of output
■ If reblockade - know immediately (cf JJ-stent would present in semi-emergency)
■ JJ-stent
■ no need to put patient prone which may compromise breathing in desaturation

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Definitive Management (*Indication for intervention = symptomatic / complications / occupation)
● Conservative (Medical expulsion therapy)
● ESWL
● URSL
● PCNL
● Laparoscopy/Open
 
Medical expulsion therapy
● for radiologically <4mm (some say to try for <10mm) stone that we expect it to pass spontaneously + no
indication for active stone removal   or   patient comorbided
● Candidate drugs (all relax ureteric smooth muscle)
○ Alpha blockers Tamsulosin
○ Calcium channel blockers Nifedipine
○ Steroids
 
Extracorporeal shockwave lithotripsy (ESWL)
● Pre-op preparation
○ Prophylactic antibiotics
○ Bowel preparation
○ Stop anticoagulants/ platelet
● Procedure
○ X-ray or USG (radioopaque stone) guidance
○ Cardiac monitoring for arrhythmia and pain induced BP shoot
○ Patient-controlled-analgesia
○ Shockwave from electrohydraulic / electromagnetic / piezoelectric
○ gel contact with emission device (~3000 shots, rate similar to heartbeats)
● Contraindications
○ Bleeding tendency
○ Urosepsis
○ Pregnancy
○ Distal obstruction to stone
○ Relative: morbid obesity or scoliosis (not fit for focus), AAA
● Pros
1. Good for small proximal stones (esp <10mm at proximal ureter or <20mm renal stones)
2. Least invasive
3. Day procedure
● Cons
○ Bad for large/staghorn stone, lower calyces stone, cysteine stone
○ Stones need to be passed by itself
○ May need multiple sessions
● Complications
○ Immediate
■ Bleeding (hematuria >> hematoma formation)
■ Infection (due to fragmentation of bacteria containing stones in situ)
■ Renal colic as stone passes out
■ Fragment impaction (steinstrasse) causing obstruction
■ Arrhythmia
■ Organ damage: pancreatitis, spleen hematoma, bowel
○ Delayed
■ Hypertension
■ Renal failure (from parenchymal damage)

175
 ■ Ureteric stenosis
 
Ureterorenoscopic lithotripsy (URSL)
● Rigid: up to pelvic, but mainly for stones in ureter
● Flexible: up to calyx
● Holmium laser/ ballistic (direct contact) lithotripter
● Pros
○ Good for >10mm ureteric stones  
○ can remove stone by clips on direct visualisation
● Cons
○ may not be able to go up to renal calcyx very well 
○ possible flush back of stones
● Complications
○ Early
■ GA, bleeding, infection
■ Urethra/bladder/ureter perforation
■ Clot retention
○ Late
■ Urethral stenosis
 
Percutaneous nephrolithotomy (PCNL)
● Procedure
○ Image guided nephrostomy usually the lower calyces, to prevent pleural injury in upper systems
○ After serial dilators, put in a nephroscope
○ Ultrasonic/ pneumatic/ letrohydrolic lithrotripsy + forceps/ basket
● Pros
○ Direct entering of renal pelvis
○ Allow immediate drainage paricularloy in sepsis
○ Suitable for staghorn renal stones
may combine with SWL to remove calyceal stones, PCNL remove central stone fragments in pelvis,
while SWL removes calyceal fragments
● Cons
○ Requires GA
○ invasive
○ patient in prone position, need to be relatively stable
● Complicatioins
○ GA, hemorrhage, infection
○ perforation of lung/pleura/colon in tube insertion
○ perforation of collecting systems leading to extravasation of saline
○ Renal parenchymal damage 
● Post-op orders
○ DAT
○ monitor vital signs (BP pulse Q1H x 6, Q4H when stable)
○ monitor nephrostomy AND foley drain
■ good if blood stained foley urine, as it indicates ureteric patency over the operated side
■ if high flow in nephrostomy drain its no good, indicates obstruction
○ paincontrol
○ post-op antibiotic coverage (2GC or quinolones)
 
Longterm management
● Hydration to at least 2.5L per day with ~2L urine output
● Diet
○ High: citrate, potassium

176
 ○ Low: sodium, red meat, oxalate
● Control any underlying cause
11. Thiazide for hypercalciuric patients
12. Oxalate restriction and pyridoxine
13. Allopurinol and urine alkalization for hyperuricemia
14. D-penicillamine for cysteine
 
========================================
 
Comment a KUB:
● General
○ Exposure (xiphoid sternum to pubic symphysis)
○ Penetration
● Preservation of psoas shadow
● Kidney shadow
● Patent ureters
○ start at L2
○ along transverse processes
○ to sacroiliac joint
○ medial to ischial spine
○ insert into bladder down
● Bladder
 
* DDx for nodule seen in KUB:
● ureteric stone
● phlebolith:
● faecolith
● prostatic calcification
● bladder stone
    
========================================
 
Renal cell carcinoma (Grawitz's syndrome)
 
Basics
● Adenocarcinoma, originates from proximal tubular epithelium
● Subtypes:
○ Clear cell carcinoma
■ most common type of RCC (von hippel lindau syndrome)
■ may response to immunotherapy
■ typically invades renal vein causing thrombosis >> varicocele if left sided
○ Papillary renal cell carcinoma
■ frequrently multifocal and bilateral
 
Risk factors
● Smoking
● Male
● Chronic accquired cystic disease
● VHL
● Long term phenacetin
 
Clinical presentations
● Local - hematuria, loin pain, mass
● Invasion - renal vein/IVC (varicocele)

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 ● Paraneoplastic
○ anemia, polycynthemia
○ hypercalcemia
○ hypertension
○ cushing's syndrome
○ hypoglycemia
○ gynacomastia/amenorhea/libidoloss/baldness
○ pyrexia of unknown origin
○ Stauffer's syndrome: impaired LFT (ALP) in the presence of a RCC
● Metastatic - Lung, bone, skin, liver
● General - weight loss, malaise, anorexia
 
Direct spread :
● Perinephric tissue
● Paraaortic nodes
● Renal vein and IVC
● Liver, lung, bone and brain
 
Investigations
● USG, contrast CT (contrast enhancing mass), Bone scan

Axial contrast-enhanced CT image shows a large enhancing mass in the left kidney with central necrosis
(asterisk). Tumor thrombus is seen within the left renal vein at the level of the renal hilum (arrowhead). A
patent left renal vein (arrow) is noted medially. A low grade (Furhman nuclear grade 2) clear-cell renal cell
carcinoma was identified pathologically after nephrectomy.
 
Management - Surgery as mainstay, metastatic disease is almost invincible from chemoRT
● Surgery
○ Radical nephectomy (with adrenal gland)
■ remove the kidney outside the Gerota fascia
■ +- remove the ipsilateral adrenal gland (risk of adrenal metastasis is infact low 3% if pre-op
CT scan unremarkable)
■ +- perform a complete regional lymphadenectomy from the crus of the diaphragm to the
aortic bifurcation if preop evidence of nodal involvem ent
○ <4cm polar tumor/ single kidney/ poor renal function: Nephron sparing techniques
■ Partial nephrectomy
■ Percutaneous imaged guided cyrotherapy or radiofrequency ablation or HIFU
● Targetted therapy
○ Sunitinib/ Sofetinib
■ only for clear cell carcinoma
■ inhibits PDGFR, VEGFR tyrosine kinases  >> Anti-angiogenesis
(also inhibits KIT-CD117, as 2nd line for GIST after imatinib)
○ Bevacizumab
■ anti-VEGF monoclonal antibody
■ (also used in metastatic CRC)
○ Temsirolimus/ Everolimus
■ mTOR inhibitor
■ act on G1 phase of cell cycle to arrest it
● Immunotherapy
○ Interleukin-2
■ induction and activation of T-lymphocytes and natural killer cells
■ partial response 15%, complete response 5%
■ S/E: fever, malaise, vomiting, diarrhea
○ Interferon alpha

178
 ■ immmunostimulatory and antiangiogenic effect
■ partial response 10%, complete response 2%
■ S/E: flu like symptoms, neutropenia, aggrevate autoimmune diseases
○ lymphokine activated killer cells
 
Other kidney tumors
● Wilm's tumor (nephroblastoma)
○ extremely anaplastic
○ usually found in <5 years old
○ mutation of WT1 gene
○ Stage I-V
■ I: local with capsule
■ II: capsular involvement, invade outwards
■ III: lymph node involvement
■ IV: hematogenous spread
■ V: bilateral renal involvement at time of diagnosis
○ Tx: nephrectomy, chemotherapy, radiation
● Angiomyolipoma
○ Types
■ 80% idiopathic (80% RIGHT kidney)
■ 20% associated with tuberous sclerosis (usually bilateral)
○ if >4cm there is high risk of catastrophic bleeding, resection needed
● Oncocytoma
 
========================================
   
Bladder cancer: Transitional cell carcinoma
 
Basics
● affects age 60-70s
● now termed urothelial cancer
● 80% papillary; 20% sessile
● common sites are bladder base, trigone, and around the ureteric orifices
 
Risk factors:
● Male
● Elderly
● Smoking
● Aromatic amine, dye, petroleum, rubber industry
● Phenacetin, cyclophosphamide
● Dietary soy
● Protective if homozygous for "fast acetylator" polymorphic form of N-acetylaction gene, that remove
aromatic amines into non-carcinogenic metabolites
 
Clinical presentation
● Hematuria (micro/macro) 75%
● Irritative symptoms 30%
● Metastatic symptoms (Weight loss, abdominal pain, abdominal mass)
● Hydronephrosis (if obstructed)
 
Spread:
● local - bladder wall, prostate, urethra, sigmoid or rectum
● lymphatics - iliac or paraaortic nodes
● blood - liver, lungs, bones

179
 
Investigation:
● Urine dipstix, M/CS
● urine cytology - not sensitive but specific
○ high grade disease G3 & carcinoma in situ (high malignant potential, mild erythematous patch)  
○ still useful in detected upper urinary tract malignancy while sometimes IVU may skip tiny lesions
● Flexible cystoscopy - biopsy
● Upper tract investigations (5% upper tract tumor)
○ Ultrasound
○ IVU
○ CT urogram
 
Tx for Superficial disease (CIS, Ta, T1)
● Transurethral resection of bladder tumor (TURBP)
○ Resect the supeficial layer with muscle
○ both diagnostic and therapeutic for superfical disease
○ * stimulating the obturator nerve adjacent to lateral bladder wall would results in strong kick, esp in
elderly women with thin wall, so beware!
● Post-op intravesical chemotherapy/immunotherapy
○ Mitomycin C - for killing the floating cancerous cells in bladder
■ indicated in all patients
■ other potential agents include adriamycin, epirubicin
○ BCG
■ for patients with high risk of recurrence
■ induce extensive local inflammatory reaction in bladder wall
■ given with 2-week interval between surgery and installation, to avoid perioperative hepatitis,
pneumonitis and even death!
■ S/E: fever, flu like symptoms
● Post-op surveillance (Recurrence rate is high!!)
○ Cystoscopy x 8 time Q3months
○ Urinary cytology - lifelong, but only sensitive for high grade disease or CIS
○ Photodynamic diagnosis - a fluorochrome re-emit light in a longer wavelength with high selectivity
towards tumor, thus demarcating tumor from normal tissue; highly specific but only with moderate
sensitivity
 
Tx for muscle invasive disease (T2, T3, T4)
● *After the histological proof for muscle invasive disease from TURBP, a full staging has to be perform to
assess resectability: CT abdomen/pelvis + CXR
● Radical cystectomy with pelvic lymphadenectomy
○ MALE: removal of seminal vesicles, prostate and distal ureters
○ FEMALE: anterior exenteration (anterior wall of vagina, cervix, uterus, uterine tube, ovaries)
● Partial cystectomy
○ for superficial isolated tumor with 3cm margin from any orifices
● Radical radiotherapy
○ Usually for inoperable patients with locally advanced disease
○ S/E: radiation cystitis, proctitis and lethary
○ * no difference in all cause 5-year survivial compared to radical surgery, those 50% suffered a local
recurrence and 20% required a salvage surgery
● Chemotherapy (methotrexate, vinblastine, Adriamycin, cyclophosphamide)
 
Urinary diversion/ bladder reconstruction (frozen section of urethra show be done to make sure not involved)
● Noncontinent
○ An ileal conduit uses a segment of small intestine to create a channel that connects ureters,and
fashioned into stoma on abdominal wall

180
 ● Continent
○ Abdominal catheterization pouch
■ Mitroffanoff
■ a pouch made from intestine, situated inside the abdomen, drains out as urostomy, smaller
than the opening for an ileal conduit
■ no bag needed to be worn outside, just need to pass a catheter through the opening to
release the urine several times a day and during the night
○ Orthotopic bladder reconstruction
■ create a neobladder
■ only if urethra is not removed in cystectomy AND  free of disease
■ allow voluntary control of urination by abdominal contraction as sphinter is preserved
■ sometimes catheter is needed to release urine (as the sensation is loss)
 
Squamous cell carcinoma
● Chronic irritations: bladder stones, neurogenic bladder, Schitosomia hematobium, long term catheterization
(due to transitional cell metaplasia under chronic external stress, into squamous cell epithelium)
● Cyclophosphamide
 
Adenocarcinoma
● Associate with urachal remnant
 
========================================
 
Benign prostatic hypertrophy
 
Basics
● Affect the transitional zone
● Static obstruction: epithelial and stromal hyperplasia
● Dynamic obstruction: smooth muscle contractions in response to alpha adrenergic
● the hyperplasia process is hormonal dependent, as shown by:
○ castrated male has no BPH
○ the effectiveness of 5a reductase inhibitor
● Bladder outflow obstruction (obstructive) >> chronic retention >> bladder detrusor instability (irritative)
 
Clinical presentations
● LUTS
● Complications
○ Prostate - hematuria (from engorged prostate venous plexus, usually end-stream)
○ Bladder - recurrent UTI, stones, retention, trabaculae
○ Kidney - hydronephrosis, obstructive uropathy
 
Investigation
● 24 hours frequency-volume chart
● International prostatic symptom score (IPSS)
○ 35marks for LUTS
■ Poor stream, straining, intermittency, incomplete voiding
■ urgency, frequency, nocturia
○ 6marks for QOL
○ Mild: 0-7
○ Moderate: 8-19
○ Severe: 20-41
● Dipstix, M/CS
● RFT, PSA
● KUB (to rule out bladder stones)
● Uroflowmetry + Bladder scan

181
 
Indication for treatment
● Symptomatic (IPSS 8-42)
● Complications
○ Prostate - hematuria
○ Bladder - recurrent UTI, stones, retention, trabaculae
○ Kidney - hydronephrosis, obstructive uropathy
 
Management outline
● Conservative
● Medical
● Surgical
● Others
 
Management
● Conservative
○ Avoid drinking too much water esp before bed
○ Try to void as complete as possible, try double voiding
● Medical
○ Alpha blockers: Terazosin, doxazosin, Alfuzosin, tamsulosin
■ to control the Dynamic obstruction, by relieving the tonic smooth muscle contraction, relax
sphinter
■ used in maximum tolerable dose
■ improve uroflow by 3-5ml/min
■ Side effects: headache, dizziness, postural hypotension & falls, nasal congestion, asthenia
Tamsulosin = ejaculatory problems
■ Other benefits: anti-hypertensive, improve lipid profile, reduce platelet adhesiveness,
improve erectile function
○ 5-alpha reductase inhibitors: finasteride, dutasteride
■ to control the Static obstruction by reducing the prostate mass directly, thus more
effective in patients with large prostate >40ml
■ inhibit conversion from testosterone to DHT, for hormonal dependent nature of BPH
■ take 3-6 months to be fully effective
■ may help in controlling BPH-hematuria as it also reduced prostate vascularity
■ Side effects: impotence, 50%reduction in PSA level, rarely breast engorgement/soreness
○ Combination treatment offers better reduction in clinical progression
○ Anticholinergic agents
○ PDE5 inhibitors
● Surgical
○ Transurethral resection of prostate
■ Put in lithotomy/Loyld-Davis position
■ Rigid cystoscopic examination
■ Transurethral resection
(Bopolar resection allows a more localised energy current, and allow the use of NS
irrigation, theoretically preventing TUR syndrome)
■ 3-wave urethal catheter with 1.5% glycine, specimens send for pathology (not NS due to
conductivity, not distilled water due to intravascular hemolysis)
■ Post-op saline irrigation at 500ml/h with close vital monitoring, CBC and RFT.
○ MIS - Thermotherapy: No tissue diagnosis!
■ interstitial laser coagulation (ILC)
■ Radiofrequency ablation (RFA)
■ high intensity focused ultrasound (HIFU)
■ tranurethral microwave thermotherapy (TUMT)
■ transrectal hyperthermia

182
 ○ MIS - Tissue ablation: No tissue diagnosis!
■ Photoselective Vaporization of prostate (PVP)
■ Holmium laser resection of prostate (HoLRP)
■ transurethral needle ablation of prostate (TUNA)
● Others
○ Longterm catherterisation
○ Clean intermittent self catheterization
○ Urethral stenting
 
Post-TURP complications
● General: GA
● Intraop
○ Bleeding
○ TUR syndrome (limit operation time)
○ Perforation/injury
● Early
○ Bleeding
○ Infection
○ Chip/Clot retention (post-op 500ml/h NS irrigation and warming to prevent blood clot)
○ Urge incontenence
○ TUR syndrome
● Late
○ Bladder neck stenosis/stricture
○ Retrograde ejaculation
○ Stress incontenence
 
========================================
 
Acute Prostatitis
● Ascending coliform infection of prostate
● Clinical presentation
○ fever, chills
○ low back and perineal pain
○ LUTS (frequency, urgency, poor stream, retention)
● P/E
○ DRE: very tender, warm prostate
(Avoid vigorous palpation that could like to septicemia)
● Investigations
○ CBC leukocytosis
○ Urine M/CS growth
● Management
○ Retention = suprapubic catheter
○ Fluoroquinolones for 3 weeks
 
Chronic Prostatitis
● Clinical presentation
○ suprapubic/low back pain, dysuria
○ LUTS (frequency urgency)
● P/E
○ soft boggy prostate
● Investigation
○ Urine M/CS no growth
○ Secretion from prostatic massage

183
 ■ numerous leukocyte (>10in hpf)
■ may become culture positive
● Managment
○ Fluoroquinolones for 6 weeks
 
========================================
 
Prostatic cancer
 
Basics
● 95% adenocarcinoma (rest are neuroendocrine tumors or sarcomas)
● A scattered slow growing tumor
● Cytological characteristic
○ Hyperchromatic enlarged nuclei
○ Prominent nucleoli
○ Abundant cytoplasm
○ Absent basal cell layer
● Prostatic intraepithelial neoplasia
○ Precursor of prostate CA where there is presence of basal cell layer
○ often found adjacent to prostatic CA, so if TRUS biopsy show PIN >> further investigation for
concurrent invasive carcinoma
● Tumor progression
○ Local invasion = outside capsule to seminal vesicle
○ Lymphatics = obturator nodes
○ Distant = axial skeleton, isolated brain met (via Batson's plexus)
 
Risk factors
● Old age
● Familial (?HPC-1 gene)
● Diet (high fat, red meat, diary products)
● Testosterone
 
Clinical presentation
● *Incidental - PSA or DRE
● Local
○ Voiding symptoms
○ Urinary retention
● Metastatic
○ Bone pain+- fracture
○ spinal cord compression
 
Investigation
● Serum PSA level
● TRUS biopsy
● MRI/CT/Bone scan (if PSA>10)
 
Prostate specific antigen
● False negative 20%
● False positive 65%
○ Prostate pathology
■ Prostatic cancer
■ BPH
■ Acute prostatitis
■ AROU

184
 ○ Prostate manipulation
■ Vigorous DRE
■ Prostatic massage
■ Recent catheterization
■ Recent biopsy
● > 10 likely to have present lymphnode metastasis
● > 20 likely to have present distant organ metastasis
● PSA velocity >0.75ng/mL/year
● PSA doubling time
● PSA density >0.15 (correct with prostate size)
● Age-adjusted PSA
○ 6.5 for >70yr
○ 4.5 for >60
○ 3.5 for >50
○ 2.5 for >40
● Free/total PSA % <18%
● * New candidate as tumor marker: the PCA3
○ a genetic marker, sample from urine
○ more CA specifc than PSA
 
Transrectal US with biopsy
● Should be done in patients with at least 10 years life expectancy
● Contraindications
○ Bleeding tendency
○ Urosepsis
● Procedure (*take PSA beforehand!)
○ Prophylactic quinolone
○ Bowel prep by fleet enema on the morning
○ Left lateral position
○ DRE to exclude faeces
○ +- LA by periprostatic block
○ USG to identify prostate
■ look for suspicious lesion
■ local spread
■ estimate volume
○ minimal 10 trucut systemic biopsy taken in all region, send for Gleason's grading
● Complications
○ Infection 3% if antibiotic given
○ Significant bleeding 2%
○ Urinary retention 1%
Tell the patient: normal to have minor bleed in urine/faeces/semen
Tell the patient: if you have fever, heavy rectal bleeding or AROU ... go to A/E!
● Grading by Gleason's score
○ look at the cellular characteristic and architecture
○ 1-5 grades, 5 being the the least differentiated
○ pick the two most common type of tissue seen then add the two values
 
Staging = TNM staging
● Early disease
● Metastatic disease
 
Management of Early prostatic CA
● Watchful waiting

185
 ○ for men >70yo / significant comorbidity
○ esp if cancer is low volume and low Gleason grade
● Radical prostatectomy
○ Procedure
■ Open (lower abdomen incision), Laparoscopic, Robot-assisted
■ Prostate and seminal vesicles removed
■ Try to preserve delicate nerves around prostate
■ Urethral anastomosed with bladder neck
■ Sample obturator nodes
■ Foley in situ for 2 weeks while urethra and bladder heals
○ S/E
■ Erectile dysfunction (50%) >> PDE3 inhibitors
■ Stress incontinence (2%) >> pelvic floor exercises, anticholinergics
● External beam RT
○ may include also the pelvic lymph nodes
○ S/E
■ Radiation proctitis
■ Rectal bleeding
■ CA rectum
■ Hematuria
■ Incontinence
● Brachytherapy
○ Under GA, direct deploying of radioactive seeds into prostate by 15-20 needles through perineum
○ Men with previous TURP are not candidates
 
Management of Metastatic prostatic CA 
● Medication castration
○ all would lead to increased CV risk and osteoporosis
○ GnRH partial agonist (buserilin, goserilin)
■ superstimulation the pituitary and casues downregulation of androgen receptors
■ short period of "flare phenomenon" with bone pain may occur, thus 3 weeks course of anti-
androgen is indicated
■ S/E: loss of libido, impotence, hot flushes, mood swings
○ Androgen antagonists (flutamide, cyproterone)
■ block action of testosterone on prostate
■ S/E: breast enlargement or soreness, mild stomach upset, hepatotoxicity
■ less sexual side effects
○ GnRH antagonists
● Surgical castration = bilateral orchiectomy
○ if PSA still high after post op >> start androgen antagonists (eg. flutamide) for adrenal blockade to
control residue androgen (Maximal androgen blockade), but mind the hepatotoxic effect of it by
checking liver function before presciption
○ Complications for orchiectomy
■ loss of libido, impotence, hot flushes
■ long spermatic cord stump causing groin discomfort
■ incisional hernia
■ granulomas in scrotum
● Cancer may recur in 1-2 years time due to acquired resisitance to hormonal therapy
○ Optimize hormone therapy (complete blockade)
○ Systemic chemotherapy
○ Palliative radiotherapy
○ Symptomatic relief eg. pain control, bisphosphonates, urinary drainage, transfusion for anemia etc

186
 
========================================
 
A Short note on Neurogenic bladder
● Key anatomy
○ Frontal lobe - micturation control centre: pose constant inhibition to pons to control bladder activity
○ Pons - pontine micturation centre: coordinate urethral sphinter and detrusor muscle, in active tone
○ Spinal cord - relay
○ Sacral cord (S2-4) - local reflex arch for micturation
○ Autonomic nervous system - sympathetic: void ; parasympathetic: retent
○ Somatic nervous system - Pudendal nerve: contract external sphinter
● Level of lesion
○ Brain CVS = Cerebral shock (Retention) >> Detrusor hyperreflexia as PMC released (Incontinence)
○ Acute spinal cord = Spinal shock (Retention) >> Detrusor sphinter dyssenergia + detrusor
hyperreflexia (Incontinence)
○ Chronic spinal cord = Detrusor sphinter dyssenergia + detrusor hyperreflexia (Incontinence)
○ Sacral cord = Hypocontractile bladder (Retention with overflow incontinence)
○ Pudendal nerve = Loss of external sphinter tone (Stress incontinence)
 
Overactive bladder syndrome (OAB)
 
● Urgency, with or without urge incontinence, usually with frequency and nocturia
● Possibly due to detrusor overactivity
● Investigate by cystometrogram
○ intravesicle pressure (from catheter) - intra abdominal pressure (from rectum)
○ calculate the DETRUSOR pressure
○ saline is then instilled into the bladder as the filling phase
○ normally in the filling phase the detrusor pressure should maintain more or less the same due to its
high compliance, while starts to increase at the end of filling (around 500ml of urine within bladder)
○ if there is OAB, the detrusor pressure will rise rapidly causing rapid urgency
 
In CMG
● if high detrusor pressure at rest, it will damage the kidney chronically
● if there is high detrusor pressure with low urine flow, it signifies BOO
 
========================================
 
Stress incontinence
 
Classification of Stress Urinary Incontinence by Blaivas and Olsson
● type 0 - type 3
● classified by the bladder position related to pubic symphysis in fluroscopic image in both RESTING and
COUGHING
● also look at the descend of bladder and urethra when coughing
 
========================================
  
Impotence
 
Causes
● Psychological - loss of morning erection
● Hormonal - low testosterone, pituitary tumor
● Neurogenic - post stroke, spinal cord or brain injury, alzheimer's, parkinson
● Arterial - PVD, hypertension, hypotension, DM
● Others - Smoking, alchohol, drugs (barbituates, thiazides, clonidine, prazosin), surgical complications
 
Medical Management

187
 ● Lifestyle modifications
○ Smoking-cessation, low lipid diet, excercise
● Phosphodiesterase 5 inhibitors
○ increase the intracellular cGMP (NO >> cGMP >> inactive GMP) in corpus cavernosum, leading to
smooth muscle relaxation thus vasodilation in penis
○ 3 drugs
■ Sildenafil (Viagra) - 60min onset, 4-12 hours duration
■ Vardenafil (Levitra) - 30min onset, 4-12 hours duration
■ Tadalafil (Cialis) - 30min onset, 36 hours duration
○ Equivocal effacacy for three drugs, while a fatty meal will reduce viagra and levitra bowel
absorption, S/E mainly blurred vision, flushing, nasal congestion
○ Side effects for cialis are mainly dyspepsia, backache, myalgia 
● Apomorphine (Uprima)
○ centrally acting agent, nonselective dopamine agonists
○ minimal effect clinically
● Intracavernosal injection (Caverjet)/ Transurethral (Befar)/ Topical
○ Alprostadil, a PGE1 analogue
○S/E as pain, hematoma, ecchymosis
 
Surgical management
● Vascular surgery
● Penile prosthesis
 
Others
● Vacuum pump
 
===================================== 
 
Priapism
 
Ischemic priapism
● Urologic emergency
● S/S: pain, tenderness, scarring of corpora cavernosa, flaccid glans
● Causes
○ sickle cell anemia sequestration
○ neoplasms esp leukemia with hyperviscosity syndrome
○ drugs: hydralazine, prazosin, trazadone, alcohol, cocaine
● Treatments
○ corporal irrigation with aspiration of old blood
○ alpha adrenergic - phenylephrine
○ surgical shunting
 
High flow priapism
● caused by perineal or genital trauma, with pudendal arterial fistula or cavernosal artery laceration, giving
rise to the high flow state
● DDx from ischmic priapism by blood aspiration for blood gas (oxygenated in this case!)
● Treatment: embolization of the ipsilateral pudendal artery
 
===================================== 
 
Testicular tumors
 
Classification
● Germ cell tumor 95%
○ Seminoma

188
 ○ Non-seminoma (Embryonal CA, Yolksac, choriocarcinoma, teratoma, mixed)

Seminoma ○ NSGCT

- 30-40s ○ - 20-30s

- Early presentation ○ - Late presentations

○ - AFP, LDH, hCG

- Radiosensitive
● Sex cord stromal tumors 5%
○ Leydig cell
○ Sertoli cell
 
Clinical presentation
● Painless solid testicular mass
● 1/3 presents as pain
● pulmonary pr gastrointestinal compliant in metastasis
 
Investigations
● USG
○ seminomas as hypoechoic lesion
○ nonseminomatous tumors as heterogeneous
● Tumor markers
○ AFP, beta HCG, LDH
 
Management of seminoma
● Stage I = Radical traninguinal orchidectomy + Active surveillance/Adjuvant RT/Adjuvant Chemo
● Stage II = Radical transinguinal orchidectomy + Adjunctive RT/Adjuvant Chemo
● Bulky nodal disease (>5mm) = Combination chemotherapy [BEP=Bleomycin+Etoposide+Cisplatin]
 
Management of NSGCT
● Stage I = Radical transinguinal orchidectomy + Active surveillance/RPLND/Adjuvant Chemo
● Stage II = Radical transinguinal orchidectomy + RPLND +- Adjuvant Chemo
● Advanced stage = Combination chemotherapy
 
Reasons for transinguinal approach
● to gain adequate surgical resection of the spermatic cord
● to facilitate subsequent incision radiotherapy (preserving the other testis)
● proposed different drainage of scrotum and testes
 
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Scrotal layers (EIGHT)
● Skin
● Dartos fascia
● External spermatic fascia
● Cremaster muscle
● Internal spermatic fascia
● Parietal and visceral layers of tunica vaginalis
● Tunica albuginea

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Nuclear medicine scans: MAG3/DMSA/DTPA scan
Radiological scans: IVU, anterograde/retrograde pyelogram, micturating cystogram
 
* normal urine flow rate= 0.5-1ml/kg/hour
* normal bladder capacity= ~500ml
 
Intravenous urogram
● Basics
○ Contraindicated in patients with impaired renal function
○ technically quite demanding to give a good series of pictures
○ Anatomical info + semi-functional info
● Content
○ Preliminary film without contrast
○ 0 min - Injection film/nephrogram - see the renal contour
○ 5 min - Excretion film - see the calyx
○ 10min - Tomographic technique (use distance to take away background feature for better outlining)
○ 20min - Release film - see the ureters
○ Prone film - relieve intraabdominal compression
○ Full bladder film
○ Empty bladder film
 
Retrograde pyelogram
● put in a catheter into ureter then inject contrast retrogradely into ureter and renal pelvis
● an alternative for IVU for renal impaired patients (poor excretion of contrast in IVU)
 
Anterograde pyelogram
● usually follow percutaneous nephrostomy indicated for hydronephrosis
○ insertion site: the petit's triangle (latissimus dorsi, iliac crest, 12th rib)
● sometimes combined with retrograde pyelogram to deliniate both upper and lower border of obstruction
 
Micturating cystogram
● inject contrast into bladder then void
● useful in assessing for VUR (vesicoureteric reflux) esp in children
 
DMSA/DTPA scan
● Static scan to assess scarring and acute pyelonephritis
● used frequently in children
● Acute pyelonephritis: focal or diffused area of reduced uptake without cortical thinning
● Scarring: reduced uptake plus cortical thinning
 
MAG3 renography
● A dynamic scan
● calculate the time taken for contrast to be picked up, and the differential functions of the two kidneys
● Diuretic renography
○ an extra investigation based on MAG3 renography
○ add lasix to increase nuclear medium flow into the dilated collecting system which pools a lot of fluid
 
Upper tract imaging for hematuria: USG vs IVU vs CT urogram
● USG
○ Noninvasive, no contrast, cheap, readily available, good for parenchyma assessment (cortical
thinning, hydronephrosis, renal cysts, large tumor)
○ Operator dependent, bad for pelvis or ureters
● IVU
○ Provide functional information, good for urethielial assessment (TCC of pelvis, ureter, stone)

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 ○ Time consuming, bad for parenchyma
● CT urogram
○ Precise anatomy, extraurinary tract information
○ High radiation
 
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Urodynamic studies
 
Equipment
3. intrarectal probe - measure the intraabdominal pressure
4. intravesicle probe - measure the intravesicle pressure
5. foley catheter - instillation of fluid (CONTRASTED in video-assisted type
 
Uroflowmetry
7. need >150ml urine volume to be valid
8. <15ml/s is considered abnormal in female
9. due to
○ urinary tract obstruction
○ atonic bladder
10. comment on:
○ hesitancy
○ total voided volume
○ peak flow rate
○ bell shape curve
○ intermitent flow
○ residue volume
 
Cystometry
2. first empty the bladder
○ record 1st peak flow rate, volume voided, hesistation period
○ note for any voiding problems
3. 12F catheter inserted measure residue volume
4. rectal catheter inserted to record intraabdominal pressure
5. fill the bladder with the catheter, in rate between 10-100ml/min
6. bladder catheter records intravesical pressure
7. ask patient to indicate first and maximal desire to void
8. note for any systolic detrusor activity at filling
9. ask patient to cough, note any leaking
10. void in flowmeter
 
Normal values
● Residue urine < 50ml
● First desire to void at 150-200ml
● Capacity 400-600ml
● Detrusor pressure rise <15cmH2O at filling
● Absence of systolic detrusor contractions
● No leakage on coughing
● Voiding detrusor pressure rise <70cmH2O
Caution! female has a shorter urethra hence a low resistance to urine flow, they may void by pure sphinter
relaxation WITHOUT ANY DETRUSOR CONTRACTION, therefore a PRESENCE OF DETRUSOR PRESSURE may
already be an abnormal finding that signifies BOO
● Peak flow rate >15ml/s for volume >150ml
 
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Surgery in Renal Replacement Therapy
Hemodialysis
● Choice
○ Arteriovenous fistula
○ Arteriovenous access graft
○ Central venous catheter
●
● AVF ● Graft ● Central venous catheter

●
Ad LA, Day case ● ●
Can bridge Not dependent on cardiac output
vantage   long distance  
Resistant to thrombosis and   Used immediately
infection Easy to establish

●
Dis Take months to ● Take ● Susceptible to infection
avantage mature weeks to mature  
    Venous stenosis may preclude future success
Difficult to estabilish Susceptible to in same limb
infection
● Consideration
○ Emergency - need CVC HD right now?
○ Fitness of patient - good cardiac output for AVF or graft?
○ Adequacy of vessels - state of arteries (atherosclerosis?) and veins (thrombosed from punctures)
○ Patient preference
 
Transplant
● Preop work up
○ Transplant may change a patient's life, but he/she has to pass through two main obstacles:
surviving the surgery + the longterm immunosuppression
Surgical risk = high cardiovascular risk + poor iliac artery flow in PVD
Immunosuppression = opportunistic disease + reactivation of latent disease
○ Excercise ECG for cardiac reserve
○ Ankle-brachial index for iliac artery status
● Types of donor
○ Life donor
○ Cadevaric donor
● Pre-op preparation
○ DAT + FMN
○ Agumentin on induction
○ Immunosuppresants
● Precedure
○ Renal harvest surgical technique (cadevaric)
■ Midline laparotomy, expose infrarenal aorta
■ double balloon catheter passed up, cold perfusion fluid forced into kidney with IVC drainage
of warm blood
■ Ice placed over kidneys
■ Remove adrenal glands, but preserved tissue around hilum and lower kidney pole (which
contains vessels to ureters)
■ Right kidney removed with a segment of aorta, kept cool
■ Left kidney removed, kept cool
○ Tranplantation technique
■ Tissue typing + consent + prenisolone/IL2R antibody
■ Curvilinear incision
■ Identify iliac vessels

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 ■ Venous >> artery anastomosis
■ Close wall
● Postop management
○ Continual Immunosuppressents + Acyclovir + Septrin
 

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