Oxford Handbook of Clinical Surgery

OXFORD MEDICAL PUBLICATIONS

Oxford Handbook of

Clinical Surgery

Published and forthcoming Oxford Handbooks

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Oxford Handbook of

Clinical

Surgery

Fourth edition

Edited by

Greg McLatchie

Consultant Surgeon,

Hartlepool General Hospital,

Hartlepool, UK

Neil Borley

Consultant Colorectal Surgeon,

Cheltenham General Hospital,

Cheltenham, UK

Joanna Chikwe

Associate Professor, Department of Cardiothoracic

Surgery, Mount Sinai Medical Center,

New York, United States

Great Clarendon Street, Oxford, OX2 6DP,

United Kingdom

Oxford University Press is a department of the University of Oxford.

It furthers the University’s objective of excellence in research, scholarship,

and education by publishing worldwide. Oxford is a registered trade mark of

Oxford University Press in the UK and in certain other countries

The moral rights of the authors have been asserted

First Edition published 1990

Second Edition published 2002

Third Edition published 2007

Fourth Edition published 2013

Impression: 1

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without the prior permission in writing of Oxford University Press,

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You must not circulate this book in any other binding or cover and you must

impose the same condition on any acquirer

British Library Cataloguing in Publication Data

Data available

ISBN 978–0–19–969947–6 (ﬂ exicover: alk.paper)

Printed in China by

C&C Offset Printing Co. Ltd.

Oxford University Press makes no representation, express or implied, that the drug

dosages in this book are correct. Readers must therefore always check the product

information and clinical procedures with the most up-to-date published product

information and data sheets provided by the manufacturers, and the most recent

codes of conduct and safety regulations. The authors and the publishers do not

accept responsibility or legal liability for any errors in the text, or for the misuse or

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and recommendations are for the non-pregnant adult who is not breastfeeding.

Preface to the fourth

edition

Sometimes we have to look backward to look forward. Since 1990, sur-

gery has witnessed cataclysmic changes. In our Trust, the ﬁ rst laparoscopic

cholecystectomy was performed in 1992, and has now become the pro-

cedure of choice for most gall bladder disease and many other surgical

operations in the western world. With the expansion of laparoscopic

surgery, we have encountered a whole new range of complications with

an escalation in the demise of general surgery as the result of hyperspe-

cialization. There are many surgical trainees who have scant experience

of open surgery and who have, due to European directives, limited time

exposure to surgical procedures. In fact, most technical training is now

obtained from emergency on call such that a new speciality of emergency

surgery is developing. A recent British Medical Journal (BMJ) article recom-

mended a training programme for surgeons wishing to work in remote

and rural surgery—not only in the Developing World, but in remote and

isolated communities in the United Kingdom! General surgery may largely

have gone, but it should not be forgotten. Most countries in the world do

not have access to these recent innovations and there is still a case in the

developed world for experience in open and general surgery to be incor-

porated in the formal training programmes of junior surgeons.

G. R. McLatchie

Hartlepool, September 2012

Preface to the third

edition

This, the third edition of the Oxford Handbook of Clinical Surgery, reﬂ ects

the changes which have occurred in general surgery over the 17 years

since the ﬁ rst edition was published.

Firstly, we have recruited the services of two new editors, a stark con-

trast to the original, which was written by a single author with the assis-

tance of a surgical registrar.

Secondly, each chapter has been written by a specialist consultant or

registrar in the subject and, therefore, presents a modern, state-of-the-art

treatise on each topic.

Again, each condition is covered in the original two-page format with

blank pages for accompanying notes.

I am particularly grateful for the commitment that Jo Chikwe and Neil

Borley have made, and also wish to thank staff at Oxford University Press

for their support and patience. I am also grateful for the contribution and

support given by many colleagues.

G. R. McLatchie

Hartlepool, March 2007

vii

Preface to the ﬁ rst

edition

The idea of this book was ﬁ rst suggested by Mr Gordon McBain, consult-

ant surgeon at the Southern General Hospital, Glasgow. We have received

considerable support from the staff of Oxford University Press, and are

also indebted to Mr J. Rhind and Dr J. Daniel for their contributions and

our surgical teachers, especially Mr J. S. F. Hutchison, Mr M. K. Browne,

Mr J. Neilson, Mr D. Young, Mr A. Young, and the late Mr I. McLennan

whose practical advice and anecdotes pepper the pages….

G. R. McLatchie

S. Parameswaran

1990

viii

Dedications

For Ross, Cameron, Ailidh, Claire, and Calum

GRM

For Alexander, Christopher, and Jennifer

Acknowledgements

We are grateful to the support of our colleagues and Oxford University

Press and to Mrs Pamela Lines for her diligent support in the ﬁ nal editing

of the manuscript.

Contents

Detailed contents xi

Contributors xxiii

Symbols and abbreviations xxv

1 Good surgical practice

2 Principles of surgery

3 Surgical pathology

141

4 Practical procedures

185

5 Head and neck surgery

221

6 Breast and endocrine surgery

239

7 Upper gastrointestinal surgery

271

8 Liver, pancreatic, and biliary surgery

311

9 Abdominal wall

335

10 Urology

353

11 Colorectal surgery

391

12 Paediatric surgery

423

13 Paediatric orthopaedic

457

14 Major trauma

477

15 Orthopaedic surgery

489

16 Plastic surgery

589

17 Cardiothoracic surgery

619

18 Peripheral vascular disease

641

19 Transplantation

675

20 Surgery in tropical diseases

701

21 Common operations

729

22 Eponymous terms and rarities

757

Anatomy and physiology key revision points index 777

Index 779

This page intentionally left blank

Detailed contents

Contributors xxiii

Symbols and abbreviations xxv

1 Good surgical practice 1

Duties of a doctor 2

Communication skills 4

Evidence-based surgery 6

Critical appraisal 10

Audit 12

Consent 14

Death 16

End-of-life issues 18

Clinical governance 20

2 Principles of surgery 23

Terminology in surgery 24

History taking and making notes 26

Common surgical symptoms 28

Examination and investigation of the patient:

Evaluation of breast disease 30

Evaluation of the neck 32

Evaluation of the abdomen 34

Abdominal investigations 36

Evaluation of pelvic disease 38

Evaluation of peripheral vascular disease 40

Evaluation of the skin and subcutaneous tissue disease 42

Surgery at the extremes of age 44

Day case and minimally invasive surgery 46

Preoperative care:

Surgery in pregnancy 48

Surgery and the contraceptive pill 50

Surgery in endocrine disease 52

xii

DETAILED CONTENTS

Surgery and heart disease 54

Surgery and respiratory disease 58

Surgery in renal and hepatic disease 60

Surgery in neurological disease 62

Pre-optimization of the patient:

Fluid optimization 64

Nutrition in surgical patients 66

Enhanced recovery after surgery 68

Perioperative care:

Getting the patient to theatre 70

Prophylaxis—antibiotics and thromboprophylaxis 72

In-theatre preparation 74

Positioning the patient 76

Sterilization, disinfection, and antisepsis 78

Scrubbing up 79

Surgical instruments 80

Incisions and closures 82

Drains 83

Stomas 84

Knots and sutures 86

Post-operative:

Post-operative management 88

Drain management 90

Fluid management 92

Acid–base balance 94

Blood products and procoagulants 96

Transfusion reactions 98

Shock 100

Post-operative haemorrhage 102

Wound emergencies 104

Cardiac complications 106

Respiratory complications 108

Renal complications 110

Urinary complications 112

Gastrointestinal complications 114

Neurological complications 116

Haematological complications 118

Deep venous thrombosis and pulmonary embolism 120

Risk scoring 122

xiii

DETAILED CONTENTS

Critical care 124

Commonly used terms in ITU 126

Invasive monitoring 128

Ventilation and respiratory support 130

Circulatory support 132

Renal support 134

Enteral support 136

Sepsis, SIRS, MODS, and ALI 138

3 Surgical pathology 141

Cellular injury 142

Inﬂ ammation 144

Wound healing 146

Ulcers 148

Cysts, sinuses, and ﬁ stulas 150

Atherosclerosis 152

Thromboembolic disease 154

Gangrene and capillary ischaemia 158

Tumours 160

Carcinogenesis 162

Screening 164

Grading and staging 168

Tumour markers 170

Surgical microbiology 172

Surgically important organisms 174

Soft tissue infections 176

Blood-borne viruses and surgery 178

Bleeding and coagulation 180

Anaemia and polycythaemia 182

4 Practical procedures 185

Endotracheal intubation 186

Cardioversion 188

Deﬁ brillation 190

Venepuncture 192

Intravenous cannulation 194

Arterial puncture and lines 196

Insertion of central venous catheter 198

xiv

DETAILED CONTENTS

Chest drain insertion 200

Management of chest drains 202

Pericardiocentesis 204

Cricothyroidotomy 206

Nasogastric tube insertion 208

Urethral catheterization 210

Suprapubic catheterization 212

Paracentesis abdominis 214

Rigid sigmoidoscopy 216

Local anaesthesia 218

Intercostal nerve block 220

5 Head and neck surgery 221

Thyroglossal cyst, sinus, and ﬁ stula 222

Branchial cyst, sinus, and ﬁ stula 224

Salivary calculi 226

Acute parotitis 228

Salivary gland tumours 230

Head and neck cancer 232

Facial trauma 234

Neck space infections 236

6 Breast and endocrine surgery 239

Breast cancer 240

Surgical treatment of breast cancer 242

Breast cancer screening 244

Benign breast disease 246

Acute breast pain 248

Goitre 250

Thyrotoxicosis 252

Thyroid tumours—types and features 254

Thyroid tumours—diagnosis and treatment 256

Post-thyroid surgery emergencies 258

Primary hyperparathyroidism 260

Multiple endocrine neoplasia 262

Cushing’s syndrome 264

Conn’s syndrome 266

Phaeochromocytoma 268

DETAILED CONTENTS

7 Upper gastrointestinal surgery 271

Upper gastrointestinal endoscopy 272

Oesophageal motility disorders 274

Pharyngeal pouch 276

Hiatus hernia 278

Gastro-oesophageal reﬂ ux disease 280

Oesophageal tumours 282

Peptic ulcer disease 284

Gastric tumours 286

Chronic intestinal ischaemia 288

Surgery for morbid obesity 290

Small bowel tumours 292

Acute haematemesis 294

Acute upper GI perforation 296

Acute appendicitis 298

Acute peritonitis 300

Acute abdominal pain 302

Gynaecological causes of lower abdominal pain 306

Intra-abdominal abscess 308

8 Liver, pancreatic, and biliary surgery 311

Jaundice—causes and diagnosis 312

Jaundice—management 314

Gall bladder stones 316

Common bile duct stones 318

Chronic pancreatitis 320

Portal hypertension 322

Cirrhosis of the liver 324

Pancreatic cancer 326

Cancer of the liver, gall bladder, and biliary tree 328

Acute variceal haemorrhage 330

Acute pancreatitis 332

9 Abdominal wall 335

Abdominal wall hernias 336

Inguinal hernia 338

Femoral hernia 340

Umbilical and epigastric hernias 342

xvi

DETAILED CONTENTS

Incisional hernias 344

Other types of hernia 346

Rectus sheath haematoma 347

Groin disruption 348

Acute groin swelling 350

10 Urology 353

Symptoms and signs in urology 354

Investigations of urinary tract disease 356

Urinary tract stones 358

Obstruction of the ureter 360

Benign prostatic hyperplasia 362

Stricture of the urethra 364

Scrotal swellings 366

Disorders of the foreskin 368

Common conditions of the penis 370

Erectile dysfunction 372

Adenocarcinoma of the kidney 374

Transitional cell tumours 376

Adenocarcinoma of the prostate 378

Carcinoma of the penis 380

Testicular tumours 382

Haematuria 384

Acute urinary retention (AUR) 386

Acute testicular pain 388

11 Colorectal surgery 391

Ulcerative colitis 392

Crohn’s disease 394

Other forms of colitis 396

Colorectal polyps 398

Colorectal cancer 400

Restorative pelvic surgery 402

Minimally invasive colorectal surgery 403

Diverticular disease of the colon 404

Rectal prolapse 406

Pilonidal sinus disease 408

Fistula-in-ano 410

Haemorrhoids 412

xvii

DETAILED CONTENTS

Acute anorectal pain 414

Acute rectal bleeding 416

Acute severe colitis 418

Post-operative anastomotic leakage 420

12 Paediatric surgery 423

Principles of managing paediatric surgical cases 424

Acute abdominal emergencies—overview 426

Oesophageal atresia 428

Pyloric stenosis 430

Malrotation and volvulus 432

Intussusception 434

Hirschsprung’s disease 436

Rare causes of intestinal obstruction 438

Abdominal wall defects 440

Necrotizing enterocolitis (NEC) 442

Inguinal hernia and scrotal swellings 444

Other childhood hernias 446

Prepuce (foreskin) and circumcision 448

Undescended testis 450

Solid tumours of childhood 452

Neck swellings 454

13 Paediatric orthopaedic 457

Developmental dysplasia of the hip (DDH) 458

Slipped upper femoral epiphysis (SUFE) 460

The limping child 462

The child with a fracture 464

Non-accidental injury (NAI) 466

Legg–Calvé–Perthes disease 468

Motor development 470

Club foot or congenital talipes equinovarus (CTEV) 471

Flat feet (pes planus) 472

The osteochondritides 474

14 Major trauma 477

Management of major trauma 478

Thoracic injuries 480

xviii

DETAILED CONTENTS

Abdominal trauma 482

Vascular injuries 484

Head injuries 486

15 Orthopaedic surgery 489

Examination of a joint 490

Examination of the limbs and trunk 492

Fracture healing 494

Reduction and ﬁ xation of fractures 498

The skeletal radiograph 502

Injuries of the phalanges and metacarpals 504

Wrist injuries 508

Fractures of the distal radius and ulna 510

Fractures of the radius and ulnar shaft 512

Fractures and dislocations around the elbow in children 514

Fractures of the humeral shaft and elbow in adults 518

Dislocations and fracture dislocations of the elbow 522

Fractures around the shoulder 524

Dislocations of the shoulder region 526

Fractures of the ribs and sternum 530

Fractures of the pelvis 532

Femoral neck fractures 536

Femoral shaft fractures 538

Fractures of the tibial shaft 540

Fractures of the ankle 544

Fractures of the tarsus and foot 546

Injuries and the spinal radiograph 550

Spinal injuries 554

Acute haematogenous osteomyelitis 558

Chronic osteomyelitis 560

Septic arthritis 562

Peripheral nerve injuries 564

Brachial plexus injuries 566

Osteoarthrosis (osteoarthritis) 568

Carpal tunnel syndrome 570

Ganglion 572

Bone tumours 574

Low back pain 578

Paget’s disease (osteitis deformans) 582

The great toe 584

xix

DETAILED CONTENTS

Arthroplasty 586

Useful reading 588

16 Plastic surgery 589

Suturing wounds 590

Skin grafts 594

Surgical ﬂ aps 596

Management of scars 598

Excision of simple cutaneous lesions 600

Skin cancer 602

Burns: assessment 604

Burns: management 606

Soft tissue hand injuries 610

Hand infections 612

Dupuytren’s disease 614

Breast reduction 616

Breast augmentation 617

Breast reconstruction 618

17 Cardiothoracic surgery 619

Basics 620

Principles of cardiac surgery 622

Coronary artery disease 626

Valvular heart disease 628

Cardiothoracic ICU 630

Lung cancer 632

Pleural effusion 634

Pneumothorax 636

Mediastinal disease 638

18 Peripheral vascular disease 641

Acute limb ischaemia 642

Chronic upper limb ischaemia 644

Chronic lower limb ischaemia 647

Intermittent claudication 648

Critical limb ischaemia 650

Aneurysms 652

Ruptured abdominal aortic aneurysm 654

DETAILED CONTENTS

Vascular developmental abnormalities 656

Carotid disease 658

The diabetic foot 660

Amputations 662

Vasospastic disorders 664

Varicose veins 666

Deep venous thrombosis 668

Thrombolysis 670

Complications in vascular surgery 672

19 Transplantation 675

Basic transplant immunology 676

Immunosuppression and rejection 678

Transplant recipients 682

Transplant donors 684

Heart and lung transplantation 690

Kidney transplantation 692

Pancreas and islet transplantation 694

Liver transplantation 696

Small bowel transplantation 698

20 Surgery in tropical diseases 701

Medicine in the tropics 702

Typhoid 704

Amoebiasis and amoebic liver abscess 706

Anaemias in the tropics 708

Malaria 710

Schistosomiasis (bilharziasis) 712

Filariasis 714

Hydatid disease 716

Ascariasis 718

Leishmaniasis 719

Trypanosomiasis 720

Tuberculosis in the tropics 722

Leprosy (‘Hansen’s disease’) 724

Guinea worm infestation 726

Threadworms 727

Mycetoma (madura foot) 728

xxi

DETAILED CONTENTS

21 Common operations 729

Diagnostic laparoscopy 730

Principles of laparotomy 732

Cholecystectomy 734

Appendicectomy 736

Inguinal hernia repair 738

Perforated peptic ulcer repair 740

Haemorrhoid surgery 742

Pilonidal sinus excision (Bascom II) 744

Femoral embolectomy 746

Right hemicolectomy 748

Stoma formation 750

Wide local excision—breast 752

Below knee amputation 754

22 Eponymous terms and rarities 757

Anatomy and physiology key revision points index 777

Index 779

This page intentionally left blank

xxiii

Contributors

Alex Acornley

Consultant Orthopaedic

Surgeon,

Airedale Hospital NHS

Foundation Trust, West

Yorkshire, UK

Anil Agarwal

Consultant General and Colorectal

Surgeon,

North Tees and Hartlepool NHS

Trust, University Hospital of

Hartlepool, UK

Khalid A. Al-Hureibi

Specialist Registrar,

Department of General Surgery,

Lister Hospital, Stevenage, UK

John Asher

Consultant Transplant Surgeon,

Transplant Unit, Western

Inﬁ rmary, Glasgow, UK

David Chadwick

Consultant Urological Surgeon,

The James Cook University

Hospital, Middlesbrough, UK

Lucy Cogswell

Specialist Registrar,

Department of Plastic &

Reconstructive Surgery, John

Radcliffe Hospital, Oxford, UK

J. H. Dark

Consultant Cardiothoracic

Surgeon,

Freeman Hospital, Newcastle upon

Tyne, UK

Richard P. Jeavons

Specialist Registrar,

Trauma and Orthopaedics

(Northern Deanery), Department

of Trauma and Orthopaedics,

University Hospital of North Tees,

Stockton, UK

Vijay Kurup

Consultant Breast and Endocrine

Surgeon,

University Hospital of North Tees,

Stockton on Tees, UK

Jamie Lyall

Consultant Head and Neck

Surgeon (Maxillofacial),

Surgical Division, James Cook

University Hospital Trust,

Middlesbrough, Queen Margaret

Hospital, Dunfermline, UK

Alan Middleton

Consultant Orthopaedic Surgeon,

Department of Hand and Wrist

Surgery, University Hospital of

North Tees, Stockton, UK

Rob Milligan

ST3 General Surgery, Northern

Deanery, UK

Sandrasekeram

Parameswaran

General Surgeon,

Cold Lake Healthcare Centre,

Visiting Surgeon, Canadian forces

base, 4 Wing, Cold Lake, Alberta,

Canada

xxiv

CONTRIBUTORS

Lakshmi Parameswaran

Senior House Ofﬁ cer,

Mater Misericordiae University

Hospital, Dublin, Ireland

Saumitra Rawat

Consultant Surgeon,

Macclesﬁ eld District General

Hospital, UK

Andreas Rehm

Consultant Paediatric Orthopaedic

and Trauma Surgeon,

Depatment of Orthopaedic and

Trauma Surgery, Addenbrooke’s

Hospital, Cambridge University

Hospitals NHS Trust, Cambridge,

David Talbot

Consultant Transplant and

Hepatobiliary Surgeon,

Transplant Institute, Freeman

Hospital, Newcastle. Visiting

Professor, University of Sunderland.

Reader, University of Newcastle

upon Tyne, UK

Mark Whyman

Consultant General and Vascular

Surgeon,

Department of Surgery,

Cheltenham General Hospital,

Cheltenham, UK

xxv

Symbols and abbreviations

d decreased

i increased

n normal

l leading to

 warning

2 important

3 don’t dawdle

b cross reference

♀ female

♂ male

p primary

s secondary

< less than

> more than

t equal to or greater than

d equal to or less than

% per cent

7 approximately

8 approximately equals to

α alpha

β beta

°C degree Celsius

AAA abdominal aortic aneurysm

ABG arterial blood gas

A&E Accident and Emergency Department

ABPI ankle–brachial pressure index

ACAS Asymptomatic Carotid Artery Stenosis Study

ACE angiotensin-converting enzyme

ACh acetylcholine

AChE acetylcholinesterase

ACJ acromioclavicular joint

ACL anterior cruciate ligament

ACST Asymptomatic Carotid Surgery Trial

ACTH adrenocorticotropic hormone

ADH antidiuretic hormone

ADP adenosine diphosphate

xxvi

AF atrial ﬁ brillation

AFP alpha-fetoprotein

AIDS acquired immunodeﬁ ciency syndrome

AIN anal intraepithelial neoplasia

AKA above-knee amputation

ALI acute lung injury

ALS advanced life support

a.m. ante meridiem

amp ampere

AMPLE allergy/medication/past medical history/last meal/events

of the incident

ANDI abnormalities of normal development and involution

(of breast)

ANF antinuclear factor

APA aldosterone-producing adenoma

APACHE Acute Physiology And Chronic Health Evaluation

APC antigen-presenting cell or argon plasma coagulation

APER abdominoperineal resection

APTR activated partial thromboplastin time ratio

APTT activated partial thromboplastin time

AR aortic regurgitation

ARDS acute respiratory distress syndrome

ARR absolute risk reduction or aldosterone/renin ratio

5-ASA 5-aminosalicyclic acid

ASB assisted spontaneous breathing

ATG anti-thymocyte globulin

ATLS advanced trauma life support

ATP adenosine triphosphate

AUR acute urinary retention

AV arteriovenous or atrioventricular

AVM arteriovenous malformation

AVN avascular necrosis

AVS adrenal venous sampling

AXR abdominal X-ray

BCC basal cell carcinoma

BCG Bacillus Calmette–Guérin

BCR B-cell receptor

B-HCG beta-human chorionic gonadotrophin

BiPAP biphasic positive airway pressure

BKA below-knee amputation

SYMBOLS AND ABBREVIATIONS

xxvii

BMI body mass index

BMJ British Medical Journal

BNF British National Formulary

BP blood pressure

BPH benign prostatic hyperplasia

BS blood sugar

BSA body surface area

BXO balanitis xerotica obliterans

Ca calcium

CABG coronary artery bypass graft

CAD coronary artery disease

CAPD continuous ambulatory peritoneal dialysis

CAVH continuous arteriovenous haemoﬁ ltration

CBP cardiopulmonary bypass

CCF congestive cardiac failure

CD cellular differentiation (molecule)

CDH congenital dysplasia of the hip

CDT Clostridium difﬁ cile toxin

CEA carcinoembryonic antigen or carotid endarterectomy

CF cystic ﬁ brosis

CFU colony-forming unit

CI conﬁ dence interval

Cl chloride

CLI critical limb ischaemia

cm centimetre

CMI cell-mediated immune (reaction)

CMV cytomegalovirus or controlled mechanical ventilation

CNI calcineurin inhibitor

CNS central nervous system

CNST criminal negligence scheme for Trusts

CO cardiac output

carbon dioxide

COAD chronic obstructive airway disease

COC combined oral contraceptive

COPD chronic obstructive pulmonary disease

CPAP continuous positive airway pressure

CPB cardiopulmonary bypass

C,P,&O cysts, parasites, and ova

CPR cardiopulmonary resuscitation

Cr creatinine

SYMBOLS AND ABBREVIATIONS

xxviii

CRCa colorectal cancer

CRP C-reactive protein

CSF cerebrospinal ﬂ uid

C-spine cervical spine

CT computerized tomography

CTA CT angiography

CTPA computerized tomography pulmonary angiography

Cu copper

CV central venous

CVA cerebrovascular accident

CVP central venous pressure

CVVH continuous venovenous haemoﬁ ltration

Cx circumﬂ ex

CXR chest X-ray

2D two-dimensional

3D three-dimensional

DA dopamine

DALM dysplasia-associated lesion or mass

DBD donor after brainstem death

DC direct current

DCD donor after circulatory death

DCIS ductal carcinoma in situ

DDAVP 1-deamino-8-D-arginine vasopressin

DDH developmental dysplasia of the hip

DHS dynamic hip screw

DHT dihydrotestosterone

DIC disseminated intravascular coagulation

DIEP deep inferior epigastric perforator (ﬂ ap)

DIPJ distal interphalangeal joint

dL decilitre

DM diabetes mellitus

DMSA dimercaptosuccinate

DNA deoxyribonucleic acid

DNR do not resuscitate

DOH Department of Health

DP distal phalanx or diastolic pressure

2,3-DPG 2,3-diphosphoglycerate

DPL diagnostic peritoneal lavage

DRUJ distal radioulnar joint

DSA digital subtraction angiography

SYMBOLS AND ABBREVIATIONS

xxix

DTPA diethylene triamine pentaacetic acid

DVT deep venous thrombosis

EBV Epstein–Barr virus

ECF extracelllular ﬂ uid

ECG electrocardiogram

ECST European Cardiac Surgery Trial

ED erectile dysfunction

e.g. exempli gratia (for example)

ELISA enzyme-linked immunosorbent assay

EMD electromechanical delay

EMG electromyography

EMR endocospic mucosal resection

EOCP (o)estrogen-containing contraceptive pill

EPL extensor pollicis longus

EPO erythropoietin

ER (o)estrogen receptor

ERAS enhanced recovery after surgery

ERCP endoscopic retrograde cholangiopancreatography

ES endoscopic sphincterotomy

ESD endoscopic submucosal dissection

ESR erythrocyte sedimentation rate

ESWL extracorporeal shock wave lithotripsy

ET endotracheal tube

EUA examination under anaesthetic

EUS endoscopic ultrasound

EVAR endovascular aneurysm repair

EVLT endovenous laser therapy

FAP familial adenomatous polyposis

FAST focused abdominal sonography for trauma

FBC full blood count

FDP ﬂ exor digitorum profundus

FDS ﬂ exor digitorum superﬁ cialis

FEV

1 forced expiratory volume in 1 second

FFP fresh frozen plasma

FiO

2 fraction of oxygen in inspired air

FLC ﬁ brolamellar carcinoma

FNAB ﬁ ne needle aspiration biopsy

FNAC ﬁ ne needle aspiration cytology

FPL ﬂ exor pollicis longus

FSH follicle-stimulating hormone

SYMBOLS AND ABBREVIATIONS

xxx

5-FU 5-ﬂ uorouracil

g gram

G gauge

GA general anaesthetic

GANT gastrointestinal autonomic nerve tumour

GCS Glasgow coma scale

GFR glomerular ﬁ ltration rate

GGT gamma glutamyl transferase

GH growth hormone

GI gastrointestinal

GIP gastric inhibitory polypeptide

GIST gastrointestinal stromal tumour

GMC General Medical Council

GORD gastro-oesophageal reﬂ ux

GP general practitioner

GTN glyceryl trinitrate

Gy gray

h hour

HAT hepatic artery thrombosis

Hb haemoglobin

HCC hepatocellular carcinoma

HCG human chorionic gonadotrophin

HCO

bicarbonate

HCV hepatitis C virus

HDU high dependency unit

HES hydroxyethyl starch

HGV heavy goods vehicle

HHD handheld Doppler

HIDA hepatobiliary iminodiacetic acid

HIT heparin-induced thrombocytopenia

HITT heparin-induced thrombocytopenia and thrombosis

HIV human immunodeﬁ ciency virus

HLA human leucocyte antigen

HMMA 4-hydroxy-3-methoxymandelic acid

HNPCC hereditary non-polyposis colorectal cancer

O water

HPV human papilloma virus

HR heart rate

HRT hormone replacement therapy

HSV herpes simplex virus

SYMBOLS AND ABBREVIATIONS

xxxi

5-HT 5-hydroxytryptamine (serotonin)

HTLV human T-cell lymphocytotrophic virus

HVA homovanillic acid

IABP intra-aortic balloon pump

IC intermittent claudication

ICA internal carotid artery

ICD intracardiac deﬁ brillator

ICP intracranial pressure

ICU intensive care unit

i.e. id est (that is)

IF intrinsic factor

IGF insulin growth factor

IHD ischaemic heart disease

IM intramuscular

IMA inferior mesenteric artery

IMHS intramedullary hip screw

in inch

INPV intermittent negative pressure ventilation

INR international normalized ratio

IPJ interphalangeal joint

IPPV intermittent positive pressure ventilation

IPSS international prostate symptom score

ITA internal thoracic artery

ITU intensive treatment unit

IU international unit

IV intravenous

IVU intravenous urogram

J joule

JCHST Joint Committee on Higher Surgical Training

JVP jugular venous pressure

K potassium

kcal kilocalorie

KCl potassium chloride

kg kilogram

kPa kilopascal

KUB kidneys/ureters/bladder

L litre

LA local anaesthetic or left atrium/atrial

LAD left anterior descending (artery)

LAP left atrial pressure

SYMBOLS AND ABBREVIATIONS

xxxii

LatexAT latex agglutination test

lb pound

LDH lactate dehydrogenase

LDL low density lipid

LESS laparoscopic and endoscopic single site (surgery)

LFT liver function test

LH luteinizing hormone

LHRH luteinizing hormone releasing hormone

Li lithium

LIF left iliac fossa

LITA left internal thoracic artery

LMS left main stem

LMWH low molecular weight heparin

LOS lower oesophageal sphincter

LSV long saphenous vein

LUQ left upper quadrant

LUTS lower urinary tract symptoms

LV left ventricle

LVEDP left ventricular end-diastolic pressure

LVEDV left ventricular end-diastolic volume

LVF left ventricular failure

m metre

MAG3

99m

Tc-mercaptoacetyltriglycine

MALT mucosa-associated lymphoid tissue

MAO monoamine oxidase

MAP mean arterial pressure

MCPJ metacarpophalangeal joint

MCRP magnetic resonance cholangiopancreatography

M,C,&S microscopy, culture, and sensitivity

MCV mean cell volume

MDT multidisciplinary team

MEN multiple endocrine neoplasia

mEq milliequivalent

mg milligram

Mg magnesium

MHC major histocompatibility complex

MHz megahertz

MI myocardial infarction

MIBG meta-iodo-benzyl-guanidine

min minute

SYMBOLS AND ABBREVIATIONS

xxxiii

MIP minimally invasive parathyroidectomy

MIST mechanism of injury/injuries identiﬁ ed/(vital)signs at

scene/treatment administered

mL millilitre

MMF mycophenolate mofetil

mmHg millimetre mercury

mmol millimole

MMR mismatch repair (genes)

MMV mandatory minute ventilation

Mn manganese

MODS multiple organ dysfunction syndrome

mph mile per hour

MR mitral regurgitation

MRA magnetic resonance angiography

MRC Medical Research Council (scale)

MRCP magnetic resonance cholangiopancreatogram

MRI magnetic resonance imaging

ms millisecond

MRSA methicillin (or multiply) resistant Staphylococcus aureus

MSU midstream urine

MTC medullary thyroid carcinoma

mTOR mammalian target of rapamycin

MTP mid-thigh perforator

MTPJ metatarsophalangeal joint

MUA manipulation under anaesthesia

MV mitral valve

Na sodium

NA noradrenaline (norepinephrine)

NaHCO

sodium bicarbonate

NAI non-accidental injury

NASCET North American Symptomatic Carotid Endarterectomy Trial

NBM nil by mouth

NCEPOD National Conﬁ dential Enquiry into Patient Outcomes

and Death

NEC necrotizing enterocolitis

ng nanogram

NG nasogastric

NGT nasogastric tube

NHS National Health Service

NICE National Institute for Health and Clinical Excellence

SYMBOLS AND ABBREVIATIONS

xxxiv

NIPPV non-invasive intermittent positive pressure ventilation

NK natural killer (cell)

NNT number needed to treat

O nitrous oxide

NSAID non-steroidal anti-inﬂ ammatory drug

NSF National Service Framework

NSGCT non-seminomatous germ cell tumour

NSPCC National Society for the Prevention of Cruelty to Children

NSTEMI non-ST segment elevation myocardial infarction

NVB neurovascular bundle

nvCJD new variant Creutzfeldt–Jakob disease

NYHA New York Heart Association

oxygen

OCP oral contraceptive pill

od omne in die (once a day)

OGD oesophago-gastro-duodenoscopy

OM obtuse marginal

OPT orthopantomogram

ORIF open reduction with internal ﬁ xation

PA pulmonary artery or posterior-anterior

PAC plasma aldosterone concentration

PaCO

2 arterial carbon dioxide tension

PAF platelet-activating factor

PAL primary hyperaldosteronism

PaO

2 arterial oxygen tension

PAP pulmonary artery pressure or placental alkaline phosphatase

PAS patient administration system

PAWP pulmonary artery wedge pressure

PCA patient-controlled analgesia

PCI percutaneous coronary intervention

PCNL percutaneous nephrolithotomy

PCO

2 carbon dioxide tension

PCR polymerase chain reaction

PCV packed cell volume or pressure control ventilation

PDA posterior descending artery

PDGF platelet-derived growth factor

PE pulmonary embolism

PEEP positive end-expiratory pressure

PEFR peak expiratory ﬂ ow rate

PEG percutaneous endoscopic gastrostomy

SYMBOLS AND ABBREVIATIONS

xxxv

PEP post-exposure prophylaxis

PET positron emission tomography

PGME Postgraduate medical education

PH portal hypertension

PHPT primary hyperparathyroidism

PICC peripherally inserted central venous catheter

PID pelvic inﬂ ammatory disease

PIPJ proximal interphalangeal joint

PLL posterior longitudinal ligament

PMETB Postgraduate Medical Education and Training Board

PMN polymorphonuclear neutrophil

PO orally (per os)

2 oxygen tension

4 phosphate

POSSUM Physiologic and Operative Severity Score for the

enumeration of Mortality and morbidity

PPH procedure for prolapse and haemorrhoids

PPI proton pump inhibitor

PPN peripheral parenteral nutrition

PR per rectum

prn pro re rata (as required)

PS pressure support

PSA prostate-speciﬁ c antigen

PSARP posterior sagittal anorectoplasty

PT prothrombin time

PTC percutaneous transhepatic cholangiogram

PTE pulmonary thromboembolism

PTEF polytetraﬂ uoroethylene

PTH parathyroid hormone

PTLD post-transplant lymphoproliferative disorder

PTT partial prothrombin time

PUJ pelviureteric junction

PV per vagina

PVD peripheral vascular disease

PVR pulmonary vascular resistance

PVRI pulmonary vascular resistance index

qds quater die sumandus (four times a day)

RA right atrial or rheumatoid arthritis

RAP right atrial pressure

RCA right coronary artery

SYMBOLS AND ABBREVIATIONS

RCT randomized controlled trial

Rh rhesus

rhTSH recombinant human thyroid-stimulating hormone

RIF right iliac fossa

RLN recurrent laryngeal nerve

RNA ribonucleic acid

RR relative risk or risk ratio

RRR relative risk reduction

RSTL relaxed skin tension line

RTA road trafﬁ c accident

RUQ right upper quadrant

RV right ventricle

s second

SA sinoatrial (node)

SAC specialist advisory committee

SaO

2 arterial oxygen saturation

SBE subacute bacterial endocarditis

SC subcutaneous

SCAT sheep cell agglutination test

SCC squamous cell carcinoma

SCI spinal cord injury

SCM sternocleidomastoid

SD standard deviation

SEMS self-expanding metal stenting

SEPL subfascial endoscopic perforator ligation

SFA superﬁ cial femoral artery

SFJ saphenofemoral junction

SILS single incision laparoscopic surgery

SIMV synchronized intermittent mandatory ventilation

SIRS systemic inﬂ ammatory response syndrome

SL sublingual

SLE systemic lupus erythematosus

SMA superior mesenteric artery

SNP sodium nitroprusside

SPJ saphenopopliteal junction

spp species

STD sodium tetradecyl sulphate

STEMI ST segment elevation myocardial infarction

STI sexually transmitted infection

SUFE slipped upper femoral epiphysis

xxxvi

SYMBOLS AND ABBREVIATIONS

xxxvii

SV stroke volume

SVC superior vena cava

SVI stroke volume index

SvO2 percentage oxygen saturation of mixed venous haemoglobin

SVR systemic vascular resistance

SVRI systemic vascular resistance index

SVT supraventricular tachycardia

3 triiodothyronine

4 thyroxine

TAP transversus abdominis percutaneous

TAPS transabdominal pre-peritoneal surgery

TB tuberculosis

TBSA total body surface area

TCC transitional cell carcinoma

TCR T-cell receptor

TCT transitional cell tumour

tds ter die sumendus (three times a day)

TEDS thromboembolic deterrent stockings

TEMS transanal endoscopic microsurgery

TEPS totally extra-peritoneal surgery

TFCC triangular ﬁ brocartilage complex

TFT thyroid function test

TGF transforming growth factor

THR total hip replacement

TIA transient ischaemic attack

TIBC total iron binding capacity

TIPS transjugular intraparenchymal portosystemic shunt/stent

TKA through-knee amputation

TKR total knee replacement

TLSO thoracolumbar spine orthosis

TMT tarsometatarsal

TNF tumour necrosis factor

TNM tumour nodes metastasis (cancer staging)

tPA tissue plasminogen activator

TPN total parenteral nutrition

TRAM transverse rectus abdominis myocutaneous (ﬂ ap)

TRUS transrectal ultrasound

H thyroid-stimulating hormone

TT thrombin time or total thyroidectomy

TTE transthoracic echocardiogram

SYMBOLS AND ABBREVIATIONS

xxxviii

TUIP transurethral incision in the prostate

TURP transurethral resection of the prostate

TVF transversalis fascia

U (international) units

UADT upper aerodigestive tract

U&E urea and electrolytes

UC ulcerative colitis

UCL ulnar collateral ligament

UFH unfractionated heparin

UK United Kingdom

UOS upper oesophageal sphincter

USA United States of America

UTI urinary tract infection

UV ultraviolet

V volts

VACTERL vertebral defects/anorectal atresia/cardiac defects/

tracheo-oesophageal ﬁ stula ± (o)esophageal atresia/

renal anomalies/limb defects

VAD ventricular assist device

VATS video-assisted thoracoscopic surgery

VF ventricular ﬁ brillation

VHL von Hippel–Lindau (disease)

VIP vasoactive inhibitory polypeptide

VMA vanillylmandelic acid

VQ ventilation/perfusion (scan)

VRE vancomycin-resistant Enterococcus

VT ventricular tachycardia

VTE venous thromboembolism

VWF von Willebrand factor

WCC white cell count

WHO World Health Organization

y year

Symbols and abbreviat

SYMBOLS AND ABBREVIATIONS

Good surgical practice

Duties of a doctor 2

Communication skills 4

Evidence-based surgery 6

Critical appraisal 10

Audit 12

Consent 14

Death 16

End-of-life issues 18

Clinical governance 20

Chapter 1

CHAPTER 1 Good surgical practice

Duties of a doctor

The General Medical Council (GMC) lists the duties of a doctor in its docu-

ment Good medical practice.

The duties can be thought of under three head-

ings (the 3 Cs): competency, communication, correctness (or probity).

Competency

• Keep your professional knowledge and skills up to date.

• Recognize the limits of your professional competence.

Perform an adequate assessment of the patient’s conditions, based •

on the history and symptoms and, if necessary, an examination.

Arrange investigations or treatment where necessary.•

Take suitable and prompt action when necessary.•

Refer the patient to another practitioner when indicated.•

Be willing to consult colleagues.•

Keep clear, accurate, legible, and contemporaneous patient records •

that report relevant clinical ﬁ ndings, decisions made, information

given to patients, and any drugs or other treatment prescribed.

Keep colleagues well informed when sharing the care of patients.•

Provide the necessary care to alleviate pain and distress whether or •

not curative treatment is possible.

Prescribe drugs or treatment, including repeat prescriptions, only •

where you have adequate knowledge of the patient’s health and

medical needs. You must neither give or recommend to patients

any investigation or treatment that you know is not in their best

interests, nor withhold appropriate treatments or referral.

Report adverse drug reactions as required under the relevant •

reporting scheme and cooperate with requests for information

from organizations monitoring the public health.

Take part in regular and systematic medical and clinical audit, •

recording data honestly, and respond to the results of audit to

improve your practice, e.g. by undertaking further training.

Communication

• Treat every patient politely and considerately.

• Respect patients’ dignity and privacy.

• Listen to patients and respect their views.

• Give patients information in a way they can understand.

Correctness (or probity)

• Make the care of your patient your ﬁ rst concern.

• Respect the rights of patients to be involved in decisions.

• Be honest and trustworthy.

• Respect and protect conﬁ dential information.

• Make sure your personal beliefs do not prejudice your patients’ care.

• Act quickly to protect patients from risk if you have good reason to

believe that you or a colleague may not be ﬁ t to practise.

• Avoid abusing your position as a doctor.

• Work with colleagues in the ways that best serve patients’ interests.

• In an emergency, wherever it may arise, you must offer anyone at risk

the assistance you could reasonably be expected to provide.

DUTIES OF A DOCTOR

Conﬁ dentiality

Patients have a right to expect that information about them will be held

in conﬁ dence by their doctors. Conﬁ dentiality is central to trust between

doctors and patients. Without assurances about conﬁ dentiality, patients

may be reluctant to give doctors the information they need in order to

provide good care. The GMC states that if you are asked to provide infor-

mation about patients, you must:

• Inform patients about the disclosure or check that they have already

received information about it.

• Anonymize data where unidentiﬁ able data will serve the purpose (this

includes your surgical logbook).

• Keep disclosures to the minimum necessary.

• Keep up to date with and observe the requirements of statute and

common law, including data protection legislation.

Daily practice

• When you are responsible for personal information about patients,

you must make sure that it is effectively protected against improper

disclosure at all times (e.g. password-protected electronic ﬁ les).

• Many improper disclosures are unintentional. You should not discuss

patients where you can be overheard or leave patients’ records,

either on paper or on screen, where they can be seen by other

patients, unauthorized health care staff, or the public. You should take

all reasonable steps to ensure your consultations with patients are

private.

• Patients have a right to information about the health care services

available to them presented in a way that is easy to follow and use.

Special circumstances

If in any doubt, contact your medical defence union for advice.

• You must disclose information to satisfy a speciﬁ c statutory

requirement, such as notiﬁ cation of a known or suspected

communicable disease. Inform patients about such disclosures,

wherever that is practicable, but their consent is not required.

• You must also disclose information if ordered to do so by a judge or

presiding ofﬁ cer of a court. You should object if attempts are made to

compel you to disclose what appear to you to be irrelevant matters.

• You must not disclose personal information to a third party, such as

a solicitor, police ofﬁ cer, or ofﬁ cer of a court, without the patient’s

express consent, except when:

The patient is not competent to give consent.•

Reasonable efforts to trace patients are unlikely to be successful.•

The patient has been or may be violent, or obtaining consent •

would undermine the purpose of the disclosure (e.g. disclosures in

relation to crime).

Action must be taken quickly (e.g. in the detection or control of •

outbreaks of some communicable diseases) and there is insufﬁ cient

time to contact patients.

Reference

1 GMC (2012). Good medical practice. Available at: M http://www.gmcuk.org/guidance/good_

medical_practice.asp

CHAPTER 1 Good surgical practice

Communication skills

Communicating with patients and relatives

When

• During admission and before discharge.

• On ward rounds.

• During clinical examinations and procedures.

• When the results of treatments are known and management changes.

• In outpatient clinics.

Where

2 Maintain the patient’s privacy. This is particularly important on an open

ward. Knock on doors and close them after you. Draw the curtains round

the bed. Ask a nurse to accompany you, particularly if you are explain-

ing something complex or breaking bad news. They will have to answer

the patients’ and relatives’ questions when you have left the ward or

clinic room.

How

• Know your facts. Are you giving the right diagnosis to the right

patient? Are you equipped to consent a patient for the surgical

procedure?

• Sit at the same level as the person to whom you are talking, maintain

appropriate eye contact, and introduce yourself.

• Find out what the patient knows and what they are expecting.

• Listen. The patient’s own knowledge, state of mind, and ability to grasp

concepts will dictate both how and how much you explain.

• Tell the truth. Know your facts, be sensitive to what the patient may

not want to know at this stage, and do not lie.

• Avoid jargon. ‘Chronic’ may simply mean ‘longstanding’ to you; to

most patients, it means ‘severe’.

• Avoid vague terms. Try to describe risk quantitatively, ‘a 1 in a

hundred chance’, rather than qualitatively, ‘a small risk’.

• Check that the patient understands. Don’t assume that they do.

• Help the patient to remember. Use information booklets, draw

diagrams, write instructions down.

• Maintain a professional relationship. Never allow your personal likes,

dislikes, and prejudices to hamper your clinical skills.

Breaking bad news

• Is there a relative or friend whom the patient might wish to have with

them, who may be a source of emotional support as well as being

better able to retain information?

• Know what options, if any, are available. If a cancer is inoperable, is

chemotherapy planned? If an operation is cancelled, when is the next

date?

• Do not be afraid to stop to allow the patient time to gather their

thoughts and emotions, and recommence at a later time.

• Do not mistake numbness for calm acceptance and try not to take

anger personally unless the bad news is actually your fault.

COMMUNICATION SKILLS

Communicating with nurses

• Introduce yourself on arrival to the staff nurse in charge.

• Establish early on which nurses are experienced. The help you get

from them will be different from the questions you get from others.

• In theatre, scrub nurses are not the enemy. Your inexperience is.

• Try to remember all their names as they will remember yours.

• Do ward work efﬁ ciently. Recognize how important it is for the

smooth running of the ward that your ward rounds, note-keeping,

prescriptions, and discharge letters are timely and accurate.

• Let the nurses know when you are going for lunch, teaching, or sleep.

If they can discuss problems now, it will save you being paged later.

• Do an evening ward round to check on problem patients and drug

requirements—your sleep is less likely to be constantly interrupted.

Communication with hospital doctors

• Don’t refer without ﬁ rst asking your consultant or registrar.

• When making requests for clinical consultations, write a concise, but

clear letter in the notes to the appropriate clinician.

• When asked to see a patient, go the same day, write your opinion

in the case notes, stating clearly what you recommend, and always

discuss it with the seniors on your own ﬁ rm.

• If a preoperative patient is complex or has signiﬁ cant comorbidity,

contact the appropriate anaesthetist. They will help you ensure that

the patient is adequately prepared for surgery.

Communication with general practitioners (GPs)

The GP has usually looked after your patient for years and, however

inspired your diagnostic or operating skills, they will be there to sort out

all the complications that are hidden from you once the patient is dis-

charged. They often know your consultant well. So think!

• Telephone the GP in the case of a death of a patient, if you

unexpectedly admit a patient, or to help with a difﬁ cult discharge.

• Write useful, legible discharge summaries. What would you want

to know if you were going to have to wait 4 weeks for the typed

discharge letter to arrive—at an absolute minimum, the date and name

of the operation, post-operative complications, and plan.

• Keep clinic letters clear and concise.

Radiology and laboratory colleagues

• Know exactly how the investigation will change your management.

• If there is doubt about the correct investigation, telephone for advice.

• Complete request forms correctly and include clinical data. It can make

a big difference, particularly if you have requested the wrong test.

Administration

• Introduce yourself to your consultant’s secretary early, ﬁ nd out how

they like things run, and then run things their way: they will usually

have more than typing input on your reference.

• Produce GMC, defence union, occupational health, holiday, and study

leave paperwork with good grace. They are mostly legal requirements

and being rude won’t change that.

CHAPTER 1 Good surgical practice

Evidence-based surgery

Summarizing simple data

This pattern of results is called a normal or Gaussian distribution: the curve

is a symmetrical bell-shaped curve. Height, weight, age, serum sodium,

and blood pressure (BP) are other examples of normally distributed data

(see Table 1.1).

• The mean is the same as the average: add up every result and divide by

the number of results. The average Hb here is 11.1g/dL.

• The standard deviation (SD) is a measure of how spread out the values

are: result – mean = its deviation.

√((sum of deviations

/(sample size – 1)) = SD. Here SD = 1.6g/dL.

• With normally distributed data, the mean ± 1 SD includes 68% of

observations; ± 2 SD includes 95%; ± 3 SD includes 99%.

This pattern of results is called a skewed distribution. Post-operative

blood loss (see Table 1.2), length of stay, and survival all show skewed

distributions.

• 2 Don’t use mean and SD to summarize skewed data.

• The mean blood requirement, which is skewed to 8U of blood

because of one outlier (*), is useful for planning budgets.

• The best summary statistic for skewed data is the median (2U of

blood) which is the value exactly halfway through the sample.

• The interquartile range is what the middle 50% of observations were

(1–2U here) and should be used instead of SD when summarizing

skewed data.

Table 1.1 Auditing preoperative Hb in 100 patients

Hb (g/dL) No. of patients Hb (g/dL) No. of patients

7–7.9 1 11–11.9 36

8–8.9 3 12–12.9 9

9–9.9 9 13–13.9 4

10–10.9 37 14–14.9 2

Table 1.2 Auditing post-operative blood transfusions in 100 patients

Units of blood No. of patients Units of blood No. of patients

0 1 45

1 34 5–10 1

2 41 10–20 0

3 17 20–30 1*

* Outlier.

EVIDENCE-BASED SURGERY

Tests (see Table 1.3)

Sensitivity (a/(a+c)) A measure of how good the test is at correctly iden-

tifying a positive result (>98% is very sensitive). If a very sensitive test is

negative, it rules the condition out (sign out).

Speciﬁ city (d/(b+d)) A measure of how good the test is at correctly iden-

tifying a negative result (>98% is very sensitive). If a very speciﬁ c test is

negative, it rules the condition in (spin).

Likelihood ratio This is the chance that a person testing positive has the

disease, divided by the chance that a person testing positive doesn’t have

the disease, or sensitivity/(1 – speciﬁ city). A likelihood ratio >10 is large and

represents an almost conclusive increase in the likelihood of disease, <0.1

is an almost conclusive decrease, and 1 signiﬁ es no change.

Treatments and hazards (see Table 1.4)

Absolute risk reduction (ARR) a/(a+b) – c/(c+d) This is the difference in

the event rate between the control and the exposed group. It reﬂ ects the

prevalence of a disease and the potency of a treatment or hazard.

Relative risk or risk ratio (RR) a/(a+b)/c/(c+d) The event rate in the

exposed group divided by the event rate in the control group. Used in

randomized controlled trials (RCTs) and cohort studies. It is not affected

by the prevalence of a disease.

Relative risk reduction (RRR) (a/(a + b) – c/(c + d))/(c/c + d) ARR divided

by the control event rate. It reﬂ ects disease prevalence.

Number needed to treat (NNT) 1/ARR The number of people who must

be treated to prevent one event.

Odds ratio This is the odds of an exposed person having the condition

divided by the odds of the control group having the condition. If the event

is rare, it approximates to relative risk. Odds ratios are less intuitive than

relative risk, but they are used because they are:

• Usually larger.

• Mathematically versatile.

Table 1.4 Risk Assessment

Outcome event No outcome event

Exposure a b

No exposure (control) c d

Table 1.3 Sensitivity

Disease present No disease

Test is positive a b

Test is negative c d

CHAPTER 1 Good surgical practice

• Always used in case control studies and appear in meta-analyses of

case control studies.

• The basis of logistic regression analysis.

Statistical signiﬁ cance

• Studies are designed to disprove the null hypothesis that ﬁ ndings are

due to chance.

• The p-value is the probability of a study rejecting the null hypothesis if

it were true (a type I error), i.e. ﬁ nding a difference where none exists.

• Statistical signiﬁ cance is commonly taken as a less than 1 in 20 chance

of this happening, i.e. p <0.05.

• Power is the probability of detecting an association if one exists.

Underpowered trials contain too few patients and may make type

II errors, accepting the null hypothesis when it is false, i.e. ﬁ nding no

difference where one does exist.

• 95% conﬁ dence intervals, derived from the mean and SD, are the range

of results predicted if the study were repeated 95 times.

EVIDENCE-BASED SURGERY

Other useful terms

Censored data Essentially incomplete data, usually due to variable lengths

of follow-up. Common in surgical studies because 1) some patients will

have been lost to follow-up and 2) patients will have shorter follow-up

where they had operations more recently in a study.

Actuarial and Kaplan–Meier survival Two methods used to calculate the

percentage of study patients that survive a speciﬁ ed time after an opera-

tion when a study provides censored data.

Survival curves Usually not curves. A linear graph, with percentage sur-

vival (or freedom from a complication) on the x-axis and time on the

y-axis, which drops as each study patient dies (or gets the complication).

If there are thousands of patients in the study, the curve is smooth. If

there are very few, it is possible to see individual deaths/events as steps

in the graph. Ideally, these graphs should have conﬁ dence intervals.

Conﬁ dence intervals These reﬂ ect the precision of the study results.

Narrow conﬁ dence intervals are better than wide ones because the con-

ﬁ dence interval provides a range of values for the percentage survival (or

odds ratio or other proportion) that has a speciﬁ ed probability (usually

95%) of containing the true value for the entire population from which

the study patients were recruited. Always look for conﬁ dence intervals;

they give you a ‘best case and worst case’ snapshot.

Regression analysis Essentially looking back from a group of patients with

a known outcome (e.g. dead/alive) to see whether there were any predic-

tors (e.g. age, recent myocardial infarction (MI)). Univariate analysis looks

at single variables in turn. Multivariate analysis looks at a group of variables

together; it is used to identify independent risk factors for an outcome. For

example, age may be found to be a risk factor for post-operative death

in univariate analysis, but that is because elderly patients are more likely

to have other risk factors for post-operative death (e.g. recent MI). If age

is not found to be an independent risk factor in multivariate analysis, it

suggests that elderly people without other risk factors (e.g. recent MI) are

not at higher risk of post-operative death.

CHAPTER 1 Good surgical practice

Critical appraisal

Types of study

Studies appraising treatments can take several forms.

Randomized controlled trial (RCT) Prospective study in which partici-

pants are allocated to control or treatment groups on a random basis.

Gold standard for assessing treatment efﬁ cacy, but time-consuming and

expensive to run.

Cohort study Partly prospective study in which two cohorts of patients

are identiﬁ ed, one of which was exposed to the treatment and one is the

control group. They are followed over time to see the outcome. Cheaper

and quicker than RCT and suitable for looking at prognosis, but prone to

bias or false associations.

Case control study Retrospective study in which patients with the out-

come of interest are identiﬁ ed and paired with patients without the out-

come of interest, and the exposure rates are compared. Cheapest and

quickest way of looking for causation. Bias arises when patients are mis-

classiﬁ ed as cases or controls.

Case series A collection of anecdotes or case reports.

Systematic review Differs from the traditional literature review by apply-

ing explicit, systematic, and reproducible methods to retrieve and appraise

literature to answer a clearly formulated question. Large amounts of data

are summarized and conclusions are more accurate.

Meta-analysis A mathematical synthesis of the results of two or more pri-

mary studies, increasing the statistical signiﬁ cance of positive overall results.

However, it reduces the ability of studies to demonstrate local effects.

Levels of evidence

Studies of treatment/hazard can be arranged in order of decreasing sta-

tistical validity.

• Level 1a. Systematic review of RCTs.

• Level 1b. High quality RCT with narrow conﬁ dence intervals.

• Level 1c. All-or-none case series (either all patients died before

treatment became available, but some now survive or some used to

die, but now with treatment, all survive).

• Level 2a. Systematic review with homogeneity of cohort studies.

• Level 2b. Cohort study or low quality RCT.

• Level 2c. ‘Outcomes’ research.

• Level 3a. Systematic review with homogeneity of case control studies.

• Level 3b. Individual case control study.

• Level 4. Case series and poor quality cohort and case control studies.

• Level 5. Expert opinion without explicit critical appraisal or based on

physiology, bench research, or ﬁ rst principles.

How to appraise a paper

Answer these questions systematically. This information should all be

stated explicitly within the manuscript.

CRITICAL APPRAISAL

How relevant is the paper?

Does the paper address a clearly focused, important, and answerable clini-

cal question that is relevant to my patients?

How valid are the ﬁ ndings?

• Was the paper published in an independent peer-reviewed journal?

• Does the paper deﬁ ne the condition to be treated, the patients to be

included, the interventions to be compared, and the outcomes to be

examined?

• Was a power calculation performed and is the power adequate?

• Were all clinically relevant outcomes reported?

• Was follow-up adequate?

• Were all patients accounted for at the end of the study?

• Was the appropriate study type selected and was the design

appropriate?

• Were the statistical methods described and were they appropriate?

• Were the sources of error discussed?

Systematic reviews

• Is the clinical question clearly deﬁ ned and an acceptable basis for

including or excluding papers?

• Was the literature search thorough and were other potentially

important sources explored?

• Were trials appropriately included and excluded?

• Was the methodological quality assessed and trials appropriately

weighted?

RCTs

• Were patients properly randomized?

• Were patients treated equally apart from the intervention being

studied?

• Was analysis on an intention-to-treat basis?

• Are conﬁ dence intervals narrow and not overlapping?

Case control studies

• Were patients correctly classiﬁ ed as case or control?

• Were all patients accounted for at the end of the study?

How important are the results?

• Were the results statistically signiﬁ cant?

• Were the results expressed in terms of numbers needed to treat and

are they clinically important?

How applicable are the ﬁ ndings?

• Were the study patients similar to mine?

• Is the treatment feasible within my practice: is information on safety,

tolerability, efﬁ cacy, and price presented?

CHAPTER 1 Good surgical practice

Audit

What is audit?

National Institute for Health and Clinical Excellence (NICE) deﬁ nes clinical

audit as ‘a quality improvement process that seeks to improve patient care

and outcomes through systematic review of care against explicit criteria

and the implementation of change. Aspects of the structure, processes,

and outcomes of care are selected and systematically evaluated against

explicit criteria. Where indicated, changes are implemented . . . and further

monitoring is used to conﬁ rm improvement in health care delivery.’

Why do it?

Clinical audit is currently seen as the most effective way of assessing rou-

tine health care delivery and the basis of improving outcomes.

• All hospital doctors are required to fully participate in clinical audit

(NHS Plan, Department of Health, 2000).

• The GMC advises that all doctors ‘must take part in regular and

systematic medical and clinical audit . . . Where necessary, you must

respond to the results of audit to improve your practice’.

How to do it

Audit of outcome or process can be divided into ﬁ ve stages: each stage

needs to be carefully planned to produce a clinically effective audit.

Preparing for audit Choose a topic and deﬁ ne the purpose of the audit.

One option is to identify (by consulting patients and clinicians) a poten-

tial problem that may involve high costs or risks for which there is good

evidence to inform standards and that may be amenable to change. NICE

stresses the importance of identifying skills and resources to carry out

the audit.

Selecting audit criteria Audit can assess process or outcome.

• Deﬁ ne the patients to be included.

• Criteria to assess performance should be derived from the available

evidence, e.g. trials, systematic reviews, society guidelines, or clinician

consensus.

• Benchmarking prevents unrealistically high or low targets.

Measuring performance This is about collecting data. Identify patients or

episodes from several sources (e.g. operating room logbooks and patient

administration system (PAS)) to avoid missing patients because of incom-

plete data. Electronic information systems can improve data collection.

Training dedicated audit personnel can improve the process further.

Making improvements Identify local barriers to change, develop a practi-

cal implementation plan, which should involve several interventions (prac-

tice guidelines, education, and training). Clinical governance programmes

should provide the structure.

Sustaining improvements Repeating the audit to assess improvements is

also called closing the audit loop. Alternatives such as critical incident

review may be effective.

AUDIT

Measuring surgical performance

Rationale The Kennedy report on the enquiry into perioperative deaths in

paediatric cardiac surgery at Bristol Royal Inﬁ rmary stated that ‘Patients

must be able to obtain information as to the relative performance of the

Trust . . . and consultant units within the Trust’. The idea that every patient

has the right to expect their surgery to be performed by a surgeon whose

results are not statistically worse than average is widely held.

• League tables ranking cardiothoracic surgeons on the basis of surgeon-

speciﬁ c mortality data have been published by the government.

• Surgeons can be ranked using a number of other outcomes.

• Ranking should incorporate a system that accounts for differences in

case mix, i.e. risk stratiﬁ cation, so that surgeons who operate on sicker

or more complicated patients are not unfairly penalized.

Risk scoring systems Examples include:

• Euroscore and Parsonnet scores for predicting operative mortality in

cardiac surgical patients.

• Apache II scores for intensive care patients.

• POSSUM (Physiologic and Operative Severity Score for the

enUmeration of Mortality and morbidity)—variants exist for vascular

and colorectal surgery.

Presenting results The aim of presenting performance data is to distin-

guish between normal variation between surgeons or institutions and sig-

niﬁ cant divergence. There are three main ways of doing this:

• Average outcome over a given time frame.

Ranking or league tables of surgical mortality or other •

complications; the data may be crude or risk-stratiﬁ ed (i.e. taking

into account the case mix).

Survival plots which may also be crude or risk-stratiﬁ ed.•

Standardized mortality ratio plots.•

• Volume and outcome control charts.

Funnel plots (see Fig. 1.1).•

Spectrum plots.•

• Performance trends over time.

Cumulative summation charts (CUSUM).•

Variable life-adjusted display charts (VLAD), risk-adjusted CUSUM.•

Upper 95% Cl Lower 95% Cl

%lanoitaNnoegruS

0 50 100 150 200 250 300

Number of cases

350 400 450 500 550 600

Crude mortality %

Fig. 1.1 Funnel plot of mortality data for 50 cardiac surgeons. The arrow marks

an outlier with mortality outside 95% conﬁ dence intervals (CI).

Reference

1 Department of Health. (2000). The NHS Plan: a plan for investment, a plan for reform. Available at: M

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/

DH_4002960

CHAPTER 1 Good surgical practice

Consent

Legal aspects

Successful surgery depends on a relationship of trust between the patient

and doctor. The patient’s right to autonomy must be respected, even if

their decision results in harm or death. This right is protected by law.

• A doctor performing a procedure on a patient without their consent

can be found guilty of battery.

• A doctor who has failed to give the patient adequate information to

allow them to give informed consent can be found guilty of negligence.

• No adult in the United Kingdom (UK) can legally consent to surgery on

behalf of another adult. It is important to involve relatives, particularly

where patients are unable to consent, but their wishes are not legally

binding and do not form part of the legal consent.

Obtaining consent

The key to good consenting is good communication (see b p. 4). It may

be necessary to use a translator and some Trusts will not accept consent

gained by using patients’ relatives as translators. GMC guidelines state ‘If

you are the doctor providing treatment or undertaking an investigation,

it is your responsibility to discuss it with the patient and obtain consent’.

In practice, this may be done verbally by the consultant or registrar in

clinic, or on a ward round with a house ofﬁ cer obtaining written con-

ﬁ rmation later. Consent must be given freely: patients may not be put

under duress by clinicians, employers, police, or others to undergo tests

or treatment. Declare any potential conﬂ icts of interest. The amount of

information should be sufﬁ cient to allow a mentally competent patient

to make an informed decision. It will vary according to the individual, the

nature of the condition, the complexity of treatment, and risks involved. It

is unacceptable to limit the amount of information on the basis that it may

cause distress, but be sympathetic to the patients’ needs. Consent must

be obtained for taking photographs for teaching or publication, and taking

samples for research.

Informed consent

There are ﬁ ve aspects that the patient must understand to give informed

consent:

• The reason for carrying out the procedure. The patient needs to

understand the nature of their illness and its prognosis.

• What the procedure involves. Where and how long is the scar; what is

being removed; what prosthesis will be implanted; will there be drains?

• The risks of the procedure. Speciﬁ c to the procedure (e.g. stoma, limb

dysfunction) and in general (e.g. anaesthesia, bed rest, deep vein

thrombosis (DVT)).

• The beneﬁ ts of the procedure. Improvement in symptoms or prognosis

or purely diagnostic.

• Alternatives. Including conservative treatment, with their advantages

and disadvantages.

CONSENT

Modes of consent

• Implied consent. The patient is presumed to consent to minor

procedures, e.g. X-rays, phlebotomy, by cooperating with ward

procedures.

• Express written consent. Whenever possible, this should be obtained for

all patients undergoing procedures involving an anaesthetic, complex

treatments with signiﬁ cant risks and side effects, or as part of research.

Written consent is not legal proof that adequate consent was obtained at

the time the document was signed.

• Express verbal consent. Should be obtained when it is not possible

to get written consent, witnessed by an independent health care

professional, and documented in the notes accordingly, or for simple

procedures with minimal risk of harm.

Special considerations

Emergencies When consent cannot be obtained, you may provide emer-

gency medical treatment, provided it is limited to what is needed to pre-

serve life. However, you must respect any valid advance refusals that you

know about or that are drawn to your attention.

Mentally incapable patients No adult in the UK can legally consent to sur-

gery on behalf of another adult. Assess the patient’s competence to make

an informed decision. If unable to decide, and provided they comply,

treatment may be instigated that is judged to be in their best interests.

Otherwise, treatment may be carried out under the Mental Health Act

1989. Controversial and non-therapeutic treatments (e.g. sterilizations)

require court approval.

Advance statements/living wills Advance statements made by patients

before losing the capacity of informed consent must be respected, pro-

vided the decision is applicable to the present circumstances and there is

no reason to believe that they may have changed their minds. The known

wishes of the patient should be taken into consideration if an advance

statement is unavailable.

Children

• Over 16s are regarded as young adults and have capacity to decide.

• Under 16s may give their own consent if they are judged to

understand what is involved.

• Unlike adults, where a competent child refuses treatment, a person

with parental responsibility (except in Scotland) or a court may

authorize treatment if deemed in the child’s best interests.

• If the parents refuse treatment deemed in the child’s best interests,

you are not bound by this and may seek a ruling from the court.

• Emergency treatment may be instigated without consent in a similar

manner to that in adults.

Pregnancy The right to autonomy applies equally to pregnant women.

It includes the right to refuse treatment that is intended to beneﬁ t the

unborn child.

CHAPTER 1 Good surgical practice

Death

Conﬁ rming death

There is no legal deﬁ nition of death in the UK. It is generally regarded as

the cessation of circulation and respiration.

• Clinically, there is:

No respiratory effort, denoted by the absence of breath sounds on •

auscultation over 1min.

Absence of a palpable pulse and heart sounds over 1min.•

No response to painful stimuli, e.g. sternal or supraorbital rub.•

Fixed dilated pupils (beware drugs such as atropine).•

• If there is doubt, perform an electrocardiogram (ECG).

• Hypothermia (core temperature <34°C) must have been corrected.

Brain death/brainstem death

The concept of brain death has arisen from the advances in intensive ther-

apy, and the ability to maintain cardiac and respiratory function artiﬁ cially

in patients who have sustained severe irreversible brain damage. Brain

death is deﬁ ned as the ‘irreversible cessation of all functions of the entire

brain, including the brainstem’.

This, alongside the traditional deﬁ nition,

is taken to equate to death in the UK, United States of America (USA),

Australia, and many other countries. In order to diagnose brain death, a

number of strict criteria must be met.

• An identiﬁ able cause for the brain death must be established, e.g.

severe head injury/intracerebral bleed, and

• Other causes, including central nervous system (CNS) depressants,

hypothermia, metabolic and endocrine disturbance, need to be

excluded, and

• The patient is unable to breathe spontaneously despite adequate CO

drive (i.e. PaCO

>6.7kPa), and

• The following brainstem reﬂ ex tests, performed by the consultant in

charge (or deputy of 5y registration) and another suitably experienced

doctor, have been failed on two separate occasions, usually 24h apart:

Both pupils are ﬁ xed and unresponsive to light (oculomotor nerve).•

Corneal reﬂ exes are absent (trigeminal nerve).•

Vestibulo-ocular reﬂ exes are absent (absent eye movements when •

20mL of ice-cold water is injected into each ear with tympanic

membranes visualized beforehand) (vestibulo-cochlear nerve).

Absent motor responses to painful stimuli in the distribution of the •

cranial nerves in the absence of neuromuscular blockade (spinal

cord injury may ablate peripheral motor responses).

Absence of respiratory effort when disconnected from the •

ventilator despite a PaCO

>6.7kPa (i in chronic obstructive

pulmonary disease (COPD)).

Absent gag and cough reﬂ ex upon pharyngeal and endotracheal •

stimulation.

Coroners

It is always wise to discuss with the consultants involved if there is any rea-

son to discuss cases with the coroner’s ofﬁ cer. Poor quality information

DEATH

can lead to death certiﬁ cates being returned or the coroner becoming

involved unnecessarily.

In-hospital deaths must be discussed with the coroner’s ofﬁ cer if:

• Death has occurred during an operation.

• Death occurred before recovery from anaesthetic.

• More than 14 days have elapsed since the patient last saw a doctor.

• There is doubt about the cause of death.

• Death is thought to be suspicious (e.g. caused by overdoses of

prescribed substances, medical error, suicide).

Certifying death

Documenting in the medical notes

If you are asked to ‘certify’ a patient, ﬁ rst conﬁ rm death (see b p. 16):

• Document the date and time that death was pronounced.

• Document your examination.

• Document the causes of death as they will appear on the death certiﬁ cate

if these have been decided. 2 If in doubt, always speak to the consultant.

The death certiﬁ cate

This can be issued by anyone with full medical qualiﬁ cations who looked

after the patient during their last illness, or where referral to the coroner

has been made and permission to issue the certiﬁ cate has been granted.

• Write legibly. The record is retained by the relatives and illegible or

incomplete certiﬁ cates may be rejected by the funeral director.

• Part I. The cause of death. Events leading to Ia are listed in Ib and Ic.

• Part II. Conditions that contributed to, but did not directly cause death.

• General terms like heart failure and sepsis may not be accepted.

Cremation forms

These forms vary slightly between regions, but certain rules always apply.

• There are two parts. The ﬁ rst is ﬁ lled in by a doctor who attended

the patient during the illness leading up to death, the second by an

independent clinician who has been fully registered for at least 5y.

• They should not be issued if the cause of death is not established.

• It is the responsibility of the issuing doctor to ensure that they have

seen and identiﬁ ed the person after death, and that there are no

radioactive implants or pacemakers present.

Post-mortems

• A coroner’s post-mortem is required for suspicious deaths, but is most

commonly performed where the Coroner’s Ofﬁ ce has ‘taken’ a case

where the cause of death is uncertain, or may be related to surgery or

interventions. The consent of relatives is not necessary to proceed.

• A hospital post-mortem may be carried out with the consent of relatives

to investigate other deaths. In 60% of post-mortems in one series, new

diagnoses that would have substantially changed management were

found—they are a vital part of audit.

Reference

1 (1981). Guidelines for the determination of death: report of the medical consultants on the

diagnosis of death to the president’s commission for the study of ethical problems in medicine

and biomedical and behavioral research. J Am Med Assoc 246, 2184–6.

CHAPTER 1 Good surgical practice

End-of-life issues

Do not resuscitate (DNR) orders

A DNR order should be considered when the frailty, comorbidity (e.g.

inoperable disseminated malignancy, multiple organ failure), maximal

medical treatment, or advanced age of a patient means that any attempt at

cardiopulmonary resuscitation (CPR) in the event of a cardiac or respira-

tory arrest will be futile. DNR decisions should be reached on a case by

case basis: a blanket ‘do not resuscitate’ policy based on a speciﬁ c patient

group, such as elderly patients, is unacceptable. An 84-y-old patient who

was an appropriate candidate for cardiac surgery is an appropriate can-

didate for CPR post-operatively, whereas a 72-y-old patient undergoing

palliative care for end-stage hepatorenal failure is probably not.

• Never make a DNR decision without discussing it with a consultant.

• Patients and, where appropriate, their relatives must be involved.

• Document the clinical reasons for the DNR order and state explicitly

whether ‘full active medical management’ is to be continued: DNR

orders do not always include withdrawing treatment. Discuss each

case with the nurses involved.

• Complete the appropriate documentation and review process, which

varies from Trust to Trust, and make sure the nursing staff are fully

aware so that they do not call the arrest team when the patient dies.

Euthanasia

Euthanasia is the painless termination of life at the request of the patient

concerned. In the UK, it is illegal to administer any drug to accelerate death,

irrespective of how compassionate the motive may be. Withdrawing futile

treatment is not euthanasia. UK law states that the intention to kill is mali-

cious and such action would be classiﬁ ed as murder. Terminally ill people

and the parents of terminally ill or severely disabled children may have

several reasons for requesting euthanasia. Effective palliative care, counsel-

ling, and multidisciplinary support should be able to address most of these

reasons, which include:

• Pain.

• Disability.

• Disﬁ gurement.

• Depression.

• Fear of being a burden, being unable to cope.

Palliative care

Palliative care is surgical, medical, and nursing care aimed speciﬁ cally at

relieving the problems associated with terminal conditions when the pos-

sibility of cure has been abandoned. Palliative care is delivered by palliative

medicine and nursing specialists and can take place in the community or

in residential care settings. Refer early: palliative care beds are limited and

acute surgical wards are rarely the best places for dying patients. Palliative

care physicians specialize in:

• Control of symptoms, including pain, anorexia, nausea and vomiting,

confusion, dysphagia, dyspnoea, incontinence.

END-OF-LIFE ISSUES

• Psychological aspects of terminal illness.

• Bereavement.

Suicide The suicide rate in the UK is currently 12.5 per 100 000.

Patients at risk

• The recently bereaved.

• Cancer patients have a ﬁ ve times increased risk.

• Men over 55y with oral cancer and a history of alcohol abuse.

• Women of any age, often suffering from gynaecological or breast

cancer. (In both of these latter groups, the treatment of the disease

involves disﬁ gurement and a change of body image.)

Action

Patients about to undergo disﬁ guring surgery for any reason should be

counselled carefully in the period after conﬁ rmation of the diagnosis and

before surgery. Doctors should discuss all treatment options and implica-

tions clearly. The support of a ‘mastectomy counsellor’ or ‘stoma thera-

pist’ is invaluable. Post-operatively:

• Look for symptoms of depression, including low mood, tearfulness,

anorexia, early morning waking, suicidal thoughts, especially in long-

term patients.

• Do not discontinue antidepressant medication.

• Ensure that arrangements for discharge include community nursing

support and that the GP is aware of the patient’s state of mind.

Organ donation

• When brain death is established, organ donation should be considered

for all patients who are under 75y of age with no history of malignant

disease or major untreated sepsis.

• All donors should be tested for human immunodeﬁ ciency virus (hiv),

hepatitis B and C, herpes simplex virus (HSV), and cytomegalovirus

(CMV).

• Organ donation is usually coordinated by regional transplant teams.

• The body should be identiﬁ ed and next of kin contacted.

• If, despite reasonable attempts, the identity of the corpse or next of

kin remains unknown, the body becomes the property of the health

authority.

• If a donor card is present, it is reasonable to assume that the deceased

wished to donate his organs and the transplant team can proceed.

• If relatives are identiﬁ ed and do not wish organ donation to proceed,

even though there is a donor card, their wishes must be respected.

• Relatives should be asked to act as agents in expressing what they

believe to be the wishes of the patient. Ideally, the person seeking

permission should be someone whom they already know. This may be

the consultant in charge, but, on occasion, a senior staff nurse, chaplain

(or other religious ﬁ gure), or the family GP may be more appropriate.

• In the case of accidental deaths, the coroner’s permission should be

sought before proceeding.

CHAPTER 1 Good surgical practice

Clinical governance

Clinical governance is the system through which National Health Service

(NHS) organizations are accountable for continuously improving the qual-

ity of their services. Clinical governance involves setting standards, per-

formance monitoring, and reporting systems at national, institutional, and

personal levels. Risk management is an integral part of clinical governance:

it is the systematic identiﬁ cation and avoidance of risks associated with

any procedure.

Setting standards

In addition to conventional clinical evidence and guidelines, the following

organizations have a responsibility for setting standards in health care.

National Service Frameworks (NSFs)

NSFs are long-term national strategies for improving speciﬁ c areas of care,

produced by government after consultation with clinicians. They set stand-

ards and establish methods of delivering them. NSFs have been published

for coronary heart disease and cancer.

National Institute for Health and Clinical Excellence (NICE)

NICE is the governmental organization responsible for setting standards

by reviewing the best available evidence and publishing guidelines. Local

authorities are obliged to fund interventions recommended by NICE,

but NICE guidance does not overrule individual clinical decision-making.

Currently, NICE produces three kinds of guidance:

• Technology appraisals. Guidance on the use of new and existing

medicines and treatments within the NHS in England and Wales.

• Clinical guidelines. Guidance on the appropriate treatment and care of

people with speciﬁ c conditions within the NHS in England and Wales.

• Guidance on whether interventional procedures used for diagnosis or

treatment are safe enough and work well enough for routine use in

England, Wales, and Scotland.

Postgraduate Medical Education and Training Board (PMETB) and

professional organizations

The PMETB was set up in 2003 to develop a single, unifying framework for

postgraduate medical education (PGME) and training across the UK.

• Medical ethics, undergraduate and pre-registration medical education,

and ﬁ tness to practise remain the responsibility of the GMC.

• Accreditation and the approval of basic surgical training remain the

responsibility of the Royal Colleges of Surgeons.

• Higher surgical training is supervised by the Joint Committee on Higher

Surgical Training (JCHST) and the specialist advisory committees

(SACs).

Performance monitoring

Healthcare Commission (replaces CHI and the Audit Commission)

The Healthcare Commission is a new body that has been set up to help

improve the quality of health care. It will do this by providing an independ-

ent assessment of the standards of services, whether they are provided

CLINICAL GOVERNANCE

by the NHS, independent health services, or voluntary organizations. It

provides an independent second stage of complaints assessment, assesses

the arrangements in place to promote public health, and acts as the coor-

dinating inspectorate in relation to health care.

National Conﬁ dential Enquiry into Patient Outcomes and Death

(NCEPOD)

NCEPOD (which used to be the National Conﬁ dential Enquiry into

PeriOperative Deaths) is an organization independent of the Department

of Health (DOH) and the professional associations, although it receives

over 85% of its funding from the DOH via NICE. It stopped collecting

data on all deaths within 30 days of surgery in 2002 when its remit was

extended to cover all medical and surgical deaths. Data is now collected

by local reporters in response to speciﬁ c areas of research.

National Patient and User Survey The Healthcare Commission has car-

ried out ﬁ ve national surveys involving over 500 institutions and 300 000

patients. The results are disseminated to health care providers and gov-

ernmental agencies to inform strategy.

Audit See b p. 12.

Revalidation The purpose of revalidation will be to create public conﬁ -

dence that all licensed doctors are up to date and ﬁ t to practise. Currently,

consultants and general practitioners undergo regular appraisal: this will

be included within revalidation which is yet to be introduced.

Reporting systems

Critical incident reporting Critical incident reporting was initially volun-

tary and anonymous. Incidents perceived to have exposed patients or staff

to actual or potential risk were reported on forms that would be sent to

responsible individuals in each directorate, serious adverse events being

discussed at regular meetings with the clinical director. Now effective criti-

cal incident reporting systems are a requirement for CNST (criminal neg-

ligence scheme for Trusts) insurance and are assessed by the Healthcare

Commission on Trust visits.

Complaints Patients make formal complaints about treatment or clinicians

to the hospital concerned: the new NHS complaints procedure, which was

reformed in 2002 to address concerns that it was fragmented, complex,

and insufﬁ ciently independent, still stresses that wherever possible, issues

should be resolved locally. Effective use of the patient advice and liai-

son services (PALS) and independent complaints advocacy service (ICAS)

should mean that only serious complaints are referred to the second level,

which is handled by the Healthcare Commission which currently handles

3000–5000 complaints per annum.

Whistle-blowing Trusts are required to have a whistle-blowing policy to

enable individual staff members to express concerns about treatment and

to protect them from reprisals. The policy must include a mechanism for

investigating and acting on such claims.

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Principles of surgery

Chapter 2

Terminology in surgery 24

History taking and making

notes 26

Common surgical symptoms 28

Examination and investigation of

the patient

Evaluation of breast disease 30

Evaluation of the neck 32

Evaluation of the abdomen 34

Abdominal investigations 36

Evaluation of pelvic disease 38

Evaluation of peripheral vascular

disease 40

Evaluation of the skin and

subcutaneous tissue disease 42

Surgery at the extremes of age 44

Day case and minimally invasive

surgery 46

Preoperative care

Surgery in pregnancy 48

Surgery and the contraceptive

pill 50

Surgery in endocrine disease 52

Surgery and heart disease 54

Surgery and respiratory

disease 58

Surgery in renal and hepatic

disease 60

Surgery in neurological disease 62

Pre-optimization of the patient

Fluid optimization 64

Nutrition in surgical patients 66

Enhanced recovery after

surgery 68

Perioperative care

Getting the patient to theatre 70

Prophylaxis—antibiotics and

thromboprophylaxis 72

In-theatre preparation 74

Positioning the patient 76

Sterilization, disinfection, and

antisepsis 78

Scrubbing up 79

Surgical instruments 80

Incisions and closures 82

Drains 83

Stomas 84

Knots and sutures 86

Post-operative

Post-operative management 88

Drain management 90

Fluid management 92

Acid–base balance 94

Blood products and

procoagulants 96

Transfusion reactions 98

Shock 100

Post-operative haemorrhage 102

Wound emergencies 104

Cardiac complications 106

Respiratory complications 108

Renal complications 110

Urinary complications 112

Gastrointestinal

complications

114

Neurological complications 116

Haematological complications 118

Deep venous thrombosis and

pulmonary embolism 120

Risk scoring 122

Critical care 124

Commonly used terms in

ITU 126

Invasive monitoring 128

Ventilation and respiratory

support 130

Circulatory support 132

Renal support 134

Enteral support 136

Sepsis, SIRS, MODS, and ALI 138

CHAPTER 2 Principles of surgery

Terminology in surgery

How to describe an operation

The terminology used to describe all operations is a composite of basic

Latin or Greek terms.

First describe the organ to be operated on

Examples:

lapar-, abdomen (• laparus = ﬂ ank);

nephro-, kidney;•

pyelo-, renal pelvis;•

cysto-, bladder;•

chole-, bile/the biliary system;•

ileo-, small bowel (distal)•

col(on)-, large bowel;•

hystero-, uterus;•

thoraco-, chest;•

rhino-, nose;•

masto/mammo-, breast.•

Second describe any other organs or things involved in the procedure

Examples:

docho-, duct;

•

angio-, vessel (blood- or bile-carrying);•

litho-, stone.•

Third describe what is to be done

Examples:

-otomy, to cut (open);•

-ectomy, to remove;•

-plasty, to change shape or size;•

-pexy, to change position;•

-raphy, to sew together;•

-oscopy, to look into;•

-ostomy, to create an opening in (• stoma = mouth);

-paxy, to crush;•

-graphy/gram, image (of).•

Lastly add any terms to qualify how or where the procedure is done

Examples:

percutaneous, via the skin;

•

trans-, across;•

antegrade, forward;•

retrograde, backward;•

ventral, anterior surface of.•

Examples of terms

Choledochoduodenostomy• . An opening between the bile duct and the

duodenum.

Rhinoplasty• . Nose reshaping.

Pyelolithopaxy• . Destruction of pelvicalyceal stones.

TERMINOLOGY IN SURGERY

Bilateral mastopexy• . Breast lifts.

Percutaneous arteriogram• . Arterial tree imaging by direct puncture

injection.

Loop ileostomy• . External opening in the small bowel with two sides.

Flexible cystourethroscopy• . Internal bladder and urethral inspection.

CHAPTER 2 Principles of surgery

History taking and making notes

Making medical notes

All medical and paramedical professionals have a duty to record their

input and care of patients in the case notes. These form a permanent legal

and medical document. There are some basic rules.

Write in blue or black ink; other colours do not photocopy well.

•

Date, time, and sign all entries; always identify retrospective entries.•

Be accurate.•

Make it clear which diagnoses are provisional.•

Abbreviations are lazy and open to misinterpretation; avoid them.•

Clearly document information given to patients and relatives.•

Avoid non-medical judgements of patients or relatives.•

Basics

Always record name, age, occupation, and method of presentation.•

Cover all the principal areas of medical history:•

Presenting complaint and past history relevant to it.•

Other past medical history, drug history, and systematic enquiry.•

Previous operations/allergies/drugs.•

Family history, social history, and environment.•

Presenting complaint

This is a one- or two-word summary of the patient’s main symptoms, e.g.

abdominal pain, nausea and vomiting, swollen leg, PR bleeding.

In emergency admissions, do not write a diagnosis here (e.g. ischaemic •

leg). The diagnosis of referral may well turn out to be wrong.

In elective admissions, it is reasonable to write: ‘elective admission for •

varicose vein surgery’.

History of presenting complaint

This is a detailed description of the main symptom and should include •

the relevant systems enquiry.

Try to put the important positives ﬁ rst, e.g. right-sided lower •

abdominal pain, sharp, worse with moving, and coughing, anorexia 24h.

Include the relevant negatives, e.g. no vomiting, no PR bleeding.•

Be very clear about the chronology of events.•

In a complicated history or with multiple symptoms, use headings, e.g. •

‘Current episode’, ‘Previous operations for this problem’, ‘Results of

investigations’.

Summarize the results of investigations performed prior to admission •

systematically: bedside tests, blood tests, histology or cytology, X-rays,

cross-sectional imaging, specialized tests.

Past medical history

Ask about thyroid problems, tuberculosis (TB), hypertension, •

rheumatic fever, epilepsy, asthma, diabetes, ischaemic heart disease,

stroke, and previous surgery, speciﬁ cally.

List and date all previous operations.•

Ask about previous problems with an anaesthetic.•

Asking ‘Have you • ever had any medical problem or been to hospital for

anything?’ at the end often produces additional information.

HISTORY TAKING AND MAKING NOTES

Systematic enquiry

This is extremely important and often neglected. A genitourinary history

is highly relevant in young females with pelvic pain. A good cardiovascular

and respiratory systems enquiry will help avoid patients being cancelled

because they have undiagnosed anaesthetic risks. Older patients may have

pathology in other systems that may change management, e.g. the patient

with prostatism should be warned about urinary retention.

Cardiovascular.• Chest pain, effort dyspnoea, orthopnoea, nocturnal

dyspnoea (see b p. 58), palpitations, swollen ankles, strokes, transient

ischaemic attacks, claudication.

Respiratory.• Dyspnoea, cough, sputum, wheeze, haemoptysis.

Gastrointestinal.• Anorexia, change in appetite, weight loss (quantify how

much, over how long).

Genitourinary.• Sexual activity, dyspareunia (pain on intercourse),

abnormal discharge, last menstrual period.

Neurological.• 3 Fs: ﬁ ts; faints; funny turns.

Social history

At what time did they last eat or drink?•

Ask who will look after the patient. Do they need help to mobilize?•

Smoking and alcohol history.•

2 Tips for case presentation

Practise• . Every case is a possible presentation to someone!

Always ‘set the scene’ properly• . Start with name, age, occupation, and

any key medical facts together with the main presenting complaint(s).

Be chronological• . Start at the beginning of any relevant prodrome or

associated symptoms; they are likely to be an important part of the

presenting history.

Be concise with the past medical history• . Only expand on things that you

really feel may be relevant either to the diagnosis or management, e.g.

risks of general anaesthesia.

For systematic examination techniques, see the relevant following •

pages.

Always summarize the general appearance and vital signs ﬁ rst.•

Describe the most signiﬁ cant systemic ﬁ ndings ﬁ rst, but be •

systematic—‘inspection, palpation, percussion, and auscultation’.

Brieﬂ y summarize other systemic ﬁ ndings• . Only expand on them if they

may be directly relevant to the diagnosis or management.

Finally, • summarize and synthesize—don’t repeat. Try to group

symptoms and signs together into clinical patterns and recognized

scenarios.

Finish with a proposed diagnosis or differential list and be prepared to •

discuss what diagnostic or further evaluation tests might be necessary.

CHAPTER 2 Principles of surgery

Common surgical symptoms

Dyspepsia (epigastric discomfort or pain, usually after eating) What is the

frequency? Is it always precipitated by food or is it spontaneous in onset? Is

there any relief, especially with milky drinks or food? Is it positional?

Dysphagia (difﬁ culty during swallowing) Is the symptom new or long-

standing? Is it rapidly worsening or relatively constant? Is it worse with

solid food or ﬂ uids? (Worse with ﬂ uids suggests a motility problem, rather

than a stenosis.) Can it be relieved by anything, e.g. warm drinks? Can

the patient point to a ‘level’ of hold-up on the surface (usually related to

the sternum)? This often accurately relates to the level of an obstructing

lesion. Is it associated with ‘spluttering’ (suggests tracheo-oesophageal ﬁ s-

tula or inhalation of food/ﬂ uid).

Oesophageal reﬂ ux (bitter or acidic tasting ﬂ uid in the pharynx or

mouth) How frequently? What colour is it? (Green suggests bile whereas

white suggests only stomach contents). When does it occur (lying only, on

bending, spontaneously when standing)? Is it associated with coughing?

Haematemesis (the presence of blood in vomit) What colour is the

blood (dark red-brown ‘coffee grounds’ is old or small-volume stomach

bleeding; dark red may be venous from the oesophagus; bright red is arte-

rial and often from major gastric or duodenal arterial bleeding)? What

volume has occurred over what period? Did the blood appear with the

initial vomits or only after a period of prolonged vomiting (suggests a

traumatic oesophageal cause).

Abdominal distension Symmetrical distension suggests one of the ‘5

Fs’ (ﬂ uid ascites, ﬂ atus due to ileus or obstruction, fetus of pregnancy, fat,

or a ‘ﬂ ipping big mass’). Asymmetrical distension suggests a localized mass.

What is the time course? Does it vary? It is changed by vomiting, passing

stool/ﬂ atus?

Pain

Pain anywhere should have the same features elicited. These can be

summarized by the acronym SOCRATES.

S• ite. Where is the pain, is it localized, in a region, or generalized?

O• nset. Gradual, rapid, or sudden? Intermittent or constant?

C• haracter. Sharp, stabbing, dull, aching, tight, sore?

R• adiation. Does it spread to other areas? (From loin to groin in

ureteric pain, to shoulder tip in diaphragmatic irritation, to back in

retroperitoneal pain, to jaw and neck in myocardial pain.)

A• ssociated symptoms. Nausea, vomiting, dysuria, jaundice?

T• iming. Does it occur at any particular time?

E• xacerbating or relieving factors. Worse with deep breathing,

moving, or coughing suggests irritation of somatic nerves either in

the pleura or peritoneum; relief with hot water bottles suggests

deep inﬂ ammatory or inﬁ ltrative pain.

S• urgical history. Does the pain relate to surgical interventions?

COMMON SURGICAL SYMPTOMS

Change in bowel habit May be change in frequency or looser or more

constipated stools. Increased frequency and looser stools is more likely

than isolated constipation to be due to a pathological cause. Is it a persist-

ent or transient? Are there associated symptoms? Is it variable?

Frequency and urgency of defecation New urgency of defecation

is almost always pathological. What is the degree of urgency—how long

can the patient delay? Is there associated discomfort? What is passed—is

the stool normal?

Bleeding per rectum What colour is the blood? Is it pink-red and only

on the paper when wiping? Does it splash in the pan? (Both suggest a case

from the anal canal.) Is it bright red on the surface of the stool (suggests

a lower rectal cause)? Is the blood darker with clots or marbled into the

stools (suggests a colonic cause)? Is the blood fully mixed with the stool

or altered (suggests a proximal colonic cause)?

Tenesmus (desire to pass stools with either no result or incomplete

satisfaction of defecation) Suggests rectal pathology.

Jaundice (yellow discoloration due to hyperbilirubinaemia; b p. 312)

How quickly did the jaundice develop? Is there associated pruritus? Are

there any symptoms of pain, fever, or malaise (suggests infection)?

Haemoptysis (the presence of blood in expectorate) What colour is

the blood? (Light pink froth suggests pulmonary oedema.) Are there clots

or dark blood (infection or endobronchial lesion)? How much blood?

Moderate bleeds quickly threaten airways: get help quickly.

Dyspnoea (difﬁ culty in or increased awareness of breathing) When does

the dyspnoea occur—quantify the amount of effort. Is it positional?

Orthopnoea.• Difﬁ culty in breathing that occurs on lying ﬂ at; quantify

it by asking how many pillows the patient needs at night to remain

symptom-free.

Paroxysmal nocturnal dyspnoea.• Intermittent breathlessness at night.

Both orthopnoea and paroxysmal nocturnal dyspnoea suggest cardiac

failure.

Claudication (the presence of pain in the muscles of the calf, thigh, or

buttock precipitated by exercise and relieved by rest) After what degree

of exercise does the pain occur (both distance on the ﬂ at and gradients)?

How quickly is the pain relieved by rest?

Rest pain (pain in a limb at rest without signiﬁ cant exercise) How long

has the pain been present? Is it intermittent? Does it occur mainly at night?

Is it relieved by dependency of the limb involved?

Dysuria (pain on passing urine) When does the pain occur (beginning, end,

or throughout the stream)? Is if felt in the penis or suprapubically? Is it asso-

ciated with frequency? Is the urine discoloured or does it contain debris?

Haematuria (blood in the urine) Does the blood occur at the start

(suggests bladder origin), during, or end (suggests prostatic or penile ori-

gin) of the stream? Is there associated pain (suggests infection or stone

disease)?

CHAPTER 2 Principles of surgery

Evaluation of breast disease

Positioning and inspection

Breasts are best examined semi-recumbent and then sitting upright.

Initially, the arms are by the side, semi-recumbent. After initial inspection,

they should be positioned ‘hands on hips’, sitting upright (initially relaxed

and then with forced pressure on the hips to tense the pectoral mus-

cles), and ﬁ nally abducted slowly above the head. For palpation, the hands

should return to the hips and the patient may lie back semi-recumbent

again.

Inspection is critical and should concentrate on the following.

Overall symmetry and position.

• Are the breasts the same size? Is there

deformity due to underlying disease? Is the position normal?

Skin appearance.• Is the skin erythematous or oedematous? Is there

ﬁ xed lymphoedema of the skin (‘peau d’orange’)? Are there scars from

previous surgery?

Skin tethering.• Does the skin move freely as the arms are raised?

(Tethering is suggestive of underlying intraparenchymal scarring or

tumour.)

Nipples.• Are the nipples indrawn, deviated, or ulcerated (suggestive of

retroareolar tumour or infection)? Is there any evidence of discharge?

Palpation

Use the ﬂ at of the ﬁ ngers and use all four ﬁ ngers at once. Palpate the

‘normal’ breast ﬁ rst. Be methodical and don’t ‘knead’ the breast. A com-

mon routine is: upper outer quadrant; lower outer; lower inner; upper

inner; central (retroareolar); supraclavicular fossa; axilla. Features to look

for include the following:

Palpable mass.• Is it hard, irregular, and tethered (cancer) or smooth,

rounded, and mobile (cysts or ﬁ broadenoma)?

Diffuse nodularity.

• Typical of benign disease.

Nipple discharge.• On palpation of the central area. Blood suggests

tumour; pus suggests infection; serous or milky may not be relevant.

Axillary and supraclavicular lymphadenopathy.• Is it multiple and tethered

(cancer)?

Investigations

Ultrasound

Easy to perform and painless—often done in breast outpatient clinic.

•

Avoids radiation dose in young women.•

Highly sensitive for differentiating between solid tumours and cysts.•

Mammography

Used both for population screening and diagnostic testing.

•

Uncomfortable for most women and involves a low radiation dose.•

Able to identify impalpable lesions.•

Able to identify premalignant lesions (e.g. ductal carcinoma • in situ).

Mammographic features of malignancy include: spiculated •

microcalciﬁ cation; irregularity; stellate outline.

EVALUATION OF BREAST DISEASE

Aspiration cytology

Well tolerated, easy to perform, and quick to report on—often done •

in one half day during breast outpatient clinic.

Does not provide histology: provides only cellular information and •

relies upon cellular atypia for a diagnosis of malignancy.

Does not differentiate between invasive and • in situ carcinoma.

Occasionally therapeutic for cysts.•

Good sensitivity and speciﬁ city.•

Guided core biopsy

Performed under ultrasound or mammographic guidance using a

•

Trucut

needle or similar device.

Can be done under general or local anaesthetic.•

Provides actual histology information—allows cancers to be graded.•

Able to differentiate between invasive and carcinoma • in situ.

Highly sensitive and speciﬁ c.•

Computerized tomography (CT) scanning

Relatively non-speciﬁ c for local breast pathology.

•

Useful for assessment of extensive local invasion and regional and •

systemic staging.

CT positron emission tomography (PET) scanning

Occasionally used to assess indeterminate lesions identiﬁ ed on plain •

CT and identify unsuspected metastatic disease.

Magnetic resonance imaging (MRI) scanning

Occasionally used for the assessment of local breast pathology.•

Key revision points—anatomy of the breast

Breast comprises epithelial ductal tissue, epithelial secretory lobules, •

fat, and connective tissue.

It is divided into four ‘quadrants’ and a peri/retroareaolar central

•

zone for clinical description of abnormalities.

The • areola is the pigmented area around each nipple.

The • arterial supply is from segmental perforators from the internal

thoracic artery (ITA).

Lymphatic drainage• —important in breast cancer management.

Non-pathological lymph drainage is almost entirely to the axillary •

nodes.

Medial half can occasionally drain to internal mammary nodes.•

Lymph nodes are divided into three levels (1, below; 2, behind; 3, •

above pectoralis minor).

CHAPTER 2 Principles of surgery

Evaluation of the neck

Evaluation of carotid artery disease is described on b p. 658.

Positioning and inspection

Sit the patient upright at rest with the head looking straight ahead. •

Inspect the neck from the front, side, and, if necessary, behind.

Observe the neck at rest and during swallowing (a glass of water). If •

necessary, inspect rotation left and right.

Observe the neck while asking the patient to protrude the tongue.•

Inspection includes looking for the following.

Overall symmetry and lumps.• Are there obvious lumps? Are they single

or multiple? Is the lump lying in or close to the midline? Does the lump

move with swallowing (suggests thyroid-related lesion)?

Skin abnormalities.• Are there any ulcers of sinuses (suggests chronic

infection such as TB)?

Associated structures.• Is there evidence of venous engorgement or

collateral vessels visible?

Palpation

Be systematic; palpate the regions of the neck in order. Use both hands

with the ﬂ ats of the ﬁ ngers to compare each side, but move only one

hand at once to prevent ‘cross-palpation’. A typical sequence of palpation

is: anterior triangle (bottom to top); submental area; submandibular area;

posterior triangle (top to bottom); supraclavicular fossae; parotid, pre-

auricular and post-auricular areas. Repalpate the neck with the patient

swallowing a mouthful of water—particularly the anterior triangle (see

Fig. 2.1). Lastly, feel speciﬁ cally for the carotid arteries.

Lumps.• Is it single or multiple (multiple strongly suggests

lymphadenopathy)? Is it strictly in the midline (likely to be related to

the thyroid)? Does it move with swallowing (almost always thyroid-

related)? What are the general features (see b p. 42)?

Thyroid lumps.• Is it unilateral or bilateral? Does it move with tongue

protrusion?

Carotid arteries.• Are they normal, ecstatic, or aneurysmal?

Supraclavicular fossae.• Is there associated lymphadenopathy (suggests

malignancy)?

Auscultation Listen to the carotid arteries and any large masses for bruits,

suggesting a hypervascular local circulation or stenosis.

Investigations

Ultrasound

Easy to perform and painless.

•

Avoids radiation dose.•

Highly sensitive for the differentiation between solid tumours and •

cysts.

Aspiration cytology

Easy to perform and quick to report on—often done in one half day

•

during outpatients.

EVALUATION OF THE NECK

Usually well tolerated in outpatients.•

Provides only cellular information and relies upon cellular atypia for a •

diagnosis of malignancy.

Does not provide histological information.•

Occasionally therapeutic for cysts.•

Good sensitivity and speciﬁ city.•

Contraindicated where there is a suspicion the lesion may be vascular.•

CT scanning

Useful for assessment of extensive local invasion and regional and •

systemic staging of tumours.

Allows evaluation of the thorax in some thyroid tumours.•

CT PET scanning

Occasionally used to assess indeterminate lesions identiﬁ ed on plain CT

and identify unsuspected metastatic disease.

MRI scanning

Useful for detailed assessment of local invasion of tumours.

Clavicle

Trapezius

Sternocleidomastoid

Midline

Mandible

Ant

Post

Fig. 2.1 Key revision points—triangle of the neck.

CHAPTER 2 Principles of surgery

Evaluation of the abdomen

Positioning

Lie the patient supine with the head slightly raised with adequate •

support for the head to ensure the abdominal muscles are relaxed.

Arms should be by the sides to relax the lateral abdominal muscles.•

The patient may be rolled into left or right lateral positions during •

palpation and percussion.

Ask the patient to cough during inspection; it may reveal hernias.•

Stand the patient up to examine the groin only if necessary; most •

hernias and groin pathology can be fully assessed in supine position.

Inspection

Perform during normal and deep respiration.•

General features.• Is there evidence of jaundice or signs of anaemia?

Does the patient looked underweight, malnourished, or cachectic?

Scars.• Where are they? How old do they appear? Is there evidence of

herniation on coughing?

Is there a stoma?• What type? Does it look healthy or abnormal? What

is the content in the stoma appliance?

Overall appearance.• Is the abdomen symmetrical? Is there evidence

of global distension (e.g. ascites, distended bowel)? Is there evidence

of local distortion (e.g. a local mass or organomegaly)? Does the

abdomen move well and symmetrically with deep respiration (reduced

in peritoneal irritation)? Is there any discoloration (periumbilical

bruising (Cullen’s sign) or ﬂ ank bruising (Grey Turner’s sign), where

either suggests retroperitoneal haemorrhage or major inﬂ ammation)?

Umbilicus.• Is it herniated? Is there discharge or ulceration suggestive of

infection or a malignant deposit?

Pulsation.• Is there visible pulsation? (Further assessment requires

palpation.)

Persistalsis.

• Is there visible peristalsis? (Identiﬁ cation may take several

minutes of observation.) It is rarely possible to suggest a cause or level

of obstruction related to the pattern of visible peristalsis.

Palpation

Be methodical. Use the ﬂ at of one hand (usually the right). It is usual to

examine and describe the abdomen in areas. It can be divided it into nine

regions or ﬁ ve ‘quadrants’ (see Fig. 2.2). Examine the areas lightly at ﬁ rst

in a set order. Identify any masses or areas of tenderness. Repeat the

examination with deeper palpation. Go back to any identiﬁ ed masses and

try to ascertain their key features.

Signs of peritoneal irritation.• Are there signs of local visceral peritoneal

irritation (tenderness and pain on palpation)? Are there signs of mild

parietal peritoneal irritation (guarding) or signs of marked parietal

peritoneal irritation (rigidity)? Rigidity may be localized or generalized.

Rebound tenderness is an unnecessary test; it merely conﬁ rms the

presence of guarding and is often excessively painful for the patient.

Masses.• Assess their surface, edge, consistency, movement with

respiration, and overall mobility.

EVALUATION OF THE ABDOMEN

Organs.•

Liver• . Palpate from right lower quadrant into right upper quadrant,

feeling for the liver edge during inspiration every few cm upwards

until it is found. Assess the edge. Is it smooth/nodular/craggy?

Assess any palpable surface. Is it smooth/nodular/craggy?

Spleen• . Palpate from right lower quadrant into left upper quadrant,

feeling for the spleen edge during inspiration as for the liver. Assess

the edge and any palpable surface.

Kidneys• . Palpate bimanually in each loin. ‘Ballotting’ (bouncing the

kidneys between each hand) is of little additional value.

Percussion

Percussion identiﬁ es the presence of excessive amounts of gas or ﬂ uid. It

is also useful, when done carefully, in the conﬁ rmation of the presence of

mild to moderate parietal peritoneal irritation (‘percussion tenderness’).

Gas• (hyperresonance). Is it generalized or localized? Is there

evidence of loss of dullness over the liver (suggestive of copious free

intraperitoneal gas)?

Fluid• (ascites). Usually identiﬁ ed as ‘shifting dullness’; dullness in

the ﬂ anks in the supine position moves to the lower portion of the

abdomen on turning to the lateral position.

Auscultation

To fully assess bowel sounds, it is necessary to listen for at least 1min, but

they are a notoriously unreliable sign of either intra-abdominal pathology

or bowel function. If commented on, bowel sounds should broadly be

divided into: absent, normal, active, or obstructive (characterized by high-

pitched, frequent sounds often with crescendos of activity, e.g. ‘tinkling’,

‘bouncing marbles’).

Abdominal assessment should always include a rectal examination in

adults; this is very rarely useful and should usually be avoided in children.

RUQ

LUQ

LLQRLQ

Central

Fig. 2.2 The ﬁ ve quadrants: RUQ, right upper quadrant; LUQ, left upper

quadrant; LLQ, left lower quadrant; RLQ, right lower quadrant.

CHAPTER 2 Principles of surgery

Abdominal investigations

Faecal occult blood testing

May be chemical or immunological.•

Commonest use is as the primary community test for colorectal •

carcinoma (see b p. 400) as part of the National Bowel Cancer

Screening Programme.

Rigid proctoscopy and sigmoidoscopy (see b p. 216).

Flexible sigmoidoscopy

Very low risk (perforation 1 in 5000) outpatient procedure, usually •

performed without sedation.

Should visualize up to the descending colon.•

Allows minor therapeutic procedures (polypectomy, biopsy, injection).•

Colonoscopy

Low risk (perforation 1 in 1000) outpatient procedure, usually •

performed with sedation; requires bowel preparation.

Should visualize the entire colon (>95% of the time).•

Allows minor therapeutic procedures (polypectomy, including •

‘advanced’ endoscopic mucosal resection (EMR) and endoscopic

submucosal dissection (ESD), injection, marking by tattoo, and biopsy).

Typically used for: assessment of (suspected) colitis, diagnosis and •

assessment of colonic neoplasia, investigation of rectal bleeding.

Transabdominal ultrasound

Easy, safe, non-invasive, and avoids radiation dose.•

Typical uses include:•

Identiﬁ cation of ovarian disease, e.g. in suspected acute appendicitis.•

Primary investigation of the biliary tree for gallstones, bile duct size, •

and liver parenchymal texture.

Investigation of suspected subphrenic or pelvic collections.•

Assessment of the liver/splenic parenchyma.•

Identifying free ﬂ uid in abdominal trauma.•

CT scanning

Easy, non-invasive; requires signiﬁ cant radiation exposure and •

intravenous (IV)/oral (PO) contrast.

Typical uses include:•

Primary assessment of all intra-abdominal masses.•

Staging of intra-abdominal and pelvic malignancy.•

Investigation of acute abdominal pain of unknown origin.•

Investigation of suspected intestinal obstruction.•

May be speciﬁ cally tailored for pancreatic, biliary, visceral vessel •

assessment.

Investigation of suspected post-operative complications.•

MRI scanning

Conventional body scanner with external coils.•

Avoids radiation dose.•

ABDOMINAL INVESTIGATIONS

May be performed with specialized ‘contrast’ agents (e.g. ferumoxides).•

Typically used for:•

Investigation of suspected bile duct disease.•

Assessment of liver disease/possible metastases.•

Assessment of pancreas.•

Assessment of pelvic and retroperitoneal soft tissue disease, e.g. •

pelvic cancers.

Plain abdominal radiograph

Limited use.•

May identify intestinal obstruction, urinary tract stones, free intra-•

abdominal air, intra-abdominal ﬂ uid.

Barium enema (double contrast, single contrast)

May be single contrast (contrast material ﬁ lling the colon) or double •

contrast (dilute contrast and air to coat the mucosal surface of the

colon).

Requires bowel preparation and relatively mobile patient.•

Single contrast used to identify strictures and obstructions (used to •

assess colorectal anastomoses in dilute or water-soluble form).

Double contrast typically used to identify colonic neoplasia, assess •

colonic anatomy.

Intestinal transit studies

Serial abdominal X-rays to identify the progress of ingested radio-•

opaque markers.

Used to assess intestinal motility and transit time.•

PET scanning

Injection of radioactive metabolic substrate to identify metabolically •

active tissue.

Combined with high resolution CT scanning to co-locate ‘hot spots’.•

Typically used to:•

Identify unsuspected metastatic tumour deposits.•

Differentiate ﬁ brosis from tumour post-surgery.•

Physiological testing

Manometry testing of the oesophagus, including lower oesophageal •

sphincter and the anal canal.

Pressure sensitivities of the oesophagus and anal canal.•

pH testing of the contents of the oesophagus (isolated or continuously •

for 24h).

Used to assess anorectal function, oesophageal motility and function, •

and gastro-oesophageal reﬂ ux.

CHAPTER 2 Principles of surgery

Evaluation of pelvic disease

Positioning and inspection

Examination is performed in up to three positions: supine (for transabdom-

inal palpation of the ‘false’ pelvis); supine with hips ﬂ exed and abducted

(for vaginal and bimanual palpation which may be performed to help assess

rectal disease); and left lateral position with hips ﬂ exed (for rectal palpa-

tion and rigid endoscopy). Any intimate examination should always have a

chaperone present and particularly so for pelvic examinations.

Anus.

• Is the anus deformed? Is there evidence of mucosal or rectal

prolapse? Does the vaginal introitus look normal? Is there vaginal

prolapse or evidence of a cystocele? Are there scars from previous

surgery, sinuses, or evidence of sepsis?

Look for additional or abnormal tissue.• Are there skin tags, external

haemorrhoids, warts, or abnormal areas of skin (such as anal

intraepithelial neoplasia (AIN))? Is there an external punctum (as may

be seen in a ﬁ stula) or the outer limit of a ﬁ ssure visible?

Palpation

Palpate the lower abdominal quadrants.•

Rectal examination.• Is anal tone normal and the sphincter symmetrical?

Is the prostate normal size with a normal central sulcus? Does the

rectal mucosa feel normal? Is there any mass or tenderness anterior

to the upper rectum (pouch of Douglas)? The latter may be due to

sigmoid disease, small bowel in the pelvis, a pelvic appendix, or ovarian

disease.

Vaginal examination• (often omitted unless there is a clear indication

that valuable information may be gained from it). Is the cervix

present and normal? Is the vagina of normal calibre and feel? Is there

tenderness in either vaginal fornix?

Investigations

Rigid proctoscopy (‘anoscopy’)

Performed in outpatients without sedation.

•

Only visualizes the very lowermost rectum and anal canal (referred to •

as anoscopy in USA). Views may not be good if done without enema

preparation.

May be combined with therapy (banding, injection, or cryotherapy) for •

anorectal disorders.

Rigid sigmoidoscopy

Performed in outpatients without sedation.

•

Aims to visualize the rectum to the recto-sigmoid junction. The •

sigmoid colon is NOT adequately seen with this (referred to as

proctoscopy in USA). Views may not be good if done without enema

preparation.

Flexible sigmoidoscopy

Low risk, outpatient procedure, usually performed without sedation.

•

Should visualize up to the descending colon.•

Allows minor therapeutic procedures (polypectomy, tattoo, injection).•

EVALUATION OF PELVIC DISEASE

Transabdominal/transvaginal ultrasound

Easy, safe, and avoids radiation dose.•

Good for identiﬁ cation of ovarian disease (e.g. in right iliac fossa pain).•

Endoanal/transrectal ultrasound

A 360• ° scanning endoanal/endorectal probe without sedation.

Endoanal scans. For assessment of anal sphincter integrity.

•

Transrectal scans. For assessment of some rectal tumours, prostatic •

disease (including biopsy), pre-sacral lesions.

CT scanning

Easy, safe, but signiﬁ cant radiation exposure and IV contrast.

•

Investigation of choice for undiagnosed pelvic symptoms and post-•

operative complications.

MRI scanning

Usually via conventional body scanner with external coils (occasionally •

performed with endorectal coil).

Investigation of choice for the assessment of advanced rectal, •

gynaecological, and urological cancer, or complex pelvic sepsis.

Investigation of choice for complex pelvic and anal sepsis.•

Key revision points—pelvic anatomy

The true pelvis lies between the pelvic inlet (sacral promontory, •

illiopectineal lines, symphisis pubis) and outlet (coccyx, ischial

tuberosities, pubic arch).

Pelvic ﬂ oor muscles (such as levator ani) support and are integral •

to the function of the anorectum, vagina, and bladder. They are

innervated by anterior primary rami of S2, 3, 4.

Anterior relations of the rectum (palpable during PR exam) are

•

(from below up):

Women—vagina, cervix, pouch of Douglas.•

Men—prostate, seminal vesicals, recto-vesical pouch.•

CHAPTER 2 Principles of surgery

Evaluation of peripheral vascular

disease

Positioning and inspection

Ideally, the patient should be examined in a warm environment at rest.

Remember ﬁ rst to take the pulse and blood pressure, and examine the

abdomen (aneurysm, scars). Inspect the limb in the supine position, then

elevated (passively), and ﬁ nally dependent. Expose the entire limb, includ-

ing the foot or hand to allow thorough inspection. If necessary, take any

dressings down (or ask for them to be removed if you are not happy to).

For venous disease, the patient should also be examined standing.

During supine inspection, look for the following.

Appearance.

• Are there any areas of established skin necrosis (dry

gangrene, e.g. apex of digits, between digits, heel of the foot)? Are

there changes of chronic venous stasis (ﬂ are veins, venous eczema,

lipodermatosclerosis, leg ulceration)?

Colour.• Waxy white suggests severe acute ischaemia; blue and mottled

suggests potentially irreversible acute ischaemia; dark red/purple

suggests chronic ischaemia.

Colour changes during position.• Note the angle at which the skin of

the limb blanches when passively elevated (Buerger’s test). Normal

limbs may not blanch at all. An angle of 15° or less suggests severe

ischaemia. Note the presence and delay in change in colour when the

limb is dependent. Ischaemic limbs slowly turn deep purple.

Ulcers.• What is the location (digital or foot suggests arterial disease)?

Be sure to inspect between the toes/ﬁ ngers and on the plantar surface

of the foot (especially for diabetic disease).

Venous inspection.• Stand the patient up. Inspect for varicose veins. Are

they in the long saphenous or short saphenous distribution?

Palpation

Temperature.• Does the skin feel cold or warm? Is there a transition

level?

Skin capillary compression and reﬁ ll.• Normal is 2s or less. A delay of

greater than 5s suggests signiﬁ cant ischaemia.

Peripheral pulses.• Start with the most proximal (major) vessels and

work distally. Record if the pulse is normal, reduced, or absent. Record

if there are any thrills palpable.

In venous disease, tests of • venous competence may be performed (see

b p. 666).

Surgical grafts.• Palpate the course of any surgical grafts and record the

presence or absence of pulses.

Auscultation

Listen for bruits. Are there bruits in the proximal vessels (suggestive of

stenosis)?

EVALUATION OF PERIPHERAL VASCULAR DISEASE

Investigations

Doppler ultrasound

Straightforward and portable.•

May be used to conﬁ rm or refute the presence of ﬂ ow in a vessel or •

graft.

May be used to evaluate the relative ﬂ ow in vessels by measuring the •

pressure at which detectable ﬂ ow ceases using a compression cuff.

The commonest example is ankle–brachial pressure index (ABPI).

May be used to evaluate the presence of reﬂ ux in veins.•

Colour ﬂ ow duplex

Combined two-dimensional (2D) ultrasound image with Doppler-•

derived ﬂ ow represented using colour, superimposed in real time.

May be used for assessment of stenosis/occlusion in vessels or grafts.•

May be used for assessment of reﬂ ux or occlusion in deep and •

superﬁ cial veins.

Direct angiography

Most commonly, digital subtraction angiography (DSA; used to reduce •

background image ‘noise’ and convert the arterial images to black for

easier viewing).

Invasive, requiring direct arterial puncture with the associated risks.•

Requires IV contrast with the small risk of allergy (relatively •

contraindicated in renal dysfunction or where renal blood ﬂ ow is

poor).

Gives direct views of arterial tree, but lumen only so not good for •

aneurysm sizing.

Magnetic resonance angiography

Provides images of an arterial tree based on the presence of arterial

•

ﬂ ow during scanning.

Safe and non-invasive; requires no ‘contrast’, but commonly gadolinium •

used to highlight ﬂ owing blood.

Tends to overestimate degree of stenosis due to very low ﬂ ow being •

underrepresented.

CT angiography

Requires multislice rapid acquisition (‘helical’/’spiral’) scanner.

•

Images acquired in arterial phase after IV injection of contrast.•

Three-dimensional (3D) reconstruction allows ‘virtual angiogram’ •

images to be produced.

Fast and relatively safe, especially where direct angiogram is difﬁ cult, •

e.g. visceral vessels.

Requires dose of IV contrast, so caution with allergy and renal •

dysfunction.

CHAPTER 2 Principles of surgery

Evaluation of the skin and

subcutaneous tissue disease

Assessment and description of a lump

Key features in the history include the following:

Speed of development.

• Rapid increase in size is suspicious of malignancy

(primary or secondary).

Recent change in size.• Suggests malignant change or infection in a

previously benign lesion.

Associated symptoms.• Paraesthesia or weakness suggests involvement

of nerves; reduced movement suggests involvement of muscle.

History of local trauma.• May indicate a cause, although a previously

undiagnosed underlying lump should always be suspected.

The following features should all be considered when examining the lump.

Basic facts

Position.

•

Size.•

Shape.•

Features of infection or inﬂ ammation

Temperature.

•

Tenderness.•

Colour.•

Features of malignancy

Surface (e.g. craggy).

•

Edge (e.g. irregular).•

Consistency (e.g. hard).•

Features of ﬂ uid or vascular lesions

Fluctuant (ﬂ uid-ﬁ lled).

•

Presence of thrill (ﬂ uid-ﬁ lled connected to the vascular tree).•

Transilluminance (ﬂ uid-ﬁ lled).•

Pulsatile (arterial lesion).•

Presence of a bruit (arterial lesion).•

Presence of expansility (indicative of an arterial aneurysm).•

Presence of compressibility (e.g. venous lesion or arteriovenous •

malformation).

Features of locoregional invasion

Tethering to surrounding structures.

•

Involvement of surrounding structures (e.g. nerves).•

Regional lymphadenopathy.•

Lumps in detail

Superﬁ cial lumps, see • b pp. 600–603.

Neck lumps, see • b pp. 222, 224.

Abdominal lumps and herniae, see • b p. 336.

Scrotal lumps, see • b p. 366.

EVALUATION OF THE SKIN AND SUBCUTANEOUS TISSUE DISEASE

Assessment and description of an ulcer

Key features in the history include the following:

Is it painful (venous, diabetic, and neuropathic ulcers are painless)?•

Did it start as an ulcer or did a lump become ulcerated (suggests a •

malignancy in/of the skin)?

Is there a history of underlying infection, e.g. of bone?•

Describe the basic morphology of the ulcer:

Location.•

Over pressure points and bony prominences suggests pressure •

sore.

Medial shin suggests venous ulcer.•

Lateral shin, dorsum of foot, toes suggest arterial ulcer.•

Edge.•

Sloping edge suggests conventional ulcer (can be many aetiologies).•

Rolled edge is typical of basal cell or squamous carcinomas.•

Everted edge suggests squamous or metastatic carcinomas.•

Vertical edge (punched out) suggests syphilis or chronic infection.•

Base.•

Friable, red, and bleeding suggests venous or traumatic.•

Green slough suggests infected.•

Black hard eschar suggests chronic ischaemia.•

Discharge.• May suggest an underlying cause, e.g. intestinal ﬁ stula with

enteric content, golden pus in chronic actinomycosis.

Surrounding tissue.• Erythema and swelling suggest secondary infection.

Ulcers in detail

Cutaneous malignancy, see • b p. 647.

Ischaemic ulcers, see • b p. 647.

Venous ulcers, see • b pp. 148, 666.

Fistulas, see • b p. 150.

Wound infections, see • b p. 104.

CHAPTER 2 Principles of surgery

Surgery at the extremes of age

Surgery is increasingly used in older and older patients and the range of

procedures available to surgeons for both the very elderly and the very

young and neonates is increasing. Minimally invasive surgery is increas-

ingly being offered to older patients at risk from open surgery. Both these

groups need particular attention and have speciﬁ c potential problems.

Surgery and the elderly

Common misconceptions corrected

Elderly patients beneﬁ t just as much from potentially curative cancer •

surgery as younger patients. Cancers demonstrate the same range of

behaviours in all ages and are neither more ‘benign’ nor less responsive

to treatment in the elderly.

Minimally invasive procedures in the elderly can offer all the beneﬁ ts •

available to younger patients.

‘Palliative’ procedures for benign disease (e.g. cholecystectomy, joint •

surgery, eye surgery) are just as important in the elderly as they

may allow preservation of independence and offer just as much

improvement in quality of life as in the young.

Common problems in the elderly

Multiple comorbidities and polypharmacy increase the scope for •

potential complications and drug interactions.

Comorbidities are often ‘silent’, either due to atypical presentation or •

underreporting of symptoms (e.g. angina may not be manifest due to

reduced mobility).

Social, family, nursing, and medical support structures are often •

complex and easily lost during a hospital admission.

Reduced or acutely impaired mental faculties may make history taking •

and consent taking difﬁ cult.

Reduced or abnormal immune responses may reduce or impair some •

physical signs (e.g. clinically detectable peritonism may be absent).

The elderly are particularly prone to mild or moderate chronic •

malnutrition, increasing general complication rates, and the risk of

pressure sores, etc.

Strategies for the management of the elderly

Involve all the necessary specialities as soon as possible (prior to •

admission for elective surgery), e.g. elderly care, anaesthetists,

physicians.

Consider pre-optimization in critical care (high dependency unit •

(HDU)), especially in urgent or emergency surgery.

Start to plan for discharge on the day of admission and liaise with the •

GP and family, if necessary.

Consider nutrition as soon as possible after surgery. Is hyper-•

alimentation necessary?

Surgery and the young

Although most surgery undertaken in neonates and very young children is

done so by specialist paediatric surgical and nursing teams, most surgeons

SURGERY AT THE EXTREMES OF AGE

will care for young children at some time and the principles of care used

in paediatric surgery can be usefully applied to older children.

Common problems in children

Young children may not be able to accurately report symptoms and

•

illness behaviour is often non-speciﬁ c.

Cardiovascular responses in the young are excellent. Tachycardia and •

particularly hypotension are (very) late signs of hypovolaemia.

2 Tips for managing children

Take the history from the parents or carers

• and the child.

Remember infections are common and often present with non-speciﬁ c •

signs.

Consider non-surgical diagnoses at all times, e.g. meningitis, urinary •

sepsis, systemic viral infections.

Examine the child as much as possible while they are sitting on a •

parent’s lap. Use the same position for phlebotomy and siting cannulae.

Put local anaesthetic cream on phlebotomy sites 30min in advance.•

Some children are simply too young to cooperate with procedures •

under local anaesthetic and will require general anaesthesia for

relatively trivial procedures.

Make sure all prescriptions for drugs and ﬂ uids are written according •

to weight to avoid inadvertent adult dosing—if in doubt, ask.

Fluid balance may be critical since small volume changes are highly •

signiﬁ cant in small children. Pay close attention to ﬂ uid resuscitation.

Paediatric surgery

Conversion tables, see • b p. 424.

Paediatric surgery, see • b pp. 424–474.

Consent and children, see • b p. 14.

CHAPTER 2 Principles of surgery

Day case and minimally invasive

surgery

Day surgery procedures

An increasing number of procedures in all aspects of surgery are being

performed as day surgery. The key features that make a procedure suit-

able include:

Low risk of major complications.

•

Predictable recovery period not requiring specialist post-operative •

therapy or treatment.

Post-operative analgesia that does not need routine opiates.•

Anaesthetic technique not requiring invasive monitoring, prolonged •

muscle relaxation, or epidural/spinal anaesthesia.

Low risk of difﬁ cult or unpredictable anaesthetic technique.•

Many areas of surgery are now performed routinely as day surgery, includ-

ing minor and intermediate anorectal surgery, hernia surgery, minor lapar-

oscopic surgery, arthroscopy, and minor endoscopic bladder surgery.

Selection of patients for day case surgery

Most hospitals have well deﬁ ned protocols to select patients for suitability

for day surgery and most day surgery units conduct their own pre-admis-

sion assessment either by telephone or questionnaire. Typical criteria

might include:

Maximum age of 75y (this upper limit has gradually increased as •

familiarity with the procedures has grown).

Appropriate social support for the patient at home, including transport •

and a responsible adult to monitor progress.

No history of more than mild to moderate cardiac or respiratory •

disease (e.g. uncomplicated asthma or controlled angina).

Non-insulin dependent diabetes only (unless for local anaesthetic (LA) •

procedures).

Body mass index (BMI) below 35 (typically)—higher than this is •

associated with increased risk of anaesthetic and surgical complications.

Minimally invasive surgical procedures

Minimally invasive surgery is becoming more common in many areas of

surgery. It is a broad term that includes many types of procedure and

there is much overlap with conventional ‘open’ surgery and, at the other

end of the spectrum, interventional radiological procedures. A useful

deﬁ nition of minimally invasive surgery is a procedure that can be per-

formed by a technique involving fewer or smaller incisions than alternative

‘conventional’ surgery or under less invasive anaesthetic techniques. This

includes most laparoscopic and thoracoscopic surgery (cholecystectomy,

gastric fundoplication, colectomy, lobectomy, nephrectomy, adrenalec-

tomy). It also includes ﬂ exible and rigid endoscopic procedures (diagnostic

and therapeutic colonoscopy, cystoscopy, transurethral prostate surgery,

hysteroscopic surgery), and several procedures using speciﬁ c techniques

or equipment (e.g. transanal endoscopic microsurgery, subfascial endo-

scopic venous surgery).

DAY CASE AND MINIMALLY INVASIVE SURGERY

Advantages of minimally invasive surgery

Many minimally invasive surgical techniques require speciﬁ c training to

perform and utilize expensive equipment and consumables so surgeons

and managers look to minimally invasive surgery to provide beneﬁ ts to

both patients and hospitals. Although some beneﬁ ts can be achieved by

modern post-surgical management, there are demonstrable beneﬁ ts in dif-

ferent areas.

Patient beneﬁ ts

Smaller, fewer, or absent scars.

•

Reduced time in hospital.•

Fewer post-operative complications (particularly wound and •

respiratory-related).

Surgeon beneﬁ ts

Reduced post-operative stay.

•

Possible avoidance of the need for interventional anaesthetic •

techniques such as epidurals.

Hospital beneﬁ ts

Increased bed use efﬁ ciency.•

Reduced post-operative complications.•

To whom should minimally invasive surgery be offered?

The advantages of minimally invasive surgery give it a wide application.

Young patients.• Small scars and short hospital stays are ideal.

Elderly. • Reduced post-operative complications and shortened hospital

stay are vital in patients who often have multiple comorbidities.

Unﬁ t patient.• Easier anaesthetic techniques and reduced surgical stress

may reduce the perioperative risk.

CHAPTER 2 Principles of surgery

Surgery in pregnancy

Changes in anatomy and physiology

Pregnancy results in several changes relevant to surgery.

First trimester

Drugs may have teratogenic effect (see Box 2.1).•

Reduced lower oesophageal sphincter tone, increasing the risk of •

gastro-oesophageal reﬂ ux and aspiration when supine.

Second trimester

Drugs may have adverse effect in fetal development or metabolism •

without causing gross malformation.

Increased susceptibility to urinary tract infections, particularly •

ascending renal infections and pyelonephritis.

Increased risk of venous thromboembolism rises in the second •

trimester and remains constantly raised in the third.

Increased susceptibility to superﬁ cial infections.•

Third trimester

Drugs may induce labour.

•

Displacement of the mobile abdominal viscera superiorly and behind •

the enlarging uterus. In particular, the appendix comes to lie in the

right upper quadrant.

Risk of hypotension in the supine position due to inferior vena caval

•

compression by the gravid uterus: this can be avoided by positioning

the sedated or unconscious patient in slight lateral decubitus.

Risks of miscarriage

The risk of miscarriage related to surgical pathology and surgery varies

according to trimester. It is highest in the ﬁ rst. The risk of a viable pre-

mature labour rises in the third trimester. The risk of miscarriage induced

by general anaesthetic (GA) is always balanced against the risk induced by

sepsis from untreated surgical pathology, particularly acute appendicitis. It

is a common dilemma in surgical practice. Ultrasound imaging may be less

useful due to poor views and CT scanning is contraindicated due to radia-

tion dose. Diagnostic laparoscopy is contraindicated due to the effects of

pneumoperitoneum on the pregnancy. The only way to a diagnosis may be

surgery, once important differential diagnoses have been excluded.

Pregnancy testing

Urinary dipstick • B-HCG is 91% sensitive (even lower for women self-

testing). Speciﬁ city ranges from 61% to 100% if tested from the ﬁ rst

day of the ﬁ rst missed period (2 weeks after ovulation).

Blood

• B-HCG is almost 100% sensitive and speciﬁ c and able to

detect pregnancy 6–8 days after ovulation.

False negatives and positives are most commonly due to user error.•

SURGERY IN PREGNANCY

Common differential diagnoses of appendicitis in pregnancy

Ectopic pregnancy complications.•

Pyelonephritis.•

Threatened miscarriage/placental abruption.•

Box 2.1 Prescribing drugs in pregnancy

It is clearly unethical to screen drugs for harmful effects on the human

fetus; many new and commonly used drugs have, therefore, never been

used in pregnancy. Some older drugs have been used in pregnancy and

are regarded as ‘safe’ in the absence of any reports of fetal harm. There

is an important balance to maintain between treating serious illness in

the mother and potentially harming the fetus. Generally:

Avoid prescribing drugs, if at all possible.•

Know the stage of the pregnancy; many drugs are only approved in •

particular trimesters.

2 Check every drug that you prescribe in Appendix 4 of the British

National Formulary (BNF).

If in doubt, seek specialist advice.•

Important teratogens include:•

Thalidomide (an antiemetic).•

Carbamazepine and sodium valproate.•

Isotretinoin (Roaccutane•

Tetracycline.•

Warfarin.•

Angiotensin-converting enzyme (ACE)-inhibitors.•

Lithium.•

Methotrexate, cyclophosphamide.•

CHAPTER 2 Principles of surgery

Surgery and the contraceptive pill

(O)estrogen-containing contraceptive pills (EOCP) increase the risk

of thromboembolic disease in women taking them prior to surgery.

Progesterone-only contraceptives appear to pose little or no additional

risk and may be continued during surgery. The increase in risk is related

to the size of the operative procedure and the existing comorbidity; the

advice is adjusted accordingly.

Low risk procedures.• Dental, day case, minor laparoscopic. EOCP may

be continued.

Medium risk. • Abdominal, orthopaedic, major breast surgery.

EOCP should be discontinued at least 1 month prior to elective •

surgery.

Urgent or emergency surgery should be conducted with full •

thromboprophylaxis (see b p. 72).

High risk.• Pelvic, lower limb orthopaedic surgery, cancer.

EOCP should be discontinued at least 1 month prior to elective •

surgery.

Urgent or emergency surgery should be conducted with extended •

thromboprophylaxis (see b p. 72).

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CHAPTER 2 Principles of surgery

Surgery in endocrine disease

Diabetes

Speciﬁ c perioperative risks

Hypoglycaemia, hyperglycaemia, or ketoacidosis.•

Underlying diabetes-related comorbidity is often unrecognized (e.g. •

mild renal impairment, small-vessel coronary and cerebrovascular

disease, mild autonomic neuropathy with associated reduced

cardiovascular homeostasis responses).

Increased susceptibility to infection, poor wound healing.•

Increased susceptibility to skin pressure necrosis.•

Management of the diabetic patient

Inform the anaesthetist, the diabetologist, and any specialists involved •

in the patient’s ongoing care, e.g. nephrologists.

Clarify if the patient is oral-controlled, insulin-dependent (low or •

high requirement), or brittle insulin-dependent since the risk of

perioperative problems increases with each group.

Diabetics should be ﬁ rst on operating lists to ensure timings can be as •

predictable as possible for blood sugar management.

Check preoperative investigations for signs of underlying comorbidity.•

Ketoacidosis in the perioperative period is associated with a very high •

morbidity and mortality and should be avoided at all costs.

Minor surgery

Oral-controlled.• Give normal regimen.

Insulin-controlled. • Omit preoperative insulin on day of surgery; monitor

blood sugar (BS) every 4h; restart normal insulin once oral diet is

established.

Major surgery

Oral-controlled.

• Omit long-acting hypoglycaemics preoperatively.

Monitor BS every 4h. If BS exceeds 15mmol/L, start IV insulin regimen.

Insulin-controlled.• Commence on IV insulin sliding scale preoperatively

once nil by mouth (NBM) and continue until normal diet is

re-established. Check BS every 4h. Restart normal insulin regimen

(initially at half dose) once oral diet is established.

Emergency surgery

Check for existing ketoacidosis. If present, use medical treatment

•

algorithm to control BS and postpone surgery until BS <20mmol/L

unless the condition is life-threatening.

Use IV insulin sliding scale for all patients to optimize BS control. A •

typical IV sliding scale (Actrapid

with 5% dextrose) is:

BS <4mmol/L, infusion 0.5U/h + consider medical review.•

BS 4–15mmol/L, infusion 2.0U/h.•

BS 15–20mmol/L, infusion 4.0U/h.•

BS >20mmol/L, infusion 4.0U/h + consult diabetology team and •

consider treatment as for ketoacidosis.

SURGERY IN ENDOCRINE DISEASE

Steroids

Speciﬁ c perioperative risks

Oral steroids are used to treat a number of common illnesses, including

rheumatoid arthritis, severe asthma, and COPD, temporal arteritis, and

polymyalgia rheumatica. Steroids reduce neutrophil and ﬁ broblast func-

tion and immune response and lead to irreversible changes in connective

tissue. Long-term use of systemic steroids results in adrenal suppression.

The following problems are associated with chronic steroid use.

Addisonian (hypoadrenal) crisis (see Box 2.2)

Increased susceptibility to infection.

•

Poor wound healing, including anastomotic leaks, pressure areas.•

Osteoporosis.•

Patients on long-term inhaled steroids, e.g. for asthma and COPD, are •

not high risk as there is minimal systemic absorption.

Management of the patient on steroids

If the steroid dose can be weaned preoperatively, this should be done.

•

Prescribe IV hydrocortisone 25–100mg qds (roughly corresponding to •

2.5–20mg od of prednisolone) to start on the morning of surgery and

continuing until the patient is able to go back to their oral steroids.

Thyroid disease (see b pp. 250–256).

Box 2.2 Addisonian (hypoadrenal) crisis

Stresses such as surgery and sepsis require increased adrenal secre-

tion of corticosteroids; failure to mount this response can result in an

Addisonian (hypoadrenal) crisis. The following groups of patients are

at high risk:

Any patient currently taking >5mg prednisolone for >2 weeks.•

Any patient who reduced their long-term steroids within 2–4 weeks.•

Patients who have undergone adrenalectomy.•

Clinical features

Lethargy and malaise.•

Abdominal pain, often poorly localized (may present as an acute •

abdomen).

Nausea and vomiting.•

Hypotension.•

Hypoglycaemia, hyponatraemia.•

Coma, death.•

Management

Treat with IV hydrocortisone 100mg qds or 400mg infusion over 24h

•

as long as the patient is NBM.

Fluid resuscitation with normal saline.•

50% dextrose IV to treat hypoglycaemia (titrate against BS).•

CHAPTER 2 Principles of surgery

Surgery and heart disease

Ischaemic heart disease

Risk factors include age (♂ >45y; ♀ >55y), family history of early MI,

current or treated i BP, smoking, diabetes, i cholesterol.

Assess severity: quantify exercise tolerance; enquire about palpitations, •

orthopnoea, use of anti-anginals, previous MI, percutaneous coronary

intervention (PCI), or coronary artery bypass graft (CABG).

The ECG is the most important routine screening test, but it is normal •

in about one-third of patients with proven ischaemia.

Symptomatic patients undergoing major surgery should be •

discussed with a cardiologist with a view to optimizing anti-anginal

medications.

Myocardial infarction

The risk of a perioperative MI relates to past history and risk factors.

Overall population incidence after abdominal surgery, 0.5%.•

Incidence with pre-existing cardiovascular symptoms, 2%.•

Incidence with previous MI (old), 5–10%.•

Incidence after recent MI, 25% (70% will die with re-infarction).•

Strategies to reduce risk

Non-urgent surgery should be delayed for at least 6 months following

•

acute MI and, possibly, acute ischaemia. Cancer surgery may be

undertaken if the risk of disease progression is felt to outweigh the

increased perioperative mortality rate.

Ensure all normal cardiovascular medication is continued up to and •

through surgery. Control any new symptoms of angina if surgery is

urgent.

Continue antiplatelet medication if not contraindicated.•

Consider involving the critical care services (HDU) for the •

perioperative period.

Valvular heart disease

Cardiac murmurs are common. Request a transthoracic echo to evaluate

the lesion and discuss abnormalities with a cardiologist.

Severe • aortic stenosis carries a high risk of mortality (see b p. 630).

Elective surgery should be postponed: high gradient aortic stenosis

carries an associated mortality of 10% with non-cardiac surgery.

Severe • mitral stenosis can lead to pulmonary oedema and heart failure.

Major elective surgery should be postponed until lesion corrected.

Aortic regurgitation• requires attention to ﬂ uid and rate control.

Antibiotic prophylaxis should be given, but surgery can go ahead.

Mitral regurgitation• (MR) should be managed with diuretics

and vasodilators. Beware: left ventricular function is frequently

overestimated in MR.

Prosthetic valves

• have several associated issues.

Mechanical valves• require anticoagulation. Stop warfarin 5 days

preoperatively and admit early for IV heparinization.

SURGERY AND HEART DISEASE

Do not heparinize if the international normalized ratio (INR) will be •

only brieﬂ y subtherapeutic.

Stop IV heparin 6h pre-surgery and resume as soon as surgical •

bleeding is no longer a problem until INR therapeutic.

Thrombosis is most likely in mechanical mitral valves, atrial ﬁ brillation •

(AF), poor left ventricle (LV), previous embolus, ball-and-cage valves.

In surgery for life-threatening bleeding, e.g. bleeding peptic •

ulcer, intracranial haemorrhage, it may be necessary to reverse

anticoagulation for several days. Liaise closely with cardiology.

2 Prosthetic valves no longer require antibiotic prophylaxis for

procedures that cause bacteraemias

; if in doubt, discuss with

cardiology.

Arterial hypertension

Control of BP preoperatively may reduce the tendency to perioperative

ischaemia. Always note BP and, if severe (>180mmHg), surgery should be

delayed until control is obtained.

Review existing antihypertensive management or start treatment:•

Beta-blockers (e.g. metoprolol 25–50mg PO tds) reduce BP and •

perioperative ischaemia and mortality.

Calcium channel blockers are often used, e.g. nifedipine 10mg •

sublingual (SL).

Look for evidence of end-organ damage and associated heart disease.•

Look for rare, but important causes: phaeochromocytoma, •

hyperaldosteronism, coarctation of the aorta, renal artery stenosis.

Congestive cardiac failure

Heart failure is associated with a poorer outcome in non-cardiac surgery.

Risk factors include ischaemic and valvular heart disease.

Listen for S•

as well as pedal oedema, raised jugular venous pressure

(JVP), bibasal crepitations.

Chest X-ray may show cardiomegaly or pulmonary oedema.•

Cardiac arrhythmias

Arrhythmias and conduction defects are common. Asymptomatic arrhyth-

mias are not associated with an increase in cardiac complications, but look

for underlying problems, e.g. ischaemic heart disease, drug toxicity, meta-

bolic derangements.

High grade conduction abnormalities, e.g. complete heart block, should •

be discussed with a cardiologist. Pacing may be indicated.

Patients with known AF and either a history of embolic stroke or •

associated structural cardiac defect normally take warfarin.

Request a cardiology review preoperatively if rate control is poor.•

Beware of the patient with the • permanent pacemaker or intracardiac

deﬁ brillator (ICD). Diathermy may cause the pacemaker to reset or

completely inhibit pacing and trigger ICD discharge.

Pacemakers and ICDs should be evaluated by a cardiac technician •

preoperatively and post-operatively.

Pacemakers should be changed to ﬁ xed-rate pacing for surgery and •

then reprogrammed after surgery.

CHAPTER 2 Principles of surgery

ICDs should be switched off to prevent discharge and external •

ﬁ brillator pads positioned on the patient.

If deﬁ brillation or synchronized cardioversion is required, place the •

paddles as far from the pacemaker or ICD as possible.

Type of diathermy used should be considered. Monopolar is not •

absolutely contraindicated, but bipolar may be preferable.

Reference

1 M http://publications.nice.org.uk/prophylaxis-against-infective-endocarditis-cg64

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CHAPTER 2 Principles of surgery

Surgery and respiratory disease

Surgery and smoking

Smoking tobacco increases the risks of anaesthesia and many of the risks

of surgery. There is a six-fold increase in post-operative respiratory com-

plications among patients smoking in excess of ten cigarettes per day.

Effects of smoking

Reduction in general and speciﬁ c immune function via reduced •

neutrophil chemotaxis and reduced natural killer (NK) cell efﬁ cacy.

Increased platelet aggregation (probably explaining the increased risk •

of perioperative acute MI and cerebrovascular accident in smokers).

Reduced oxygen-carrying capacity of blood per unit volume due to the •

presence of carboxyhaemoglobin increasing the risk of tissue hypoxia

in susceptible organs.

Increased upper aerodigestive mucosal secretions. This worsens •

initially after stopping smoking until the chronic effects on the mucosa

wear off.

Reduced mucociliary escalator function.•

Reduced lung compliance and increased ‘closing volume’ of the small •

airways, increasing the risk of air trapping, especially whilst supine in

the post-operative period.

Stopping smoking

Within 48h: carboxyhaemoglobin is cleared from the blood, platelet •

aggregation begins to return to normal.

Within 7 days: neutrophil, macrophage, and NK cell function improve. •

Mucus production temporarily increases, but mucociliary escalator

function takes up to 6 weeks to recover, leading to a ‘rebound’ effect.

Within 6 weeks: upper aerodigestive function returns to underlying •

level, lung dynamics improve to ‘normal’ levels (depending on the

extent of ﬁ xed parenchymal disease).

The optimal time for stopping smoking is at least 6 weeks prior to surgery,

but a minimum of 7 days is required to reduce the ‘rebound’ effects of

stopping on upper aerodigestive tract function.

2 Mitigating the effects of smoking in the post-operative period

Active and recently stopped smokers should receive extra attention to

prevent the risks associated with smoking and surgery.

Ensure patients remain well hydrated until oral intake is restored.

•

Use thromboembolic prophylaxis in most cases.•

Use preoperative chest physiotherapy and education on breathing and •

coughing techniques.

Mobilize as soon as possible post-operatively.•

Consider the use of epidural anaesthesia to improve compliance with •

post-operative physiotherapy.

Use preoperative and post-operative saline nebulizers 5mL qds.

•

Ensure post-operative analgesia is effective.•

SURGERY AND RESPIRATORY DISEASE

Respiratory conditions

Respiratory tract infection

An active respiratory tract infection may be sufﬁ cient reason to cancel

elective patients, so ask about cough, fevers, and sputum, but minor colds

and nasal discharge may not prevent GA.

If you suspect the patient has a respiratory tract infection, check their •

temperature, C-reactive protein (CRP), and white cell count (WCC)

early.

Elective patients should be cancelled and asked to return in 2 weeks if •

their symptoms are better.

Reserve antibiotics for patients with suspected bacterial infections; •

most acute respiratory tract infections are viral.

Asthma

Assess severity of asthma by asking about hospital admissions, inhalers, •

nebulizers, peak expiratory ﬂ ow rates (PEFR), and home oxygen.

Elective surgery should ideally coincide with remission of symptoms.•

Identify patients on long-term steroid therapy.•

Sometimes it is possible to time surgery to coincide with a •

reduction in steroids, but this requires several weeks’ notice.

Any patient taking more than 5mg daily prednisolone and •

undergoing inpatient surgery or presenting with sepsis should

be started on an equivalent dose of IV hydrocortisone; adrenal

suppression may otherwise result in an Addisonian crisis (see b

p. 52)

Patients receiving a general anaesthetic generally experience •

deterioration in their lung function (see b p. 108). Prophylactically

increase their normal therapy by converting inhalers to nebulizers and

increasing frequency.

Chronic obstructive pulmonary disease (COPD)

If dyspnoea is the prominent symptom and the patient has COPD, get

•

lung function tests, including blood gases.

Admitting these patients a few days early for physiotherapy, education, •

and nebulizers can reduce the length of hospital stay.

Patients receiving a general anaesthetic generally experience •

deterioration in their lung function (see b p. 108). Prophylactically

increase their normal therapy by converting inhalers to nebulizers and

increasing the frequency.

Prescribe 6-hourly 5mL nebulized saline and give humidiﬁ ed oxygen •

wherever possible (to prevent mucus plugging).

Ensure the patient gets twice daily chest physiotherapy.•

Ensure the patient is on their usual inhalers and consider converting •

these to nebulizers for major surgery (see b p. 108).

CHAPTER 2 Principles of surgery

Surgery in renal and hepatic disease

Renal impairment

Renal impairment covers a spectrum, ranging from patients with subclinical

dysfunction (normal serum creatinine and urea, but borderline creatinine

clearance) to patients with end-stage renal failure. It is helpful to consider

these patients in two main groups: patients with chronic renal impairment

and dialysis-dependent patients. Post-operative management of renal

impairment is discussed on b p. 110; dialysis is discussed on b p. 134.

Chronic renal impairment

Surgery may precipitate acute renal failure in patients with chronic renal

impairment.

Avoid hypovolaemia and hypotension. Ensure these patients receive •

adequate IV hydration if they are to be NBM for any length of time.

Avoid nephrotoxic drugs wherever possible, including non-steroidal •

anti-inﬂ ammatory drugs (NSAIDs), aminoglycosides, ACE-inhibitors,

and radiological contrast.

Reduce doses of drugs with renal elimination, e.g. morphine, low •

molecular weight heparin (LMWH), digoxin, and request appropriate

levels frequently.

Patients with established renal failure, on dialysis

Discuss post-operative management of patients undergoing major •

surgery with the anaesthetist and intensive care unit (ICU) as early as

possible.

Dialysis should be performed the day before surgery.•

Patients must have full blood count (FBC) and urea and electrolytes •

(U&E) on admission, pre- and post-dialysis, and twice daily U&E post-

major surgery until the patient is stabilized on their normal dialysis

regime.

Reduce doses of drugs with renal elimination, e.g. morphine, LMWH,

•

digoxin, and request appropriate levels frequently.

If the patient is normally anuric, there is little point in inserting a •

urinary catheter which exposes them to unnecessary infection risk.

Note the sites of arteriovenous ﬁ stulas. • Never use them for

phlebotomy or cannulation and avoid using BP cuffs on that side.

These patients are prone to several problems. • 2 Hyperkalaemia,

acidosis, and pulmonary oedema are potential life-threatening

emergencies. Management is described on b p. 110.

Infection.•

Anaemia and coagulopathy.•

Fluid and electrolyte disturbances.•

Metabolic acidosis.•

Systemic hypertension, pericarditis.•

Hepatic impairment

The risk posed by liver disease to patients undergoing general surgery was

graded by Child and Turcotte (see Box 2.3). Child grade C is associated

with high perioperative mortality.

SURGERY IN RENAL AND HEPATIC DISEASE

Liver failure causes the following problems:•

Hypoglycaemia.•

Hepatic encephalopathy.•

Coagulopathy.•

Ascites.•

Infection.•

Several factors may cause acute decompensation of mild hepatic •

impairment and should be avoided or treated aggressively in this

group:

Infection, especially bacterial peritonitis.•

Sedation.•

Diuretics.•

Constipation.•

Electrolyte imbalance.•

Dehydration and hypotension.•

Preoperatively:•

Check hepatitis serology.•

Request liver ultrasound in newly diagnosed hepatic impairment.•

Discuss requesting additional blood products with haematology.•

Discuss doses of standard medication with a specialist.•

Jaundice

Patients with obstructive jaundice are at risk of developing renal failure

post-operatively (hepatorenal syndrome). This is thought to be due to

the nephrotoxic effect of toxins normally eliminated by the liver as well

as circulatory changes.

Ensure adequate hydration. When the patient is NBM, prescribe IV

•

normal saline 1L over 6–8h.

Insert a urinary catheter and start an hourly ﬂ uid balance chart.•

Measure U&E and liver function tests (LFTs) daily.•

Coagulopathy in longstanding cholestatic jaundice may be improved •

with vitamin K 1mg IV: discuss with haematology.

Avoid or reduce the doses of hepatotoxic drugs and drugs with •

hepatic elimination.

Box 2.3 Child’s classiﬁ cation of surgical risk in hepatic

dysfunction

A (minimal risk) B (moderate risk) C (advanced risk)

Serum bilirubin

•

<20mg/L

Serum bilirubin •

20–30mg/L

Serum bilirubin •

>30mg/L

Serum albumin •

>35g/L

Serum albumin •

30–35g/L

Serum albumin •

<30g/L

No ascites• Controlled ascites• Uncontrolled ascites•

No focal neurology• Minimal neurological •

dysfunction

Coma•

Excellent nutrition• Good nutrition• Cachexia•

CHAPTER 2 Principles of surgery

Surgery in neurological disease

Cerebrovascular accidents (stroke)

Ischaemic events are associated with a risk of re-infarction or •

extension of the infarct area due to interference with cerebrovascular

autoregulation by anaesthetic agents. Autoregulation is re-established

in around 6 weeks.

Haemorrhagic infarcts are associated with a small increased risk of

•

further bleeding, especially if the patient is given thromboprophylaxis.

Penumbral oedema also interferes with autoregulation as for ischaemic

events.

Strategies to reduce risk

Delay all non-essential surgery for 6 weeks following infarcts, especially •

ischaemic ones.

Consider omitting thromboprophylaxis in patients with a recent •

haemorrhagic event.

Ensure BP is well controlled (the prevention of both hypotension and •

hypertension) in the perioperative period to reduce ﬂ uctuations in

cerebral blood ﬂ ow.

Avoid positioning the patient head down on the operating table as this •

increases cerebral venous pressure.

Epilepsy

Paroxysmal neuronal discharge from various areas of the brain causes a

range of disturbances that may affect consciousness (grand mal seizures,

and petit mal or absences), movement, or sensory perception. In addition

to epilepsy, cerebral space-occupying lesions, uraemia, cerebral oedema,

drug toxicity, and hypercalcaemia may cause the same problems. In

patients with known epilepsy, the following measures are advised.

Try to establish the normal frequency and severity of seizures, what •

form they take, and features, if any, of the prodrome.

Ensure that normal anticonvulsant medication is continued while the •

patient is NBM preoperatively and immediately post-operatively.

If this is not possible, phenytoin and sodium valproate may be given IV: •

check the BNF for equivalent dosing regimes.

Phenytoin interacts with a number of drugs used perioperatively.•

Phenytoin induces monoamine oxidase, increasing elimination •

of the following commonly used drugs: prednisolone, warfarin,

lignocaine.

The following drugs increase oral absorption of phenytoin: •

amiodarone, ﬂ uconazole, omeprazole, paroxetine.

The following drugs reduce oral absorption of phenytoin: antacids •

containing magnesium, calcium carbonate, or aluminium, and

enteral tube feeding.

Management of status epilepticus (uncontrolled ﬁ tting).•

Airway.• Remove dentures; insert Guedel or nasophayngeal airway if

unable to open jaw.

Breathing.• Give high ﬂ ow oxygen (O

); get Yankauer sucker and

wall suction.

SURGERY IN NEUROLOGICAL DISEASE

Give diazepam 10mg IV over 2min (PR if no IV access); repeat once •

if seizures do not stop.

Check blood sugar and give 50mL 50% dextrose IV if BS <5mmol/L.•

If seizures persist start, phenytoin 18mg/kg IV at a maximum rate of •

50mg/min in a separate line to the diazepam.

Seizures should resolve quickly. If they do not:•

Get expert help. —

Discuss with anaesthetist. —

Consider pseudoseizures (pelvic thrusts, ﬂ ailing limbs, resistance —

to attempts to open eyes).

Myasthenia gravis

An antibody-mediated autoimmune disease with insufﬁ cient muscle ace-

tylcholine receptors, leading to muscle weakness. Usually found in young

adults, the disease presents with extraocular (ptosis, diplopia), bulbar

(weak voice), neck, limb girdle, distal limb, and ﬁ nally trunk weakness.

Patients may present for thymectomy as speciﬁ c treatment or for inciden-

tal surgery. Management includes the following:

Continue normal medication.•

Elective post-operative ventilation is indicated in major thoracic or •

upper abdominal surgery or if the patient’s vital capacity <2L. Discuss

with an anaesthetist and ICU.

If ventilation is prolonged post-operatively, a tracheostomy may be •

required. This should be discussed with the patient at time of consent.

Post-operative respiratory failure may occur as a result of muscle •

weakness. Precipitants include:

Hypokalaemia.•

Infection.•

Over- or undertreatment.•

Emotion, exertion.•

CHAPTER 2 Principles of surgery

Fluid optimization

2 Identifying patients in need of ﬂ uid optimization

Any patient may be in need of preoperative ﬂ uid resuscitation, but several

groups are typically affected. Remember to think of less obvious cases of

ﬂ uid depletion—there are typically more patients who would beneﬁ t from

ﬂ uid optimization than get it.

Acute presentations with vomiting or diarrhoea, including intestinal

•

obstruction, biliary colic, gastroenteritis.

Acute presentations where the patient has been immobile or •

debilitated for a period before presentation, causing reduced ﬂ uid

intake, e.g. pancreatitis, chest infections, acute-on-chronic vascular

insufﬁ ciency, prolonged sepsis with pyrexia.

Elderly patients in whom reduced renal reserve makes ﬂ uid balance •

control less effective.

Drugs that impair renal responses to ﬂ uid changes, e.g. diuretics.•

Patients with low body weight with overall lower total body ﬂ uid •

volume in whom similar losses have a greater effect.

Children are more susceptible to ﬂ uid depletion and may not show •

such obvious physical signs.

Fluids used for optimization

The most important aspects of ﬂ uid optimization are using the correct vol-

umes at the correct rate. Other than exceptional circumstances, isotonic

crystalloids are the ﬂ uid of choice to correct imbalances.

Isotonic (‘normal’) 0.9% saline—the most widely used ﬂ uid. Provided •

there is adequate renal function, isotonic saline prevents rapid cellular

ﬂ uid shifts during rehydration and excess Na

is excreted via the

kidney. K

should usually be added only if d K

is present or likely (e.g.

prolonged vomiting, pancreatic or small bowel ﬁ stula).

Dextrose (4%) saline (0.18%).

•

Hartmann’s solution.•

Ringer’s lactate solution—technically, the closest ﬂ uid to serum •

composition although theoretical advantages are of limited practical

value.

Fluids that should only be used in very speciﬁ c circumstances include

hypertonic (1.8%) or hypotonic (0.45%) saline since they risk causing sig-

niﬁ cant ﬂ uid shifts in and out of cells, which can cause cellular injury, par-

ticularly to neurons. If there is a signiﬁ cant disorder of sodium balance that

may require non-isotonic ﬂ uid optimization, the patient is likely to require

optimization in HDU.

How to give the ﬂ uids

Before giving ﬂ uid, it is important to assess the volume of depletion. It is

rarely possible to use estimates of losses due to vomiting or diarrhoea as

these are wholly inaccurate. Useful calculations include the following:

Body weight on admission (provided a recent, accurate body weight •

during normal health is known) since acute weight loss is mostly water.

FLUID OPTIMIZATION

Haematocrit on admission (provided a recent haematocrit during •

normal health is known) since the degree of haemoconcentration is

due to ﬂ uid depletion. An approximate calculation is given by:

Fluid depletion (L) = ((PCV

– PCV

)/PCV

) x 0.7 x weight in kg

PCV

= normal haematocrit; PCV

= current haematocrit

Serum urea is raised disproportionately more than serum creatinine

•

in dehydration, renal disease, gastrointestinal (GI) bleeds, and acute

proteolysis.

Signs of extracellular ﬂ uid depletion (lax skin tone, reduced sweating, •

dry mucosae) are often misleading and can be affected by age and

underlying diseases, including pyrexia and tachypnoea.

Signs of intravascular volume depletion (hypotension, tachycardia) •

may be unreliable and usually only occur with loss of 10–15% of body

water.

Once the volume of ﬂ uid required is assessed, it can be given. There are

some broad rules on how to give ﬂ uid resuscitation.

Young, ﬁ t patients with normal renal and cardiac function can usually •

be given up to 15% of body ﬂ uid volume by rapid infusion. A typical

regimen might include: 1000mL 0.9% saline over 2h, further 1000mL

infusions of 0.9% saline over 4h each until corrected.

Elderly patients and patients with renal or cardiac impairment should •

have infusions more slowly to prevent acute intravascular volume

overload. A typical regimen might include: 1000mL 0.9% saline over 4h,

500mL infusion of 0.9% saline over 3–4h with regular review of vital

signs, including chest auscultation. Patients requiring more ﬂ uid volume

more rapidly than this should be monitored closely in critical care

during resuscitation.

Monitoring ﬂ uid optimization

Methods of assessing the progress of ﬂ uid optimization include the

following:

Skin turgor and mucosal hydration change slowly after optimization •

and are unreliable guides.

1-hourly urine output measurement is a good guide to renal blood •

ﬂ ow, which indirectly relates to intravascular ﬂ uid volume and cardiac

output. It is an easy and reliable indicator of adequate blood volume

repletion. It is not a good indicator of total body water and there may

be signiﬁ cant intra- and extracellular depletion in the presence of an

acceptable urine output. A commonly used minimum is 0.5mL/kg/h.

Monitoring of serum urea is an approximate guide provided renal •

function is adequate and there is no acute GI bleeding or proteolysis.

In the emergency situation, particularly where patients require urgent

surgery and require ﬂ uid optimization prior to anaesthesia, more rapid

ﬂ uid infusions may be required and it may be appropriate for this to be

monitored on HDU.

CHAPTER 2 Principles of surgery

Nutrition in surgical patients

Nutrition is critical to the well-being of surgical patients and timely nutri-

tional support helps reduce acute catabolism and resultant skeletal muscle

weakness due to increased metabolic demands.

It is common and amenable to effective intervention that inﬂ uences •

the outcome of surgical patients.

Incidence of pre-existing malnutrition is substantial and rises with age.•

Anticipate those patients with higher than normal nutritional •

requirements (e.g. severe burns, severe sepsis, intestinal ﬁ stulas,

advanced malignancy, immunosuppression); even if they are well

nourished prior to illness, they may need nutritional support to prevent

excessive acute catabolism due to increased metabolic demands.

Assessment of nutritional status

All patients should be considered for nutritional assessment. Many meth-

ods can be used:

BMI• (weight/height

in kg/m

). Relatively insensitive for all but major

malnutrition, but easy to perform. A BMI of 18–25 is normal, <18 is

underweight, >30 is obese.

Triceps skinfold thickness.• Easy to perform and a good measure of body

fat as a marker of chronic nutritional status.

Grip strength.• Easy repeatable index of lean skeletal muscle.

Serum albumin.• Poor indicator of acute nutritional status. Responds

slowly to nutritional supplementation and is affected by many other

diseases and conditions.

Serum transferrin. • Accurate responsive indicator of acute status and

response to treatment. Not commonly used.

Effects of protein–calorie malnutrition

Reduced neutrophil and lymphocyte function.•

Impaired albumin production.•

Impaired wound healing and collagen deposition.•

Skeletal muscle weakness (‘critical illness myopathy’) with resultant •

increase in respiratory and abdominal complications.

Micronutrient deﬁ ciencies may cause speciﬁ c clinical syndromes.•

Types of nutritional support

Oral supplementation.• High calorie, high protein nutritional

supplements (e.g. Fortisip

, Calshakes

, Ensures

/Enlives

). May be

used in addition to promotion of conventional oral intake.

Nasogastric (NG)/nasojejunal feeding.• Often used in addition to oral

supplementation. Sometimes given overnight to reduce the impact on

appetite suppression during the day.

Feeding gastrostomy/jejunostomy• (via a surgically implanted tube). Not

routinely used. Reserved for patients where the GI tract is functioning,

but food cannot be taken via the oropharyngeal route.

Parenteral nutrition.• May be central or peripheral. (See b p. 67.)

The oral route is always to be preferred in nutritional supplementation. It

promotes the normal health of the GI ﬂ ora and has been shown to reduce

the risk of complications after GI surgery.

NUTRITION IN SURGICAL PATIENTS

Total parenteral nutrition (TPN)

TPN is commonly encountered in surgical wards. It is a major advance

in the treatment of surgical malnutrition, but has serious side effects and

both long- and short-term potential complications.

Routes of administration for TPN

Peripheral (PPN).

• Given via a medium calibre cannula in a peripheral

vein. Maximum calorie input limited by the maximum osmolarity of the

solution. Avoids the risks of central venous cannulation. Usually used

for short-term supplementation.

Central (TPN). • Given into a central vein (superior vena cava (SVC) or

brachiocephalic). May be via a dedicated tunnelled line (e.g. Hickman

line), a conventional central venous (CV) cannula, or a peripherally

inserted central venous catheter (PICC line). Maximum calorie input

only limited by volume of ﬂ uid that can be infused. Carries risks of

central venous catheterization.

General risks of TPN/PPN

Hyperosmolarity.

•

Lack of glycaemic control.•

Micronutrient deﬁ ciencies.•

Liver cell dysfunction, cholestasis, and pancreatic atrophy.•

Fluid volume overload.•

Speciﬁ c catheter-related risks of TPN

Complications of insertion (air embolism, pneumothorax, vascular •

injury, dysrhythmias).

Catheter thrombosis and thromboembolism.•

Central line infection, infective endocarditis, and bacteraemia.•

Care of TPN patients

Patients on TPN require regular review and monitoring, including:

U&E (initially daily, then twice weekly once established).•

Glucose (initially od, then twice weekly unless signs of abnormal •

glucose levels).

LFTs (twice weekly).•

Micronutrients, including magnesium (Mg), phosphate (PO•

manganese (Mn), copper (Cu) (weekly).

CV catheters require speciﬁ c attention. They should not be used for non-

TPN infusions and/or phlebotomy unless in exceptional circumstances as

this increases the risk of catheter sepsis dramatically. Dressings should be

dated, changed regularly, and the catheter entry site kept clean.

Common indications for TPN

Short term

Prolonged post-operative ‘ileus’ (unresolved GI tract dysfunction).•

Acute abdominal sepsis with ITU likely (possibly slow oral route).•

Long term

Inability for GI tract to absorb adequate nutrition (e.g. extensive resection,

extensive radiotherapy damage, extensive disease such as Crohn’s).

CHAPTER 2 Principles of surgery

Enhanced recovery after surgery

Enhanced recovery after surgery (ERAS) is one of many similar approaches

to patient recovery after major surgery, which aims to coordinate many

aspects of patient care to minimize the perioperative physiological

derangement of the patient, reduce the stress response to surgery, opti-

mize speed of recovery and reduce complication rates. It is usually applied

to otherwise healthy individuals who do not need particular preoperative

correction or adjustments.

The major areas of consideration are the following.

Nutrition

Preoperative carbohydrate loading.• Often given as oral solutions over

the 24h prior to surgery, including up to 4h prior to anaesthetic. Has

been shown to reduce the early catabolic response to major surgery.

Early re-introduction of carbohydrate rich ﬂ uids. • Given from 6h post-

surgery and encouraged from ﬁ rst post-operative day.

Early re-introduction of full nutrition.• Nutritional supplements and ‘light

diet’ components from 48h post-op to encourage ‘immediate’ return

of GI tract function.

Anaesthetic technique

Avoidance of the use of opiates • (e.g. IV/PO morphine, opiate patient-

controlled analgesia (PCA), opiate epidurals). Aims to prevent

reduction in GI tract motility and nausea associated with opiates.

Avoidance of the use of epidurals • (some regimens use LA epidurals).

Aims to improve early mobilization and reduce cardiovascular and GI

effects of autonomic spinal blockade.

Use of regional LA-based techniques • (e.g. transversus abdominis

percutaneous (TAP) block, regional LA inﬁ ltration, regional LA

infusional catheters). Aims to minimize central nociceptor input, which

may enhance the systemic stress response to surgery.

Surgical technique

Laparoscopic or other minimally invasive techniques • are often, but

not always a feature of ERAS type programmes. Aim to reduce the

metabolic response to surgery, aid early mobilization, and reduce

GI tract exposure (and associated impact on function) in abdominal

surgery.

Avoidance of bowel preparation• for abdominal surgery where possible.

Reduces the risk of ﬂ uid and electrolyte imbalances, reduces disruption

to GI tract ﬂ ora and has been associated with lower GI tract-related

complications (e.g. anastomotic leakage).

Physiotherapy

Early mobilization. • Speciﬁ c exercises, including sitting out within 12h of

surgery, walking within 48h of surgery.

Perioperative respiratory exercises.•

ENHANCED RECOVERY AFTER SURGERY

Nursing

Intensive patient preparation.• Preoperative leaﬂ ets and education on

what to expect.

Intensive perioperative and post-operative nursing.• Encouraging early

re-establishment of diet, early mobilization and early self-care.

Although intensive and demanding, ERAS type protocols are as effective

in the elderly as the young.

They are not suitable for:

Some insulin-dependent diabetics.

•

Patients with pre-existing signiﬁ cant nutritional compromise.•

Patients with cognitive impairment.•

CHAPTER 2 Principles of surgery

Getting the patient to theatre

Preparing the patient for a surgical procedure is all about organization and

routine. If the preparation is not good, much can go wrong with major

consequences for the patient.

Background paperwork

Ensure the theatre or endoscopy list is correctly ﬁ lled in and avail-

able well in advance. The list should specify the patient’s name, hospital

number, location, operation details as well as the operating surgeon and

anaesthetist.

Patient paperwork

Make sure the medical notes are available and contain the most up-to-•

date history and examination for this admission.

Check the blood results are up to date and speciﬁ c blood results, e.g. •

clotting function in anticoagulated patients, K

in patients with renal

failure, Ca

in parathyroidectomy patients, have been collected.

If they are not available in digital format, ensure imaging results •

that might be needed in theatre are available with the notes (e.g.

arteriograms, staging CT scans, barium enema ﬁ lms).

Check that the consent form has been completed and is on the •

medical notes even though you may not be responsible for seeing the

form signed.

The drug chart should be completed and include any speciﬁ c •

prescriptions for drugs to be administered in theatre or the

anaesthetic room. It is the job of the surgical team to prescribe

prophylactic antibiotics, etc.

Patient preparation

Check that the side is marked on the patient for any operation that •

might involve an organ or tissue that is bilateral. This must be done

with the patient awake and veriﬁ ed by the nursing staff.

If necessary, check that the patient has been assessed and marked by •

any relevant specialists (stoma care if a stoma is possible; prosthetist

for amputees).

Ensure that if the patient requires any blood or blood products, these •

are available or requested from the transfusion department. Most

hospitals have protocols to ensure that the correct number of units of

blood is requested for major surgery.

Find out well in advance if any speciﬁ c preparation is required. •

Examples follow.

Bowel preparation

Bowel preparation is sometimes used for operations on or around the

large bowel. Types of preparation include the following.

Stimulant mechanical bowel preparation, e.g. Picolax

•

(piccosulphate),

two sachets taken with plenty of ﬂ uid at least 8h prior to surgery.

Should be avoided whenever there is a risk of obstruction present.

Commonly used for barium enemas.

GETTING THE PATIENT TO THEATRE

Osmotic mechanical bowel preparation, e.g. Citramag•

(Mg citrate),

Kleen Prep

, two or four sachets taken dissolved in water up to 8h

prior to surgery. Used for most colonic operations where bowel

preparation is required, colonoscopy, and CT colonography.

Stimulant left colon preparation, e.g. phosphate enema. Used for •

operations on the rectum/anus or for ﬂ exible sigmoidoscopy.

Mechanical bowel preparation is less commonly used than previously.

•

There is evidence that it may actually increase the septic complication

rates following bowel surgery and has well recognized side effects.

These include the risks of:

Electrolyte imbalances.•

Hypovolaemia, especially in the elderly.•

Nausea and vomiting (particularly with the large volume osmotic •

preparations).

Anaesthetic premedication

Principles

Anaesthetic premedication is used for the following reasons:

Relaxing the patient to reduce anxiety during preparation for

•

anaesthesia.

Relaxation of the patient decreases the amount of anaesthetic agent •

required for induction of anaesthesia.

Typical agents used for premedication

Benzodiazepines.• Often given 1–2h preoperatively on the ward (e.g.

diazepam PO). May be given shortly before some procedures (e.g.

midazolam 5mg IV).

Buscopan•

. Rarely given, but sometimes used to reduce upper

aerodigestive tract secretions.

CHAPTER 2 Principles of surgery

Prophylaxis—antibiotics and

thromboprophylaxis

Antibiotic prophylaxis

Prophylactic antibiotics are used to reduce the risk of surgical site •

infection and are usually of very short course (one to three doses).

Active antibiotic treatment for established infections encountered •

during surgery may be for 5 or more days.

Most prophylaxis is directed at prevention of infection of the surgical •

wound or to counter the effect of potential spillage of organisms from

colonized organs such as the bowel once it has been opened.

The broad principles of prophylaxis are the following:

It is most important to have a high circulating serum level of antibiotics •

at the time of potential tissue contamination, i.e. administered around

the time of induction of anaesthesia.

Prophylaxis rarely needs to continue beyond the time of the •

procedure unless there are high risk factors or speciﬁ c indications,

i.e. most prophylaxis is one or occasionally three doses on the day of

surgery.

Many clean wounds, e.g. skin lesion excision, do not require •

prophylaxis.

High risk patients who may warrant an extended prophylactic course •

(e.g. up to 3 days) or speciﬁ c prophylaxis include:

Neutropenic or immunosuppressed patients.•

Severely malnourished patients.•

Prophylactic regimens

Most hospitals have established guidelines for prophylaxis and these should

be consulted for prescribing. See Table 2.1 for an example of a regimen.

Thromboprophylaxis

Types of thromboprophylaxis

Mechanical devices

Thromboembolic deterrent stockings (TEDS).

• Reduce stasis in

infrapopliteal veins by continuous direct compression.

Pneumatic compression boots.• Reduce stasis in infrapopliteal veins

by intermittent compression emptying of foot and lower leg veins,

promoting venous ﬂ ow.

Drugs acting on the clotting cascade

Heparin.

• Activates antithrombin III.

Prophylaxis: 5000U SC od.•

Treatment: IV 2000U loading dose, 2000U/h (usually 1000U/mL of •

normal saline). Check APTT 6h after starting and 6–12h thereafter.

Titrate to maintain APTT 50–70.

LMWH.

• Activates antithrombin III. Given by SC injection.

Prophylaxis: 20–40mg SC Clexane•

od.

Treatment: 2mg/kg SC in two divided doses.•

PROPHYLAXIS—ANTIBIOTICS AND THROMBOPROPHYLAXIS

Antiplatelet drugs (not used as venous thromboembolism (VTE)

prophylaxis)

Aspirin (300mg PO od).

•

Dipyridamole (75mg PO qds).•

Clopidogrel (75mg PO od).•

Drugs indirectly affecting clot formation

Dextran 70.

• Interferes with clot formation. Given as regular bolus

infusions (500mL over 1h od).

At risk groups

2 All patients are ‘at risk’ of developing deep vein thrombosis just as is the

general population. National requirements for VTE prophylaxis require

all patients to be assessed for risk factors on admission and after 24h in

hospital.

Risk is judged according to:

Procedure factors. • Prolonged anaesthetic time, lower limb or pelvic

surgery.

Patient factors. • Immobility, malignancy, age, dehydration, obesity,

diabetes, cardiorespiratory disease, inﬂ ammatory pathologies, oral

contraceptive pill or hormone replacement therapy (HRT), past or

family history of thromboembolic disease.

Balanced against:

Bleeding risks.• Active bleeding, stroke, invasive procedures, bleeding

disorders (liver disease, thrombocytopenia, inherited disorders).

Risks of compression devices.• Peripheral vascular disease (PVD).

The risks should be recorded on the patient’s drug chart or VTE docu-

mentation and mechanical devices (e.g. TEDS) and/or chemical thrombo-

prophylaxis (e.g. LMWH) prescribed according to local policy.

Reference

1 M http://publications.nice.org.uk/venous-thromboembolism-reducing-the-risk-cg92

Table 2.1 An example of an antibiotic prophylactic regimen

Indication

Typical prophylaxis (single dose

on induction)

‘Clean’ bowel surgery, e.g. acute

non-perforated appendicitis,

elective colonic resection

Cefuroxime, 1.5g IV + metronidazole

500mg IV or gentamicin 120mg

IV Amoxicillin 500mg IV +

metronidazole 500mg IV

‘Clean’ hepatobiliary surgery, e.g.

ERCP, open biliary surgery

Gentamicin 120mg IV + amoxicillin

500mg IV + metronidazole 500mg

‘Clean’ gynaecological surgery Metronidazole 500mg IV or 1g PR

Elective orthopaedic surgery Flucloxacillin 1g IV

‘Clean’ vascular surgery Flucloxacillin 500mg IV + gentamicin

120mg IV + amoxicillin 500mg IV

CHAPTER 2 Principles of surgery

In-theatre preparation

Theatre is a potentially dangerous place for patients; many of these dan-

gers arise directly as a result of poor preparation and checking of basic

facts. For example:

Wrong side surgery (e.g. healthy kidney removed, wrong hip joint •

replaced).

Wrong site surgery (e.g. inguinal, not femoral, hernia repaired; hip, not •

knee, arthroscoped).

Allergic reaction to medication.•

Vital material not available, if required (e.g. blood not cross-matched).•

Vital equipment required for surgery not available (e.g. image •

intensiﬁ er, specialist joint replacement jig).

Retained swabs or instruments.•

Experience from other high risk industries (e.g. the airline industry) has

shown that strict adherence to a checklist can minimize the risk of these

‘never events’ happening. The World Health Organization (WHO) rec-

ommends a standardized checklist approach.

WHO checklist

The WHO checklist is a basic template that sets out a series of steps,

which can be modiﬁ ed or adapted in different organizations, but has four

areas of focus.

Before commencement of the list

Conﬁ rm surgical, anaesthetic, and nursing team present and identiﬁ ed.

•

Conﬁ rm patients on the list and the order of the procedures to be •

performed.

Check anaesthetic requirements are correct and functioning (machine, •

medication, monitoring).

Conﬁ rm vital imaging/equipment required for the list.•

Before induction of anaesthesia

Check patient identity and consent valid.•

Check site and side marked, if appropriate.•

Check anaesthetic requirements are correct and functioning (machine, •

medication, monitoring).

Check allergies, anticipated blood loss.•

Before skin incision

Check all team members present and known.•

Check the procedure to be performed.•

Conﬁ rm any surgical/anaesthetic/nursing concerns.•

Conﬁ rm vital imaging/equipment available.•

Before the patient leaves the theatre

Check the correct name for the procedure actually performed is •

known and recorded.

Check the swab and instrument count correct.•

IN-THEATRE PREPARATION

Conﬁ rm any surgical specimens collected, ‘potted’, and labelled •

correctly.

Conﬁ rm any speciﬁ c instructions, either surgical or anaesthetic, which •

apply to the patient in recovery or on transfer to the ward.

Reference

1 M http://www.who.int/patientsafety/safesurgery/ss_checklist/en/index.html

CHAPTER 2 Principles of surgery

Positioning the patient

Getting the patient on to the operating table

The surgical team is partly responsible for the safety of the patient all

the way onto and off the operating table. Be sure the basic rules of

safety are being observed. See Fig. 2.3 for some typical patient positions

in surgery.

The anaesthetist is responsible for the patient’s airway and should •

coordinate all moves of the patient to ensure it is maintained.

Be sure not to dislodge IV cannulae, epidural sites, or existing drains.•

Use approved manual handling techniques (e.g. a ‘Patslide’ or similar •

device, rather than lifting the patient).

Be aware if extra care needs to be taken, e.g. prosthetic joints that •

may dislocate once protective muscle tone is lost during relaxation,

unstable fractures, potentially unstable joints due to rheumatoid

arthritis, existing ulcers or skin lesions.

Once in position

Ensure that no points on the patient are in contact with the metal of •

the operating table to prevent diathermy exit point burns.

Make sure bony prominences and areas of thin skin are well padded, •

e.g. the neck of the ﬁ bula in leg stirrups.

Ensure any diathermy pad is correctly applied and not liable to be •

affected by skin preparation.

Ensure there are appropriate supports for the patient to secure the •

position, particularly if the table may be moved, tilted, or rotated

during the procedure (e.g. arm, thoracic, and abdominal supports

for lateral positions; shoulder bolsters if the patient will be head

down).

For procedures requiring access to the perineum, be sure that the •

pelvis is properly supported, but that the perineum is exposed over

the end of the operating table.

Consider the positioning of ancillary equipment (e.g. where will video •

stacks be positioned? Is more than one energy source required and

where will the generators be located? Is there access of mobile imaging

equipment or on-table radiography?). All equipment positioning needs

to allow enough access to the patient for the surgical team.

POSITIONING THE PATIENT

Supine

Prone jack-knifed

Lateral

Lloyd–Davis

Lithotomy

Fig. 2.3 Typical positions for surgery. Supine (most abdominal surgery); prone

jackknifed (some rectal or vaginal procedures); lateral (thoracotomy); Lloyd–Davis

(pelvic surgery); lithotomy (most perineal procedures).

CHAPTER 2 Principles of surgery

Sterilization, disinfection, and

antisepsis

Sterilization

Heat

Dry heat (e.g. incineration, ﬂ aming to red hot) is effective, but rarely

•

useful. Dry heat requires temperatures of 160°C for at least 60min.

Moist heat (e.g. autoclave heating using pressurized steam 121• °C at

15lb/in

, 15min) is effective and useful, especially in operating theatres.

Irradiation

Gamma radiation. Effective for inorganic materials.

Filtration

Air or ﬂ uids can be sterilized by ultraﬁ ne membrane ﬁ lters, but are rarely

useful in hospital practice.

Disinfection

Chemical

Acids/alkalis, e.g. bleach. Effective for non-human contact use.

•

Alcohols/phenols, e.g.•

Ethyl alcohol—skin swabs.•

Alcohol solutions (Aqagel•

)—hand disinfection.

Carbolic.•

Chloroxylenols (Dettol•

Phenol (Clearsol•

Oxidizers, e.g.•

Povidone–iodine (Betadine•

)—skin disinfection/surgical scrubbing.

Hydrogen peroxide (H•

)—superﬁ cial wound cleansing.

Aldehydes (Cidex•

)—surgical instruments such as endoscopes.

Cationic solutions, e.g. Chlorhexidine•

—antiseptic washes.

Organic dyes, e.g. Proﬂ avine•

Antisepsis

Principles of antisepsis include the following.

Always remove gross contamination with simple soap ﬁ rst.•

Use high potency acid/alkali disinfection on inert surfaces.•

Use less corrosive oxidizers on delicate inert materials.•

Use weak alcohols, oxidizers for skin cleansing.•

Deﬁ nitions

Sterilization• is removal of all viable microorganisms, vegetative, and

spores.

Disinfection• is the removal of actively dividing vegetative

microorganisms.

Antisepsis• is the process whereby the risk of medical cross-infection

by microorganisms is reduced.

SCRUBBING UP

Scrubbing up

Scrubbing up is designed to reduce the risk of infection from the sur-

geon to the patient. A thorough clean with bactericidal soaps reduces the

number of organisms that can be cultured from skin swabs, but the skin

(particularly sweat glands and hair follicles) cannot be sterilized. Moisture

and heat occurring under surgical gloves quickly raise the bacterial count

again and despite modern cleaning agents, signiﬁ cant growth can be

achieved within 2h. Common bactericidal soaps include:

Hibiscrub•

(chlorhexidine).

Betadine•

(povidone–iodine).

Protocol

The ﬁ rst time you come to theatre, ensure that the senior scrub nurses

know who you are. It is polite and safe. Everybody should know who the

people in theatre are and what they are there for/can do.

How to scrub

Wet your hands and arms ﬁ rst.•

Lather well with disinfectant soap and wash off.•

‘Scrub’ under the nails and heavily soiled areas with a sterile brush and •

more disinfectant soap. Don’t scrub too vigorously, especially on clean

skin as this causes irritation without any increased bactericidal effect.

Wash again with soap, being sure to cover the commonly missed •

areas—between the ﬁ ngers, back of the hands, under ﬁ ngernails, base

of the thumbs.

Rinse thoroughly to remove all soap to reduce the chance of skin •

irritation.

Rinse off, trying to ensure the water runs off the arms at the elbows.•

Dry the hands completely ﬁ rst and do not go back to them once •

drying the arms. Be sure your hands are completely dry before trying

to put on gloves—there’s nothing worse than gloves that aren’t on

properly due to wet hands!

How to gown and glove

Be sure to open the gown without touching the outer ‘face’.•

Don’t push your hands through the cuffs.•

Pick up the right glove with your right hand ‘through’ the cuff of the •

gown, holding it by the edge of the glove on the palm side with the

ﬁ ngers pointing down your forearm.

With your left hand, fold the other side of the edge of the glove ‘over’ •

your right hand.

Slide your right hand into the glove.•

Once on, pick up the left glove, holding it by the edge and pull it over •

the cuff of the left hand.

Slide your left hand into the glove and adjust glove positions.•

It is becoming common practice to wear eye protection and two pairs of

gloves to reduce the risk of exposure to infectious agents (see b p. 178).

CHAPTER 2 Principles of surgery

Surgical instruments

See Fig. 2.4.

‘Sharps’

Scalpels. • Two sizes of handle (4 and 6). Types of blade and uses

include: no. 11 (used for stab incisions), no. 10 (most skin incisions),

no. 15 (ﬁ ne incisions), no. 22 (adhesiolysis).

Scissors.

• May be dissecting or stitch cutting. Dissecting scissors

may be straight (e.g. Mayo) or curved (e.g. curved Mayo, McIndoe,

Metzenbaum, Nelson’s).

Forceps

Non-toothed. • Fine non-toothed (e.g. DeBakey, Adson’s forceps) used

for handling delicate tissues such as vessels, bowel. Heavy non-toothed

used for general handling, including specimens and sutures.

Toothed.• Fine toothed (e.g. Gillie’s, McIndoe’s forceps) used for

handling skin, ﬁ ne fascia, and occasionally for precise holds on delicate

tissues. Heavy toothed (e.g. Lane’s forceps) used for holding heavy

tissues such as fascia and scar tissue.

Ring-tipped and microforceps.• Used in microvascular anastomoses.

Clips and clamps

Artery clips (e.g. Spencer–Wells, Robert’s (large), Dunhill’s, Mosquito •

(small)) have serrated jaws. Used for vascular clamps and tissue/suture

holding.

Tissue clamps, for example:•

Lahey clamp• . Similar to a curved arterial clip.

Doyen bowel clamp• . Non-crushing atraumatic.

Babcock/Duval clamp• . Non-toothed semi-atraumatic tissue-holding

clamp.

Lane’s/Allis’s/’Littlewood’ clamp• . Heavy toothed traumatic tissue-

holding clamps.

Retractors

Self-retaining retractors:•

Large (e.g. Goligher retractor for abdominal incisions, Finichetto •

retractor for thoracic incisions).

Small (e.g. Travers/Norfolk and Norwich retractors for small skin •

and abdominal incisions).

Handheld retractors:•

Large (e.g. Deaver, Kelly, Morris).•

Small (e.g. Kilner ‘Catspaw’, Langenbeck).•

SURGICAL INSTRUMENTS

Metzenbaum scissors

Lane’s forceps

Dunhill’s forceps

Travers retractor

Morris retractor Langenbeck retractor

Deaver retractor Kilner retractor

Babcock forceps Lahey clamp

DeBakey forceps Gillie’s forceps

No. 11

Blades:

No. 10 No. 15

No. 20 No. 22

No. 23

Fig. 2.4 Commonly used surgical instruments.

CHAPTER 2 Principles of surgery

Incisions and closures

Body cavity incisions

General terms are applied to the incisions of access to each body cavity.

Laparotomy.• Any incision accessing the peritoneal cavity or

retroperitoneal space. Separate types of laparotomy are described

according to their location in the abdomen, tissues that are crossed,

or, occasionally, the individual who described them (see Fig. 2.5).

Thoracotomy.• Accessing the chest cavity, typically the pleural space

or posterior mediastinum. Median sternotomy is a particular type of

thoracotomy for access to the anterior and middle mediastinum.

Craniotomy.• Accessing the compartments of the skull.

Incision closures

Incisions in body cavities are generally closed according to some basic

principles.

Fascial layers offer the best tissue to bear the strength of apposition •

and form the main closure in the abdomen. Closure is usually made

with heavyweight non-permanent sutures.

Bony defects, such as in a craniotomy, should be apposed to allow •

minimal movement.

Defects in fascial or bony tissues should be replaced either with •

transposed tissues (e.g. skin, fascial, muscle ﬂ aps) or with inserted

tissues (e.g. synthetic products such as polypropylene mesh)

(see b p. 596).

Large cavities and potential spaces between tissues should be avoided •

to reduce the risk of ﬂ uid collections which run the risk of becoming

infected.

1. Kocher

2. Midline

3. Muscle splitting loin (ureter)

4. Pfannenstiel

5. Thoraco-abdominal

(oesophagogastrectomy

9th or 10th intercostal

space)

Paramedian 1.

McBurney 3.

Lanz 4.

Muscle-cutting traverse 5.

Roof-Top 6.

McEvedy (femoral hernia) 7.

Inguinal hernia incision 8.

Fig. 2.5 Incisions. Reproduced with permission from Longmore, M. et al. (2007).

Oxford Handbook of Clinical Medicine, 7th edn. Oxford University Press, Oxford.

DRAINS

Drains

Uses and complications

Drains may be used for several reasons (see also b p. 93).

To remove existing abnormal collections of ﬂ uid, blood, pus, air (e.g. •

drainage of a subphrenic abscess, removal of a pneumothorax).

To prevent the build-up of either normal bodily ﬂ uids (e.g. bile after •

surgery to the bile duct) or potential abnormal ﬂ uids or air (e.g.

bloody ﬂ uid in the pelvis after rectal surgery).

Occasionally used to prevent or ‘warn’ of potentially serious or life-•

threatening complications (e.g. neck drains after thyroid surgery, chest

drains after chest trauma in patients undergoing GA).

Potential complications should be balanced against drain use.

Damage to structures during insertion, even if under CT or ultrasound •

guidance (e.g. risk of injury to spleen in subphrenic abscess drainage,

haemorrhage from abdominal vessels in operative drains).

Drains provide a potential route of introduction of infection, especially •

external drains that remain for longer than a few days.

Damage to structures close to the drain, e.g. pressure injury to bowel •

if subjected to high pressure suction drainage.

Drains do not always drain the substance expected and may give a •

false ‘sense of security’, e.g. failure to drain bleeding after thyroid

surgery or failure to drain faecal ﬂ uid after anastomotic leakage.

There is no place for ‘routine’ use of drains after surgery unless there is a

clear indication—‘Better no drainage than ignorant use of it.’ (Halstead).

Types of drain (see Box 2.4)

Materials used include latex rubber (e.g. T tubes), silastic rubber (e.g.

long-term urinary catheters), polypropylene (e.g. abdominal drains), poly-

urethane (e.g. NGT).

Box 2.4 Types of drains

Open passive drains

These provide a conduit around which secretions may ﬂ ow.

Yates corrugated drain (after subcutaneous abscess drainage).

•

Penrose tube drain.•

Drainage setons placed in anal ﬁ stulas.•

Closed passive drains

These drain ﬂ uid by gravity (‘siphon effect’) or by capillary ﬂ ow.

Robinson tube drain (after intra-abdominal abscess drainage).

•

NGT.•

Ventriculoperitoneal shunt.•

Chest drain (tube thoracostomy).•

Closed active drains

These generate active suction (low or high pressure).

Exudrains

•

, Redivac drains

, Minivac

, Jackson Pratt drains (after

pelvic or breast surgery).

CHAPTER 2 Principles of surgery

Stomas

Terminology and types

The term stoma is usually applied to an external opening (temporary or

permanent) in a lumenated organ.

Ileostomy.• Formed from any part of the mid- or distal small bowel. May

be loop (often to ‘rest’ the distal bowel) or end (usually as a result of

surgical removal of distal bowel).

Colostomy.

• Formed from any part of the large bowel. May be loop (to

rest distally) or end (because of surgical resection).

Urostomy.• Formed from a short length of disconnected ileum into

which one or both ureters are diverted (usually after radical lower

urinary tract surgery).

Gastrostomy.• Either a surgically created or endoscopically formed

connection between anterior stomach and anterior abdominal wall.

Often for stomach drainage or direct feeding.

Jejunostomy.• Either a surgically created or endoscopically formed

connection between proximal jejunum and anterior abdominal wall.

Often for direct feeding.

Identifying stomas

Any stoma may have many different appearances. Typical features that

help in identifying stomas are the following:

Ileostomies (loop or end) are usually spouted, have prominent •

mucosal folds, tend to be dark pink/red in colour, and are most

common in the right side of the abdomen.

Colostomies (loop or end) are usually ﬂ ush, have ﬂ at mucosal folds, •

tend to be light pink in colour, and are most common in the left side

of the abdomen.

Urostomies (end) are usually spouted, have prominent mucosal folds, •

tend to be dark pink/red in colour, and are most common in the right

side of the abdomen. They are indistinguishable from end ileostomies

unless the output can be seen.

Gastrostomies and jejunostomies are usually narrow calibre, ﬂ ush with •

little visible mucosa, and are most common in the left upper quadrant

of the abdomen. They are usually ﬁ tted with indwelling tubes or access

devices.

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CHAPTER 2 Principles of surgery

Knots and sutures

Types of suture

See Fig. 2.6 and Table 2.2.

Non-absorbable sutures tend to be used where any loss of strength •

might compromise the future integrity of the tissues being joined, e.g.

vascular anastomoses, hernia mesh ﬁ xation, tendon repairs, sternal

wiring.

Absorbable sutures tend to be used where the persistence of foreign •

material would cause unnecessary tissue reaction or increased risk of

infection, e.g. bowel anastomoses, skin and subcutaneous tissues.

Monoﬁ laments have the advantage of smooth tissue passage and •

minimal tissue reaction, but tend to have a crystalline structure that

increases the ‘memory’ effect of the suture, making knotting less

secure and increasing the risk of suture ‘fracture’.

Braided polyﬁ laments exert more tissue friction during the passage •

through, but are intrinsically more ﬂ exible and knot securely more

easily.

Sizes of suture

Size is denoted by imperial sizes from 10/0 (smallest—invisible to naked

eye) through 4/0 (typical size for ﬁ ne vascular anastomoses), 2/0 (typical

size for bowel anastomoses), and 1 (typical size for abdominal closure), to

4 (largest available—size of sternal wires).

Types of needle

Needles may be curved (anything from half round to shallow curved) or

straight.

Blunt-ended, round-bodied• (often used for closing major incisions).

Relatively safe as it has low tissue penetrance.

Round-bodied• (sharp-pointed, but smooth, round, cross-sectional

proﬁ le). ‘Pushes’ tissue apart so often used for delicate tissues such as

bowel, blood vessels, etc.

Cutting point • (sharp point with triangular cross-section giving a speciﬁ c

cutting edge). Slices through tissues so often used for dense structures

such as fascia and tendons (also reverse cutting point).

Table 2.2 Types of suture material

Natural ﬁ bre Synthetic ﬁ bre

Non-absorbable

monoﬁ lament

Silver wire Steel wire Polypropylene nylon

Non-absorbable

braided polyﬁ lament

Silk (eventually does

decay)

Ethilon

Absorbable

monoﬁ lament

Monocryl

PDS

Absorbable braided

polyﬁ lament

Vicryl

Dexon

KNOTS AND SUTURES

Figure-of-eight Interrupted

Halsted

Purse-string

dnahrevo suounitnoCtrebmeL detpurretnI

Horizontal mattress Subcuticular continuous

Fig. 2.6 Types of suturing used (illustrated as skin sutures).

CHAPTER 2 Principles of surgery

Post-operative management

Routine tests

Protocols vary widely according to the complexity of surgery and the age

of the patient: this is a rough guide to management of the older patient

following major abdominal, cardiac, or reconstructive surgery.

Blood tests FBC and U&E on days 1, 2, and 5. Look for the following.

Anaemia: consider haemodilution or slow surgical bleeding.•

Raised WCC: look for other signs of sepsis (see • b pp. 104, 138).

Monitor INR/clotting daily if the patient is anticoagulated and before •

insertion of drains or central lines.

Check Na•

and K

to guide choice of crystalloid (see b p. 92).

Monitor urea and creatinine, especially in preoperative renal •

dysfunction, cardiac and aortic surgery, nephrotoxic drugs (e.g.

NSAIDs, ACE-inhibitors, vancomycin/gentamicin, ﬂ uid restriction).

ECG Very rarely used routinely outside post-cardiac surgery. Look for:

rhythm disturbances such as AF or evidence of ischaemia.

CXR

Request daily if chest drains are present on suction, after drain removal,

and to check position of newly placed central lines. Look for:

Position of indwelling lines;

•

Consolidation, pneumothorax (on side of central line), pulmonary •

oedema, pleural effusion.

Ward rounds

See patients once a day (twice if unwell, not progressing as expected, or

undergoing investigations or treatment). In the evening, review the blood

results and other investigations from that day. For formal ward rounds,

do the following:

Make sure you have a nurse with you—the nursing record.

•

Make sure someone writes a summary in the patient’s notes.•

Ask the patient if they are experiencing any problems: establish •

whether they are mobilizing appropriately, eating and drinking, have

adequate pain control, passing urine, and opening bowels.

Check the obs chart for ‘ABCDE’ (oxygen saturations, pulse, and •

BP trends), as well as temperature, ﬂ uid balance, and drainage if

monitored.

Look at exposed wounds for evidence of infection or seromas, but do •

not expose covered wounds.

Check diabetic charts for BS control.•

Review the drug chart. Restart regular oral medication as soon as •

possible. Convert IV to PO where appropriate. Look actively for drugs

that can be discontinued to minimize polypharmacy.

Review the most recent blood results.•

Review the nutritional status of the patient—what is the best route?•

Make a clear problem list and a clear plan.•

POST-OPERATIVE MANAGEMENT

Special cases

Surgery for malignancy

Liaise with specialist nurses; they will know the overall plan from the multi-

disciplinary team (MDT). Don’t discuss results without consulting them

ﬁ rst. Breaking bad news is discussed on b pp. 4 and 16.

Plastic and reconstructive surgery

Check perfusion of ﬂ aps daily.

•

Check take of split-skin grafts on day 5.•

Book post-operative medical illustration for photos prior to discharge.•

Orthopaedic surgery

Check X-rays of prosthesis to assess position, fraction reduction.

Vascular surgery

Check distal pulses and capillary reﬁ ll in patients after reconstructive

•

surgery.

Perform neurological examination to evaluate patients post-carotid •

endarterectomy.

Arrange prosthesis ﬁ tting for amputees.•

Cardiac surgery

Check sternal stability daily (ask the patient to cough while you feel for •

abnormal sternal movement).

Request transthoracic echo for day 4–5 post-operatively in valve repair •

patients and auscultate daily.

Discharge

Plan discharge from the day of admission. Use the hospital discharge •

team and identify patients requiring special facilities, such as

rehabilitation as soon as possible.

Make sure the patient understands what operation they have had.•

Tell them how to look out for common problems like wound •

infections, what is normal, and who to contact if they are worried.

Tell them when they will be seen in clinic.•

Tell them when they can expect to go back to work.•

Ensure an informative, but concise, discharge summary for the GP •

(see b p. 5).

Rehabilitation

The average times for patients to be ﬁ t to go back to work are as

follows:

Two to six weeks after abdominal or thoracic surgery, depending on

•

size and approach (e.g. laparoscopic or open).

Weight bearing takes up to 2 months after lower limb arthroplasties •

and 3 months after lower limb fractures.

Patients can usually drive once they are fully mobile as long as they •

have not experienced blackouts or ﬁ ts.

There are detailed rules for heavy goods vehicle (HGV) drivers and •

pilots available online.

Reference

1 M http://www.dvla.gov.uk/medical.aspx

CHAPTER 2 Principles of surgery

Drain management

Uses and types of abdominal drains are covered on b p. 83. A summary

follows:

Drains may remove collections of ﬂ uid or gas from body cavities.•

They can be inserted as • prophylaxis or treatment.

Efﬂ uent can be collected in • closed or open containers.

Closed containers may have a • simple or an underwater seal.

Drainage can be • suction or non-suction.

Drains may be made of latex, PVC, polyurethane, or silicone.•

Chest drains

Indications for chest drains and insertion are described on b p. 194.

Chest drainage should always be into an underwater sealed container.

Management of chest drains inserted for pneumothorax

Put the drain on low pressure, high volume wall suction (–3–5kPa) •

initially (not the high pressure wall suction used for tracheal toilet).

Request and review CXRs daily.•

Bubbling in the underwater seal, either continuously or only when •

the patient coughs, indicates an air leak and implies that the lung

parenchyma has not healed. 2 You can only remove the drain when

there is no air leak; otherwise a pneumothorax will rapidly re-form.

When the air leak stops, take the drain off suction for 12h and repeat •

the CXR: if the lung is fully up, the drain can be removed.

Get a CXR after drain removal to check for a pneumothorax.•

Management of chest drains inserted to drain collections

Management of chest trauma is described on b p. 480.

There is no evidence that suction improves outcome.•

Make sure that the nursing staff measures the drainage: hourly in the •

post-operative patient, every 24h in longer-term drains.

A haemodynamically unstable post-operative patient or one who is

•

draining more than 200mL blood/h should be discussed urgently with

the thoracic surgeons.

Post-operative thoracic drains are normally removed when they drain •

nothing for 2 consecutive hours unless there is an air leak.

Drains for pleural effusions can be removed when they drain less than •

250mL in 24h.

Drains for empyemas can be removed when they stop draining.•

Always request and review a CXR after drain removal to check for •

pneumothorax.

DRAIN MANAGEMENT

Clamping chest drains

Clamping drains when transferring patients stems from the days of TB

treatment with caustic solutions and was aimed to prevent drain efﬂ uent

draining back into the chest. In modern practice, the only indications to

clamp a drain are: (1) in the trauma setting if the patient is exsanguinating

through it; (2) under specialist supervision in patients with chronic air

leaks or pneumonectomy.

Clamping a thoracic drain in a patient with an air leak may rapidly

•

result in a tension pneumothorax.

Clamping a mediastinal drain in a patient who is bleeding may rapidly •

result in cardiac tamponade.

The safest mode is an • unclamped drain connected to an underwater

seal that is kept below the level of the patient at all times.

If you connect the drain to wall suction, but do not put the wall •

suction on, this is effectively clamping the drain; if you and the nurses

do not know what you are doing, ask for help.

If you press in the one-way valve on the top of the underwater seal •

too tightly, this effectively clamps the drain. If in doubt, leave it alone!

CHAPTER 2 Principles of surgery

Fluid management

Fluid management is aimed at making sure the patient is neither ﬂ uid

depleted nor ﬂ uid overloaded. The principle is to replace whatever is lost.

Success can make the difference between a short, uncomplicated post-

operative course and the patient ending up on ICU.

Maintenance crystalloid

The principle is to replace Na

, K

, and water loss from urine, vomit-

ing, diarrhoea, high output ﬁ stulae and stomas, and ﬂ uid ‘third-spaced’

(e.g. ascites, tissue oedema). For ﬂ uid management in burns, see b

pp. 604–7.

Approximate average daily loss of ﬂ uid and electrolytes

Water loss 2500mL/day• (insensible loss from skin, respiratory and GI

tract, and in urine). i loss in sepsis, ventilation, diarrhoea, vomiting,

high output ﬁ stulas, polyuric renal failure.

Na+ 100mmol/day• (in urine). i loss in pyrexia, diarrhoea, vomiting,

high output ﬁ stulas. Urine concentration is less effective in elderly

patients and dextrose infusions may cause hyponatraemia.

K+ 80mmol/day• (in urine). i loss in pyrexia, diarrhoea, vomiting, high

output ﬁ stulas.

Regime 1

This gives 3L of ﬂ uid, 200mmol Na, and 80mmol KCl in 24h. It is only

suited to adult patients with no signiﬁ cant comorbidity. It takes no account

of patient age, size, cardiac function, or ﬂ uid loss.

1L normal saline with 40mmol KCl over 8h.

•

1L normal saline with 40mmol KCl over 8 h.•

1L 5% dextrose over 8h.•

Regime 2

This adjusts ﬂ uid given to ﬂ uid lost, but needs the nursing resources to

run an hourly ﬂ uid balance chart and infusion pumps. It is more suited to

patients on HDU.

1mL/kg/h normal saline.

•

Gelofusine or 5% dextrose ﬂ uid challenges to maintain central venous •

pressure (CVP) 8–12cmH

O or BP >120mmHg.

10–40mmol KCl in 100mL 5% dextrose via central line if K•

<3.0.

Regime 3—Alder Hey paediatric regimen

Useful in all ages and all body weights, except extreme starvation.

Fluid volume/24h

• . 100mL/kg for each kg 0–10kg; 50mL/kg for each kg

10–20kg; 20mL/kg for each kg over 20kg.

Electrolytes• . Na

2mmol/kg/24h; K

1mmol/kg/24h.

Colloid

Colloids (especially blood) produce a more lasting expansion of intravas-

cular volume than crystalloid which rapidly enters the interstitial tissues.

Gelofusine is succinylated gelatin (a bovine collagen) which has a •

half-life of about 2h in plasma and is associated with increased bleeding

times in post-operative patients.

FLUID MANAGEMENT

Dextran is a glucose polymer mixture that has a plasma half-life of •

about 2h; it has been associated with anaphylactic reactions and

profound coagulopathy.

HES preparations are derived from hydroxyethyl starch; they have •

widely differing plasma half-lives and effects on plasma expansion.

Albumin is a naturally occurring plasma protein, sterilized by •

ultraﬁ ltration: 5% albumin is isotonic; 20% albumin is hypertonic.

Indications for use of albumin as a volume expander are very limited.

Blood, platelets, fresh frozen plasma (FFP), and cryoprecipitate •

(see b p. 96).

Assessing volume status This is usually straightforward, but in the

HDU patient 24h post-complex surgery, you need information from sev-

eral sources.

History and examination

The dry patient.• May have been NBM several days preoperatively and

feels thirsty, complains of a dry mouth, may be dehydrated because

of diarrhoea or vomiting, has a low JVP, dry mucous membranes, and

reduced skin turgor.

The overﬁ lled patient.• Usually doesn’t feel thirsty, has a raised JVP,

normal skin turgor, and may have dependent oedema and evidence of

pulmonary oedema on auscultation.

Observations chart

The dry patient.

• May have falling BP, rising pulse rate, low CVP

that does not rise with ﬂ uid challenges, weight is several kg below

preoperative weight.

The overﬁ lled patient.• Is not usually tachycardic and has a high CVP

that rises and plateaus with ﬂ uid challenges. BP may fall with ﬂ uid

challenges; weight is several kg above preoperative weight.

Fluid balance chart In sick patients, ask the nurses to start an hourly ﬂ uid

balance chart. Add up all ﬂ uid loss (urine output, wound, stoma, and ﬁ stula

drainage) and subtract from all IV, NG, and oral ﬂ uids given.

The dry patient.

• Will usually be in several litres of negative ﬂ uid

balance, possibly over a few days, with a urine output <1mL/kg/h.

The overﬁ lled patient.• Will be in several litres of positive ﬂ uid balance,

possibly over a few days. Urine output may be low because of heart

failure or renal dysfunction.

Blood results

The dry patient.

• Has high Na, K, creatinine, and urea, with the urea

often disproportionately raised.

The overﬁ lled patient.• May have low Na.

CXR

The dry patient.

• Has no evidence of pulmonary oedema or effusions.

The overﬁ lled patient.• May have both pulmonary oedema and effusions.

CHAPTER 2 Principles of surgery

Acid–base balance

The pH of arterial blood is maintained at 7.35–7.45. Normal function-

ing of the body’s complex enzyme systems depends on this stability.

Derrangements may be primarily due to respiratory or metabolic dysfunc-

tion (see Box 2.5). Compensatory mechanisms are also divided into meta-

bolic and respiratory. The true clinical picture is mixed.

Box 2.5 Diagnosing acid–base abnormalities

pH <7.35 is an acidaemia; pH >7.45 is an alkalaemia

Look at the pH—is there an acidaemia or an alkalaemia?•

Look at the PaCO•

—is there a change in keeping with the pH

derangement? If so, the derangement is a respiratory one.

Look at the base deﬁ cit (or anion gap). This will tell you if there is a •

metabolic derangement; if pH is normal, it is fully compensated.

The Flenley nomogram (see Fig. 2.7) is a useful diagnostic aid where

mixed metabolic and respiratory derangements are present.

Base excess, base deﬁ cit, and anion gap

These are derived numbers, calculated by blood gas analysers, quantifying

changes in metabolic or ﬁ xed acids, but because they depend on several

assumptions, they do not always reﬂ ect the true acid–base balance.

Base excess• is deﬁ ned as the mmol/L of acid that would be required to

titrate the blood pH back to 7.4 if the pCO

were normal.

Base deﬁ cit• (negative base excess) is deﬁ ned as the mmol/L of base to

titrate the blood pH back to 7.4 if the pCO

were normal.

A base deﬁ cit is negative and a base excess is positive by convention. •

Normal values are –2mmol/L to +2mmol/L. A base deﬁ cit greater than

this (e.g. –6mmol/L) indicates a metabolic acidosis.

The

• anion gap is the difference between measured cations and

measured anions (= K

+ Na

– Cl

–

+ HCO

–

). This is made up of

metabolic acids: ketones, lactate, and phosphates. The anion gap is

normally 8–16mmol/L; an increase in anion gap indicates a metabolic

acidosis.

Metabolic acidosis

Uncompensated: • dpH, npCO

, dHCO

–

Compensated: • dnpH, dpCO

, dHCO

–

Metabolic acidosis due to increased metabolic acids (i anion gap)

Lactic acid (global and/or regional hypoperfusion, hypoxia, sepsis,

•

hepatic failure as the liver normally metabolizes lactate).

Uric acid (renal failure).•

Ketones (diabetic ketoacidosis, alcoholic and starvation ketoacidosis).•

Drugs/toxins (salicylates, sodium nitroprusside overdose).•

Due to loss of bicarbonate or hyperchloraemia (normal anion gap)

Renal tubular acidosis (loss of bicarbonate).•

Diarrhoea, high output ileostomy (loss of bicarbonate).•

ACID–BASE BALANCE

Pancreatic ﬁ stulas (loss of bicarbonate).•

Hyperchloraemic acidosis (excessive saline administration).•

Metabolic alkalosis

Uncompensated: • i pH, n pCO

, i HCO

–

Compensated: • in pH, i pCO

, i HCO

–

Loss of H

•

from gut (vomiting, NG tube suction).

Renal loss of H•

(diuretics), i reabsorption of

HCO

–

(hypochloraemia).

Administration of base (NaHCO•

, citrate in blood transfusions).

Respiratory acidosis

Uncompensated: • d pH, i pCO

, n HCO

–

Compensated: • dn pH, i pCO

, i HCO

–

Any cause of respiratory failure or hypoventilation.•

Increased production of CO•

, e.g. sepsis, malignant hyperpyrexia.

Rebreathing CO•

(circuit misconnections, soda lime exhaustion).

Respiratory alkalosis

Uncompensated: • i pH, d pCO

, n HCO

–

Compensated: • ni pH, d pCO

, d HCO

–

Hyperventilation: deliberate, inadvertent, or in non-ventilated patients •

caused by stroke, anxiety, pulmonary embolism (PE), pneumonia,

asthma, pulmonary oedema.

110

100

]

nmol/L

024681012

Respiratory

alkalaemia

Acute respiratory acidaemia

Chronic respiratory acidaemia

Metabolic

acidosis

20 30 40 50 60 70 80 90 mmHg

Metabolic alkalosis

7.6

7.5

7.4

7.3

7.2

7.1

7.0

Fig. 2.7 Flenley nonogram. Reproduced with permission from Longmore M. et al.

(2007). Oxford Handbook of Clinical Medicine, 7th edn. Oxford University Press,

Oxford.

CHAPTER 2 Principles of surgery

Blood products and procoagulants

Blood

One unit of blood increases Hb by about 1g/dL in a 70kg adult.•

Blood is normally provided as packed red cells (1U • 8 350mL).

Cross-matched blood can normally be provided within 20min; it •

contains blood from a single donor.

In dire emergencies, O-negative blood (universal donor) can be given •

to recipients of any ABO Rh group without incompatibility reaction.

Autologous blood transfusion may be used with up to 2U of blood •

withdrawn from patients preoperatively, which may be stored for up

to 5 weeks.

Cell salvage reduces the need for allogeneic blood. Shed blood is •

collected intraoperatively, heparinized, spun with normal saline to

remove all material, including residual heparin, platelets, and clotting

products, and repackaged as red blood cells suspended in saline for

transfusion.

Simple measures to reduce the need for blood transfusion include:•

Treating anaemia and coagulopathies preoperatively.•

Stopping warfarin, heparin, aspirin, and clopidogrel appropriately.•

Special methods to reduce homologous blood transfusion include:•

Autologous blood transfusion.•

Cell salvage.•

Procoagulants (see • b p. 97).

Erythropoietin (EPO) stimulates erythrocyte production.•

Platelets

One unit of platelets increases platelet count by 10•

/L in a 70kg adult.

Platelets are provided as units (1U • 8 50mL).

Platelets do not need to be cross-matched, but they should be ABO-•

compatible (and rhesus-matched in females of childbearing age).

One unit contains platelets from a single donor.•

They are stored at 22• °C and have a shelf life of 5 days.

Indications for blood products

Young, ﬁ t patients tolerate haemodilution much better than elderly •

patients with multiple comorbidities (particularly cardiovascular and

respiratory disease).

There is a higher threshold for giving blood products in the patient •

who is not actively bleeding or about to undergo a procedure.

Blood.• In general, aim to maintain Hb at 7–9.0g/dL; in older patients,

in those with cardiorespiratory disease, maintain Hb >9.0g/dL.

FFP.• Patient’s circulating blood volume replaced or activated partial

thromboplastin time ratio (APTR) >1.5 with active bleeding.

Platelets.• Platelets <50 x 10

/L or <100 x 10

/L with active bleeding

(lower threshold if patient was on aspirin or clopidogrel within 5

days and is actively bleeding).

Cryoprecipitate.• Patient’s circulating blood volume replaced or

ﬁ brinogen <1g/L with active bleeding.

BLOOD PRODUCTS AND PROCOAGULANTS

Fresh frozen plasma (FFP)

One unit of FFP contains all the coagulation factors except platelets.•

1mL of FFP per kg will raise most clotting factors by 1% in a 70kg adult.•

One unit of FFP = 150–250mL and 5–10mL/kg is normally given.•

One unit of FFP usually contains product from a single donor, but is •

sometimes pooled, in which case it may be from several donors.

FFP does not need to be cross-matched, but should be ABO •

compatible (and rhesus-matched in females of childbearing age).

FFP must be stored at <–18• °C. It must be thawed, usually over 20min,

before giving and discarded if not used within 2h.

Cryoprecipitate

One bag of ‘cryo’ contains 150–250mg ﬁ brinogen and factors VII and •

VIII.

If cryopreciptate is unavailable, 5U of FFP contain the same amount of •

ﬁ brinogen as 10U of cryoprecipitate.

Ten bags of ‘cryo’ raises the ﬁ brinogen 0.6–0.7mg/L in a 70kg adult.•

One bag of cryoprecipitate = 20mL; 5–10 pooled bags are normally •

given.

ABO and rhesus compatibility are not relevant.•

Antiﬁ brinolytics (e.g. aprotinin and tranexamic acid)

Action.• Inhibit plasminogen and plasmin; reduce active ﬁ brinolysis.

Indications.• Prophylaxis against bleeding in cardiovascular surgery,

especially high risk (e.g. redo surgery). Some studies suggest they

are useful in ‘high risk’ orthopaedic surgery. Treatment of excessive

bleeding post-operatively (liver surgery; very rarely, radical pelvic

resections).

Key revision points—physiology of blood groups

ABO antigens • pre-exist on red cells. ABO antibodies pre-exist in

the circulation and will cause immediate reaction if incompatible.

Anti-rhesus (D/E) antibodies• only develop following exposure to

the RhD antigen, e.g. during blood transfusion or delivery.

O Rh negative are • universal donors (red cells carry no ABO/Rh

antigens).

AB Rh positive are • universal recipients (serum contains no A, B,

RhD antibodies).

Blood grouping• involves adding A, B, RhD agglutinins to donated

blood to determine blood type; it takes less than 5min.

Cross-matching• involves mixing donated blood with the intended

recipient serum; assessing compatibility takes about 20min.

CHAPTER 2 Principles of surgery

Transfusion reactions

3 Acute haemolytic reaction

ABO incompatibility as a result of clerical, bedside, sampling, or laboratory

error is the most common cause. It may also be caused by incompatibility

within other antigen systems (Duffy/Kidd). Donor erythrocytes carrying

either A and/or B erythrocyte antigens bind to the recipient’s anti-A or

anti-B antibodies, resulting in complement formation, membrane attack

complex, and immediate haemolysis. Cytokine and chemokine release

mediates sympathetic inﬂ ammatory response characterized by sudden

onset of hypotension, tachycardia, pyrexia, breathlessness, tachypnoea,

and back pain. Bilirubinaemia, anaemia, and haemoglobinuria as a result

of haemolysis ensue.

Stop the transfusion immediately and give basic life support if required.•

Keep the bag and giving set for analysis; inform haematology.•

Give crystalloid and furosemide to encourage diuresis.•

Dialysis may be required.•

3 Anaphylaxis and allergic reactions

Normally, IgE-mediated histamine release reactions to plasma, platelets,

and red blood cells. Mild allergic reactions are relatively common and

are characterized by erythematous papular rashes, wheals, pruritus, and

pyrexia. These are treated by stopping the transfusion and administering

chlorpheniramine (10mg IV). Anaphylaxis characterized by hypotension,

bronchospasm, and angioedema occasionally occurs.

Stop the transfusion immediately and disconnect connection tubing.•

Basic life support may be required.•

Treat bronchospasm and angioedema with adrenaline (1mL of 1:10 000 •

IV), chlorpheniramine (10mg IV), and hydrocortisone (100mg IV).

Non-haemolytic febrile reaction

These common and normally mild reactions are caused by recipient

antibodies directed against donor human leucocyte antigen (HLA) and

leucocyte-speciﬁ c antigen on leucocytes and platelets. Cytokine release

mediates mild pyrexia, typically over an hour after transfusion is started.

Antipyrogens such as paracetamol 1g PO/PR limit pyrexia, but antihista-

mines are not helpful. Severe reactions feature high grade fever, rigors,

nausea, and vomiting. The severity of symptoms is proportional to the

number of leucocytes in the transfused blood and the rate of transfusion.

Leucocyte-depleted blood helps prevent these reactions.

Delayed extravascular haemolytic reaction

Although pre-transfusion antibody testing is negative (a satisfactory cross-

match), these patients experience accelerated destruction of transfused

red blood cells 7–10 days following transfusion. This is an antibody-medi-

ated reaction, usually by a patient’s antibody (commonly Rh E, Kell, Duffy,

and Kidd), present in levels too low to be detected clinically until pro-

duced in larger amounts on exposure to circulating antigen. As haemolysis

is extravascular, haemoglobinaemia and haemoglobinuria are uncommon:

TRANSFUSION REACTIONS

it is characterized by an unexpected fall in haematocrit a few days post-

transfusion, hyperbilirubinaemia, and positive Coombs’ test.

Transfusion-related acute lung injury

Non-cardiogenic pulmonary oedema, typically within 6h of transfusion, is

mediated by recipient antibodies against donor HLA. Activated recipient

leucocytes migrate to the lung, releasing proteolytic enzymes that cause a

localized capillary leak syndrome and pulmonary oedema.

Infection

Bacterial

Serious bacterial contamination of stored blood may occur although

platelets, which are usually stored at room temperature, are at greater

risk of this. Common organisms include Staphylococcus spp., Enterobacter,

Yersinia, and Pseudomonas spp. Contamination is difﬁ cult to detect. The

recipient becomes pyrexial at >40°C and hypotensive. This may occur

during the transfusion or hours after completion and unlike febrile transfu-

sion reactions, is not self-limiting.

Volume resuscitation.•

Culture the patient and send bag and giving sets to microbiology.•

Start empirical broad-spectrum antibiotics.•

Non-bacterial

Pre-transfusion testing includes screening for hepatitis B (HbsAg, anti-

HBc), hepatitis C (anti-HCV), HIV (anti-HIV-1/2, HIV-1 p24 antigen),

HTLV (anti-TLC-1/2), and syphilis. HIV can be transmitted by an infective,

but seronegative, donor for about 15 days after infection. The HCV win-

dow is 20 days. CMV is common in the donor population (40–60%) and

immunocompromised donors must receive leucocyte-depleted or CMV-

negative blood. Malaria may be transmitted by blood transfusion as may

new variant Creutzfeldt–Jakob disease (nvCJD).

Fluid overload

Characterized by hypotension, acute dyspnoea, high CVP, and hypoxia.

Stop the transfusion.•

Give high ﬂ ow O•

and loop diuretics (40mg furosemide IV).

Massive transfusion

Replacement of the patient’s circulating volume within 24h.•

Stored red cells are depleted of ATP and 2,3-DPG and leak K•

and the

ﬂ uid contains citrate.

Large volumes of this blood lead to a blood volume that has poor O•

carrying capacity, i K

, hypothermic (if blood is not warmed), and

coagulopathic due to Ca

sequestration.

Reduce the effect of massive transfusion by the following.

Use infusion warmers and a warming blanket.•

Monitor central circulation and respiratory function closely.•

Consider giving Ca•

supplements (with care!).

Check platelets, APTT, and ﬁ brinogen: replace if needed.•

Check potassium regularly.•

CHAPTER 2 Principles of surgery

100

Shock

Deﬁ nition

Inadequate end-organ perfusion and tissue oxygenation. ‘Cellular shock’

is a term describing failure of normal cellular processes, including oxygen

processing.

Emergency management

Assess the airway. If patent, give high ﬂ ow O•

by non-rebreathing mask.

Check carotid or femoral pulse.•

Secure • IV access and start giving 500mL crystalloid rapidly.

Recheck BP. If low and falling fast, call crash team.•

Take a rapid history and examine patient to differentiate between the •

following types of shock.

Hypovolaemic shock

Causes.• Trauma, ruptured abdominal aortic aneurysm (AAA), ruptured

ectopic, post-operative haemorrhage, profound dehydration, burns,

pancreatitis.

Clinical features.• As above with history of trauma/surgery/illness.

Treatment.•

Lie patient ﬂ at; high ﬂ ow O•

; lift legs to autotransfuse if no IV

access.

Repeat ﬂ uid infusion 500mL IV rapidly: you should see rise in BP.•

Take blood and send for FBC, U&E, clotting, and cross-match.•

Take arterial blood gas (ABG): estimate Hb, K•

as well as ABG.

Treat • i K

If no rapid improvement in BP, look for other causes.•

Anaphylactic shock

Causes.

• Drug allergy, blood product reaction, latex allergy.

Clinical features.• History of sudden onset after administration of drug.

Stridor or bronchospasm, angioedema, urticaria, pruritus, rash.

Treatment.•

Sit patient up; give high ﬂ ow O•

; call anaesthetist if stridor.

If IV access: give 1mL of 1:10 000 adrenaline bolus; ﬂ ush; then •

100mg hydrocortisone bolus; ﬂ ush; then 10mg chlorpheniramine IV.

Repeat again in 5–10min if no improvement.•

If no IV access: give 1mL 1:1000 adrenaline IM. Then secure IV •

access.

If wheezy, give 5mL nebulized salbutamol.•

Septic shock

Cause.• Overwhelming sepsis (see b p. 138).

3 Recognizing shock

d• BP, i pulse, and usually cold, clammy, pale, sweating.

Confused—may be agitated • or drowsy.

Young patients will compensate, with the only signs being decreased •

pulse pressure, tachycardia, and decreased urine output.

SHOCK

101

Clinical features.• May be the same as hypovolaemic shock or, if

established, with circulatory collapse. Earlier in the evolution, the

patient may look ‘septic’—pyrexial, ﬂ ushed, bounding pulses.

Treatment.•

As for hypovolaemic shock.•

Take blood cultures; then give IV cefuroxime 750mg tds.•

Cardiogenic shock

Rapidly reversible causes.• cardiac tamponade (trauma, post-cardiac

surgery), arrhythmias, tension pneumothorax.

Other causes.• Fluid overload and congestive cardiac failure (CCF),

MI, PE, subacute bacterial endocarditis (SBE), aortic dissection,

decompensated valvular heart disease.

Clinical features.• History of recent surgery/trauma, chest pain,

dyspnoea, palpitations.

Treatment.•

Give high ﬂ ow O•

Give 2.5mg morphine IV (anxiolytic, venodilator, analgesic, anti-•

arrhythmic).

Put patient on cardiac and sats monitors; request 12-lead ECG.•

Treat arrhythmias (see advanced life support (ALS) algorithm on •

inside back cover).

Treat myocardial ischaemia with 0.1mg GTN, 300mg aspirin.•

Auscultate heart sounds and lung ﬁ elds.•

Treat tension pneumothorax (see • b p. 636), cardiac tamponade

(see b p. 638).

Discuss with ITU.•

Consider central venous and peripheral arterial monitoring.•

Send blood for ABGs, FBC, U&E, clotting, troponin.•

Catheterize the patient.•

Request CXR—look for pulmonary oedema.•

Treat ﬂ uid overload with diuretics: furosemide 40mg IV.•

Consider transthoracic echo to exclude pericardial effusion and •

valvular lesions, and to assess LV function.

CHAPTER 2 Principles of surgery

Post-operative haemorrhage

Post-operative haemorrhage may be arterial or venous. Signiﬁ cant arterial

haemorrhage is rare and usually occurs from vascular anastomoses. Very

rarely, it arises from solid organ injury or loosening of arterial ties. It is

rapid, bright red in colour, and often pulsatile. Venous bleeding is a more

common cause of post-operative haemorrhage and is usually due to the

opening up of unsecured venous channels, or from damage to the liver

or spleen at surgery. Although it is non-pulsatile, low pressure, and dark

in colour, it can be very large volume and is every bit as life-threatening

as arterial bleeding. Most post-operative bleeding is not overt and is con-

tained within body cavities. Drains, even correctly placed, are an unreli-

able sign of bleeding. Rely on your clinical instincts even if the drains are

empty.

Causes and features

Primary haemorrhage.• Occurs immediately after surgery or as a

continuation of intraoperative bleeding. Usually due to unsecured

blood vessels (e.g. liver bleeding following trauma).

Reactionary haemorrhage.• Occurs within the ﬁ rst 24h. Usually due to

venous bleeding and is commonly thought to be due to improved

post-operative circulation and ﬂ uid volume, exposing unsecured

vessels that bleed (e.g. delayed splenic bleeding following minor

trauma at laparotomy).

Secondary haemorrhage.• Occurs up to 10 days post-operatively. Usually

due to infection of operative wounds or raw surfaces, causing clot

disintegration and bleeding from exposed tissue.

Symptoms

Confusion and agitation (due to cerebral hypoxia secondary to

hypotension).

Signs

Soaked dressings, acute wound swelling, blood in drains.•

Pallor, sweaty, tachypnoea, tachycardia, hypotension (a late sign in •

children and young adults).

Emergency management

Resuscitation

Establish large calibre IV access. Give crystalloid ﬂ uid up to 1000mL •

bolus if tachycardic or hypotensive. Do not waste time trying to insert

a CV catheter. They are unreliable measures of CVP at the bedside in

acute situations and are too long and too ﬁ ne calibre to be of use for

rapid volume resuscitation.

Attempt to control superﬁ cial bleeding with direct compression. Do •

not use tourniquets on limb wounds.

Take blood for emergency cross-match if serum is not already •

available. Detail an assistant to telephone blood transfusion for

emergency cross-match of a minimum of 2U of blood.

Inform senior help immediately if signiﬁ cant blood loss. Consider •

alerting theatres and/or ITU.

102

POST-OPERATIVE HAEMORRHAGE

Do not use O Rh negative blood for resuscitation unless the patient •

is in extremis. In these cases, the patient should already be being

transferred to theatre or ITU.

Catheterize and place on a ﬂ uid balance chart if hypotensive, but •

stable.

Establish a diagnosis

The cause may be obvious from the bleeding or the operation.

Read the operation notes. Is there any potential cause mentioned?

•

If the bleeding is severe, the only way to establish a diagnosis may be •

at re-operation.

If the patient is stable and re-operation is undesirable, consider imaging.

CT scanning may reveal intra-abdominal or intrathoracic blood.•

Angiography may reveal active bleeding sites and may be therapeutic •

(coil embolization).

Deﬁ nitive management

Most post-operative bleeding does not require re-operation, but if it does,

it should always be done by a senior surgeon. If this is not the surgeon who

performed the original surgery, it may be wise to try to contact them in

case they can give useful information about the original procedure.

If re-operation is highly undesirable, e.g. rebleeding after solid organ

trauma, then deﬁ nitive conservative management might include:

Radiologically guided embolization;•

FFP infusions (see • b p. 96);

Controlled, permissive hypotension;•

Monitoring on ITU.•

Wound haematoma

A localized collection of blood beneath the wound or at the site of sur-

gery, usually characterized by swelling and discoloration.

• If this occurs after vascular surgery, ﬂ ap surgery, or procedures

on the limbs or neck, get senior help as urgent surgical exploration

and evacuation may be indicated to avoid ischaemia, compartment

syndromes, airway obstruction, ﬂ ap failure, or ongoing haemorrhage.

Apply ﬁ rm pressure followed by a pressure dressing.•

Check clotting and FBC and treat appropriately (see • b p. 96).

Withhold heparin.•

Surgical management is the same as for haemorrhage.•

103

CHAPTER 2 Principles of surgery

Wound emergencies

Infection

Causes

Most wound infections are acquired from the patient’s own ﬂ ora. The

majority are skin organisms (e.g. Staphylococcus aureus, Staphylococcus

epidermidis), although the second commonest cause is contamination

from opened viscera during surgery (e.g. Escherichia coli from the GI tract,

Pseudomonas from the biliary tree).

Symptoms

Pain and discharge in the wound.

•

Malaise, anorexia, and fever (systemic inﬂ ammatory features).•

Signs

Fever, tachycardia.•

Red, swollen, tender wound (may be discharging pus or ﬂ uctuant due •

to contained pus).

Complications

Bacteraemia is common, but rarely signiﬁ cant.

•

Septicaemia is rare unless the organism is resistant or the patient is •

immunosuppressed.

Emergency management

Resuscitation

Ensure there is IV access. Give crystalloid ﬂ uid up to 1000mL if tachycardic

or hypotensive.

Establish a diagnosis

Send any discharging pus for microscopy, culture and sensitivities •

(M,C,&S).

Send blood for FBC (Hb, WCC) and blood cultures.•

Early treatment

Give IV antibiotics if there are any systemic features. If there is no pre-

•

existing infection, use anti-staphylococcals: ﬂ ucloxacillin 1g + 500mg

qds. If the patient is immunosuppressed or very unwell, add in broad-

spectrum cover to include anaerobic cover: metronidazole 500mg IV +

500mg IV tds and cefuroxime 1.5g IV + 500mg IV tds.

If there is real concern about MRSA infection, consult microbiology •

and consider adding IV vancomycin 500mg. If so, monitor drug plasma

concentration.

Open or aspirate the wound if there is contained pus. Wash the •

wound.

Dehiscence

Wound dehiscence may be superﬁ cial (including skin and subcutaneous

tissue) or full thickness/deep (involving fascial closures or bony closures).

Full thickness dehiscence may expose deep structures. In the abdo-

men, this includes the viscera which may protrude through the wound

(evisceration).

104

WOUND EMERGENCIES

Causes

Most wound dehiscences are secondary to wound infection. Contributary

factors include immunosuppression, malnutrition, steroid use, poor surgi-

cal technique, previous surgery or procedures. Occasionally, the dehis-

cence is due to intracavity pathology causing wound breakdown from

within (e.g. anastomotic leakage causing enteric ﬁ stulation).

Symptoms

Usually painless.

Signs

Open wound, visible fat and fascia if superﬁ cial; visible viscera if full

•

thickness.

Occasionally associated organ dysfunction if involved by the •

accompanying wound infection (e.g. pericarditis/anterior mediastinitis

in sternal dehiscence).

Emergency management

Resuscitation

Ensure there is IV access.

•

Calm the patient, particularly if there is any degree of evisceration.•

Early treatment

If there are exposed viscera, cover these with saline soaked dressings.•

Give IV antibiotics if there features of wound infection (see • b p. 104).

If the dehiscence is superﬁ cial, ensure the wound is open and any pus •

is fully drained. Lightly pack the wound with absorbent dressing (e.g.

Sorbsan

Deﬁ nitive management

Superﬁ cial

Continue regular wound lavage and dressings.

•

For large defects, consider vacuum-assisted closure.•

Full thickness

Resuturing/closure of the defect in theatre may be appropriate.

•

For some deep defects, re-closure may be inappropriate (e.g. •

the presence of infection, intestinal contents/ﬁ stulas, severe

immunocompromise, physiologically unstable, intracavity pathology

causing the dehiscence). In these cases, the wound should be allowed

to form a chronic wound and close by secondary intention (e.g. called

a laparostomy in the abdomen). This may be assisted by vacuum

closure devices.

Bleeding (see b p. 102).

105

CHAPTER 2 Principles of surgery

Cardiac complications

Chest pain

Taking a careful pain history should help differentiate between the causes

of chest discomfort listed in Box 2.6 below.

Diagnosis

Take a careful history and examine the patient.•

A CXR will demonstrate most lung pathology.•

12-lead ECG should help exclude myocardial ischaemia.•

Recent WCC and CRP help identify sepsis.•

Review previous medical history for peptic ulcer disease and the drug •

chart for NSAID use.

Myocardial ischaemia

Patients, particularly in vascular surgery, may have pre-existing ischaemic

heart disease. Surgery can precipitate ischaemia through:

Stress response to major surgery (endogenous catecholamine release •

triggered by anxiety, pain).

Fluid overload post-operatively.•

Profound hypotension.•

Failing to restart anti-anginal medication post-operatively.•

Diagnosis

Take a history, particularly of chest discomfort brought on by exertion and

relieved by GTN. Check that the patient is back on any regular cardiac

medication. The physiotherapists may report bradycardia on exercising.

A 12-lead ECG will conﬁ rm the presence of myocardial ischaemia (see

Box 2.7). Cardiac enzymes (troponin T (and I) or CK

) may be slightly

raised post-operatively, but a high level or serial measurements showing a

continued rise would suggest ongoing myocardial damage.

Box 2.6 Causes of post-operative chest pain

Dull, central ache

Myocardial ischaemia.•

Gastric distension.•

Central pain radiating through to back

Thoracic aneurysm or dissection.•

Peptic ulcer disease, oesophagitis, rarely pancreatitis.•

Pain on movement

Musculoskeletal pain.

•

Chest drains.•

Pleuritic pain

Chest infection.•

Pneumothorax.•

Haemothorax, pleural effusion, empyema.•

Chest drain • in situ.

PE.•

106

CARDIAC COMPLICATIONS

Management

Sit patient up; give high ﬂ ow O•

Ensure the patient is on aspirin 75mg od PO and LMWH, e.g. 40mg •

enoxaparin (Clexane

) SC.

Give GTN sublingually.•

Restart preoperative anti-anginal medication.•

Discuss urgently with a cardiologist.•

Perioperative MI

Perioperative MI may be difﬁ cult to diagnose because the patient may be

unable to give a good history or to distinguish between chest and upper

abdominal pain.

The presentation is similar to that of myocardial ischaemia, but •

the duration is longer (>20min) and may be associated with

haemodynamic instability, nausea, vomiting, confusion, and distress.

The patient will often be cold, clammy, and may be hypoxic.•

Management

Attach an ECG monitor and a sats probe and get a 12-lead ECG.

•

Make sure the deﬁ brillator trolley is close at hand.•

Give high ﬂ ow O•

Get IV access.•

Give morphine 5mg IV and metoclopramide 10mg IV.•

Give aspirin 300mg • PO/PR and GTN 0.5mg SL.

Contact cardiologists urgently for consideration of acute intervention.•

Box 2.7 Diagnostic criteria for MI

In the setting of symptoms suggestive of acute coronary syndrome:

ECG shows ST segment elevation—ST segment elevation MI •

(STEMI).

No ST elevation, but elevated CK•

(2 x normal) or troponin

T-positive—non-Q wave or non-ST segment elevation MI (NSTEMI).

Key revision points—physiology of coronary blood ﬂ ow

Myocardial cells extract up to 70% of O•

from blood.

Coronary blood ﬂ ow occurs during diastole.•

Tachycardia reduces diastolic interval and increases O•

demand,

which may reveal occult ischaemia.

Coronary vasodilatation is mediated by adenosine, K•

, hypoxia, and

stimulants and the N

O pathway.

107

CHAPTER 2 Principles of surgery

Respiratory complications

These are common after surgery as a result of the effect of general anaes-

thetic, post-operative pain, and immobility.

Respiratory failure

Basic assessment and management

Sit the patient up and give high ﬂ ow O•

through a tight ﬁ tting mask.

Assess the airway. Is chest expansion asymmetrical?•

Auscultate the chest. Listen for bilateral breath sounds, poor air entry, •

wheeze, bronchial breathing, crepitations.

Assess circulation and treat shock which causes hypoxaemia (see • b

p. 100).

Treat bronchospasm with nebulized salbutamol 5mg.•

Get a CXR. Look for consolidation, oedema, effusions, and •

pneumothoraces.

Chest infection

Diagnosis

Cough with purulent sputum.•

Pyrexia.•

Bronchial breath sounds and reduced air entry on auscultation.•

Leucocyte neutrophilia, raised CRP.•

Consolidation on CXR.•

Culture of sputum may yield sensitivities of causative organisms.•

In the dyspnoeic, hypoxic patient perform ABGs to guide immediate •

management.

Prevention

There is no good evidence that prophylactic physiotherapy helps to pre-

vent chest infection after surgery. The single most important intervention

is to prevent patients with active chest infections undergoing surgery. Any

elective patient with a current cough (dry or productive), temperature,

clinical signs of chest infection, neutrophilia, or suspicious CXR should be

deferred for a fortnight and then reassessed. Other risk factors include

active smokers or those who have stopped smoking within the last 6

weeks; patients with COPD, obesity; patients requiring prolonged ventila-

tion post-operatively; and patients who aspirate.

Management

Physiotherapy helps the patient with a cough to expectorate sputum •

and prevent mucus plugging.

Effective analgesia is important to allow patients to cough.•

Deﬁ nitions of respiratory failure

Hypoxia. • PaO

<10.5kPa.

Hypercapnia.• PaCO

>6.5kPa. Hypocapnia. PaCO

<3.5kPa.

Type I respiratory failure. • PaO

<8.0kPa on air.

Type II respiratory failure.• PaO

<8kPa and PaCO

>6.0kPa.

108

RESPIRATORY COMPLICATIONS

Deﬁ nitive treatment is antibiotics: ciproﬂ oxacin 500mg bd • PO provides

good Gram –ve and +ve cover until organism sensitivities are known.

Suspected aspiration pneumonia should be treated (e.g. • IV cefuroxime

1g tds and IV metronidazole 500mg tds).

If the patient requires oxygen (PaO•

<8.0kPa on room air), humidifying

it reduces the risk of mucus plugs and makes secretions easier to shift.

Continuous positive airway pressure (CPAP) can be used to improve •

basal collapse.

The hypoxic, tachypnoeic, tiring patient on respiratory support should •

be reviewed urgently by the critical care team.

Exacerbation of COPD

The incidence of moderate to severe COPD in surgical patients is 5%.

Most studies show that moderate COPD is not associated with an •

increase in post-operative complications, mortality, or length of stay.

Severe COPD and preoperative steroid use are associated with •

increased morbidity and mortality after surgery.

Ensure that all patients on preoperative • β-agonist inhalers are

routinely prescribed regular post-operative nebulizers (saline 5mL prn,

salbutamol 2.5–5mg qds prn, and becotide 500 micrograms qds prn).

In hypoxic patients with COPD, give maximal O•

by CPAP and titrate

against PaCO

and PO

: do not restrict O

empirically.

Key revision points—monitoring/measuring lung function

Pulse oximetry estimates the percentage of saturated Hb present in •

capillary blood by the change in wavelength ratios of absorbed red

light. It is inaccurate in carbon monoxide poisoning, cold peripheries,

low ﬂ ow states, and tachydysrhythmias.

PaO•

can be approximately estimated from the SaO

95%, >12kPa.•

85%, • 710kPa.

75%, <6kPa.•

Capnography works on similar principles; different gases (e.g. CO•

)

absorb different amounts of infrared light.

109

CHAPTER 2 Principles of surgery

110

Renal complications

Aetiology of renal failure

Preoperative risk factors.• Age >75y; creatinine >150μmol/L; LV

dysfunction; hypertension; diabetes; peripheral vascular disease;

hypoperfusion as a result of diuretic therapy and vasodilators;

sepsis; CCF; intrinsic renal damage caused by NSAIDs, contrast,

aminoglycosides, diuretics; endocarditis; obstructive uropathy.

Intraoperative risk factors.• Cardiac surgery, aortic surgery.

Post-operative risk factors.•

Pre-renal• . Shock, e.g. hypovolaemic, septic, cardiogenic (see b

p. 106).

Renal• . Sepsis, hypoxia, drugs (NSAIDs, gentamicin, vancomycin,

teicoplanin), haemoglobinuria, myoglobinuria.

Post-renal• . Obstructive uropathy, obstructed Foley catheter,

prostatic hypertrophy.

Preventing renal failure

There are a number of measures that reduce the risk of renal

dysfunction.

Preoperatively, • ensure adequate hydration, particularly before

undergoing procedures involving contrast.

Identify and • eliminate nephrotoxic medications where possible,

particularly NSAIDs and ACE-inhibitors.

Consider whether the patient would beneﬁ t from HDU •

preoperatively.

Avoid intraoperative hypotension.•

Post-operatively maintaining satisfactory cardiac output and optimizing •

intravascular volume are the most important factors in avoiding renal

dysfunction.

Management of renal failure

The management of oliguria is described on b pp. 112–3. This section

deals with the management of established oliguric renal failure. The aim is

ﬁ rstly to avoid the potentially lethal complications of renal failure (hyper-

kalaemia, acidosis, pulmonary and cerebral oedema, severe uraemia,

and drug toxicity) and secondly to avoid exacerbating the renal insult.

Investigation of the underlying causes of renal failure is also important.

Aim for higher BP (stop antihypertensives; optimize ﬂ uid balance), •

except in established anuria.

Treat hypoxia aggressively.

•

Aim for daily ﬂ uid balance of even to negative 500mL to avoid •

pulmonary oedema in anuric patients.

Renal dysfunction

Creatinine: >126μmol/L in males; >102μmol/L in females.•

Urea: >7.0mmol/L.•

Creatinine clearance: <90mL/min.•

RENAL COMPLICATIONS

111

Monitor electrolytes daily, and potassium and acid–base balance •

every few hours. Avoid potassium supplements and medication that

increases potassium levels (ACE-inhibitors).

Avoid nephrotoxic drugs (aminoglycosides, NSAIDs, ACE-inhibitors) •

and monitor serum levels of drugs dependent on renal excretion

(digoxin, antibiotics such as vancomycin and gentamicin).

Essential amino acid diets are recommended for patients who are able

•

to eat. Patients on dialysis require high protein content (1.5g/kg/day) as

dialysis results in negative nitrogen balance.

Enteral and parenteral feeds can be similarly adjusted.•

Renal ultrasound, renal angiography may be indicated.•

Hyperkalaemia

Hyperkalaemia (K

>5.0) is seen in the setting of renal failure, tissue necro-

sis, and potassium-sparing diuretics and supplements. Acute hyperkalemia

>6.0) can cause life-threatening ventricular arrhythmias. ECG changes

that herald myocardial dysfunction are ﬂ attened P waves, wide QRS com-

plexes, tenting of T waves, and, in peri-arrest, a sine wave.

2• Treat the patient with ECG changes as an emergency.

Treat the underlying cause.•

Give • 50mL of 50% dextrose containing 15U of Actrapid

as an IV

infusion over 10–20min, repeating as necessary, monitoring BS after

each infusion. If inadequate response:

Give 10mL calcium gluconate 10% IV over 2min• ; repeat as necessary.

Calcium resonium enema binds K•

and removes it from the body.

Dialysis • should be urgently considered in patients with refractory

hyperkalemia despite these measures, irrespective of renal function.

Hypokalaemia

Hypokalaemia (K

<3.0) is common. It predisposes patients to dysrhythmias.

It is normally related to diuretic therapy, insulin sliding scales, diarrhoea

and vomiting, steroids, and poor nutrition. Acute severe hypokalaemia (K

<2.5) may result in life-threatening arrhythmias. It can be recognized by

small or inverted T waves, depressed ST segments, prolonged PR interval,

and U waves on the ECG.

Educate the patient about which foods are rich in potassium (bananas, •

prunes, apricots, tomatoes, orange juice) and ensure availability.

Change furosemide to co-amilofruse 5/40 or 2.5/20 which contains •

furosemide (either 40mg or 20mg) and amiloride (5mg or 2.5mg).

Add oral potassium supplements up to 160mmol daily (1 tablet of •

Sando K

contains 20mmol of K

, 1 tablet of Slow K

, which is better

tolerated by most patients, contains 12.5mmol KCl).

If a central line is in place, give 20mmol KCl in 50–100mL of 5% •

dextrose over 20min to 1h.

If it is necessary to use a peripheral line, place a maximum of 40mmol •

of potassium in 1L 5% dextrose running at a maximum of 125mL/h.

Monitor K•

daily and avoid discharging the patient home on a

combination of potassium supplements and potassium-sparing

diuretics.

CHAPTER 2 Principles of surgery

112

Urinary complications

Oliguria

Urine ouput is an indicator of glomerular ﬁ ltration rate which is an indica-

tor of renal plasma ﬂ ow and renal perfusion. Hence, urine output is an

indirect measure of renal (and hence systemic) blood ﬂ ow as well as renal

function. Patients with normal renal function usually maintain a urine out-

put of at least 0.5mL/kg/h.

Management of oliguria

Check that the Foley catheter is not the problem.•

The urine catheter may be obstructed, bypassing, or malpositioned. Is •

the bed wet? Flush with 60mL saline—can you draw this amount back

without difﬁ culty? If not, or if the urine is bypassing the catheter, or if

the bladder is palpable, change the catheter.

Optimize cardiac function

Patients who were markedly hypertensive (see

• b pp. 92, 132)

preoperatively may require high BPs to maintain a satisfactory urine

output.

Is the patient overﬁ lled or underﬁ lled• ?

Make sure the patient is adequately ﬁ lled • by giving careful ﬂ uid

challenges to achieve CVP of 14–16mmHg or raise the JVP moderately.

But not too ﬁ lled. • If the CVP rises to >16mmHg and stays up with a

ﬂ uid challenge or if the BP falls, the patient may be overﬁ lled and need

diuretics (see below).

Invasive monitoring.

• If the patient does not rapidly respond to basic

measures, need CVP line insertion and monitoring (see b p. 198).

Loop diuretics

Furosemide will not prevent acute tubular necrosis, but it does have a use-

ful role in ofﬂ oading ﬂ uid from the overﬁ lled patient. It converts oliguric

renal failure to polyuric renal failure.

If the patient is adequately ﬁ lled and mean arterial pressures are •

satisfactory, give a loop diuretic: 20mg of furosemide IV. If there is no

response, give a further 40mg furosemide IV.

If the urine produced in response to diuretic challenges is •

concentrated, the patient is probably inadequately ﬁ lled.

Important problems associated with oliguria of any cause

Pulmonary and cerebral oedema.•

CCF (see • b p. 106).

Hyperkalaemia (see • b p. 110).

Acidosis.•

Drug toxicity.•

Terminology

Oliguria—urine output <0.5mL/kg/h.•

Anuria—no measurable urine output.•

URINARY COMPLICATIONS

113

Further assessment and management

Haemodialysis is indicated in the oliguric patient to avoid pulmonary

oedema indicated by deteriorating blood gases despite increasing respira-

tory support, hyperkalaemia, and acidosis. It is not indicated purely for

rising serum creatinine and urea in the ﬁ rst instance (b p. 134).

Acute urinary retention

Common post-operatively, especially in elderly males, after abdomino-

pelvic or groin surgery and after anticholinergics.

Clinical features

Suprapubic discomfort, inability to initiate micturition, or dribbling.

•

History of prostatic disease or symptoms preoperatively (see • b p.

362).

Percussable bladder on examination.•

Management

Conservative. Improve analgesia, treat constipation, mobilize, warm

•

bath to encourage micturition, restart preoperative tamsulosin.

Insert urethral catheter if conservative measures fail and patient in •

great discomfort or renal dysfunction is suspected.

Urinary tract infection

Common in females and patients catheterized for prolonged periods.

Clinical features

Dysuria, frequency, dribbling, offensive smell, pyrexia, • i WCC.

Dipstick urine to conﬁ rm (dipstick should test nitrites and leucocytes).•

Send specimen for microbiology to identify organism and sensitivities.•

Management

Remove catheters as soon as possible.

•

Encourage drinking or increase ﬂ uid infusion if safe to increase urine •

ﬂ ow.

Treat empirically with trimethoprim 400mg bd until sensitivities •

known.

Key revision points—physiology of diuretics

Osmotic diuretics• , e.g. mannitol, are not well reabsorbed in

the distal tubules. Increased osmotic pressure reduces H

reabsorption.

Loop diuretics• inhibit Na

–

exchange in the ascending loop of

Henle, decreasing osmolality in the medulla and water reabsorption.

Aldosterone antagonists• , e.g. spironalactone, and sodium channel

blockers, e.g. amiloride, reduce Na

reabsorption and K

and H

secretion in the distal tubule.

Alcohol• inhibits antidiuretic hormone (ADH) release.

CHAPTER 2 Principles of surgery

114

Gastrointestinal complications

Paralytic ileus

This is the cessation of GI tract motility.

Causes

Prolonged surgery, exposure and handling of the bowel.

•

Peritonitis and abdominal trauma.•

Electrolyte disturbances (most can affect GI function!!).•

Anticholinergics or opiates.•

Prolonged hypotension or hypoxia.•

Immobilization.•

Clinical features

Nausea, vomiting and hiccoughs.•

Abdominal distension, tympanic or dull on percussion.•

Air-/ﬂ uid-ﬁ lled loops of small and/or large bowel on abdominal X-ray •

(AXR).

Prognosis

Intestinal ileus usually settles with appropriate treatment.

Treatment

Pass an NGT to empty the stomach of ﬂ uid and gas if the patient is •

nauseated or vomiting. Small volumes of tolerated oral intake may help

mild ileus to resolve.

Ensure adequate hydration by • IV infusion (‘drip and suck’).

Maintain the electrolyte balance.•

Reduce opiate analgesia and encourage the patient to mobilize.•

Consider other causes (e.g. occult intra-abdominal sepsis) and consider •

nutritional status.

Post-operative mechanical small bowel obstruction

It is important to distinguish between mechanical obstruction and ileus

since management may be different.

Causes

Early adhesions (usually self-limiting).•

Internal, external, parastomal, or wound herniation.•

Intra-abdominal sepsis (usually slightly later presentation).•

Clinical features

Nausea and vomiting.

•

Colicky abdominal pain.•

Abdominal distension, tympanic on percussion.•

Examine hernial oriﬁ ces and stoma, if any, for incarcerated hernias.•

High-pitched ‘tinkling’ bowel sounds MAY be present.•

Dilated loops of small bowel (relative paucity of gas in colon).•

Treatment

As for paralytic ileus with strict bowel rest.

•

Consider CT scan to deﬁ ne diagnosis and level of the obstruction.•

GASTROINTESTINAL COMPLICATIONS

115

Prognosis

Surgery is rarely indicated (for suspected herniation or complications or,

very occasionally, adhesional obstruction that fails to resolve).

Nausea and vomiting

This affects up to 75% of patients. It predisposes to increased bleeding,

incisional hernias, aspiration pneumonia, d absorption of oral medication,

poor nutrition, and d K

. Causes include:

Prolonged surgery; anaesthetic agents, e.g. etomidate, ketamine, N•

opioids; spinal anaesthesia; gastric dilatation from CPAP;

Post-operative ileus; bowel obstruction; constipation; gastric reﬂ ux; •

peptic ulceration or bleeding; medications, including many antibiotics,

NSAIDs, opiates, statins; pancreatitis; sepsis; and hyponatraemia.

Constipation

Failure to pass stool is common. Caused by lack of privacy, immobility,

pain from wounds or anal ﬁ ssures, dehydration, poor nutrition, d dietary

ﬁ bre, opiates, iron supplements, and spinal anaesthesia. Treat with:

Bulking agents• , e.g. Fybogel one sachet PO bd.

Stool softeners• , e.g. sodium docusate 30–60mg od PO.

Osmotic agents• , e.g. lactulose 5–10mL bd.

Stimulants• , e.g. senna one tablet bd PO, bisacodyl 5–20mg nocte PO.

Diarrhoea

Common causes in post-operative patients:

Resolving ileus or obstruction.•

Related to underlying disease or surgery (e.g. ileal pouch or Crohn’s).•

Antibiotic-related diarrhoea (send for M,C,&S).•

Clostridium (C.) difﬁ cile• diarrhoea (send stool for C. difﬁ cile toxin) and

pseudomembranous colitis (see b p. 396).

Anastomotic leakage (see b p. 420).

Classiﬁ cation of antiemetics

Combining two different types of antiemetic increases efﬁ ciency.

Antidopaminergic agents

Good against opioid nausea and vomiting, sedative, extrapyramidal •

side effects.

For example, prochlorperazine 12.5mg IM, metoclopramide 10mg • IV/

IM/PO tds.

Antihistamines

Sedation, tachycardias, hypotension with • IV injection.

For example, cyclizine 50mg • IM/IV/PO tds.

Anticholinergics

Active against emetic effect of opioids, sedation, confusion, dry mouth.

•

For example, hyoscine (scopolamine) 0.3–0.6mg • IM.

Antiserotonergics

Lowest side effect proﬁ le of all antiemetics.•

Ondansetron 1–8mg • PO/IV/IM tds, granisetron 1mg PO/IV tds.

CHAPTER 2 Principles of surgery

116

Neurological complications

Confusion

Confusion is common post-operatively. It is often obvious with a disori-

ented, uncooperative, or hallucinating patient. Frequently, it is more sub-

tle, consisting of inactivity, quietness, slowed thinking, and labile mood,

and it is only spotted by relatives or nursing staff. Actively assess whether

the patient is oriented in time, person, and place. Perform a quick mini-

mental state examination if you are still unsure.

Management

If the patient’s behaviour poses a physical danger to themselves •

or others, it may be necessary to sedate as ﬁ rst-line management.

Haloperidol 2.5mg may be given up to a total of 10mg in 24h PO,

IM, or IV, but if the patient remains disturbed, 2.5–5mg of midazolam

should be given IV and the patient placed under close observation.

2 Beware of sedating the hypoxic or hypotensive patient as this may

trigger a cardiorespiratory arrest: confusion is a common symptom of

shock and profound hypoxia.

Assess and treat hypoxia (see • b p. 130) and hypotension (see b p. 132).

Reassess the drug chart: stop opiates and benzodiazepines.•

Correct abnormalities, e.g. • d glucose, d Na.

Alcohol withdrawal is diagnosed from a history of chronically •

high alcohol consumption often with raised GGT, combined with

psychomotor agitation post-operatively. It can be treated with either

diazepam 5–10mg tds PO/PR, haloperidol 2.5–5mg tds PO/IM/IV, or

allowing the patient alcohol 1U orally.

Perform a neurological examination to look for focal neurological •

deﬁ cit and consider head CT to exclude stroke.

Reassure patient and relatives: confusion is common, almost always •

reversible, and it is not a sign that the patient is ‘going mad’.

Stroke

Stroke is most common in vascular and cardiac surgical patients (2%), but

elderly patients undergoing other major surgery are at risk.

Risk factors for stroke

Increasing age (>80y risk of cerebrovascular accident (CVA) 5–10%).•

Diabetes.•

Common causes of confusion

Medication (particularly benzodiazepines, opiates, anticonvulsants).•

Stroke.•

Hypoxia, hypercapnia.•

Shock.•

Sepsis.•

Alcohol withdrawal.•

Metabolic disturbances (• d glucose, Na

, pH; i Ca

, creatinine, urea,

bilirubin).

Post-ictal.•

Preoperative dementia.•

NEUROLOGICAL COMPLICATIONS

117

Previous history of stroke or transient ischaemic attack (TIA) •

(increases risk three-fold).

Carotid artery atherosclerosis.•

Perioperative hypotension.•

Left-sided mural thrombus.•

Mechanical heart valve.•

Post-operative AF.•

Aetiology

Embolic.• Carotid stenosis/atheroma, thrombus from AF.

Haemorrhagic.• Post-operative warfarinization.

Cerebral hypoperfusion.• Profound hypotension, raised intracranial

pressure (ICP).

Hypoxia.•

Clinical features

Any deﬁ cit resolving within 24h is called a TIA. Clinical features of periop-

erative stroke include:

Failure to regain consciousness once sedation has been weaned.•

Hemiplegia (middle cerebral artery or total carotid artery occlusion).•

Initial areﬂ exia becoming hyperreﬂ exia and rigidity after a few days.•

Aphasia, dysarthria, ataxia (gait or truncal), inadequate gag reﬂ ex.•

Visual deﬁ cits, unilateral neglect, confusion, seizures.•

Persistent, marked hypertension.•

Hypercapnia.•

Diagnosis

The aim is to establish a deﬁ nitive diagnosis, establish a cause to guide

appropriate secondary prevention, and establish a baseline of function to

help plan long-term rehabilitation or withdrawal of therapy.

Carry out a full neurological examination (cognitive function, cranial

•

nerves, and tone, power, reﬂ exes, and sensation in all four limbs).

Modern contrast head CT will show infarcts within 2h (older scanners

•

may not pick up lesions until they are 2–3 days old. You must

distinguish between haemorrhagic and ischaemic CVAs (1 in 10 are

haemorrhagic). MRI is necessary to image brainstem lesions.

Initial management

Assess the airway, breathing, and circulation.

•

If the patient is unable to maintain their airway, insert a Guedel airway, •

bag and mask, ventilate with high ﬂ ow O

, and call an anaesthetist.

Monitor BP, but do not attempt to correct high pressures as these are •

critical for adequate cerebral perfusion.

Monitor oxygen saturations.•

Secure • IV access and give colloid if indicated.

If the patient is able to maintain their own airway and is not •

haemodynamically compromised, explain what has happened and

reassure them.

Perform a full neurological examination.•

Put the patient NBM if there is no gag reﬂ ex.•

Send FBC, U&E, glucose, and clotting.•

Send blood cultures if there is any history of endocarditis, pyrexia.•

Request a CT head and consider a transthoracic echo.•

CHAPTER 2 Principles of surgery

118

Haematological complications

Heparin-induced thrombocytopenia (HIT)

HIT occurs in about 5% of patients receiving heparin (5.5% of patients

on bovine heparin, 1.0% with porcine heparin). It is characterized by the

formation of complement-mediated heparin-dependent IgG platelet anti-

body. It occurs 5–10 days after initiation of heparin therapy or after the

ﬁ rst dose of heparin in patients with previous exposure to heparin within

the last 3 months.

Diagnosis

Fall in platelet count by over 30% to <150

• x 10

/L or by over 50%.

And• positive serology for HIT antibodies.

Heparin-induced thrombocytopenia and thrombosis (HITT) occurs •

in about 20% of patients with HIT and is characterized by major

thrombotic episodes. It has a mortality of about 30%.

Patients may show tachyphylaxis to heparin as well as bleeding •

complications.

Treatment

Discontinue all heparin therapy, including heparinized saline ﬂ ushes.•

If it is at all possible, delay any surgery requiring bypass until HIT •

antibodies are undetectable and then follow standard heparinization,

but do not use heparin in the post-operative period.

If it is impossible to delay bypass surgery, then danaparoid and iloprost •

are alternatives to heparin with the major disadvantages that they

cannot be reversed after bypass and require specialized assays.

Hirudin, iloprost, danaparoid, and warfarin are alternative •

anticoagulants to heparin in the post-operative period.

Discuss with haematologist.•

Disseminated intravascular coagulation (DIC)

DIC may occur as a complication of sepsis, transfusion reaction, drug

reaction, transplant rejection, and aortic aneurysm surgery. It is character-

ized by widespread activation of coagulation, resulting in the formation

of intravascular ﬁ brin, ﬁ brin degradation products, consumption plate-

lets, and clotting factors, and ultimately, thrombotic occlusion of vessels.

Patients may present with bleeding from indwelling venous lines, wounds,

and minor abrasions.

Diagnosis

There is no single diagnostic test. The following ﬁ ndings suggest DIC:

Sudden fall in platelet count to <100

• x 10

/L.

Bleeding and/or thrombotic complications.•

i• APTT, PT, INR.

i• ﬁ brin degradation products.

d• ﬁ brinogen in severe DIC.

HAEMATOLOGICAL COMPLICATIONS

119

Management

The key is to treat the underlying disorder. Bleeding patients should

receive FFP, platelets, blood, and cryoprecipitate as indicated by coagula-

tion screens. Patients with thrombosis should be heparinized.

Excessive warfarinization

Warfarin inhibits carboxylation of vitamin K, inhibiting the synthesis of

vitamin K dependent factors (V, VII, XI). Management depends on whether

the patient is bleeding, why they are warfarinized and if urgent/emergency

surgery is indicated.

If the INR is <5.0 and the patient is not bleeding, simply omit warfarin •

and recheck INR daily, restarting warfarin once the INR is within range.

If the INR is >5.0, give 10mg vitamin K • PO.

If INR is elevated and emergency reversal to normal clotting is •

required (e.g. for high risk surgery), IV Beriplex (mixed FII/VII/IX/X

protein C/S) may be used.

If the patient is bleeding, give FFP and up to 5mg vitamin K • PO.

If the patient has a mechanical valve, the risk of thromboembolic •

events when anticoagulation is reversed is <0.1% per day.

Anticoagulation with heparin or warfarin should be recommenced

within 1–2 weeks once any bleeding complications have resolved.

Key revision points—physiology of haemostasis

Vascular phase• . Vasospasm, local oedema, and haematoma.

Platelet phase• . Adherence of platelets activated by ADP, collagen,

von Willebrand factor and mediated by IIb/IIIa, ﬁ brinogen, 5-HT,

thromboxane A2.

Clotting phase• :

Intrinsic• (kallikrein, XII, XI, and IX).

Extrinsic• (thromboplastin, VII) pathways converge on common

pathway (X, thrombin, ﬁ brinogen).

Fibrinolysis depends on plasmin, antithrombin III, proteins C and S, tissue

factor pathway inhibitor.

CHAPTER 2 Principles of surgery

Deep venous thrombosis and

pulmonary embolism

Deep venous thrombosis (DVT) is most common in patients over 40

years of age who undergo major surgery. A post-operative increase in

platelets coupled with venous endothelial trauma and stasis all contribute

(Virchow’s triad). If no prophylaxis is given, 30% of these patients will

develop DVT and 0.1–0.2% will die from pulmonary thromboembolism

(PTE).

High-risk groups (see Prophylaxis b p. 72)

Patients undergoing pelvic or hip surgery.•

Patients with malignant disease.•

Patients on the contraceptive pill (pregnancy).•

Previous history of • DVT or PTE.

Older patients. The increase in • DVT is almost linear with advancing

age.

Other factors: obesity, diabetes mellitus, polycythaemia, varicose veins, •

cardiac and respiratory disease, thrombophilia (e.g. factor V Leiden

protein C or S deﬁ ciency).

Diagnosis

Clinical

Systemic pyrexia at 7–8 days post-operatively.•

May present with embolism (pulmonary).•

Pain, swelling of the leg, and a rise in local skin temperature.•

Investigations

DVT may be diagnosed using:

•

Duplex Doppler: less sensitive for calf DVT than thigh DVT.•

Ascending venography: invasive, but more sensitive than duplex.•

PE may be diagnosed using:•

CTPA (almost universally favoured now over VQ lung scans).•

VQ lung scanning with radioactive technetium-labelled •

microaggregates of albumin (

Tcm MAA).

Treatment

Conﬁ rm the site and the extent of the DVT by Doppler and lung scan.

Calf vein thrombosis may be treated by compression alone.•

All other thrombi should be treated with heparin for 4–7 days (40 •

000U/24h), checked by bleeding times (5000–10 000U by bolus, then

1000–1500U/h IV alone), or followed by oral anticoagulation for 6–12

weeks (warfarin, checked by PT/INR).

Lytic therapy—urokinase, streptokinase—is most effective within •

24–36h of onset of DVT. This may be effective in life-threatening PE.

Surgical thromboectomy or embolectomy is used when there is •

massive PTE. In bilateral ileofemoral DVT, embolism may be prevented

by inserting an ‘umbrella’ ﬁ lter into the vena cava at a level below the

renal vessels.

Prevention (see b p. 72).

120

DEEP VENOUS THROMBOSIS AND PULMONARY EMBOLISM

Pulmonary embolism

Diagnosis of pulmonary embolism

PE is incorrectly diagnosed in almost 75% of patients. The differential diag-

nosis includes acute MI, aortic dissection, septic shock, chest infection,

haemothorax, and pneumothorax. Massive PE is PE resulting in haemo-

dynamic compromise or where >30% of the pulmonary vasculature is

compromised.

Outcome

The 30-day mortality of acute massive PE is about 50%.•

About 10% of mortality occurs within the ﬁ rst hour.•

Up to 80% of mortality occurs within the ﬁ rst 2h.•

The mortality of surgical intervention is up to 70% for patients •

requiring CPR or mechanical circulatory support preoperatively.

The operative mortality of stable patients is about 30%.•

Management

If the patient is haemodynamically unstable, emergency pulmonary

embolectomy should be considered. In patients with large PE and no con-

traindications (i.e. surgery within previous 30 days), thrombolysis is the

deﬁ nitive management. Otherwise do the following:

Sit the patient up and give 100% O

•

Patient may require intubation.•

Get • IV access and give heparin 5000U bolus IV.

Start a heparin infusion (50 000U heparin in 50mL of normal saline) at •

1000–2000U/h.

Check APTT after 6h (target APTT 70–90), adjust infusion rate •

accordingly, and recheck APTT after 6h.

Once APTT is stabilized, APTT should be checked every 12–24h.•

Low molecular weight tinzaparin is licensed for use in acute PE. It has •

the same efﬁ cacy as unfractionated heparin without the requirement

for repeated APTT checks.

Begin warfarinization.•

Look for causes of PE.•

Clinical features of PE

Symptoms• . Dyspnoea, pleuritic or dull chest pain.

Signs• . Tachypnoea, tachycardia, hypotension, elevated JVP.

Risk factors for or clinical evidence of DVT.•

ECG shows RV strain pattern (S1, Q3, T3), but this is neither a •

speciﬁ c nor a sensitive test.

d• PaO

; PaCO

may be low.

CXR may show consolidation and effusion early on.•

Echo may show right ventricular (RV) dilatation, tricuspid •

regurgitation, and right atrial or RV thrombus.

Pulmonary angiography, CT-angio, and VQ scanning are diagnostic.•

121

CHAPTER 2 Principles of surgery

122

Risk scoring

Scoring systems attempt to quantify the severity of illness so that:

Different interventions, clinicians, or centres can be compared, •

adjusting for differences in case mix.

Clinicians can predict prognosis more accurately.•

APACHE III scoring system (Acute Physiology and Chronic

Health Evaluation)

This predicts an individual’s risk of dying in hospital. Twenty-seven patient

variables (physiological variables such as core temperature, heart rate, BP,

creatinine, age, and chronic illness variables) are entered into a programme

that gives a score which can be compared against previous performance

to give a risk of dying in the hospital. There are approximately another 60

hospitals worldwide where the APACHE III methodology is used to gener-

ate reports that compare their actual average ICU outcomes with those

predicted by the APACHE III methodology.

EuroSCORE (European System for Cardiac Risk Evaluation)

This is a weighted additive score, based on a European sample of cardiac

surgical patients. Variables such as age, renal function, and comorbidity

are given points that add up to an approximate percentage of predicted

perioperative mortality. Scoring systems like this are useful when consent-

ing patients for surgery and in risk-stratifying operative outcomes so that

surgeons and hospitals can be compared with each other.

POSSUM (Physiologic and Operative Severity Score for the

enUmeration of Mortality and morbidity)

This is a weighted additive score. Eighteen variables are combined to pro-

duce a physiological score and an operative score, which in turn are com-

bined to produce an estimate of the percentage risk of deﬁ ned morbidity

and mortality. (Variants exist for vascular, orthopaedic, and colorectal

surgery.)

Examples of risk scoring systems

Predicting risk of dying in hospital (APACHE III).•

Quantifying morbidity (ASA score, Apgar score).•

Quantifying symptoms (NYHA angina classiﬁ cation).•

Predicting operative mortality (EUROscore, Parsonnet score in •

cardiac surgery, POSSUM).

Predicting risk of dying on waiting list (New Zealand score in cardiac •

surgery).

Predicting risk of dying for speciﬁ c illnesses (Glasgow and Ranson •

criteria in pancreatitis).

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CHAPTER 2 Principles of surgery

124

Critical care

Recognizing the critically ill surgical patient (see Box 2.8)

It may be obvious that a patient needs a critical care bed, e.g. the patient

needing ventilation, inotropes, or dialysis. But anticipating, and maybe

avoiding, this is more difﬁ cult. The ﬁ rst step is recognizing compensated

critical illness (e.g. shock compensated by tachycardia and peripheral shut-

down or respiratory failure compensated by unsustainable respiratory

effort).

Immediate management

First identify and treat potentially life-threatening conditions. Then quantify

the problem (important for referring patients to other clinicians and for

establishing a baseline by which to guide treatment and monitor progress).

Finally start looking for the underlying problem. Some of these tasks over-

lap. Keep reassessing the patient and adjust your management.

Quickly assess airway, breathing, and circulation: ALS algorithms are •

printed on the inside back cover; management of shock is described on

b p. 100; management of haemorrhage is described on b p. 102.

Sit patient up and give high ﬂ ow O•

Secure • IV access and take blood for FBC, U&E, amylase, glucose, LFTs,

cardiac enzymes, clotting, group and save, and blood cultures.

Take ABG: good O•

saturations do not rule out respiratory failure and

ABGs will also show acidosis and electrolyte abnormalities.

Give 500mL gelofusine if patient not obviously ﬂ uid overloaded.•

Request a 12-lead ECG.•

Review drug, diabetic, and ﬂ uid balance charts.•

Perform a focused history and examination: ask about symptoms that •

have changed recently and focus your examination on that.

Review recent bloods and X-rays and request appropriate radiology.•

If the patient needs HDU or ITU, talk to your registrar or consultant.•

A patient may need to be discharged from HDU or surgery need to be •

postponed: think ahead.

Box 2.8 Signs that should ring alarm bells

History• . ‘I feel like I’m going to die.’ Timor mortis (fear of dying) may

accompany MI, hypovolaemic shock, respiratory failure. Never ignore

the patient who thinks they are dying; they are often right.

Nurses• . ‘Mr Smith just doesn’t look right.’ Experienced nurses

quickly recognize the patterns of critical illness; listen to them.

General• . Hypothermia or hyperpyrexia, sweating.

Cardiovascular• . d BP, id pulse, arrhythmias, peripheral shutdown.

Respiratory• . Tachypnoea, difﬁ culty getting full sentences out.

Renal• . Oliguria <0.5mL/kg/h.

Gastrointestinal• . New anorexia, nausea, and vomiting.

Neurological• . Confusion, agitation or drowsiness, ﬁ ts.

CRITICAL CARE

125

High dependency unit

The HDU allows a level of care between ICU and the general ward.

Invasive monitoring and inotropic support are routine, but ventilation and

renal support are not. Nurse:patient ratio is 1:2. Patients with single organ

failure requiring basic respiratory support, including non-invasive mask

ventilation with CPAP, should be admitted to HDU.

Guidelines for admission to HDU

Need for monitored bed.•

Need for invasive monitoring.•

Need for inotropes.•

Need for CPAP or other respiratory support.•

Need for 1:2 nursing.•

Intensive care unit

The ICU offers advanced ventilatory and inotropic support, renal replace-

ment therapy, full invasive monitoring, and 1:1 nursing care.

How to use critical care

The surgical team should consider using critical care services for both

elective and emergency surgical patients. Some guides follow:

Is the elective patient in need of intensive infusional treatment prior to

•

surgery (e.g. IV anticoagulation, IV clotting factors)? l HDU.

Has the patient undergone major surgery with signiﬁ cant transfusion •

requirements that might lead to haemodynamic and clotting

abnormalities (e.g. elective extensive pelvic surgery, aortic surgery,

extensive burns surgery)? l HDU.

Is the patient over 80, having had major abdominal, thoracic, or limb •

surgery? l HDU.

Does the patient have known signiﬁ cant respiratory disease making •

intensive respiratory therapy likely? l ITU.

Would a patient due for emergency surgery beneﬁ t from aggressive, •

closely monitored ﬂ uid resuscitation prior to anaesthesia? l HDU.

Does the post-op patient need infusional inotropic support, renal •

replacement therapy, or invasive monitoring? l ITU/HDU.

2 The golden rule is, ‘If in doubt, ask for the advice of the critical care

team—more patients can beneﬁ t than do.’

Guidelines for admission to ITU

Need for mechanical ventilation.•

Failure of two or more organ systems.•

Need for advanced monitoring, e.g. pulmonary artery catheter.•

Need for escalating or additional inotropes.•

Primary pathology should be reversible.•

Consultant involvement from both surgery and ITU is essential.•

Patient’s stated or written preference against intensive care should •

be taken into account and documented.

CHAPTER 2 Principles of surgery

126

Commonly used terms in ITU

Cardiac function (see b p. 620—cardiothoracic surgery).

Oxygenation and ventilation

Oxygenation• , the amount of oxygen in arterial blood, is described in

terms of the partial pressure of oxygen in arterial blood (PaO

) and the

percentage saturation of arterial haemoglobin with oxygen (SaO

Ventilation• , the movement of air in and out of the lungs, is described

in terms of minute volume, and assessed by measuring the partial

pressure of carbon dioxide in arterial blood (PaCO

Oxygenation is independent of minute volumes until they are very low.•

In post-operative patients, the primary cause of hypoxia is atelectasis •

and this must be reversed before the patient can beneﬁ t from

increasing the fraction of oxygen in inspired air (FiO

Positive end expiratory pressure• (PEEP) and CPAP treat and prevent

atelectasis.

Oxygen consumption is assessed indirectly by measuring the •

percentage saturation of mixed venous haemoglobin with oxygen (SvO

;

indirect measurement of oxygen uptake by peripheral tissues).

Pulmonary ventilation is described in terms of four ‘volumes’ (• tidal

volume, inspiratory reserve volume, expiratory reserve volume, and

residual volume) that may be combined to give four ‘capacities’

(inspiratory capacity, functional residual capacity, vital capacity, and

total lung capacity). Tidal volume is the only measurement used on

ITU.

Loss of functional residual capacity through atelectasis, supine position, •

lobar consolidation and collapse, effusions, and obesity results in

hypoxia. CPAP, PEEP, and physiotherapy are aimed at limiting this loss.

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CHAPTER 2 Principles of surgery

128

Invasive monitoring

Invasive monitoring is used on ITU and HDU because it provides accurate

and sensitive real-time measurements, routes for sampling blood, routes for

administration of drugs.

Arterial monitoring

Insertion technique and complications are described on b p. 196.

Indications

Precise measurement where inotropic or mechanical support used.•

Frequent sampling of ABGs.•

Contraindications

Absolute.

• Infection at the site of insertion, distal limb ischaemia.

Relative.• Coagulopathy, proximal obstruction, surgical considerations.

Central venous pressure lines

Insertion technique and complications are described on b p. 198.

Indications

Continual RA pressure (RAP) measurements in patients requiring •

circulatory support.

Infusion port for some drugs that cannot be given peripherally.•

Insertion pulmonary artery catheter or transvenous pacing wires.•

Infusion port for TPN.•

Contraindications

Absolute.

• SVC syndrome, infection at the site of insertion.

Relative.• Coagulopathy, undrained contralateral pneumothorax,

uncooperative patient. DVT of the head and neck vessels may make

insertion difﬁ cult. Patients with septal defects are at risk of CVA from

air emboli caused by poor technique.

Pulmonary artery catheter

Complications are as for CVP lines, additionally arrhythmias and pulmo-

nary artery infarction or perforation. The catheter has four lumens: a

proximal lumen 25cm from the tip that sits in the RA; a distal lumen con-

nected to a pressure transducer sitting in the pulmonary artery; a balloon

lumen allowing balloon inﬂ ation; a thermistor lumen.

Indications

These are indicated in patients with hypoperfusion states refractory to

ﬁ rst- and second-line inotropic support.

Pressure monitoring: RAP, RV pressure (RVP), PAP, pulmonary artery

•

wedge pressure (PAWP).

Flow monitoring: cardiac output.•

Mixed venous oxygen saturations.•

Derived parameters: systemic vascular resistance (SVR), SVR index (SVRI), •

pulmonary vascular resistance (PVR), PVR index (PVRI), LVSV, VO

, DO

Temporary atrial and ventricular pacing.•

Contraindications As for CV catheters (see b p. 198). Those speciﬁ c to

pulmonary artery catheterization include tricuspid or pulmonic valvular

stenosis, RA and RV masses that may embolize, tetralogy of Fallot, severe

arrhythmias, coagulopathy.

INVASIVE MONITORING

129

Waveforms See Fig. 2.8.

The arterial waveform

The arterial waveform has a fast upstroke and slower downstroke with a

notch that represents aortic valve closure.

The CVP waveform

The waveform is composed of three upstrokes (the ‘a’, ‘c’, and ‘v’ waves)

and two descents (the ‘x’ and ‘y’ descent). The ‘a’ wave—atrial systole;

‘v’ wave—venous return ﬁ lling the RA; ‘c’ wave—bulging of the closed

tricuspid valve cusps into the RA. The ‘x’ descent occurs in atrial diastole.

The ‘y’ descent occurs in ventricular diastole.

The pulmonary artery pressure waveform

Waveform progression during correct insertion of the pulmonary artery

catheter shows a sudden increase in systolic pressure as the catheter

enters the RV. As the catheter enters the pulmonary artery, the diastolic

pressure increases. There is a decrease in mean pressure as the catheter

enters the wedge position.

120

Dicrotic notch

Pressure (mmHg)

(c)

(b)

(a)

RA RV PA PAWP

Ballon

inflated

Ballon

deflated

Fig. 2.8 (a) Arterial waveform. (b) Central venous pressure waveform and

responses to ﬂ uid boluses. (c) Pulmonary artery pressure waveform.

CHAPTER 2 Principles of surgery

130

Ventilation and respiratory support

Invasive methods

Intermittent positive pressure ventilation (IPPV); controlled mechanical

ventilation (CMV); pressure control ventilation (PCV)

IPPV or CMV is the mode commonly used during routine surgery. Raising

airway pressure forces air into the lungs via an endotracheal or tracheos-

tomy tube. Expiration occurs when airway pressures are allowed to fall to

zero. This mode is poorly tolerated by the awake patient.

Positive end-expiratory pressure (PEEP)

If, instead of allowing airway pressures to fall to zero, a small positive air-

ways pressure is maintained throughout expiration (positive end-expiratory

pressure or PEEP), the collapse of small airways and alveoli that occurs at

the end of expiration is prevented.

Functional residual capacity, intrapulmonary shunts, lung compliance,

•

and PaO

are improved and the work of breathing is reduced.

High levels of PEEP (>15cmH•

O) may be necessary to reverse

established atelectasis, but increase intrathoracic pressure, reducing

venous return and cardiac output, which may reduce PaO

Barotrauma is a complication of high PEEP. PEEP as low as 5cmH•

may cause haemodynamic compromise in the patient with poor LV.

Physiological PEEP is provided by an intact glottis: patients with COPD •

purse their lips during expiration to increase physiological PEEP.

Synchronized intermittent mandatory ventilation (SIMV)

One variation of IPPV is SIMV, where positive airway pressure may be

synchronized with patient-initiated breaths. Mandatory (machine-initi-

ated) breaths are given if no spontaneous breaths occur in a preset time.

Machine-initiated breaths do not occur at the same time as patient-initi-

ated breaths. This mode is used in patients that are awake, but any patient

may safely be ventilated on SIMV.

Mandatory minute ventilation (MMV)

Another variation of IPPV is MMV where the ventilator initiates breaths

only if patient-initiated ventilation falls below a preset minute volume.

Pressure support (PS) and assisted spontaneous breathing (ASB)

Patient-initiated breaths can be supported with a preset positive airway

pressure of 6–20cmH

O. The ventilator detects the drop in airway pres-

sures as the patient begins inspiration and assists air inﬂ ow with a positive

airway pressure. This is lower than the preset inﬂ ationary pressures in

IPPV as the patient is making some inspiratory effort.

At high levels of pressure support (>20cmH

O), the patient, although

controlling the timing and frequency of respiration, is on IPPV.

Continuous positive airway pressure (CPAP)

In CPAP, a standing airway pressure, continuous throughout all phases of

respiration, is applied via the endotracheal tube. It is more commonly used

in the extubated patient via a tight ﬁ tting facemask (see b p. 131).

VENTILATION AND RESPIRATORY SUPPORT

131

Non-invasive methods

Intermittent negative pressure ventilation (INPV) Virtually never used

today, INPV involves placing the patient inside a tank ventilator sealed at

the neck. Tank pressure is intermittently lowered, expanding the chest and

lowering intrapleural pressure.

Non-invasive intermittent positive pressure ventilation (NIPPV) This is

IPPV delivered by face or, more commonly, nasal mask. The patient must

be cooperative in order to understand how to synchronize breaths with

the ventilator. It may be used in the tiring COPD patient.

Continuous positive airway pressure (CPAP) In CPAP, a standing airway

pressure, continuous throughout all phases of respiration, is applied via an

entotracheal tube, tracheostomy, nasal, or, more commonly, face mask to

a spontaneously breathing patient.

This results in a kind of non-invasive PEEP, where additional alveoli are •

recruited with the beneﬁ ts described (see b p. 130).

CPAP is a useful adjunct in the extubated patient with COPD, •

atelectasis, pulmonary oedema, or acute respiratory distress syndrome

(ARDS).

CPAP cannot produce ventilation by itself.•

Biphasic positive pressure ventilation (BiPAP) is a solution to the problem

of air trapping that can occur in patients, particularly those with COPD,

on CPAP. Airway pressure is cycled at preset rates between high and

low levels.

High ﬂ ow (Venturi) face mask (ﬁ xed performance) The key part of the

Venturi facemask is the Venturi valve which draws in an amount of air

through calibrated inlets, which is mixed with O

ﬂ owing into the valve

before entering the mask.

More mixed air (up to 30L/min) is delivered to the mask than the •

patient can use: the excess escapes though holes in the mask.

The FiO

•

is set by the choice of valve, not by the patient’s breathing

pattern (hence the term ﬁ xed performance).

The maximum FiO•

that can be delivered by a Venturi mask is about

60%. There is a minimum ﬂ ow rate of O

for each Venturi.

Low ﬂ ow (Hudson) face mask (variable performance) O

ﬂ ows at a set

rate (e.g. 2L/min) into the mask. It is diluted by air drawn into the mask,

which depends on the patient’s minute volumes, ranging 5–30L/min.

The FiO•

achieved depends primarily on the patient and the delivery

system should not be used when accurate control of FiO

is required.

The maximum FiO•

that can reliably be delivered is about 30%.

Use of a non-rebreathing mask and reservoir bag, into which high ﬂ ow •

is drawn during expiration and then inhaled, increases FiO

to up to

60%: the reservoir bag must be ﬁ lled with O

before the patient uses it.

Nasal prongs Nasal prongs deliver an FiO

that is determined primarily

by the patient, as in a low ﬂ ow mask, but they are less obtrusive, allowing

the patient to expectorate and eat. They increase tracheal FiO

to barely

more than room air levels, particularly if the patient breathes through

their mouth.

CHAPTER 2 Principles of surgery

132

Circulatory support

Principles

Improving cardiac function and end-organ perfusion involves:

Careful ﬂ uid balance to optimize preload or ‘ﬁ lling’ (see • b p. 64);

Using vasoconstrictors and vasodilators to optimize afterload;•

Using inotropes and chronotropes to improve cardiac output (CO);•

Mechanical support in selected cases.•

Inotropes

Adrenaline (epinephrine) 0.03–0.5micrograms/kg/min or bolus

Catecholamine produced by the adrenal medulla.

Action.• Direct agonist at α, β

, and β

receptors.

Pharmacodynamics.• Instant onset, half-life 2min. Metabolized by MAO.

Indications.• Cardiac arrest (asystole, ventricular ﬁ brillation (VF),

electromechanical delay (EMD)); anaphylaxis; low CO states;

bronchospasm.

Dopamine 3–10micrograms/kg/min

A catecholamine precursor to noradrenaline (NA) and adrenaline.

Action.

• α, β

, β

, and DA

agonist, and release of stored neuronal

NA. At the lower doses, B and DA effects (increased heart rate

(HR), contractility) predominate. At >10micrograms/kg/min, A effects

predominate (i SVR, dysrhythmias).

Pharmacodynamics.

• Fast onset, slow offset. Metabolized by monoamine

oxidase (MAO).

Indications.• Low CO states; renal insufﬁ ciency.

Milrinone 0.3–0.8micrograms/kg/min

Bipyridine derivative that inhibits phosphodiesterase.

Action.

• Potent inotropic and vasodilator effects.

Pharmacodynamics.• Half-life is 4h. Metabolism is hepatic.

Indication.• Low CO state in the setting of i SVR.

Vasopressors

Inotropes increase inotropy (contractility)

A• -adrenergic receptor stimulation leads to i SVR and PVR.

B•

stimulation leads to i contractility, heart rate, and conduction.

B•

stimulation causes peripheral dilatation and bronchodilation.

Dopamine (DA)• stimulation causes coronary, renal, and mesenteric

vasodilatation.

Vasopressors cause vasoconstriction

A•

-adrenergic stimulation increases SVR and PVR.

•

-adrenergic stimulation i contractility without i HR.

CIRCULATORY SUPPORT

133

Noradrenaline (norepinephrine) 0.03–1.0micrograms/kg/min

Catecholamine produced by the adrenal medulla.

Action.• Direct α agonist: potent vasoconstriction + β

effect = i BP.

Pharmacodynamics.• Immediate onset; half-life 2min.

Indication.• Hypotension because of low SVR in good to high CO states.

Chronotropes

Atropine (0.3–1mg IV bolus)

Atropine is a belladonna alkaloid.

Action.• A competitive antagonist at muscarinic cholinergic receptors,

reducing parasympathetic tone to ‘reveal’ underlying sympathetic tone.

Pharmacodynamics.• Almost instant onset. When given IV, offset is

15–30min. When given IM, SC, or PO, 4h. Renal elimination.

Indication.• Bradydysrhythmias, reduction of oral secretions.

Isoprenaline (0.01–0.3micrograms/kg/min)

Synthetic catecholamine.

Action.• Direct β

(i contractility, conductivity, and HR) and β

(vasodilatation and bronchodilatation) effect. No α activity.

Pharmacodynamics.• Plasma half-life 2min. Hepatic metabolism by MAO,

40% conjugated, 60% excreted unchanged.

Indication.• Bradycardia unresponsive to atropine.

Mechanical support

Intra-aortic balloon counterpulsation

Mechanism

The intra-aortic balloon pump (IABP) is a polyethylene balloon ﬁ lled with

helium, ranging from 2 to 50cm

in size, that sits in the descending aorta

just distal to the left subclavian artery. The balloon inﬂ ates in early dias-

tole, improving coronary perfusion, and deﬂ ates just before systole, reduc-

ing afterload. The myocardial oxygen supply:demand ratio is improved and

CO may be increased by up to 40%.

Indications

Weaning from cardiopulmonary bypass, refractory ischaemia, cardiogenic

shock.

Contraindications

Aortic regurgitation (AR) (balloon inﬂ ation during diastole will worsen

•

AR).

Aortic dissection.•

Ventricular assist devices (VADs) These are pumps that are anastomosed

to the great vessels or cardiac chambers to support failing right, left, or

both ventricles.

Chronotropes increase heart rate

B•

stimulation leads to i contractility, HR, and conduction.

Muscarinic cholinergic• activity is predominantly parasympathetic.

CHAPTER 2 Principles of surgery

134

Renal support

The main aims of treatment of renal failure are:

Maintain renal perfusion.•

Optimize ﬂ uid balance.•

Provide adequate enteral support.•

Correct hyperkalaemia and acidosis.•

Identify and treat sepsis.•

Target therapy to underlying pathology.•

Provide renal replacement therapy.•

Haemodialysis and haemoﬁ ltration

There are two main techniques of renal replacement therapy used on car-

diac ICUs: haemodialysis and haemoﬁ ltration. In both techniques, access

to the circulation is required and blood passes through an extracorporeal

circuit that includes either a dialyser or a haemoﬁ lter.

In haemodialysis, blood ﬂ ows along one side of a • semipermeable

membrane as a solution of crystalloids is pumped against the other side

of the membrane, against the direction of blood ﬂ ow.

In haemoﬁ ltration, • blood under pressure passes down one side of a

highly permeable membrane on the other side of which is a static

crystalloid solution.

In haemodialysis, removal of solutes depends on diffusion: molecules •

move from high to low concentration and smaller molecules move

faster so the amount of solute removed depends on its concentration

in the dialysis ﬂ uid and on the size of the molecule.

In haemoﬁ ltration, removal of solutes with a molecular weight up •

to 20 000 depends on convective ﬂ ow as in glomerular ﬁ ltration:

all molecules are removed at a similar rate and virtually all ions are

removed.

In haemodialysis, large molecules are not efﬁ ciently removed.•

In haemoﬁ ltration, large molecules are so effectively removed that •

drugs such as heparin, insulin, and vancomycin may need to be

replaced and reduction in circulating inﬂ ammation mediators and

pyrogens leads to a reduction in pyrexia and systemic inﬂ ammation.

In haemodialysis, controlled amounts of sodium and water are •

removed by creation of a transmembrane pressure gradient.

In haemoﬁ ltration, large amounts of salt and water are removed

•

and must be replaced by an infusion of an appropriate amount of

physiologic crystalloid into the distal port of the haemoﬁ lter.

Indications for renal replacement therapy

Refractory hyperkalemia (see • b p. 111).

Refractory acidosis.•

Pulmonary oedema.•

Drug toxicity.•

Progressive uraemia or uraemia associated with pericarditis, •

encephalopathy, seizures, or coagulopathy.

RENAL SUPPORT

135

Types of haemoﬁ ltration

Haemoﬁ ltration has become an increasingly popular form of renal replace-

ment therapy for acute renal failure post-operatively, even though it is

several times more expensive than dialysis. This is because the continuous

nature of the process avoids the big swings in ﬂ uid balance and electro-

lytes that characterize dialysis. There are several variants.

Continuous arteriovenous haemoﬁ ltration (CAVH) This is the original and

simplest form of ﬁ ltration. The femoral artery and vein are cannulated and

blood passes through the haemoﬁ lter under arterial pressure alone. It is

therefore less appropriate for patients with low CO states. Prolonged

arterial cannulation carries complications (see b p. 197).

Continuous arteriovenous haemodialysis with ﬁ ltration Because clearance

rates are as low as 10mL/h with CAVH, a dialysis circuit is added to the

equipment, improving clearance rates at considerable cost.

Continuous venovenous haemoﬁ ltration (CVVH) An occlusive pump is

incorporated into the circuit to drive blood so that venous cannulation

is all that is required. This also allows control of blood ﬂ ow and ﬁ ltration

rate. Clearance of up to 100mL/min can be achieved. This is the most com-

monly used system in ICUs.

Continuous venovenous haemodialysis with ﬁ ltration Some systems add

haemodialysis to the CVVH circuit for additional ﬁ ne control.

Management of the haemoﬁ ltered patient

A double lumen catheter (Vascath) is inserted into a central vein. The

blood pump is set at 125mL/min and the haemoﬁ ltration rate to 25mL/

min. The replacement ﬂ uid pump is programmed to balance the inﬂ ow

and outﬂ ow of ﬂ uid to achieve a preset rate of ﬂ uid loss. The circuit

is heparinized with an infusion of 200–1600U/h. Lactate is the common-

est replacement anion, but in lactic acidosis, a lactate-free replacement

solution must be employed. Mg

, Ca

, PO

, and HCO

are replaced.

Hypotension is common when commencing haemoﬁ ltration.

CHAPTER 2 Principles of surgery

136

Enteral support

(See also b p. 66.) Neglecting the patient’s nutritional needs increases

morbidity and mortality.

Routine management

Patients may be started on oral intake directly after most forms of •

surgery unless contraindicated. There is good evidence of reduced

pulmonary, septic, and anastomotic complications in patients fed early.

Patients with a history of dyspepsia or peptic ulceration should be •

commenced electively on an IV proton pump inhibitor (PPI).

Analgesia should be downscaled from IV and oral opiates to non-•

opiate analgesia such as paracetamol 1g qds PO/PR as soon as possible

to avoid ileus, constipation, anorexia, nausea, and vomiting.

Avoid NSAID analgesia in patients at risk of peptic ulceration.•

Give regular • IV antiemetics to treat persistent nausea and vomiting.

Enteral nutrition

This is nutrition using the GI tract. It is superior to, safer, and cheaper

than TPN.

Routes/methods for supplemented enteral nutrition

Sip feeds.

•

Fine bore NG tube (NGT) with use of infusion pump.•

Nasojejunal tube (needs radiographic imaging).•

Percutaneous endoscopic gastrostomy (• PEG) and jejunostomy.

Open surgical gastrostomy or jejunostomy.•

Enteral tube feeds come in sterile, ready to hang 500mL and 1000mL packs.

Standard feeds are nutritionally complete and provide 1kcal/mL. They are

based on whole protein. Fibre-enriched feeds also provide 1kcal/mL. They

contain soy polysaccharides that are soluble, but remain undigested pass-

ing to the colon where they are fermented by bacteria to produce short

chain fatty acids, promoting absorption of sodium and water and reducing

diarrhoea. They are also probiotic. High energy feeds provide 1.5kcal/mlL

and are used in patients requiring reduced ﬂ uid input.

Renal failure patients require high energy, low volume, and electrolyte •

feeds. Nepro

provides 2kcal/mL and high protein content.

Drugs can be given by the NGT being used for enteral feeding. Liquid •

preparations designed for oral administration should ideally be used as

crushed tablets may block the tube. The feed should be stopped and

the NGT ﬂ ushed with saline before and after administration of drugs.

The therapeutic effect of warfarin is reduced by the vitamin K content •

in feeds; it is frequently necessary to increase the dose of warfarin.

Examples of enteral feeds

Standard feeds—Osmolite•

, Nutrison

standard.

Fibre enriched—Jevity•

, Nutrison

Multi-Fibre.

High energy—Nutrison•

Energy, Ensure

Plus.

ENTERAL SUPPORT

137

Phenytoin interacts with enteral feeds, which should be stopped for 2h •

before and after phenytoin administration.

Indications for supplementary enteral feeding

Inadequate oral intake due to anorexia, practical difﬁ culties with

•

feeding, being on ITU/HDU, drug-induced nausea, poor oral health or

dentition.

Hypercatabolism exceeding normal intake (e.g. chronic major sepsis, •

malignancy, trauma, burns).

Gut intact, but absorption impaired excessive losses; chronic •

diarrhoea, high output stoma or ﬁ stula (usually low residue or

elemental feeds to maximize absorption).

Complications of supplementary enteral feeding

Complications of feeding tube. • Malposition, blockage (wound infection

around jejunostomy tubes).

Complications of administration. • Pulmonary aspiration, regurgitations,

diarrhoea, bloating, nausea, cramps.

Complications of contents. • Vitamin and trace mineral deﬁ ciencies,

electrolyte imbalances, drug interactions.

Diarrhoea is the most common complication. If feed-related, reducing the

osmotic load is effective (using half-strength feed or slowing the infusion).

Omeprazole, Lomotil

, and erythromycin may be tried. It is mandatory to

exclude other causes of diarrhoea such as subacute obstruction and infec-

tious causes (particularly Clostridium difﬁ cile).

Total and peripheral parenteral nutrition (TPN, PPN)

TPN consists of specially formulated feed given IV. Because TPN solutions

have high osmolality, they cause thrombophlebitis if infused into periph-

eral veins. They are given via central lines (subclavian or internal jugular)

which may be tunnelled for long-term use. PPN uses heparin, in-line ﬁ ltra-

tion, buffering, ﬁ ne bore cannulas, and reduced osmolality feeds to avoid

thrombophlebitis.

Indications

Failure of bowel to absorb food, e.g. radiation damage, severe acute •

enteritis, or malabsorption syndromes.

Failure of adequate length of bowel for absorption (short bowel •

syndrome due to Crohn’s disease or after massive intestinal resection).

GI tract not accessible for enteral route, e.g. acute severe pancreatitis, •

oesophagogastric surgery, or disease where tube feeding not possible.

Failure of enteral feeding to accomplish nutritional targets (rare).•

Complications

Complications of CV catheters (see

• b p. 199).

Late complications: sepsis, migration, erosion, DVT, occlusion.•

Metabolic complications: • id glucose, K

, Na

, i Ca

, d PO

, d Zn,

Mg, folate.

CHAPTER 2 Principles of surgery

138

Sepsis, SIRS, MODS, and ALI

Systemic inﬂ ammatory response syndrome (SIRS) is a pro-inﬂ ammatory

state that does not include a documented source of infection. It may lead

to multiple organ dysfunction syndrome (MODS).

Pathophysiology

The pathophysiology involves systems involved in inﬂ ammation, immunity,

ischaemia, and homeostasis, including complement, clotting and cytokine

cascades, cell-mediated immunity, and humoral immunity.

Metabolic acidosis is a frequent accompaniment to SIRS and it is

•

derived principally from lactate.

SIRS may affect all organ systems and may lead to MODS.•

Deﬁ nitions

SIRS

Any two or more of the four following signs:

•

Tachycardia >90 beats/min.•

Tachypnoea >20 breaths/min.•

Pyrexia >38• °C (or hypothermia <36°C).

White blood count >12 • × 10

/L (or <4 × 10

/L).

Without • identiﬁ able bacteraemia or need for organ support and in

the setting of a known cause of endothelial inﬂ ammation such as:

Suspected infection.•

Pancreatitis.•

Ischaemia.•

Multiple trauma and tissue injury.•

Haemorrhagic shock.•

Immune-mediated organ injury.•

Sepsis

Systemic response to infection manifested by two or more of:

Tachycardia >90 beats/min.

•

Tachypnoea >20 breaths/min.•

Pyrexia >38• °C (or hypothermia <36°C).

White blood count >12 • × 10

/L (or <4 × 10

/L).

Multiple organ failure Presence of altered organ function in an acutely

ill patient such that homeostasis cannot be maintained without

intervention.

Acute lung injury (ALI)

Acute onset.•

PaO•

/FiO

<300.

Bilateral inﬁ ltrates on CXR.•

PAWP <18mmHg or no clinical evidence of raised left atrial •

pressure.

Acute/adult respiratory distress syndrome (ARDS) As for ALI, except PaO

FiO

<200.

SEPSIS, SIRS, MODS, AND ALI

139

Cell signalling molecules involved include interleukins IL-1, IL-5, and •

IL-6; chemokines; tumour necrosis factor (TNF).

Theories explaining why SIRS develops include:•

Immunologically mediated inﬂ ammation.•

i• intestinal permeability and colonization with Gram –ve anaerobes

that produce endotoxins that migrate across the mucosa to drive

the inﬂ ammatory and immune response.

‘Second hit’ hypothesis.•

Acute lung injury (ALI)

Thirty per cent of patients with SIRS develop ALI. It is the pulmonary

manifestation of the global physiological insult (rarely occurs in isola-

tion). ARDS is one end of the continuum of ALI. Management of ALI

is supportive, including prone ventilation and aggressive diuresis or early

ultraﬁ ltration.

Investigations

These are aimed at excluding differential diagnoses such as overwhelming

sepsis, cardiogenic shock, hypovolaemic shock, and hypersensitivity reac-

tions as well as identifying an underlying cause.

U&E, LFTs, serum amylase, lactate and cardiac enzymes.•

FBC, APTT, PT, ﬁ brinogen, D-dimers.•

Cultures of blood, urine, sputum, stool.•

ABGs.•

Pulmonary artery catheter measurements of cardiac function and •

mixed venous oxygen saturations.

Cytokine assays can be used as markers of severity.•

Management

Volume resuscitation:•

Aims to achieve normovolaemia: increases CO and oxygen delivery •

without large increase in oxygen consumption.

Hypervolaemia appropriate in selected cases.•

Albumin probably beneﬁ cial in selected cases.•

Pulmonary artery catheter may guide management.•

Maintenance of oxygen delivery:•

Airway protection and ventilatory support usually necessary.•

Inotropic support of cardiac function has important role.•

Vasoactive drugs selected so that BP is not maintained at the •

expense of splanchnic vasoconstriction and hypoperfusion.

Organ support:•

In addition to cardiovascular and respiratory support, these patients •

frequently need renal, hepatic, and enteral support.

Attempts to reduce translocation, e.g. introduction of competing •

bacteria (e.g. lactobacillus of yoghurt), early enteral nutrition,

particularly with the use of immunostimulating enteral diets.

Prognosis Mortality ranges from 25% to100%, depending on the number

and type of organ failures involved, age, and pre-existing comorbidity.

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141

Surgical pathology

Cellular injury 142

Inﬂ ammation 144

Wound healing 146

Ulcers 148

Cysts, sinuses, and ﬁ stulas 150

Atherosclerosis 152

Thromboembolic disease 154

Gangrene and capillary ischaemia 158

Tumours 160

Carcinogenesis 162

Screening 164

Grading and staging 168

Tumour markers 170

Surgical microbiology 172

Surgically important organisms 174

Soft tissue infections 176

Blood-borne viruses and surgery 178

Bleeding and coagulation 180

Anaemia and polycythaemia 182

Chapter 3

CHAPTER 3 Surgical pathology

142

Cellular injury

Causative agents

Cellular injury is caused by:

• Trauma.

• Thermal injury.

• Chemicals, including drugs.

• Infectious organisms.

• Ionizing radiation.

Mechanisms of injury

These causative agents cause cell damage via a number of mechanisms.

• Mechanical disruption. Trauma, freezing, osmotic imbalance.

• Failure of membrane integrity. Failure of ion pumps, cytolysis, trauma.

• Blockage of metabolic pathways. Cellular respiration (e.g. cyanide),

protein synthesis (e.g. streptomycin), DNA damage or loss (e.g.

X-rays).

• Deﬁ ciency of essential metabolites. Oxygen (ischaemia), glucose

(diabetic ketoacidosis), hormones (d trophic hormones results in

apoptosis).

• Free radicals. Toxins (e.g. carbon tetrachloride), ischaemia-reperfusion

injury, intracellular killing of bacteria.

Necrosis

Coagulative necrosis

This is the most common form of necrosis and occurs in all organs.

Cells retain their shape as cell proteins coagulate and metabolic activ-

ity stops. Digestion by macrophages may cause the tissue to become

soft. Histologically, there is progressive loss of staining. The presence of

necrotic material normally provokes an inﬂ ammatory response.

Colliquative necrosis

This occurs in the brain because of the lack of tissue architecture provided

by substantial surrounding stroma.

Caseous necrosis

Dead tissue lacks any structure and is characterized by a white, soft, or

liquid ‘cheesy’ appearance. This is common in TB.

Gangrene

Necrosis with dessication or putrefaction (see b p. 158).

Fibrinoid necrosis

In malignant hypertension, necrosis of smooth muscle vessel walls allows

seepage of plasma into the media and deposition of ﬁ brin.

Fat necrosis

• Direct trauma. Release of extracellular fat produces an inﬂ ammatory

response, ﬁ brosis and eventually, in some cases, a palpable mass.

• Acute pancreatitis. Fat is digested by pancreatic lipase to produce fatty

acids which precipitate with calcium in the process of saponiﬁ cation.

Necrosis is death of tissue or cells.

CELLULAR INJURY

143

Apoptosis

Apoptosis is a physiological process requiring energy. It is the normal

means of maintaining the size of an organ in the face of continuing cell

turnover or a reduction in size during atrophy. It is mediated by endog-

enous endonucleases. The cell shrinks and fragments into apoptotic bod-

ies. Examples include:

• Physiological. Epithelium of GI tract, bone marrow, clonal selection in

immune system, targets of cytotoxic T cells.

• Pathological. After exposure to ionizing radiation, chemotherapy,

smooth muscle cells around atherosclerotic plaque, viral hepatitis.

Apoptosis (programmed cell death) is the cell-mediated, controlled

elimination of individual cells.

CHAPTER 3 Surgical pathology

144

Inﬂ ammation

Acute inﬂ ammation

This is the initial tissue reaction to a wide range of agents: accumulation of

neutrophil polymorphs in the extracellular space is diagnostic. It lasts hours

to days and is usually described with the sufﬁ x ‘-itis’.

Causes

• Physical and chemical, e.g. mechanical trauma, X-rays, acid, alkali.

• Infection: bacteria, viruses, parasites, fungi, or protozoa.

• Ischaemia.

• Hypersensitivity.

Macroscopic appearance

Calor, rubor, tumor, dolor, and functio laesa (heat, redness, swelling, pain,

and impaired function). Special macroscopic appearances include:

• Serous. Inﬂ ammation + abundant ﬂ uid-rich exudates, e.g. peritonitis.

• Catarrhal. Inﬂ ammation + mucus hypersecretion, e.g. common cold.

• Haemorrhagic. Inﬂ ammation + vascular injury, e.g. pancreatitis.

• Suppurative. Inﬂ ammation + pus produced to form abscess or

empyema.

• Fibrinous. Exudates contain ﬁ brin which forms coating, e.g. pericarditis.

• Membranous. Coating of ﬁ brin and epithelial cells, e.g. laryngitis.

• Pseudomembranous. Superﬁ cial mucosal ulceration with slough, e.g.

pseudomembranous colitis secondary to C. difﬁ cile (see b p. 396).

• Necrotizing (gangrenous). Inﬂ ammation + tissue necrosis (see b

p. 158).

Microscopic changes

Mediated by endogenous chemicals released by cells (histamine, prostaglan-

dins, leukotrienes, serotonin, and lymphokines) and plasma factors (com-

plement, kinin, coagulation, and ﬁ brinolytic cascades). Changes are:

• Changes in vessel calibre and ﬂ ow.

Immediate and transient smooth muscle vasoconstriction.•

Vasodilation (active hyperaemia) lasting 15min to hours.•

Capillaries, then arterioles dilate to increase blood ﬂ ow.•

• Increased vascular permeability and ﬂ uid exudates.

Capillary hydrostatic pressure is increased.•

Endothelial cells contract, creating gaps.•

Plasma proteins escape into extracellular space.•

Increase in colloid osmotic pressure draws more ﬂ uid.•

• Formation of cellular exudates.

Accumulation of neutrophil polymorphs in extracellular space.•

Begins with margination of neutrophils (ﬂ ow next to vessel walls).•

Neutrophils then adhere to vessel walls: mechanism unknown.•

Migrate by amoeboid movement through gaps between cells.•

Inﬂ ammation is the local physiological response to tissue injury. It can

be acute or chronic.

INFLAMMATION

145

Neutrophil polymorphs phagocytose debris and kill microbes •

intracellularly using oxygen-dependent (hydrogen peroxide and

hydroxyl radicals) and -independent (lysosymes) means.

Sequelae of acute inﬂ ammation

• Resolution. Restoration of tissue to normal; likely if minimal tissue

damage, rapid destruction of causal agent, rapid removal of exudates

by good vascular drainage, and organ with restorative capacity, e.g.

liver.

• Suppuration. Formation of pus (see b p. 144).

• Organization. Replacement by granulation tissue.

• Chronic inﬂ ammation.

Chronic inﬂ ammation

This is an inﬂ ammation where lymphocytes, plasma cells, and macrophages

predominate, granulation tissue often accompanies.

Causes

• Resistance of infective agent to phagocytosis (TB, viral infections).

• Foreign body (endogenous, e.g. urate or exogenous, e.g. asbestos).

• Autoimmune (e.g. contact hypersensitivity, RA, organ-speciﬁ c).

• Primary granulomatous disease (e.g. Crohn’s, sarcoidosis).

• Unkown aetiology (e.g. ulcerative colitis).

Macroscopic appearances

The commonest appearances are:

• Chronic ulcer, e.g. peptic ulcer;

• Chronic abscess cavity, e.g. empyema;

• Thickening of wall of hollow viscus, e.g. Crohn’s disease;

• Granulomatous inﬂ ammation, e.g. TB;

• Fibrosis, e.g. chronic cholecystitis.

Microscopic changes

Lymphocytes, plasma cells, and macrophages (see b p. 145) predominate;

neutrophil polymorphs are scarce, eosinophil polymorphs are present.

Fluid exudate is not prominent.

Granuloma

This is different to granulation tissue (see b p. 147).

Causes

• Speciﬁ c infections.

Endogenous. necrotic bone or fat, keratin, urate.•

Exogenous. Talc, silicone, asbestos, sutures.•

• Drugs. Sulphonamides, allopurinol.

• Unknown. Crohn’s, sarcoidosis, Wegener’s granulomatosis.

A granuloma is an aggregate of epithelioid histiocytes.

CHAPTER 3 Surgical pathology

146

Wound healing

General principles of healing

Tissue healing in any organ follows some basic principles:

• Cells may be labile (good capacity to regenerate, e.g. surface epithelial

cells), stable (capacity to regenerate slowly, e.g. hepatocytes), or

permanent (no capacity to regenerate, e.g. nerve and striated muscle

cells).

• Tissue architecture is important: complex arrangements cannot be

reconstructed if destroyed, e.g. renal glomeruli.

• Complete restitution occurs when part of a labile population of cells is

damaged, e.g. a minor skin abrasion.

Classiﬁ cation of wounds

• Clean. Non-traumatic wounds with no break in surgical technique,

no septic focus, and no viscus opened (e.g. hernia repair).

• Clean contaminated. Non-traumatic wounds with contaminated

entry into a viscus, but with minimal spillage (e.g. elective

cholecystectomy).

• Contaminated. Clean, traumatic wounds or signiﬁ cant spillage from

a viscus or acute inﬂ ammation (e.g. emergency appendectomy).

• Dirty. Includes traumatic wounds from a dirty source or when

signiﬁ cant bacterial contamination or release of pus is encountered.

Key revision points—the four stages of wound healing

When specialized tissue is destroyed, it cannot be replaced and a stere-

otyped response called repair then follows in four stages:

• Haemostasis (immediate). In response to exposed collagen, platelets

aggregate at the wound and degranulate, releasing inﬂ ammatory

mediators. Clotting and complement cascades activated. Thrombus

formation and reactive vasospasm achieve haemostasis.

• Inﬂ ammation (0–3 days). Vasodilation and increased capillary

permeability allow inﬂ ammatory cells to enter wound and cause

swelling. Neutrophils amplify inﬂ ammatory response by release of

cytokines, reduce infection by bacterial killing, and debride damaged

tissue. Macrophages follow and secrete cytokines, growth factors,

and collagenases. They phagocytose bacteria and dead tissue

and orchestrate ﬁ broblast migration, proliferation, and collagen

production.

• Proliferation (3 days–3 weeks). Fibroblasts migrate into the wound

and synthesize collagen. Specialized myoﬁ broblasts containing actin

cause wound contraction. Angiogenesis is stimulated by hypoxia and

cytokines and granulation tissue forms.

• Remodelling (3 weeks–1y). Reorientation and maturation of collagen

ﬁ bres increases wound strength.

WOUND HEALING

147

• Granulation tissue is the combination of capillary loops and

myoﬁ broblasts. This is unrelated to a granuloma (see b p. 145).

• Organization is the process where specialized tissues are repaired by

formation of mature connective tissue, e.g. pneumonia or infarcts.

• Wound contraction mediated by myoﬁ broblasts; can reduce the tissue

defect by up to 80%, but can lead to problems, e.g. burns contractures.

• Collagen is secreted at the same time to form a scar.

Factors affecting wound healing

• Impaired arterial supply or venous drainage (global or local).

• Excessive movement, local distension, or distal obstruction.

• Infection, malignancy, foreign body, necrotic tissue, smoking.

• Malnutrition. Obesity, recent weight loss, nutrient deﬁ ciency.

• Immunosuppressive. Cancer, steroids, immunosuppressants, HIV.

• Anticancer therapies. Radiotherapy and chemotherapy.

• Metabolic. Diabetes, jaundice, uraemia, musculoskeletal diseases, age.

Wound healing in speciﬁ c tissues

Skin: ﬁ rst intention healing

This takes place where there is close apposition of clean wound edges.

• Thrombosis in cut blood vessels prevents haematoma formation.

• Coagulated blood forms a surface scab which keeps the wound clean.

• Fibrin precipitates to form a weak framework between the two edges.

• Capillaries proliferate to bridge the gap.

• Fibroblasts secrete collagen into the ﬁ brin network.

• Basal epidermal cells bridge the gap and are eventually resorbed.

• The elastic network in the dermis cannot be replaced.

Skin: second intention healing

This takes place in wounds where skin edges cannot be cleanly apposed.

• There is phagocytosis to remove debris.

• Granulation tissue to ﬁ ll in defects.

• Epithelial regeneration covers the surface.

Gastrointestinal tract

• Erosion is loss of part of the thickness of the mucosa.

Adjacent epithelial cells proliferate to regenerate the mucosa.•

Healing may take place this way in a matter of hours.•

• Ulceration is loss of the full thickness of the mucosa.

Mucosa is replaced from the margins.•

The muscularis propria cannot be regenerated: it is replaced by scar.•

Damaged blood vessels bleed, ﬁ brin covers the raw surfaces.•

Macrophages migrate in and phagocytose dead tissue.•

Granulation tissue is produced in the base.•

If the cause persists, the ulcer becomes chronic.•

Fibrous scar tissue may result in contractions.•

CHAPTER 3 Surgical pathology

148

Ulcers

Classiﬁ cation

Venous, arterial, diabetic, neuropathic, malignant, traumatic.

Features to note on examination

• Site. Neck, groin, and axilla (TB); legs and feet (vascular); anywhere

(malignant).

• Surface. Usually depressed. Elevated in malignancy, vascular

granulations.

• Size. Measure the ulcer. Is it large by comparison to the length of

history?

• Shape. Oval, circular, serpiginous, straight edges.

• Edge. Eroded (actively spreading), shelved (healing), punched out

(syphilitic), rolled or everted (malignant).

• Base. Fixed to underlying structures? Mobile? Indurated? Penetrating?

• Discharge. Purulent (infection), watery (TB), bleeding (granulation or

malignancy).

• Pain. Usually occurs during the extension phase of non-speciﬁ c ulcers.

In diabetic patients, ulcers are relatively painless.

• Number. Widespread locally (local infection such as cellulitis),

widespread generally (constitutional upset).

• Progress. Short history (pyogenic), chronic (vascular or trophic, e.g.

post-phlebitic syndrome, decubitus ulceration of paraplegia).

• Lymph nodes. In the region of an ulcer may indicate secondary infection

or malignant change.

Natural history

• Extension. There is discharge, thickened base, inﬂ amed margin. Slough

and exudates cover the surface.

• Transition. Slough separates and the base becomes clean. The discharge

becomes scanty, the margins less inﬂ amed.

• Repair. Granulation becomes ﬁ brous tissue and forms a scar after

re-epithelialization.

Investigations

History, biopsy and histology, serology, as indicated by presentation.

Chronic leg ulcers

Their aetiology is diverse, but can usually be diagnosed clinically.

Venous ulcers

Part of post-phlebitic limb syndrome where there may be a history of past

DVT. The ulcer is associated with oedema, lipodermatosclerosis (woody

thickening of soft tissues around the calf), and venous congestion with

secondary calf perforators and varicose veins. The ulcer is usually over

the medial malleolus, but can be large, involving the whole of the gaiter

region.

An ulcer is a breach in an epithelial surface.

ULCERS

149

• If pulses are absent in the foot, there may be an arterial element which

can be excluded by measurement of the ankle to brachial pressure

index (ABPI).

• If any doubt persists, a vascular referral for arterial reconstruction

should be considered, but four-layer bandaging must be avoided when

there is arterial insufﬁ ciency.

Arterial ulcers

These are often multiple and occur distally over and between the toes or

at pressure points such as heels or malleoli. They may occur elsewhere on

the leg, usually when there is an associated diabetic or venous element.

There is usually a history of arterial disease, particularly peripheral vascular

disease with claudication.

• Unlike venous ulcers where bacterial colonization is common, the

presence of organisms suggests infection, particularly when there is

moisture around the ulcers: wet gangrene (caused by staphylococci

and streptococci, not clostridia, see later) may ensue with cellulitis.

• If the leg is kept dry, infection is minimized and a line of demarcation

may aid in decision-making for the level of amputation.

• Arterial reconstruction should be considered before this stage.

Diabetic ulcers

These commonly occur in conjunction with arterial disease. They repre-

sent large- and small-vessel disease with an impaired ability to heal and

increased susceptibility to infection. Ulcers may occur in the arterial distri-

bution, particularly at pressure points, and involve deep tissue infections

(such as plantar abscesses) and osteomyelitis. The associated diabetic neu-

ropathy with Charcot’s joints presents with deformed feet and joints, which

are susceptible to ulceration.

• Management involves good diabetic and ulcer care, which includes

orthotist help with shoes and gait.

• Surgery aims to avoid major amputation, but requires debridement

of necrotic tissue, drainage of abscesses, and excision of dead tissue,

often involving bone as ‘ray’ excisions of toes.

Other causes

Include pressure, vasculitic, lymphatic, infective, and artefactual causes. Leg

ulcer clinics have emphasized the value of a team approach.

CHAPTER 3 Surgical pathology

150

Cysts, sinuses, and ﬁ stulas

Cysts

Classiﬁ cation

Congenital

• Sequestration dermoid. Due to displacement of epithelium along

embryonic ﬁ ssures during closure, e.g. skin. Sites include outer and

inner borders of orbit, midline of the body, anterior triangle of neck

(brachial cyst), (cf. implantation dermoid due to skin implantation from

injury).

• Tubulo-dermoid/tubulo-embryonic. Abnormal budding of tubular

structures, e.g. enteric cysts, post-anal dermoid, thyroglossal cyst.

• Dilatation of vestigial remnants. For example, urachal, vitellointestinal,

paradental and branchial cleft cysts, hydatid of Morgagni, Rathke’s

pouch.

Acquired

• Retention cysts. Due to the blocking of a glandular or excretory duct,

e.g. sebaceous cyst (sweat gland); ranula (salivary gland); and cysts

of the pancreas, gall bladder, parotid, breast, epididymis, Bartholin’s

glands, hydronephrosis, hydrosalpinx.

• Distension cysts. Due to the distension of closed cavities as a result

of exudation or secretion, e.g. thyroid or ovarian cysts; hygroma

(lymphatic cysts), hydrocoele, ganglia, bursas (false cysts).

• Cystic tumours. For example, cystadenoma, cystadenocarcinoma of

ovary.

• Parasitic cysts. For example, hydatid cysts (Taenia echinococcus).

• Pseudocysts. Due to necrosis of haemorrhage with liquefaction and

encapsulation, e.g. necrotic tumours, cerebral softening, or coalescence

of inﬂ ammatory ﬂ uid collections, e.g. pseudocyst of pancreas.

Clinical features

Subcutaneous/superﬁ cial

Smooth, spherical, soft, and ﬂ uctuant when palpated in two planes with

the ﬁ ngers at right angles to each other. If tense contents, may produce

pain in the cyst or surrounding tissue. If the ﬂ uid is clear, the swelling

will transilluminate. Ultrasound and aspiration of contents are methods

of determining whether a given swelling is cystic and may differentiate a

cyst from a lipoma. May compress surrounding tissues. May produce pain

if complications supervene. They are also subject to infection, torsion if on

a pedicle, haemorrhage, and calciﬁ cation.

A cyst is a collection of ﬂ uid in a sac lined by endothelium or epithelium

which usually secretes the ﬂ uid.

• True cysts are lined by endo- or epithelium.

• False cysts are the result of exudation or degeneration, e.g.

pseudocyst of pancreas, cystic degeneration in a tumour.

CYSTS, SINUSES, AND FISTULAS

151

Treatment

• Excision. Only if symptomatic, cosmetic, or concern over diagnosis.

• Marsupialization (derooﬁ ng and suture of the lining to skin). If chronic

or infected.

• Drainage (deep site). If symptomatic or complicated. Not if concern

over malignancy.

Sinuses/ﬁ stulas

Causes

• Speciﬁ c disease, e.g. Crohn’s.

• Abscess formation and spontaneous drainage, e.g. diverticular abscess

discharging into vagina with ﬁ stula formation.

• Penetrating wounds.

• Iatrogenic (e.g. anastomotic leak discharging via wound).

• Neoplastic.

Persistence of a ﬁ stula is due to the following

• Presence of foreign material, e.g. suture/bone in a sinus.

• Distal obstruction of the viscus of origin.

• Continuing active sepsis, e.g. TB, actinomycosis.

• Epithelialization of the track.

• Chronic inﬂ ammation, e.g. Crohn’s.

• Malignancy in the track.

Investigation

Establish the extent by sinography/ﬁ stulogram. MRI scan is often helpful.

Treatment

Principles of sinus treatment:

• Ensure adequate drainage, laying it open and remove granulations.

• Remove septic material, foreign bodies.

• Biopsy sinus wall if concern over underlying diagnosis.

• Loose packs may be used to help drainage.

Principles of ﬁ stula treatment:

• Treat any sepsis, ﬂ uid imbalances, and poor nutrition if associated.

• Ensure good drainage to prevent ﬁ stula extension.

• Identify the anatomy, use examination under anaesthetic (EUA) or

imaging if required.

• Biopsy the ﬁ stula if concern over underlying diagnosis.

• Deﬁ nitive treatment requires:

Excision of the organ of origin or closure of the site of origin.•

Removal of chronic ﬁ stula track and surrounding inﬂ amed tissue.•

Closure of ‘recipient’ organ if internal or drainage of external site •

if to skin.

• A sinus is a blind epithelial track, lined by granulation tissue which

extends from a free surface into the tissues, e.g. pilonidal sinus.

• A ﬁ stula is an abnormal communication between two epithelial

surfaces. It is lined by granulation tissue and colonized by bacteria,

e.g. ﬁ stula-in-ano, pancreaticocutaneous, colovesical, vesicovaginal.

CHAPTER 3 Surgical pathology

152

Atherosclerosis

Aetiology

Reversible risk factors include smoking, hypercholesterolaemia, obesity,

and hypertension. Irreversible risk factors include diabetes, male sex, age,

and family history.

Pathological features

• There are three stages of atheromatous lesion; fatty streaks are linear

lesions on the artery lumen, composed of lipid-ﬁ lled macrophages, and

which progress to ﬁ brolipid plaques and ﬁ nally, complex lesions.

• In sites predisposed to atherosclerosis (sites of vessel bifurcation,

turbulent ﬂ ow, post-stenotic areas, areas denuded of endothelial

cells), lipid-laden macrophages enter the vessel wall via gaps between

endothelial cells.

• A ﬁ brolipid plaque contains a mixture of macrophages and smooth

muscle cells which migrate into the plaque, capped by a layer of

ﬁ brous tissue.

• Growth factors, particularly platelet-derived growth factor (PDGF),

stimulate the proliferation of intimal smooth muscle cells and the

synthesis of collagen, elastin, and mucopolysaccharide.

• Lipid accumulates within the plaque extracellularly and in the

myocytes, ultimately producing foam cells.

• Cell death eventually ensues with the release of intracellular lipids,

calciﬁ cation, and a chronic inﬂ ammatory reaction.

• High levels of circulating LDL-cholesterol are thought to lead to

atherosclerosis by damaging endothelium, both directly by increasing

membrane viscosity and indirectly through free radical formation, and

by inducing secretion of PDGF.

• In larger vessels such as the aorta, atherosclerotic plaques may release

atheroemboli and mural thrombus or impinge on the vessel media,

causing tissue atrophy resulting in aneurysm formation or dissection.

• Acute MI is caused by three processes in coronary vessels: progressive

atherosclerosis, disruption of unstable plaque with acute thrombosis,

and acute haemorrhage into the intima around the plaque.

Atherosclerosis is a degenerative disease of large and medium-sized

arteries characterized by lipid deposition and ﬁ brosis.

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CHAPTER 3 Surgical pathology

154

Thromboembolic disease

Thrombus

The formation, structure, and appearance of thrombus and clot are com-

pletely different. Clinical features of thrombus—see b p. 120.

Aetiology

Described by Virchow, the three types of risk factors for thrombus are

called Virchow’s triad (see Box 3.1). Not all three are needed: any one

of them may result in thrombus formation in arteries or veins. Arterial

thrombus is most commonly associated with atheroma, venous thrombus

with stasis.

Thrombus formation

Wherever thrombus forms, the principal mechanisms are similar.

• Initial trigger is one or more of Virchow’s triad.

• Fibrin deposition on vessel wall and formation of platelet layer.

• Red cells trapped in ﬁ brin meshwork on top of platelet layer.

• Mass projects into lumen, causing turbulent blood ﬂ ow.

• Thrombus grows in direction of blood ﬂ ow: propagation.

• In veins, alternating patterns of white platelets and red blood cells may

be seen: lines of Zahn.

• Thrombophlebitis is inﬂ ammation of veins secondary to thrombus.

• Phlebothrombosis is thrombus formation secondary to phlebitis.

• Phlegmasia alba dolens (white painful leg) occurs after slow thrombosis

formation in the ileofemoral veins and is a chronic condition.

• Phlegmasia cerulean dolens (blue painful leg) is due to acute massive

ileofemoral venous thrombosis and can result in shock and gangrene.

• Thrombophlebitis migrans are transient thromboses in previously

healthy veins anywhere in the body, suggesting visceral cancer.

A thrombus is a solid mass of blood constituents formed within the

vascular system.

Box 3.1 Virchow’s triad

• Disruption in the blood vessel endothelium.

Atheromatous plaque, e.g. acute MI.•

Thrombophlebitis, e.g. DVT.•

Trauma, e.g. from pressure, surgery, fractures, previous thrombus.•

• Disruption in the pattern of blood ﬂ ow.

Stasis, e.g. immobilization, surgery, low CO states.•

Turbulence, e.g. post-stenotic, atherosclerotic plaques.•

• Changes in blood constituents.

Age.•

Smoking.•

Malignancy.•

DIC, HITT.•

Pregnancy, oral contraceptive pill.•

THROMBOEMBOLIC DISEASE

155

Embolism

Types of embolism

The aetiology is very different, depending on the cause of embolism.

The clinical effects depend on the territory supplied by the vessel that is

blocked. Emboli can be divided into:

• Systemic emboli (see b p. 642) (cause stroke, end-organ ischaemia, MI);

• PE (see b p. 120).

Both types of embolism can be further classiﬁ ed by the substance

involved:

Thrombus.• Most emboli are derived from thrombi.

Gas.• Injection or entraining of air, decompression sickness.

Fat.• Long bone fractures, severe burns, extensive soft tissue

trauma.

Amniotic ﬂ uid.• i Intrauterine pressure forces ﬂ uid into uterine veins

and into systemic circulation.

Septic emboli.• Vegetations from heart valves.

Atheromatous plaque.• Peripheral vascular disease, iatrogenic.

Tumour.• Common route of metastasis.

Foreign bodies.• IV drug users, medically inserted catheters.

Clot

Clot forms in vessels after death or outside the body as part of the

response to trauma. Activation of the clotting cascade (see b p. 119)

results in formation of ﬁ brin from ﬁ brinogen, resulting in the formation of

ﬁ brin meshwork that enmeshes cells in a solid, elastic clot.

Ischaemia and infarction

Oxygen supply-demand mismatch is caused by:

• Vascular narrowing (atherosclerosis, thrombus, embolus, spasm).

• Global hypoperfusion (shock, cardiopulmonary bypass).

• Hypoxaemia (anaemia, hypoxia).

• Vascular compression (ventricular distension, venous occlusion).

• Increased oxygen demand (exercise, pregnancy, hyperthyroidism).

Pathological features

The shape of the infarct depends on the territory and perfusion of the

occluded vessel.

• Seconds. Change from aerobic to anaerobic metabolism.

• Minutes. d Contractility of muscle, cell and mitochondria swell.

An embolism is a mobile mass of material in the vascular system capable

of blocking its lumen.

A clot is a solid collection of blood cells within a ﬁ brin network.

Ischaemia is tissue effect due to insufﬁ cient oxygen delivery.

Infarction is tissue death due to insufﬁ cient oxygen delivery.

CHAPTER 3 Surgical pathology

156

• Hours. Myocyte death, coagulation necrosis, muscle pale, oedematous.

• Days. Inﬂ ammatory exudates with polymorphonuclear leucocytes, then

ﬁ broblast inﬁ ltration beginning scar formation; macroscopically, the

infarcted area appears yellow and rubbery with haemorrhagic border.

• Weeks. Neovascularization and margins.

• Months. Scar maturation—tough, white, contracted area.

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CHAPTER 3 Surgical pathology

158

Gangrene and capillary ischaemia

Gangrene

Aetiology

• Thrombosis, e.g. appendiceal artery secondary to inﬂ ammation.

• Embolus, e.g. atherosclerotic emboli in peripheral vascular disease.

• Extrinsic compression, e.g. fracture, organ torsion, tourniquet.

Clinical appearances

Dry gangrene

The affected limb, digit, or organ is black because of breakdown of hae-

moglobin, dry, and shrivelled. Dry gangrene shows little or no tendency

to spread. A zone of demarcation appears between the dead and viable

tissue and separation begins to take place by aseptic ulceration in a few

days.

Wet gangrene

Veins as well as arteries are blocked. Pain is initially severe, but lessens as

the patient becomes more septic. There is always infection (putrefaction).

The skin and superﬁ cial tissues become blistered. There is a broad zone

of ulceration which separates it from normal tissue. Proximal spread is a

feature, leading to septicaemia and death.

Gas gangrene

Gangrene complicated by infection with gas-producing anaerobic bacteria,

e.g. Clostridium perfringens. Gases elaborated from putrefaction lead to

surgical emphysema and crepitus (see b p. 175).

Principles of treatment

• Systemic treatment.

Aggressive ﬂ uid resuscitation is often necessary.•

Pain relief (IV morphine 5–10mg).•

IV antibiotics—broad-spectrum (e.g. benzylpenicillin, metronidazole, •

piperacillin/tazobactam, or according to microbiological advice).

• Conservative treatment. Only possible for non-vital organs affected

by dry gangrene (e.g. toes/forefoot). Aim is to let the affected areas

mummify and spontaneously separate.

• Surgical salvage procedures. Conservative excision possibly combined

with reconstruction or restoration of blood supply (e.g. foot

amputation and bypass surgery for distal lower limb gangrene).

• Radical surgical excision. Only possible where affected organ is

completely resectable (e.g. limbs, perineal tissues)—excision must

be radical in spreading or gas gangrene. Ensure all pus is released, all

affected tissue (not just the necrosed area) is excised back to bleeding

healthy tissue. Often requires ‘relook’ surgery to ensure adequate

excision of infected tissue.

Gangrene is ischaemic tissue necrosis with dessication (dry gangrene)

or putrefaction (wet gangrene).

GANGRENE AND CAPILLARY ISCHAEMIA

159

• Palliative care. Consider for unresectable gangrene (e.g. retroperitoneal

gangrene, very extensive intestinal gangrene) or for elderly sick

patients where surgery is inappropriate.

Capillary ischaemia

This is ischaemia mediated by injury to capillaries.

• Frostbite. Exposure to cold with freezing results in ﬁ xed capillary

contraction, ischaemia, and infarction.

• Trenchfoot. Exposure to cold without freezing results in capillary

contraction followed by ﬁ xed dilation.

• DIC (see b p. 116).

• Cryoglobulinaemia, sickle cell, parasites.

CHAPTER 3 Surgical pathology

160

Tumours

Metaplasia

This represents an adaptive response of a tissue to environmental stress.

It is mediated by changes in expression of genes involved in cellular differ-

entiation. It does not progress to malignancy: if the environmental changes

persist, dysplasia may result and progress to malignancy. For example:

• Change from ciliated to squamous cells in the respiratory epithelium of

the trachea and bronchi in smokers;

• Change from squamous to columnar cells in the oesophageal

epithelium of patients with gastro-oesophageal reﬂ ux disease

(Barrett’s) (see b p. 280).

Dysplasia

Potentially premalignant condition. May be a response to chronic inﬂ am-

mation or exposure to carcinogens. Early forms may be reversible: severe

dysplasia has a high risk of progression to malignancy, for example:

• Dysplasia arising in colonic epithelium due to chronic ulcerative colitis.

• Squamous dysplasia in the bronchi of smokers (sputum cytology).

Classiﬁ cation of tumours

Use this classiﬁ cation to give a differential diagnosis for any neoplasm.

• Tissue of origin. Organ and tissue type (see Table 3.1).

• Behaviour. Benign or malignant.

• Primary or secondary.

Benign tumours

• Slow growing, usually encapsulated, do not metastasize, do not recur

if completely excised, rarely endanger life. Effects are due to size and

site.

• Histology: well differentiated, low mitotic rate, resemble tissue of

origin.

Malignant tumours

• These expand and inﬁ ltrate locally, encapsulation is rare, metastasize

to other organs via blood, lymphatics or body spaces, endanger life if

untreated.

• Histology: varying degrees of differentiation from tissue of origin,

pleomorphic (variable cell shapes), high mitotic rate.

Deﬁ nitions

• Metaplasia. Reversible transformation of one type of terminally

differentiated cell into another fully differentiated cell type.

• Dysplasia. Potentially premalignant condition characterized

by increased cell growth, atypical morphology, and altered

differentiation.

• Neoplasia. Autonomous abnormal growth of cells which persists

after the initiating stimulus has been removed.

• A neoplasm is a lesion resulting from neoplasia.

TUMOURS

161

Invasion

Invasion is the most important single criterion for malignancy and is also

responsible for clinical signs and prognosis as well as dictating surgical

management. Factors that enable tumours to invade tissues include:

• Increased cellular motility.

• Loss of contact inhibition of migration and growth.

• Secretion of proteolytic enzymes, such as collagenase, which weakens

normal connective tissue bonds.

• Decreased cellular adhesion.

Metastasis

Metastasis is a consequence of these invasive properties: it is the proc-

ess by which malignant tumours spread from their site of origin (primary

tumour) to form secondary tumours at distant sites. Carcinomatosis

denotes extensive metastatic disease. The routes of metastasis are:

• Haematogenous. Via the bloodstream.

Five tumours—breast, bronchus, kidney, thyroid, prostate—•

classically metastasize via haematogenous spread to bone.

Lung, liver, and brain are common sites for secondaries.•

• Lymphatic. To local, regional, and systemic nodes.

• Transcoelomic. Across pleural, pericardial, and peritoneal cavities.

• Implantation. During surgery or along biopsy tracks.

Table 3.1 Structural classiﬁ cation

Tissue of origin Tumour type

Epithelium Benign: papilloma, adenoma (glandular epithelium)

Malignant: carcinoma (adenocarcinoma, squamous cell

carcinoma indicate cell types)

Connective tissue Benign: ﬁ broma (ﬁ brous tissue), lipoma (fat),

chondroma (cartilage), osteoma (bone), leiomyoma

(smooth muscle), rhabdomyoma (striated muscle)

Malignant: sarcoma, e.g. ﬁ brosarcoma, osteosarcoma,

etc. (if well differentiated); spindle cell sarcoma, etc.

(if poorly differentiated)

Neural tissue These arise from nerve cells, nerve sheaths, and

supporting tissues, e.g. astrocytoma, medulloblastoma,

neurilemmoma, neuroma, etc.

Haemopoietic The leukaemias, Hodgkin’s disease, multiple myeloma,

lymphosarcoma, reticulosarcoma

Melanocytes Melanoma

Mixed origins E.g. ﬁ broadenoma, nephroblastoma, teratoma (all three

germ layers), choriocarcinoma

Developmental

blastomas

E.g. neuroblastoma (adrenal medulla), nephroblastoma

(kidney), retinoblastoma (eye)

CHAPTER 3 Surgical pathology

162

Carcinogenesis

• Initiators produce a permanent change in the cells, but do not

themselves cause cancer, e.g. ionizing radiation: this change may be in

the form of gene mutation.

• Promoters stimulate clonal proliferation of initiated cells, e.g. dietary

factors and hormones: they are not mutagenic.

• Latency is the time between exposure to carcinogen and clinical

recognition of tumour due to:

Time taken for clonal proliferation to produce a signiﬁ cant cell •

mass.

Time taken for exposure to multiple necessary carcinogens.•

• Persistence is when clonal proliferation no longer requires the presence

of initiators or promoters and the tumour cells exhibit autonomous

growth.

See Table 3.2 for a list of common risk factors for cancer.

Tumour growth

Tumour doubling time depends on cell cycle time, growth function, and cell

loss fraction. In tumours such as leukaemias, the doubling time remains

remarkably constant: the cell mass increases proportionally with time.

This is exponential growth. In solid tumours, doubling time slows as size

increases. This is referred to as Gompertzian growth.

Genetic abnormalities in tumours

Two genetic mechanisms of carcinogenesis are proposed:

• Oncogenes. Enhanced expression of stimulatory dominant genes.

• Tumour suppressor genes. Inactivation of recessive inhibitory genes.

Oncogenes

At least 60 oncogenes have been identiﬁ ed. They can be classiﬁ ed accord-

ing to the function of the gene product (e.g. growth factors, cell signalling

agents). The proteins produced (oncoproteins) can be produced in abnor-

mal quantities or be abnormally active forms and cause:

• Independence from extrinsic growth factors.

• Production of tumours in immunotolerant animals.

• Production of proteases to assist in invasion of normal tissues.

• Reduced cell cohesiveness assisting metastasis.

• Growth to higher cell densities and abnormal cellular orientation.

Examples include BRCA1, p53, k-ras, APC, DCC.

Carcinogenesis is the process that results in malignant neoplasm for-

mation. Usually more than one carcinogen is necessary to produce

a tumour, a process which may occur in several steps—multistep

hypothesis.

CARCINOGENESIS

163

Table 3.2 Common risk factors for cancer

Known carcinogen Type of cancer

Chemicals

Polyaromatic hydrocarbons Lung cancer (smoking), skin cancers

Aromatic amines Bladder cancer (rubber and dye workers)

Alkylating agents Leukaemia

Viruses

HIV Kaposi’s sarcoma, lymphoma

Epstein–Barr virus Burkitt’s lymphoma, nasopharyngeal cancer

Human papillomavirus Squamous papilloma (wart), cervical cancer

Hepatitis B virus Liver cell carcinoma

Radiation

UV light (UVB>UVA) Malignant melanoma, basal cell carcinoma

Ionizing radiation Particularly breast, bone, thyroid, marrow

Biological agents

Hormones, e.g. oestrogens Breast and endometrial cancer

Mycotoxins, e.g. aﬂ atoxins Liver cell carcinoma

Parasites, e.g. schistosoma Bladder cancer

Miscellaneous

Asbestos Mesothelioma and lung cancer

Nickel Nasal and lung cancer

Host factors Type of cancer

Race

Caucasians Malignant melanoma, stomach cancer

Diet

High dietary fat Breast, colorectal cancer

Alcohol Breast cancer

Gender, inherited risks

Female sex Breast cancer

Familial polyposis coli Colorectal cancer

Multiple endocrine neoplasia Phaeo, parathyroid, medullary cancer thyroid

BRCA1–17q21 Breast, ovarian and prostate cancer

Premalignant lesions and conditions

Adenomatous rectal polyp Colorectal adenocarcinoma

Mammary ductal hyperplasia Breast carcinoma

Ulcerative colitis Colorectal adenocarcinoma

Transplacental exposure

Diethylstiboesterol Vaginal adenocarcinoma

CHAPTER 3 Surgical pathology

164

Screening

The aim is reduction in morbidity and mortality from screened diseases.

Requirements for successful screening

• Screening test must be:

Sensitive (see • b p. 7).

Speciﬁ c (see • b p. 7).

Safe.•

Inexpensive.•

Acceptable.•

• The population screened must be:

Easily identiﬁ ed and contactable.•

Compliant.•

• The disease screened must be:

Detectable in a treatable, premalignant form or earlier stage.•

Preventable or more amenable to successful or curative •

treatment.

A sufﬁ cient burden on the population to justify cost of screening.•

Chronic or of suitable evolution for sporadic testing to detect it.•

Disadvantages of screening

• Cost (time and resources).

• The beneﬁ t may be small.

• False positive tests may be physically or psychologically detrimental.

Examples of screening programmes

Abdominal aortic aneurysm (4000 deaths/y)

The UK multicentre aneurysm screening study of 68 000 men showed

screening halves aneurysm-related deaths by reducing risk of rupture. The

conclusion was that aneurysm screening should be offered in the UK. The

MASS study showed a beneﬁ t where other studies failed because:

• It was adequately powered (see b p. 8).

• Screening compliance was higher:

GP-based ultrasound had a better compliance than specialist •

clinics.

Participants unlikely to attend were excluded from the study.•

Breast cancer (14 000 deaths/y)

A meta-analysis of thirteen breast cancer screening trials concluded that

screening mammography signiﬁ cantly reduced breast cancer mortality in

women aged 50–74. A BMJ analysis concluded that:

• For every 1000 women screened over 10y, around 200 (depending on

age) are recalled because of an abnormal result and of these:

Around 60 will have at least one biopsy.•

About 15 will have invasive cancer and 5 will have ductal carcinoma •

in situ (DCIS).

Screening is testing any population for a disease.

SCREENING

165

• About 0.5, 2, 3, and 2 fewer deaths from breast cancer occur over 10y

per 1000 women aged 40, 50, 60, and 70y, respectively, who choose to

be screened.

• Ten per cent of invasive carcinoma is not radiologically detectable.

• Risk of a false positive screen is approximately 25% over 10y.

• Studies suggest up to a 30% reduction in mortality from screen-

detected early breast cancer.

• Features looked for on screening mammography include: spiculated

calciﬁ cation, microcalciﬁ cation.

What is offered?

• Since 1988, population-based screening offered.

• Starts age 50 and continues to age 70 (covers peak ages of incidence

of new diagnoses and excludes low risk younger women—prevents

‘psychological morbidity of screening the well’).

• Seventy per cent of women offered it accept screening (lowest take-up

in lower socio-economic groups and those difﬁ cult to contact, e.g.

rapidly changing addresses or no ﬁ xed address).

• Two-view (lateral and oblique) mammography of both breasts.

• Suspicious or malignant-looking lesions invited for clinical assessment

by standard triple assessment.

Cervical cancer (1500 deaths/y)

Since the mid-1980s, incidence of and mortality from cervical cancer in

women under 70 in England and Wales has fallen. Screening is thought to

be the most likely explanation. A BMJ analysis concluded that:

• In the NHS cervical screening programme, 1000 women need to be

screened for 35 years to prevent one death:

150 have an abnormal result and 75 need repeat for inadequate test.•

80 undergo biopsy.•

55 have an abnormal biopsy result.•

2 have carcinoma, the rest have dysplasia.•

• At least one woman dies within the 35y despite being screened.

Prostate cancer (9000 deaths/y)

A third of men over 50y have evidence of prostate cancer at post-mortem,

but less than 1% of these have clinically active disease. Screening is con-

troversial because:

• Prostate-speciﬁ c antigen (PSA), rectal examination, and transrectal

ultrasound have low speciﬁ city and sensitivity alone or in combination.

• Treatment of prostate cancer is controversial (see b p. 374).

• No randomized trial has shown a survival beneﬁ t in screened

populations: screening may cause more harm than good.

• Screening can be carried out on request despite the evidence above.

Colorectal cancer (16 000 deaths/y)

The lifetime risk of colorectal cancer is about 1 in 20. A nationwide screen-

ing programme is likely, following current pilot centres:

• Several possible screening tests exist:

Faecal occult blood (low sensitivity, 90% speciﬁ city)—requires •

colonoscopy for positive results (false positives common).

CHAPTER 3 Surgical pathology

166

Colonoscopy (sensitivity and speciﬁ city near 100%).•

Flexible sigmoidoscopy (sensitivity 80%, speciﬁ city near 100%).•

• Colorectal cancer is suited to screening:

It has a detectable premalignant phase.•

It is detectable at an earlier and potentially highly treatable stage.•

Screening has been shown to be cost-effective and acceptable.•

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CHAPTER 3 Surgical pathology

168

Grading and staging

Key facts

The objectives of staging and grading a tumour are:

• To plan appropriate (treatment) for the individual patient.

• To give an estimate of the prognosis.

• To compare similar cases when assessing outcomes or designing

clinical trials.

Staging and grading methods

Staging

The commonest system is the internationally agreed TNM classiﬁ ca-

tion (see Table 3.3). It is not appropriate for leukaemia, lymphomas, or

myeloma. A four-stage classiﬁ cation (I. II, III, IV) is also often used and is

compatible with TNM. Speciﬁ c staging systems also exist for some tumour

sites (e.g. Duke’s stage in colorectal cancer, see b p. 400).

Staging may be:

• Radiological (often performed preoperatively): indicated by the preﬁ x

‘r’ before the letter (e.g. rT3, rM1). If different radiological modalities

are used, separate preﬁ xes can be used, e.g. ‘u’ for ultrasound (uT2).

Radiological staging is used to plan treatment (e.g. neoadjuvant

therapy, selection for surgery, planning of surgery).

• Pathological (performed on surgical specimens): indicated by the

preﬁ x ‘p’ before the letter (e.g. pT3, pN2, pM1). If there has

preoperative radiotherapy used, the preﬁ x ‘y’ is used to denoted that

the pathological stage may have been modiﬁ ed by this (e.g. ypT2).

Pathological staging is used to plan adjuvant treatment (chemotherapy

or radiotherapy) and for informing prognosis.

An example of lung cancer staging is:

• Stage I (T1N0, T2N0), 85% 5y survival with surgery.

• Stage II (T1N1, T2N1, T3N0), 60% 5y survival with surgery.

• Stage IIIa (T3N1 or any N2), 20% 5y survival with surgery.

• Stage IIIb (any T4, any N3), <20% 5y survival, no beneﬁ t with surgery.

• Stage IV (M1), <10% 5y survival, no beneﬁ t with surgery.

Other pathological features may be included with the TNM system for

some tumours, for example:

• Presence of extratumoural vascular invasion V0 or V1.

• Presence of extratumoural lymphatic invasion Ly0 or Ly1.

• Presence of viable tumour cells at or within 1mm of the surgical

margin of excision R0, R1 (microscopic), R2 (macroscopic).

• Staging is the process of assessing the extent of local and systemic

spread of a malignant tumour or the identiﬁ cation of features which

are risk factors for spread.

• Grading is the process of assessing the degree of differentiation of a

malignant tumour.

GRADING AND STAGING

169

Histological grading

Gives a guide to the behaviour of a cancer by describing the degree of

differentiation of the tumour (e.g. breast cancer).

• Grade 1, represents the least malignant tumours.

• Grade 2, 25–50% of the cells are undifferentiated.

• Grade 3, 50–75% of the cells are undifferentiated.

• Grade 4, >75% of the cells are undifferentiated.

Other methods of describing tumours

• Depth of invasion (e.g. Breslow thickness in malignant melanoma).

• Tumour type (e.g. small cell versus non-small cell lung cancer).

Table 3.3 Basic form of TNM classiﬁ cation*

Classiﬁ cation Interpretation

Primary tumour (T)

TX Primary tumour cannot be

evaluated

T0 No evidence of primary tumour

Tis Tumour in situ

T1, T2, T3, T4 Size and extent of primary tumour

Regional lymph nodes (N)

NX Regional lymph nodes cannot be

evaluated

N0 No regional lymph node

involvement

N1, N2, N3 Number and location of involved

lymph nodes

Distant metastasis (M)

MX Distant metastasis cannot be

evaluated

M0 No distant metastasis

M1 Distant metastasis

* Additional codes used with the TNM: pul, pulmonary; hep, hepatic; V, vascular; Ly, lymphatic

vessels; R, radial margin. Preﬁ xes used with the TNM: u, ultrasound; r, radiological; p,

pathological.

CHAPTER 3 Surgical pathology

170

Tumour markers

Key facts

• Tumour markers (see Table 3.4) are complex molecules, often

proteins that can be detected by a variety of techniques, including

chemical, immunological, or bioactivity testing.

• Most are molecules normally produced by normal cells in small

amounts, but which may be produced in increased amounts by tumour

cells due to changes in cellular function (e.g. increased production,

increased gene expression, decreased degradation, increased release).

Testing

Testing is most commonly in vitro via serum measurements or testing tis-

sue specimens. Common uses include:

• Screening (detection of subclinical disease).

• Diagnosis (including differentiation of tumour origin in metastatic

disease).

• Monitoring response to treatment.

• Monitoring for development of recurrence.

Non-tumour related elevations in tumour marker levels (reducing the spe-

ciﬁ city of these tests for tumours) may occur due to:

• Increased production/release due to inﬂ ammation, infection, trauma,

or surgery.

• Decreased removal/destruction due to renal or liver disease.

Abbreviations for some tumour markers

• AFP (alpha-fetoprotein).

• β-HCG (beta-human chorionic gonadotrophin).

• PAP (placental alkaline phosphatase).

• CEA (carcinoembryonic antigen).

• LDH (lactic dehydrogenase).

• PSA (prostate-speciﬁ c antigen).

TUMOUR MARKERS

171

Table 3.4 Commonly used tumour markers

Marker Useful in Notes/use

AFP Hepatoma; teratoma

(75% of cases); pancreatic

carcinoma some patients)

Elevated in liver disease,

e.g. hepatitis, cirrhosis, and

pregnancy

β-HCG Choriocarcinoma (almost

all cases); testicular

tumours/teratoma (75%);

other germ cell tumours

Measured both in blood

and urine

PAP Seminoma; ovarian

adenocarcinoma

CEA Colonic adenocarcinoma;

ovarian adenocarcinoma;

advanced breast cancer;

pancreatic cancer

Not useful for diagnosis or

screening. Used to monitor

response to treatment and

identify relapse in tumours

showing raised CEA at

diagnosis. May be elevated

in pancreatitis, ulcerative

colitis, gastritis, and heavy

smokers

CA 19–9 Pancreatic cancer (80%);

advanced colorectal cancer

(75%)

A polysialated antigen

(Lewis blood group antigen).

Ratio of CA 19–9:CEA most

sensitive for pancreatic

cancer diagnosis

LDH Lymphoma

Thyroglobulin Thyroid cancer Used to monitor and

identify relapse after

treatment

Calcitonin Medullary carcinoma of the

thyroid

Used to monitor and

identify relapse after

treatment

PSA Prostate cancer May be measured in

serum and tissue by

immunohistochemistry.

Serum level closely relates

to disease status

Alkaline

phosphatase

Osteosarcoma Also raised in bony

metastases, osteitis, Paget’s

disease

CHAPTER 3 Surgical pathology

172

Surgical microbiology

Key facts

• Three-quarters of nosocomial infection occur in surgical patients who

account for 40% of hospital inpatients.

• Risk factors for wound infection include the type of surgery, patient age,

malnutrition, immunosuppression, obesity, lack of appropriate antibiotic

prophylaxis, foreign bodies, and residual malignancy or necrotic tissue.

Nosocomial infections are acquired in hospital.

Community acquired infections are acquired outside hospital.

Sources of surgical infection

Three-quarters of nosocomial infections occur in surgical patients (see

Table 3.5) who account for 40% of hospital inpatients. Sources of infection

include:

• Patient’s own body ﬂ ora:

Failure of correct aseptic technique.•

Contaminated surgery (see • b p. 146).

• Indirect contact:

Contact from hands of doctors, nursing staff, patients, visitors.•

Contaminated surfaces, e.g. door handles, cups.•

• Direct inoculation:

Surgeon or environmental ﬂ ora through failure of aseptic technique.•

Contaminated instruments or dressings.•

Colonization of indwelling drains, catheters, intravenous lines.•

• Airborne contamination:

Skin and clothing of staff, patients, and visitors.•

Air ﬂ ow in operating theatre or ward.•

• Haematogenous spread:

Intravenous and intra-arterial lines.•

Contaminated infusions.•

Sepsis at other anatomical sites.•

• Food and waterborne.

• Faecal-oral.

• Insect borne.

Risk factors for wound infection

• General:

Age.•

Malnutrition, obesity, malnutrition.•

Immunosuppression, including steroid therapy, chemotherapy.•

Endocrine and metabolic disorders, e.g. diabetes, jaundice, uraemia.•

Hypoxia and anaemia.•

• Local:

Type of surgery (see Table 3.5), lengthy procedures.•

Necrotic tissue.•

Residual local malignancy.•

Foreign bodies, including prosthetic implants.•

Ischaemia, haematoma.•

SURGICAL MICROBIOLOGY

173

• Microbiology:

Lack of antibiotic prophylaxis.•

Type and virulence of organism, size of inoculate.•

Modes of occupational infections of health workers

• Direct percutaneous inoculation of infected blood (e.g. needle-stick

injury, scalpel wounds).

• Entry of infection through minute skin abrasions after contact with

spilled infectious bodily ﬂ uids (e.g. blood, saliva, semen, urine, faeces).

• Entry of infection via mucosal surfaces after exposure to contaminated

infectious bodily ﬂ uids (e.g. eye splashes in theatre, faecal-oral route).

• Transfer of infection by fomites (e.g. via contaminated equipment—

prions transferred by neurosurgical equipment).

Procedures designed to minimize transmission

See also b p. 174 for HIV and hepatitis.

• Identify infected (infectious) patients by serology.

• Identify potentially infected (infectious) patients by risk factors (e.g. IV

drug users at risk from hepatitis B carriage).

• Speciﬁ c procedures for the care of infected (infectious) patients (e.g.

barrier nursing for C. difﬁ cile diarrhoea).

• Careful disposal of disposable items related to patient care.

• Speciﬁ c treatment and sterilization of non-disposable equipment.

• Additional/speciﬁ c precautions for theatre staff:

Make all procedures ‘safe’ procedures by having the highest •

standards of safety and care using instruments and sharps:

remember ALL patients may be infected/infectious.

Wearing of plastic aprons in procedures with expected soiling with •

urine/faeces/ascites.

Wearing of two pairs of gloves to reduce the risk of skin exposure •

when gloves tear.

Wearing of re-enforced gloves for procedures with a high risk of •

penetrating injury (e.g. fragmented fractures).

Wearing of glasses, goggles, or visors for eye protection.•

Handle all sharps using a transfer container: never pass them hand •

to hand.

Don’t allow unnecessary blood or ﬂ uid spillage.•

Table 3.5 Expected wound infection rates after surgical procedures

Type of surgery

Rate of post-operative

infection (%)

Clean (no viscus opened), e.g. hernia repair <2

Clean contaminated (viscus opened minimal

spillage), e.g. cholecystectomy

<10

Contaminated (open viscus with spillage or

inﬂ ammatory disease), e.g. simple appendicectomy

15–20

Dirty (pus or perforation or incision through

abscess), e.g. perforated appendicectomy

>40

CHAPTER 3 Surgical pathology

174

Surgically important organisms

Normal body ﬂ ora

These are usually involved in infections in surgical patients and include:

Staphylococci

• Normal ﬂ ora of skin, oropharynx, and nasopharynx.

• S. aureus is an important pathogen in many surgical infections.

• S. aureus is the only staphylococcus that can coagulate plasma.

• ‘Coagulase negative’ effectively means non S. aureus staph, e.g. S.

epidermis: they are usually dismissed as contaminants, but they are

an increasingly common cause of line and prosthesis infections,

particularly in immunocompromised patients.

• Antibiotic sensitivities: cephalosporins especially cefuroxime, gentamicin,

fusidic acid, vancomycin, rifampicin, teicoplanin.

• Antiseptic sensitivities: chlorhexidine, povidone-iodine.

• Methicillin-resistant S. aureus (MRSA) is resistant to all cephalosporins;

vancomycin, teicoplanin, fusidic acid should be reserved to treat this.

Streptococci

• Normal ﬂ ora of skin, oropharynx, and nasopharynx.

• ‘α-haemolytic’ streptococci haemolyse blood agar, e.g. S. pyogenes.

• ‘B-haemolytic’ streptococci also haemolyse erythrocytes, e.g. S. viridens.

• Pneumococci and enterococci (below) are subtypes of streptococci.

• S. pyogenes has been called ‘the most important human pathogen’: it

causes ‘strep throat’, a range of skin infections, septicaemia, necrotizing

fasciitis, toxic shock syndrome, and valvular disease in rheumatic fever.

• Antibiotic sensitivities: penicillin, erythromycin, cephalosporins,

clindamycin, fusidic acid, mupirocin.

• Antiseptic sensitivities: chlorhexidine, povidone-iodine.

Enterococci

• Normal ﬂ ora of large intestine.

• These are an increasingly important cause of nosocomial infections.

• Involved in wound infections, intra-abdominal sepsis, urinary tract

infections, intravascular line infections, and dialysis-related infections.

• Antibiotic sensitivities: enterococci are intrinsically resistant to many

antibiotics, including all cephalosporins, and must usually be treated by

a combination drug regime, e.g. ampicillin plus glycoside.

• Vancomycin-resistant enterococcus (VRE) is resistant to all

cephalosporins and vancomycin, and sometimes teicoplanin.

‘The Gram-negative rods’

• Normal ﬂ ora of large intestine.

• Gram-negative bacilli (also known as coliforms) include Escherichia coli,

Salmonella, Klebsiella, Enterobacter, and Proteus.

• Pseudomonas and Actinobacter are non-coliform Gram-negatives.

•

Antibiotic sensitivities: most are intrinsically resistant to penicillin

and there is increasing resistance to amoxicillin and ampicillin;

cephalosporins are the commonest ﬁ rst-line treatment for non-

resistant forms or ‘extended range’ penicillins (e.g. piperacillin/

SURGICALLY IMPORTANT ORGANISMS

175

tazobactam), aminoglycosides (e.g. gentamicin, streptomycin, amikacin,

tobramycin), alone or in combination with cephalosporins, offer good

bactericidal action.

Anaerobes

• Normal ﬂ ora of skin, oropharynx, large bowel, terminal ileum, and

genitourinary tract.

• Include Bacteroides and clostridia (bowel).

• C. difﬁ cile causes pseudomembranous colitis (see b p. 396).

• Cause anaerobic infections, including cellulitis, gas gangrene,

empyemas, and colonize diabetic foot ulcers.

• Act usually with aerobes to produce ‘synergistic’ necrotizing infections

of skin, fascia, and muscle spontaneously or after trauma or surgery.

• Antibiotic sensitivities: metronidazole is only active against anaerobes

and resistance is rare; most anaerobes are also sensitive to penicillins,

cephalosporins, clindamycin, erythromycin, and co-trimoxazole.

Speciﬁ c infections

Gas gangrene

Gas gangrene is caused by Clostridium perfringens, a Gram-positive bacillus,

found in soil or faeces. Injury may be trivial. More common in immuno-

compromised patients. There is exudate and gas in the tissues; skeletal

muscle is affected. Oedema, spreading gangrene, and systemic signs follow.

Aggressive debridement and fasciotomies are required, with resuscitation,

organ support, and penicillin (2g 4-hourly IV) and metronidazole.

Synergistic spreading gangrene (Meleney’s or Fournier’s gangrene)

Also known as necrotizing fasciitis. The organisms involved are not clostrid-

ial, but rather aerobes and synergistic microaerophilic/anaerobes. Patients

may be immunocompromised. The initial wound might have been minor

or an uneventful operation. Severe wound pain and gas in the tissues

(crepitus) may be seen: the extent of subdermal gangrene may not be

apparent. Systemic support and antibiotics are required, with excision of

involved tissues.

Tetanus

This is a rare infection in the UK, but is common in many parts of the

world, with a mortality rate of about 60%. The causal organism, Clostridium

tetani, produces a powerful exotoxin which is neurotoxic. It enters the

spinal cord via peripheral nerves where it blocks inhibitory spinal reﬂ exes.

It is found widely: infection often follows a trivial puncture wound.

Treatment is benzylpenicillin, 1g every 6h IV, metronidazole, and human

anti-tetanus immunoglobulin 30U/kg IM. If a wound is present, it is excised

and left open to heal by secondary intention. Immunization with 10-yearly

boosters is protective.

CHAPTER 3 Surgical pathology

176

Soft tissue infections

Cellulitis is the presence of actively dividing infectious bacteria within

the skin tissues.

Abscess is a liquid collection of pus lined by granulation tissue and ﬁ bro-

sis (if chronic).

Lymphangitis is the presence of actively dividing infectious bacteria in

the lymphatic vessels of an area of the body.

Fasciitis is inﬂ ammation of connective tissue that may be infective.

Myositis is infection or inﬂ ammation of muscle tissue.

Cellulitis

Pathological features

• Skin entry by pathogenic bacteria (scratch, ulcer, hair follicle).

• Usually Gram +ve cocci (e.g. Streptococcus pyogenes, S. aureus).

• Usually heals by resolution if treated promptly.

• Spread may result in lymphangitis, suppuration results in a furuncle (skin

gland), carbuncle (upper dermis), or an abscess (deep skin tissue).

Clinical features

• Skin widely involved: warm, red (usually blanches with pressure),

swollen (often pitting), and exquisitely painful.

• Crepitus indicates the development of gas-forming tissue necrosis

which may be an emergency (see b p. 175).

Treatment

• IV antibiotics: benzylpenicillin (1g qds) and ﬂ ucloxacillin (500mg qds).

• Always assess with microscopy and culture, if possible.

Abscess

Pathological features

• Contain polymorphonuclear neutrophils (PMNs)/macrophages,

lymphocytes (live and dead), bacteria (dead and viable), and liqueﬁ ed

tissue products.

• May rupture (‘pointing’), discharge into another organ (forming a

ﬁ stula eventually), or open onto another epithelial surface (sinus) (see

b p. 151).

• Incomplete treatment due to resistant organisms (mycobacteria) or

poor treatment may lead to chronic abscesses.

• Complete elimination of the organisms in a chronic abscess without

drainage can lead to a ‘sterile abscess’ (‘anti-bioma’).

Typical causes

• Suppuration of tissue infection (e.g. renal abscess from pyelonephritis).

• Contained infected collections (e.g. subphrenic abscesses).

• Haematogenous spread during bacteraemias (e.g. cerebral abscesses).

Diagnosis

• Deep abscesses are characterized by swing fever, rigors, high WCC,

and high CRP. Untreated, they lead to catabolism, weight loss, and a

SOFT TISSUE INFECTIONS

177

falling serum albumin. Ultrasound, CT, MRI, or isotope studies may be

necessary to conﬁ rm the diagnosis.

Treatment

• Drain the pus, e.g. incision and drainage (perianal abscess), CT-guided

drain (renal abscess), closed surgical drainage (chest empyema), or

surgical drainage and debridement (intra-abdominal abscess).

• IV antibiotics (may require course of several weeks, indicating PICC

line insertion).

Fasciitis

Suspect when pain, oedema, and skin necrosis appear within 24–48h of

injury or operation.

Signs

The skin may be normal, oedematous, or mottled. There may be spiking

fever, hypotension, mental confusion.

Treatment

• IV ﬂ uids; extensive excision may be indicated.

• Antibiotics on the basis of Gram stain.

• Dress incisions with moist gauze impregnated with dilute aqueous

antiseptics. Change these frequently under general anaesthetic.

Myositis

The bacterial infection has penetrated and destroyed muscle bundles.

Cause

Usually Clostridium perfringens, a Gram-positive, anaerobic, spore-forming

rod.

Management

• Recognize the condition: there is oedema and serosanguinous exudate;

exposed muscle is swollen and ranges from salmon pink to

• deep green/black in appearance. Crepitation may be present. There is

a ‘sickly sweet’ smell.

• Excise dead tissue until healthy, contractile, bleeding muscle is

encountered.

• Carry out Gram staining immediately. Streptococcal myositis rarely

needs amputation, clostridial may.

• Replace extracellular ﬂ uid (ECF) deﬁ cit. Transfuse if needed.

• High-dose penicillin (IM or IV, 0.6–1.2g every 2h). May need

antianaerobic therapy.

• Excision of all infected tissue may necessitate full thickness excision of

abdominal wall with prosthetic mesh replacement. Amputations are

performed by guillotine technique and the wounds packed open.

• There is no proven advantage to hydrogen peroxide dressings or

the use of hyperbaric oxygen, but passive immunization in proven

clostridial gangrene has been suggested, using a variety of bacterially

derived products.

Osteomyelitis Covered on b pp. 558–62.

CHAPTER 3 Surgical pathology

178

Blood-borne viruses and surgery

Viral hepatitis

• Commonest liver disease in the world.

• May cause acute liver failure or chronic active hepatitis.

Hepatitis A

Formerly known as infectious hepatitis. This is the most common form of

jaundice in children and young adults.

• Spread is by the faecal-oral route; the incubation period is 1 month.

• The antibody to the virus is anti-HAV.

• There is no vaccine and health care workers do not have to be tested.

Hepatitis B

• Double-shelled DNA virus: 565 new cases in UK in 2000. Ten per

cent of adults fail to clear the virus after infection. Up to 5% people

worldwide are carriers.

• Infection is largely blood-borne and is transmitted by blood transfusion,

inoculation, sharing syringes (drug addicts), sexual intercourse during

menstruation (with an infected partner), and anal intercourse.

• Transmission from a contaminated sharps injury is 30%.

• Antigens appear in the serum: HBsAg, the surface antigen; HBcAg,

the hepatitis core antigen; HBeAg, the ‘e’ antigen; the Dane particle;

double-stranded DNA; and DNA polymerase activity.

• Antibodies formed against these antigens (anti-HBs, anti-HBe) can be

detected in the peripheral blood:

HBsAg +ve.• Failure to clear infection, residual infectivity.

HBsAb +ve.• Protection marker from immunization or infection.

HBeAg +ve.• Close correlation of infectivity.

• Hospital staff are routinely offered vaccination for hepatitis B:

Infectious carriers may not perform exposure-prone procedures.•

Vaccination against hepatitis B is not compulsory. The alternatives •

are frequent testing to check infectivity or limited clinical practice.

The NHS Injury Beneﬁ ts Scheme provides some beneﬁ ts where •

hepatitis B has been occupationally acquired.

• Treatment. Any health care worker who remains HBeAg +ve may

undergo antiviral therapy under supervision by a hepatologist including:

Immunomodulation with interferon.•

Viral suppression with nucleoside analogues.•

Hepatitis C

RNA virus which causes cirrhosis of the liver and primary liver cancer.

There is no vaccination. Detected in 1 in 150 screened blood donations:

0.4% of the UK population are chronically infected. Transmission from a

contaminated sharps injury is 2–3%. Surgeons must be tested for hepatitis C

and may not carry out exposure-prone procedures if hepatitis C +ve.

Human immunodeﬁ ciency virus (HIV)

Double-stranded RNA retrovirus transmitted by passage of infected body

ﬂ uids from one person to another by several methods: anal and vaginal

sexual intercourse, peripartum, sharps, and infected blood products.

BLOOD-BORNE VIRUSES AND SURGERY

179

• HIV infection results in widespread immunological dysfunction,

manifested by a fall in CD4 +ve lymphocytes, monocytes, and antigen-

presenting cells (APCs).

• There is usually a 3-month asymptomatic, but infective viraemia.

• During this period, ELISA tests for HIV antibodies are negative.

• At seroconversion, an acute illness can occur.

• This is followed by generalized lymphadenopathy.

• Acquired immunodeﬁ ciency syndrome (AIDS) develops in 5–10y.

• Median survival with untreated AIDS is 2y, treated is >20y.

High risk populations (2004 WHO statistics)

• Prevalence in adult population of southern Africa is 15–30%.

• Prevalence in adult population of sub-Saharan Africa is 5–15%.

• Prevalence in homosexual men at London genitourinary clinics is 10%.

• Prevalence of HIV in injecting drug users in UK is about 1%.

High risk procedures

The UK General Medical Council (GMC) has made it clear that surgeons

are obliged, if required, to operate on patients with AIDS or HIV infection.

Always use universal precautions. High risk procedures include:

• Any invasive procedure in HIV +ve patients.

• Invasive procedures in at-risk populations (see above).

• Biopsies for the diagnosis of opportunistic infection or suspected HIV.

• Procedures to deal with malignancies, e.g. Kaposi’s sarcoma, B-cell and

non-Hodgkin’s lymphoma, squamous oral carcinoma.

Precautions and post-exposure prophylaxis (PEP)

• The HIV risk from an HIV contaminated hollow needle is 0.3%.

• The risk from splashes on broken skin or mucous membranes is 0.1%.

• PEP 2 Go to occupational health or A&E out of hours. PEP

reduces the risk of seroconversion by over 80% if started within

1h of exposure; PEP is continued for 4 weeks. Side effects include

diarrhoea and vomiting.

Universal precautions

These are designed to protect workers from exposure to diseases

spread by blood and body ﬂ uids. 2 All patients are assumed to be infec-

tious for blood-borne diseases, including HIV.

• They apply to blood; amniotic, synovial, pleural, peritoneal and

pericardial ﬂ uid; semen, vaginal secretions; and CSF.

• They do not apply to faeces, sputum, urine, vomit, or saliva.

• Universal precautions include:

Use of protective clothing, e.g. gloves, gowns, masks, eye-guards.•

Removing hazards from work place, e.g. sharps bins, ventilation.•

Work practice, e.g. hand washing, handling of sharps, transport of •

soiled goods, reducing unnecessary procedures.

Single use disposable injection equipment.•

Hospital policy for all sharps injuries: squeeze, wash, and report.•

CHAPTER 3 Surgical pathology

180

Bleeding and coagulation

Blood products and transfusion reactions are described on (b

pp. 96–9).

Haemostasis

This is the physiological process by which bleeding is controlled. It has

four components:

• Vessel wall response, primarily vasoconstriction due to smooth muscle

contraction, is the ﬁ rst response.

• Platelet activity results in formation of a platelet plug.

Platelets • adhere to exposed endothelial collagen, a process which

required von Willebrand factor (VWF) (factor VIII).

Release of adenosine diphosphate (ADP), arachidonic acid, •

prostaglandin, and thromboxane A2 promotes platelet aggregation.

Aggregated platelets react with thrombin and ﬁ brin, forming a • plug.

Aspirin• irreversibly inhibits the cyclooxygenase-mediated formation of

prostaglandin, lasting for the life of the platelet (7–10 days); clopidogrel

irreversibly inhibits ADP-mediated aggregation (7–10 days).

• The coagulation cascade converts prothrombin to thrombin to

produce a ﬁ brin clot: two interacting pathways are involved.

The • intrinsic pathway involves only normal blood components and

starts when factor XII (Hageman factor) is activated by binding to a

damaged vessel, resulting in the sequential activation of factors XI,

IX, VIII, and X.

The • extrinsic pathway requires thromboplastin (a tissue

phospholipid) which forms a complex with calcium and factor VII,

which activates factor X.

Both these pathways converge at the activation of factor X, which •

converts prothrombin to thrombin: thrombin converts soluble

ﬁ brinogen to ﬁ brin to produce a stable clot.

All of the soluble factors are manufactured by the liver except •

factor VIII (made by endothelium).

Warfarin• inhibits the manufacture of vitamin K-dependent clotting

factors (prothrombin, VII, IX, and X): taking 3–4 days to have effect.

• The ﬁ brinolytic system terminates thrombus propagation to maintain

circulating blood in a ﬂ uid state; it depends on four proteins.

Plasmin• , a serine protease which is produced by the action of

thrombin on plasminogen and attacks unstable bonds between

ﬁ brin molecules to generate ﬁ brin degradation products.

Antithrombin• III which deactivates thrombin, XIIa, IXa, and Xa.

Proteins• C and S which prevent thrombin generation by binding

factors Va and VIIIa. Tissue factor pathway inhibitor, produced by

platelets, inhibits factors Xa and VIIa.

Heparin• potentiates antithrombin III with immediate effect;

protamine binds heparin, reversing its effect almost immediately.

Disorders of haemostasis

These can be thought of in terms of the four components below:

• Vessel wall abnormalities, e.g. Henoch–Schonlein purpura, Cushing’s

syndrome, steroid use, vitamin C deﬁ ciency (scurvy).

BLEEDING AND COAGULATION

181

• Platelet abnormalities.

Thrombocytopaenia• (<100 x 10

) caused by reduced production

(bone marrow failure, radiotherapy, chemotherapy, inﬁ ltrative

disease, e.g. neoplasia, leukaemia); faulty maturation (e.g. folate and

B12 deﬁ ciency); abnormal distribution (splenomegaly); increased

destruction (autoimmune disorders, drugs, DIC, haemorrhage);

dilutional thrombocytopaenia in massive banked blood transfusion.

Abnormal function• , e.g. von Willebrand’s disease, uraemia, idiopathic

causes, drug effects, especially aspirin and clopidogrel.

• Coagulation abnormalities.

Congenital• , e.g. haemophilia A (d factor VIII), haemophilia B or

Christmas disease (d factor IX), von Willebrand’s disease (d VWF).

Acquired• , e.g. DIC (see b p. 118); d vitamin K (which is produced

by gut ﬂ ora) secondary to poor nutrition, antibiotic therapy,

obstructive jaundice; liver disease; exogenous anticoagulants.

Preoperative evaluation of haemostasis

NICE guidelines

• Routine testing not recommended unless patient is ASA 3 as a result

of renal disease.

• For at-risk patients undergoing ‘major +’ cardiac or neurosurgery,

testing may be considered.

History and examination

• Ask about bleeding problems, e.g. menorrhagia, bruising, family history

of bleeding, and medication (speciﬁ cally aspirin, clopidogrel, and

warfarin which should all be stopped 5 days before elective surgery)

(see b p. 72).

• Look for petechiae and purpura, jaundice, and hepatosplenomegaly.

Laboratory investigation

• Platelet count. Normally 200–400 x 10

/L; 70 x 10

/L is needed for

surgical haemostasis, <20 x 10

/L results in spontaneous bleeding.

• Blood ﬁ lm. Estimate of platelet count and indicates morphology.

• Bleeding time. Useful as normal bleeding time indicates normal

platelets, normal function, and normal vascular response to injury, but

uncommonly used as a screening test.

• Prothrombin time (PT). Reﬂ ects the extrinsic pathway (I, II, V, VII, X).

• Partial thromboplastin time (PTT). Reﬂ ects the intrinsic pathway (all

factors except VII).

• Individual clotting factor assays.

• Thrombin time (TT). Rate of conversion from ﬁ brin to ﬁ brinogen.

• Fibrin degradation products. These are released by the action of plasmin

and are raised in DIC.

Principles of management

• Indications for FFP, platelets, and anti-ﬁ brinolytics are listed on b p. 96.

• IV heparin may be reversed with protamine and/or FFP.

• Warfarin may be reversed over 12–24h with 1mg vitamin K SC or

acutely with FFP.

CHAPTER 3 Surgical pathology

182

Anaemia and polycythaemia

Anaemia

This is a reduction in haemoglobin concentration below normal (approxi-

mately 13–16g/dL in men, 11.5–15g/dL in females). It is classiﬁ ed as

follows:

• Decreased red cell production.

Haematinic deﬁ ciency (• d Fe, B12

folic acid).

Bone marrow failure (congenital, chemotherapy, radiotherapy, •

inﬁ ltrative disease).

• Abnormal red cell maturation.

Myelodysplasia.•

Sideroblastic anaemia.•

• Increased red cell destruction (haemolytic anaemias).

Inherited (e.g. sickle cell, thalassaemia).•

Acquired (e.g. autoimmune, DIC—see • b p. 118).

• Chronic disease (common cause of anaemia in surgical patients).

Renal failure (• d production of erythropoietin).

Endocrine, liver disease.•

Iron deﬁ ciency anaemia

Commonest cause of anaemia in surgical patients. Causes include:

• Menstruation (in 15% of females).

• GI losses (peptic ulcer, oesophagitis, gastric carcinoma, colorectal

carcinoma).

• Reduced iron uptake (poor diet, coeliac disease, malabsorption).

Sickle cell anaemia

Single base substitution gene defect causing an amino acid substitution in

haemoglobin, making HbS instead of HbA. Deoxygenated HbS polymer-

izes and causes red blood cells to sickle, resulting in occlusion of small

blood vessels and infarction. Common in black Africans. Homozygotes

have high levels of HbS and are prone to crises. Heterozygotes (‘sickle

trait’) are only symptomatic in hypoxic conditions, e.g. unpressurized air-

craft, limb ischaemia.

• Most patients are diagnosed: screening for sickle cell is widespread.

• The patient typically has an Hb of 6–8g/dL, reticulocytes 10–20%.

• There are three types of sickle cell ‘crisis’:

Thrombotic crises.• Precipitate by cold, dehydration, infection,

ischaemia, may mimic acute abdomen or pneumonia, priapism;

Aplastic crises.• Due to parvoviruses and require urgent transfusion;

Sequestration crises.• Spleen and liver enlarge rapidly from trapped

erythrocytes, resulting in right upper quadrant (RUQ) pain, i INR,

i LFT, dd Hb.

• Treatment involves removing causes and decreasing percentage of

HbS.

Keep warm and well hydrated, if necessary with IV ﬂ uids.•

Give O•

ANAEMIA AND POLYCYTHAEMIA

183

Give opiate analgesia.•

Empirical antibiotics if any evidence of sepsis.•

If Hb <6g/L, give blood; if Hb >9g/dL, exchange transfusion.•

• Exchange transfusion to maintain HbA >60% before cardiac surgery.

Thalassaemia

Thalassaemias are genetic diseases of Hb synthesis, resulting in underpro-

duction of one chain which results in destruction of red cells while they

are still in the bone marrow. α-thalassaemia leads to d α chain production

with unbalanced β chain production and β-thalassaemia leads to d β chain

production. Common in the Mediterranean to Far East.

• Severity correlates with the genetic deﬁ cit.

• Death may result by 1y of age without transfusion.

• Symptoms of iron overload after 10y: endocrine failure, liver disease,

and cardiac toxicity.

• Death at 20–30y due to cardiac siderosis.

Preoperative screening of anaemia: NICE guidelines

• FBC ‘should be considered’ for all surgery in adults >60y of age.

• FBC is recommended for ‘intermediate’ surgery (e.g. primary repair of

inguinal hernia, varicose vein surgery) in adults >60y of age.

• FBC is recommended in any adult undergoing major surgery.

• Sickle cell screening is recommended in any patient of African descent

undergoing a general anaesthetic: consent should be obtained.

Preoperative evaluation of anaemia

d Mean cell volume (MCV) or microcytic anaemia

• Iron deﬁ ciency (blood loss, dietary): d serum ferritin and iron, i total

iron binding capacity (TIBC).

• Thalassaemia (i serum iron and ferritin, d TIBC).

• Hyperthyroidism.

i MCV or macrocytic anaemia

• B12 or folate deﬁ ciency (dietary, pernicious anaemia, anti-folate drugs).

• Alcohol.

• Liver disease.

• Myelodysplasia and bone marrow inﬁ ltration.

• Hypothyroidism.

Normal MCV or normocytic anaemia

Anaemia of chronic disease, renal failure, bone marrow failure, haemolysis,

pregnancy, dilutional.

Management of anaemia

• Elective patients should be investigated and treated appropriately.

• Blood transfusion (see b p. 96) is indicated in patients with Hb <8g/

dL undergoing emergency or elective surgery.

• Evidence suggests that maintaining Hb 7–9g/dL has a better outcome

than maintaining Hb 10–12g/dL, except in patients with unstable

angina.

CHAPTER 3 Surgical pathology

184

Polycythaemia

• Relative (d plasma volume). Dehydration from alcohol or diuretics).

• Absolute (i red cell mass).

Primary• (polycythaemia rubra vera).

Secondary• (altitude, smoking, COPD, tumours, e.g. ﬁ broids).

• Treat underlying cause; consider venesection.

185

Practical procedures

Endotracheal intubation 186

Cardioversion 188

Deﬁ brillation 190

Venepuncture 192

Intravenous cannulation 194

Arterial puncture and lines 196

Insertion of central venous catheter 198

Chest drain insertion 200

Management of chest drains 202

Pericardiocentesis 204

Cricothyroidotomy 206

Nasogastric tube insertion 208

Urethral catheterization 210

Suprapubic catheterization 212

Paracentesis abdominis 214

Rigid sigmoidoscopy 216

Local anaesthesia 218

Intercostal nerve block 220

Chapter 4

CHAPTER 4 Practical procedures

186

Endotracheal intubation

Key facts

Indicated in cardiac arrest, serious head injury, certain acute respiratory

and trauma settings, and prior to many surgical operations.

• 2 Effective bag-and-mask ventilation is better than ineffective attempts

at endotracheal intubation in the arrest setting.

• 2 Except in a dire emergency, this procedure should not be

performed without expert supervision.

Equipment

• Empty 10mL syringe.

• Endotracheal tube (ET; size 8–9 for females and 9–11 for males).

• Laryngoscope.

• Ribbon to secure tube, lubricating jelly.

• Connection tubing, Ambubag, and O2 (cylinder or wall connection).

• Working wall suction, tubing, and Yankauer.

Preparation

• Move bed forward so that you can stand behind patient’s head and

raise it so that you are working a comfortable height. Put on gloves.

• Elective setting. Pre-oxygenate the patient; attach pulse oximeter to

patient, connect Ambubag to 100% O

, use effective bag-and-mask

ventilation for 2–3min to achieve O

saturations >95%.

• Emergency setting. Suction mouth (aspiration is major risk, bag-and-

mask ventilation with Ambubag, and 100% O

• Check laryngoscope light works and blade opens and ET tube cuff

inﬂ ates and deﬂ ates with 10mL syringe.

• Remove any dentures and suction again any saliva and secretions.

• Extend the neck.

• Insert the laryngoscope, pushing the tongue to the left.

• Advance the scope anterior to the epiglottis and pull gently, but ﬁ rmly,

upwards to expose the vocal cords.

• Insert the lubricated ET tube between the cords into the trachea.

• Conﬁ rm correct positioning of the tube by observing chest

movements and listening over lung bases and stomach.

• Progressively inﬂ ate the cuff and attach ventilation equipment.

• Conﬁ rm correct cuff inﬂ ation by listening for whistling or bubbling in

the larynx suggesting air leak and secure the tube in place with ribbon.

• 2 Patients not in cardiac arrest or who maintain a gag reﬂ ex will need

anaesthetizing prior to oropharyngeal intubation, i.e. administration of

inducing agent plus muscle relaxant: this should be done only under

supervision of a trained anaesthetist.

• 2 The best setting to learn intubation is preoperatively in the anaesthetic

room of a theatre with good supervision in controlled conditions.

Tips and pitfalls

• Oesophageal intubation. Potentially fatal if not recognized. Always check

for bilateral breath sounds, chest movement, absence of stomach

sounds, pulse oximetry, blood gas, and capnography, if available. Bag-

ENDOTRACHEAL INTUBATION

187

and-mask ventilation is the safest and most effective way to oxygenate

a patient if you are not experienced at endotracheal intubation.

• Cannot visualize vocal cords. Ask for ‘cricoid pressure’—ﬁ rm

downwards pressure from an assistant over the cricoid can help bring

cords into view. Some patients are ‘difﬁ cult intubations’ just because

of their particular anatomy and build; the safest way to maintain their

airway is to avoid repeat attempts at intubation, resume bag-and-mask

ventilation, and wait for senior help.

• Inadequate cuff pressure. Too little and airway not protected from

aspiration, too much and pressure injury can result in erosion or

stenosis. The balloon should feel as ﬁ rm as your ﬁ ngertip.

Key revision points—anatomy of the lower pharynx and larynx

(Fig. 4.1)

Trachea

Uvula

Vocal cords

Epiglottis

Catheter mount for connecting

endotracheal tube to inflation bag

Cuff

inflated

Fig. 4.1 (a) Diagram of the larynx as seen at intubation. (b) Correct position of

inﬂ ated endotracheal tube cuff.

CHAPTER 4 Practical procedures

188

Cardioversion

Key facts

• Synchronized direct current (DC) cardioversion is the treatment of

choice for tachyarrhythmias compromising cardiac output (CO), such

as AF and supraventricular tachycardia (SVT) and for AF refractory to

chemical cardioversion.

Checklist for elective DC cardioversion

• Is it indicated? Is the patient still in AF?

• Is it safe (see b p. 189)?

Either AF has lasted <24h; or•

The patient must have had at least 6 weeks of formal •

anticoagulation; or

The patient must have a TOE excluding intracardiac thrombus.•

• Is the patient ready?

The potassium should be 4.5–5.0 (otherwise, repeat AF likely).•

The INR, if anticoagulated, should be >2.0.•

The patient should have a valid consent form.•

• The patient should be starved for 6h.

DC cardioversion for AF and SVT

Patient should be anaesthetized: some anaesthesiologists prefer not to

intubate, managing the airway with a bag and mask. You can either use

adhesive external deﬁ brillator pads which remain ﬁ xed to the patient until

the procedure is completed or handheld paddles and gel pads. As soon as

the anaesthesiologist is happy:

• Expose chest.

• Place pads on chest in position shown in Fig. 4.2: the aim is to direct as

much of the current as possible through the heart.

• Place three ECG electrodes on the patient as shown and connect to

the deﬁ brillator so that an ECG trace is visible.

• Switch deﬁ brillator on and turn dial on to appropriate power setting

(100J, 200J, 360J).

• 2 Press the ‘SYNC’ button and ensure that each R wave is accented on

the ECG: failure to do this can mean that a DC shock is delivered while

the myocardium is repolarizing, resulting in VF. Check that the ‘SYNC’

button is on before every shock for AF.

• If you are using handheld paddles, hold them ﬁ rmly on the gel pads.

• Perform a visual sweep to check that no one is in contact with the

patient at the same time as saying clearly, ‘Charging. Stand clear’.

• Press the ‘CHARGE’ button.

• Press the ‘SHOCK’ button when the machine is charged.

• If the shock has been delivered successfully, the patient’s muscles

will contract violently: anyone in contact with the patient risks

experiencing an electric shock.

• Check the rhythm.

• If still AF, press the ‘CHARGE’ button and repeat the sequence.

CARDIOVERSION

189

Complications of DC cardioversion

• Complications of general anaesthesia(see b p. 218).

• Systemic embolization (see b pp. 155, 642.)

• Failure to cardiovert.

• Burns from incorrect application of gel pads.

• Muscle pain from involuntary contraction.

• Arrhythmias, including asystole and ventricular ﬁ brillation (VF).

Common pitfalls

Failure to deliver a shock

Check that the deﬁ brillator is switched on and adequately charged. Check

that the correct power setting has been selected. Change the machine.

Failure to cardiovert

Check the latest available serum K

was 4.5–5.0. Check that the cor-

rect power setting has been selected. Replace gel pads with fresh ones.

Reposition the patient on their side and the pads as shown and try two

further shocks at 200J (see Fig. 4.2). Don’t start at too low a power set-

ting: each shock leaves the myocardium less sensitive to further shocks.

There is some evidence that 360J as the ﬁ rst power setting results in less

myocardial damage and a better conversion rate than multiple shocks at

lower power settings.

(a)

(b)

Fig. 4.2 Using deﬁ brillators. (a) Correct positioning for deﬁ brillation and

cardioversion. (b) Alternative positioning for synchronized DC cardioversion.

CHAPTER 4 Practical procedures

190

Deﬁ brillation

Key facts

• Deﬁ brillation is the treatment of choice for VF and pulseless VT.

• Biphasic deﬁ brillators cycle current direction every 10ms: the same

amount of current (roughly 12amp and 1500V) is delivered, but with

less energy (200J compared to 360J in older monophasic models),

reducing the risk of burns and myocardial damage.

External deﬁ brillation for VF and pulseless VT

Do not delay deﬁ brillation for manoeuvres such as intubation, massage, or

administration of drugs.

• Expose chest.

• Place gel pads on chest in position shown in Fig. 4.2: the aim is to

direct as much of the current as possible through the heart.

• Switch deﬁ brillator on and turn dial on to appropriate power setting

(200J for external deﬁ brillation).

• Press ‘CHARGE’ button.

• If you are using handheld paddles instead of adhesive external

deﬁ brillator pads, place them ﬁ rmly on gel electrodes and hold.

• Perform a visual sweep to check that no one is in contact with the

patient at the same time as saying clearly, ‘Charging. Stand clear’.

• Press the red/orange ‘SHOCK’ button on the paddles.

• If the shock has been delivered successfully, the patient’s muscles

will contract violently: personnel in contact with the patient may

experience an electric shock.

• Check the rhythm: if VF, charge again and repeat the sequence.

• If the rhythm changes to one compatible with an output, check the

pulse before proceeding further.

Common pitfalls

Failure to deliver a shock

Check that the deﬁ brillator is switched on and adequately charged. Check

that the correct power setting has been selected. Check that the ‘SYNC’

button is off if you are trying to deﬁ brillate VF. Change the machine and

paddles.

Failure to deﬁ brillate

Exclude causes of intractable VF, i.e. failure to effect rhythm changes com-

patible with an output despite repeated attempts. In internal deﬁ brilla-

tion, decompress the heart using massage (with the ﬂ ows down if you’re

on cardiopulmonary bypass). Double-check that the rhythm is not in fact

asystole. Epinephrine, lidocaine, or amiodarone may improve chances of

converting VF and maintaining rhythm.

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CHAPTER 4 Practical procedures

192

Venepuncture

Key facts

This is a mandatory skill to learn for all doctors, but many patients will

have ‘difﬁ cult’ veins and regular practice is needed.

Indications

Obtaining venous blood samples for laboratory analysis, venesection.

Equipment

• Tourniquet.

• 23G or 21G needle, vacutainer holder.

• Syringe (appropriate size: 10–20mL).

• Alcohol swabs.

• Appropriate laboratory sample tubes.

• Cotton wool ball and tape.

• Pillow if the vein looks difﬁ cult.

Most hospitals now have vacuum tube systems as an alternative to the

‘needle and syringe’ approach for obtaining blood samples.

Preparation

Apply tourniquet above the elbow and inspect the arm for suitable

engorged veins. Place arm on a pillow, especially if you may be a while.

Method

• Clean the skin thoroughly with alcohol at the site of access.

• Tether the skin distal to the site with the thumb of your left hand.

• Pass the needle obliquely through the skin at a point approximately

2mm distal to the point of planned entry to the vein.

• Advance the needle slowly until a ‘give’ is felt as the vein is entered

and a ‘ﬂ ashback’ is seen in the needle: push vacutainer onto holder.

• Aspirate the desired amount of blood while holding the barrel of the

syringe ﬁ rmly.

• Release the tourniquet before gently withdrawing needle and syringe.

• Apply pressure to the site to arrest any bleeding. Do not assume the

patient can help with this, e.g. stroke patients.

Tips and pitfalls

• Poor veins. If the patient is cold and the samples non-urgent, place the

arm in warm water as this may aid venodilation. Veins on the dorsum

of the hand may be the only ones readily available; try using a smaller

or butterﬂ y needle to obtain samples. Aspirate gently using a syringe

on a butterﬂ y needle, not a vacutainer as this may collapse veins.

• Obese patients. Try the dorsum of the hand or the radial aspect of the

wrist, access may be easier here.

• Failed attempts. Repeated failed attempts will distress the patient

and demoralize the doctor! Ask someone to help. If the samples are

extremely urgent, a femoral stab may be the best option for obtaining

blood samples, e.g. during cardiac arrest.

VENEPUNCTURE

193

• IV cannulae. If blood samples and IV access are needed, obtain samples

through the cannula—simple and saves the patient another needle,

although be careful to draw blood slowly as haemolysis is more

common via a cannula.

• Sample bottles and request forms. Ensure these are labelled correctly

and the appropriate tests are ordered. If in doubt about a particular

investigation, seek advice from a senior or the laboratory.

• Blood cultures. Ensure that the skin is swabbed thoroughly. Do not

touch the skin again unless sterile gloves are worn. Once the sample

is taken, change the needle before transferring the sample to the

appropriate culture bottle. Document whether the patient was on

antibiotics at the time of the sample and ensure the sample is not

placed in the fridge during transfer to the lab.

Key revision points—venous drainage of the upper limb

• Superﬁ cial venous system.

Cephalic vein.• Commences from the lateral end of the dorsal

venous network overlying the anatomical snuffbox, ascending the

lateral and anterolateral aspect of the arm to the deltopectoral

groove, piercing the clavipectoral fascia to join the axillary vein.

Basilic vein.• Commences from medial end of the dorsal venous

network, ascending along medial and anteromedial aspect of

forearm, piercing the deep fascia to join the venae comitantes of

the brachial artery which eventually join the axillary vein.

Median cubital vein.• Connects these two veins in the cubital

fossa.

• Deep system: venae comitantes of ulnar, radial, and brachial artery,

which ﬂ ow into the axillary vein.

• Most common sites for phlebotomy and cannulation are:

Dorsal venous network.•

Median cubital vein.•

• Cephalic vein in the forearm.

CHAPTER 4 Practical procedures

194

Intravenous cannulation

Key facts

A similar skill to that of simple venepuncture, but needs plenty of practice

to become competent. If having difﬁ culty, observe a few experts in action;

an ideal setting is in the anaesthetic room of theatres.

Indications

Venous access for administration of IV ﬂ uids, blood, or IV drugs.

Equipment

• Tourniquet.

• Cannula (20G or 18G) (see Table 4.1).

• Adhesive dressing/tape.

• Alcohol swabs.

• 5mL syringe containing 0.9% saline or heparinized saline.

• IV ﬂ uid bag with giving set, if necessary.

Preparation

Apply tourniquet above or below the elbow and inspect the arm for suit-

able engorged veins.

Method

• Clean the skin thoroughly at the site of access; put on sterile gloves.

• Identify a suitable vein.

• Tether the skin distal to the proposed site of puncture.

• Pass the cannula obliquely through the skin at a point approximately

2mm distal to the point you wish to enter the vein.

• Advance the cannula smoothly until the vein is entered: a ‘give’ will be

felt and a ‘ﬂ ashback’ seen in the hub of the cannula.

• Hold the hub of the needle with one hand and advance the cannula

into the vein, while maintaining skin ﬁ xation until the cannula is well

into the vein.

• Remove the tourniquet and press on the vein proximal to the cannula as

the needle is removed. Apply the screw cap to the end of the cannula.

Table 4.1 Size and function of different cannulae

Colour Size Flow (mL/min) Use

Blue 22G 31 Small veins,

paediatrics

Pink 20G 55 Slow infusions

Green 18G 90 IV ﬂ uids, drugs,

transfusions

White 17G 135

Grey 16G 170 Rapid IV ﬂ uids,

emergencies

Brown 14G 265

INTRAVENOUS CANNULATION

195

• Secure the cannula in place with a dressing.

• If the cannula is not going to be used immediately, ﬂ ush with

heparinized saline.

Tips and pitfalls

• Poor veins, obese patients, and failed attempts. See ‘Venepuncture’

section (see b p. 192).

• Agitated or ﬁ tting patients. Try not to place the cannula over a joint as

these tend to become easily dislodged or ‘tissued’.

• Secure the cannula. Cannulae are all too easily dislodged because of

poor ﬁ xation to the skin. Use of two cannula dressings (one placed

above and one below) and a bandage is often needed.

• Hairy arm. Shaving the skin at the planned cannula site seems tedious,

but will allow the cannula to be secured adequately.

• Non-dominant hand. Placing the cannula in the non-dominant hand,

if possible, will allow the patient a little bit more freedom and may

prevent the cannula becoming dislodged easily.

• Fragile veins. Tends to be a problem in elderly or debilitated patients.

Try using a smaller cannula; the dorsum of the hand is often ideal site.

• Poor peripheral access. In some patients with multiple collapsed or

damaged veins, alternative cannula sites may have to be considered,

e.g. feet. If peripheral cannulation becomes impossible, a central line

will have to be considered.

• Blood transfusion. If blood is being given IV, then an 18G or 16G

cannula will be needed.

Complete failure to cannulate

• Is a cannula necessary?

Can IV medication or ﬂ uids be omitted until elective central/long •

line insertion is possible?

Can medication or ﬂ uids be given orally or via NGT?•

Discuss with microbiology if antibiotics are involved: changing route •

of administration often requires appropriate changes in antibiotic.

Fluid and insulin regimes can be modiﬁ ed to be given •

subcutaneously if desperate.

Many painkillers and antiemetics can be given PR or IM.•

• Ask another member of your team to try: sometimes a ‘fresh’ pair of

hands is all that is needed.

• If no one in your team can site the cannula, ask the on-call anaesthetist

if they can help, but remember they are not a cannulation service and

do not ask them until you have asked every member of your team

unless it is an emergency!

• If peripheral access is impossible or required for a long time (e.g. IV

antibiotic regimes for infected prostheses), consider:

Elective PICC line insertion (long-term line inserted electively by •

specialist nurse into the basilic vein);

Elective central line insertion: this should be done in an anaesthetic •

room rather than on ward and during daytime hours (b p. 198).

Femoral line insertion (less ideal as this site is more prone to line •

sepsis).

CHAPTER 4 Practical procedures

196

Arterial puncture and lines

Key facts

Arterial puncture is needed to sample ABGs; if serial measurements are

required or continuous monitoring of arterial blood pressure is needed,

then an arterial line should be sited (see b p. 128).

Equipment

• Arterial puncture only requires a 22G needle on the green 5mL blood

gas syringe, an alcohol swab, and cotton wool.

• Arterial line insertion equipment generally comes prepacked in sterile

kits, but if unavailable, you will need:

Two 20G arterial cannulas with guidewire.•

Connectors, transducer, and three-way tap.•

2mL 1% lidocaine.•

5mL syringe and blue needle.•

10mL saline.•

Skin prep, sterile gloves, small drape.•

Gauze swabs.•

Preparation

• Explain the procedure to the patient if appropriate.

• It is good practice to perform Allen’s test (see below) to demonstrate

that the ulnar arterial supply to the hand arcades is intact.

• For radial artery cannula insertion, place the forearm on a pillow so

that the wrist is dorsiﬂ exed; for femoral artery insertion, abduct and

ﬂ ex the hip slightly.

Landmarks

• Radial artery. Lies between tendon of ﬂ exor carpi radialis and head of

radius.

• Femoral artery. Lies midway between the anterior superior iliac spine

and the symphysis pubis.

Technique

• Prepare and check equipment and prep skin; put on sterile gloves.

• Inﬁ ltrate local anaesthetic in the skin, but avoid distorting the anatomy.

• Palpate pulse between two ﬁ ngers for 2–3cm.

• Pass cannula at 45° into skin.

• Once the cannula is in situ, aspirate and ﬂ ush via the three-way tap.

Transﬁ xion technique (see Fig. 4.3)

The cannula is passed through both artery walls, the needle completely

withdrawn, and the cannula then withdrawn slowly until ﬂ ashback occurs,

at which point it is advanced into the artery.

Partial transﬁ xion technique

The cannula is advanced until ﬂ ashback stops and the needle withdrawn

while holding the cannula steady which is then advanced into the artery.

ARTERIAL PUNCTURE AND LINES

197

Artery not transﬁ xed

The cannula is advanced carefully in 0.5mm increments until ﬂ ashback is

seen, at which point the catheter is slid off the needle in the artery.

Guidewire

A guidewire is useful where it is possible to get ﬂ ashback, but difﬁ cult to

advance the catheter up the artery.

Complications

Ischaemia, thrombosis, bleeding, damage to radial and median nerve.

Inadvertent intra-arterial injection of drugs.

Allen’s test

Allen’s test demonstrates a patent palmar collateral circulation: the patient

clenches his ﬁ st to exclude blood from palm and the doctor ﬁ rmly com-

presses both ulnar and radial pulses while patient opens his palm, which

should be blanched. The doctor releases the ulnar compression whilst still

occluding the radial pulse: the palm becomes pink in <5s if there is good

collateral supply from the ulnar artery (see b p. 647). About 3% of people

do not have a collateral palmar supply and hand ischaemia is a real risk if

the radial artery is cannulated.

Fig. 4.3 Transﬁ xion technique of arterial cannula insertion.

CHAPTER 4 Practical procedures

198

Insertion of central venous catheter

Key facts

Indications are listed on b p. 128. Cannulae can be single or multi-lumen,

sheaths (for insertion of pulmonary artery (PA) catheters and pacing

wires), tunnelled, or long lines.

Equipment

• Appropriate central venous (CV) catheter.

• Ultrasound probe and condom if ultrasound is to be utilized.

• Enough three-way taps for all individual lumens.

• 10mL 1% lidocaine.

• 10mL syringe.

• Blue needle and a green needle.

• 20mL saline.

• 2 or 3/0 silk on a large handheld needle.

• 11-blade scalpel.

• Skin prep, sterile drape, sterile gloves, and gown.

• Gauze swabs, dressing.

Preparation

• Explain the procedure to the patient if appropriate.

• Ask a nurse to be present.

• Patient’s ECG and pulse oximetry should be continually monitored.

• Ensure that there is adequate light, a space behind the bed which you

can work in, and that it is possible to place the bed in Trendelenberg.

Landmarks

Internal jugular vein

• Central approach. Apex of triangle formed by clavicular and sternal

heads of sternocleidomastoid (SCM) muscle, aiming the needle

towards the opposite nipple.

• Posterior approach. Point where line drawn horizontally from the

cricoid cartilage to the lateral border of the clavicular head of SCM,

aiming the needle towards the sternal notch.

• Anterior approach. Medial border of the sternal head of SCM, aiming

needle towards ipsilateral needle.

Subclavian vein

Advance the needle at 45° to the junction of the outer and middle third of

the clavicle 1–2cm, then direct needle towards sternal groove.

Technique

There are numerous techniques: only one is described below.

• Prep the patient, gown, and glove.

• Drape so that all landmarks are exposed.

• Palpate the carotid pulse.

• Inﬁ ltrate local anaesthetic around the planned puncture site.

• Spend 2–3min laying out the equipment in the order of use, secure

three-way taps to central line, and turn to closed position.

• Ask the nurse to place the bed in 10–20° of Trendelenberg.

INSERTION OF CENTRAL VENOUS CATHETER

199

• Ballot the internal jugular vein.

• Using aseptic technique and a 20G catheter on a 10mL syringe, enter

the skin at 45° as described in ‘Landmarks’ section (see b p. 196).

• On aspirating venous blood, remove the syringe and needle, but leave

the catheter in situ: check that the puncture is venous, not arterial, by

attaching manometry tubing, letting it ﬁ ll with blood, and holding it

up—level should fall if venous.

• Pass the guidewire down the catheter, keeping hold of it at all times.

• Once an adequate length of wire is in place, remove the catheter over

the wire, and apply pressure to the vein.

• Make a 3mm nick in the skin over the wire with a scalpel.

• Pass the dilators over the wire through the skin, but not into the vein.

• Remove the dilators, apply pressure, and pass the CV cannula over the

wire into the vein up to an appropriate length.

• The wire normally protrudes through the brown (proximal) lumen of a

triple lumen line which should therefore be left open.

• Aspirate, ﬂ ush, and close all lumens and suture the catheter to the skin.

• Check that there is a satisfactory pressure trace if a transducer is used.

• Chest X-ray (CXR) to identify pneumothorax.

Complications

Immediate

Damage to nearby structures (carotid artery puncture, pneumothorax,

haemothorax, chylothorax, brachial plexus injury, arrhythmias), air embo-

lism, loss of guidewire into right side of heart, haematoma.

Late

Sepsis, thromboembolism, arteriovenous (AV) ﬁ stula formation.

Key revision points—anatomy of the internal jugular vein

• In the upper neck, the internal jugular vein may be cannulated as it

lies within the carotid sheath. The important relations here are:

Sheath is just anterior to the anterior border of SCM.•

Carotid artery is anteromedial.•

Vagus nerve lies between the two.•

• In the lower neck, the internal jugular vein may be cannulated as it

lies behind the SCM. The important relations are:

Vein lies 45• ° lateral and 45°

inferior to the junction of the sternal

and clavicular heads of the SCM.

The pleural lies inferomedial.•

The subclavian artery lies lateral.•

• The internal jugular drains into the brachiocephalic vein; on the right,

this is shorter and drains more vertically into the superior vena cava

(SVC), making the internal jugular vein cannulae easier to pass into

the SVC.

CHAPTER 4 Practical procedures

200

Chest drain insertion

Key facts

There are three main options for most patients with pleural effusions or

pneumothoraces that need intervention:

• Needle thoracentesis. Used for ﬁ rst-time treatment of simple effusions

or pneumothoraces with low likelihood of recurrence.

• Pigtail thoracostomy. A 16G tube inserted using modiﬁ ed Seldinger

technique; good for simple pneumothorax or effusion.

• Chest tube. Large bore tube inserted, either blunt (recommended) or

using trocar to treat tension pneumothorax, recurrent pneumothorax,

haemothorax, or empyema. Indications are listed below.

Indications (British Thoracic Society guidelines)

• Pneumothorax.

In any ventilated patient.•

Tension pneumothorax after initial needle relief.•

Persistent or recurrent pneumothorax after simple aspiration.•

Large secondary spontaneous pneumothorax in patients over 50y.•

• Malignant pleural effusion.

• Empyema and complicated parapneumonic pleural effusion.

• Traumatic haemopneumothorax.

• Post-operative, e.g. thoracotomy, oesophagectomy, cardiac surgery.

Equipment

• 28G intercostal drain.

• Underwater seal containing water to up to mark.

• Connection tubing.

• Line clamp.

• Roberts or other instrument for blunt dissection.

• 20mL 1% lidocaine.

• 10mL syringe.

• Blue needle and a green needle.

• 20mL saline.

• 2 or 3/0 silk on a large handheld needle.

• 11-blade scalpel.

• Skin prep, sterile drape, gloves and gown, gauze swabs.

Preparation

• Explain the procedure to the patient if appropriate; recheck side on

X-ray and sign consent form.

• Ensure continual monitoring of pulse oximetry.

• Position the patient at 45° with the arm abducted.

Technique

• Usual insertion site is the 5th intercostal space in the mid-axillary line.

• It may extend anteriorly to the anterior axillary line.

• Prep and drape the skin, gown, and glove.

• Inﬁ ltrate site for tube insertion with local anaesthetic, ensuring

anaesthesia at all layers down to and including parietal pleura and the

periostem of the ribs posterior to the line of the incision.

CHEST DRAIN INSERTION

201

• A 2cm transverse skin incision is made and the intercostal space (see

Fig. 4.4) is dissected bluntly.

• Place purse string suture and suture to secure drain now.

• Firmly and carefully pass a blunt-ended clamp over the lower rib

through the pleura (you will feel a pop as the tissue gives) and spread

to widen the hole.

• Place a ﬁ nger into the pleural space to ensure there are no adhesions.

• Pass a chest tube without a trocar into the pleural space, guiding it

superiorly for a pneumothorax and basally for a haemothorax.

• Secure drain with at least one strong suture and connect immediately

to an underwater seal and place on –20mmH

O suction.

Tips and pitfalls

• Misplacement. Subcutaneous (more common in obese patients),

intraparenchymal; always check for an air leak on coughing and a swing

to conﬁ rm that the chest tube is in the pleural space, particularly if no

effusion draining.

• Trauma to other structures (diaphragm, spleen, liver, heart, aorta, lung

parenchyma, intercostal arteries). Entry sites too low (common mistake,

remember you are much less likely to cause damage if you are too

high than if you are too low), too posterior or trocar used instead of

blunt dissection. Stay on the top of the lower rib to avoid injuring the

intercostal artery and causing a haemothorax.

• Surgical emphysema. Implies there is massive air leak not being drained

effectively by the chest tube. Is the tube blocked, kinked, pulled out so

that holes are communicating with skin, in too far so that it is wedged

in ﬁ ssure, in the subcutaneous tissue rather than the pleura?

• Wound infection, empyema.

• Pain.

Rib

Vein

Artery

Nerve

Innermost

Internal

Intercostal

muscles

External

Visceral

pleura

Lung

Parietal

leura

Fig. 4.4 Anatomy of the intercostal space.

CHAPTER 4 Practical procedures

202

Management of chest drains

Technique of insertion is described on b p. 200. This section describes

the types of chest drainage systems available and basic protocols for man-

aging chest drains.

Types of drainage system

Underwater seal

Underwater seal drains used to consist of three bottles connected by

tubing, the third bottle providing suction control determined by the depth

the connection tube penetrated below the water level in the bottle. Now

most hospital wards have reliable high volume, low pressure wall suction,

which means that simple, lightweight, single underwater seal bottles can

be used instead of the cumbersome three-bottle systems. The system has

to be kept upright.

• Underwater seals are suitable for any condition requiring chest

drainage.

• They can be used with or without suction.

• Suction is usually –2–5kPa.

Heimlich valves

The Heimlich valve is a one-way ﬂ utter valve within rigid tubing. It can be

connected to a standard chest drain. The system allows air and ﬂ uid out

of the chest cavity, but prevents both from entering. The system has to be

open to air, which makes collecting liquid efﬂ uent more difﬁ cult.

Heimlich valves are usually considered in patients with a permanent air

leak for whom surgery is not appropriate and for whom the main goal of

therapy is discharge to home or palliative care.

Portex bag

• The Portex bag was designed as an ambulatory chest drainage system.

It consists of a Heimlich valve within a drainage bag which has a

capacity of about 1500mL and can be emptied intermittently. This

drainage system cannot be connected to suction.

• These drains are indicated in patients with chronic pleural collections,

in whom surgery is not appropriate.

• As the systems are airtight, an air leak is a contraindication.

Suction

Almost all conditions can be safely managed by an underwater seal system

without suction, but suction helps to reinﬂ ate the acutely collapsed lung

and improves drainage of ﬂ uid. There is a huge range in surgeons’ prefer-

ences for suction protocols: the points below represent commonly used

protocols.

• 1kPa = 7.5mmHg = 10cmH

• Suction should be high volume, low pressure: approximately 2–3kPa.

• Blocked suction tubing or a blocked ﬁ lter at the wall is the equivalent

of clamping the drain; have a low threshold for suspecting either.

• Most patients with chest drains should be on suction; the exceptions

to this are patients with pneumonectomies who are not placed on

suction.

MANAGEMENT OF CHEST DRAINS

203

• Ventilated patients cannot generate their own negative intrapleural

pressures and therefore all chest drains in these patients, with the

exception of post-pneumonectomy drains, should be placed on

suction.

• It is usually safe for a patient with an underwater seal on wall suction

to mobilize off suction for brief periods.

• Discontinue suction in extubated patients after 24–48h when the lung

is fully inﬂ ated on CXR and there is no air leak (the drain does not

bubble when the patient coughs).

• Suction is unlikely to secure expansion in the lung that has been

collapsed chronically; it is most effective in the immediate post-

operative period.

Clamping drains

More patients have died as a result of clamped drains than unclamped

drains. The practice of clamping chest drains during transfer is a danger-

ous one. It reveals a failure to understand how a modern underwater seal

drain works as well as reﬂ ecting outmoded practice that dates back to the

time of TB when drain bottles contained caustic sterilizing ﬂ uid that could

drain back into the patient if lifted above the level of the chest during

transfer. The only indications for clamping a chest drain are below.

Post-pneumonectomy

The post-pneumonectomy chest drain is usually clamped for an hour at

a time and unclamped brieﬂ y to allow blood to drain. Leaving the drain

unclamped risks causing mediastinal shift towards the pneumonectomy

side and cardiovascular compromise. The drain is usually removed on day

1 post-operatively.

Massive haemothorax or effusion

If more than 1500mL of ﬂ uid is drained immediately on insertion of a

chest tube and/or the patient appears haemodynamically compromised as

a result of drainage, it is appropriate to clamp the drain for a brief period.

In massive haemothorax, the effect is to attempt to tamponade the bleed,

buying a little time to organize surgical exploration. In a massive effusion,

this allows time for the lung to expand without re-expansion pulmonary

oedema and to reduce mediastinal shift caused by rapid drainage.

Decision making in long-term drains

Occasionally, a surgeon may decide to see if a patient with a chronic

effusion or air leak can manage without a drain by clamping the drain.

Tension pneumothorax may result from doing this in a patient with an air

leak. Such patients must be observed frequently for any sign of respira-

tory or haemodynamic compromise, surgical emphysema, or radiological

evidence of lung collapse, and if any of the above occur, the drain must

be unclamped and placed on underwater seal. If the patient tolerates the

clamp for 24h, it is usually possible to remove the drain.

CHAPTER 4 Practical procedures

204

Pericardiocentesis

Key facts

• Occasionally used, usually by cardiologists under ﬂ uoroscopic

guidance, to relieve acute pericardial tamponade.

• There is almost no indication, outside emergencies in an under-

equipped setting, to perform this procedure blindly without

ﬂ uoroscopic or echo guidance.

• In an emergency due to trauma where tamponade is due to

active bleeding, clots will prevent effective needle aspiration and a

thoracotomy, sternotomy, or subxipoid incision, depending on the

circumstances, should be performed.

Equipment

• Pericardiocentesis needle or catheter.

• 10mL 1% lidocaine.

• 10mL syringe.

• 18G catheter.

• 20mL saline.

• 2 or 3/0 silk on a large handheld needle.

• 11-blade scalpel.

• Skin prep.

• Sterile drape.

• Sterile gloves and gown.

• Gauze swabs.

Preparation

• Explain the procedure to the patient where appropriate.

• Ensure patient has continual ECG monitoring.

Landmarks

One half centimetre below and to the left of the xiphoid, aiming at 45° to

skin, pointing at left shoulder or nipple.

Technique (see Fig. 4.5)

• Prep and drape the skin, gown, and glove.

• Inﬁ ltrate 5mL 1% subcutaneous lidocaine and make a nick in the skin.

• To begin, identify the needle entry site 0.5cm immediately to the left

of the xiphoid tip.

• Insert the catheter, applying continuous aspiration in the direction

described above.

• After needle entry into the skin and sc tissue, watch the ECG monitor

(or echo/ﬂ uoroscopic screening monitor if available) as the needle is

slowly advanced; if there are ectopics or changes in the ST segments,

stop and withdraw the needle a few mm.

• When in contact with the pericardium, advance the needle a few cm

into the pericardial space.

• If ST segment elevation is present, this indicates contact with the

myocardium and the needle should be withdrawn slightly into the

pericardial space where no ST segment elevation should be seen.

PERICARDIOCENTESIS

205

• When in the pericardial space, withdraw needle from catheter and

aspirate ﬂ uid.

• If the tamponade is successfully reduced, right atrial pressures should

be decreased, cardiac output should increase and pulsus paradoxus

should disappear.

• Echocardiography, normally transoesophageal, is required to show

reduction in the size of the collection and improvement in the signs of

tamponade such as compression of right atrium and ventricle.

• Clotted blood cannot be evacuated in this way; a patient with

tamponade from a haemopericardium needs emergency surgical

evacuation, usually via a sternotomy if trauma is suspected.

Complications

• Cardiac puncture.

• Laceration of a coronary artery.

• Air emboli.

• Cardiac arrhythmias.

• Haemothorax.

• Pneumothorax.

• Infection.

(a)

(b)

Myocardium

Fluid

Pericardum

Needle

Fig. 4.5 Technique of pericardiocentesis. (a) Landmarks for needle.

(b) Pericardiocentesis.

CHAPTER 4 Practical procedures

206

Cricothyroidotomy

Indications

Emergency need for a surgical airway

• Major maxillofacial injury.

• Oral burns.

• Fractured larynx.

• Need for tracheal toilet in the extubated patient.

Needle cricothyroidotomy

• Patient peri-arrest.

• Use the landmarks described below.

• Omit local anaesthetic inﬁ ltration, cut-down, and dissection.

• Pass a 12G (brown or larger) needle directly though the cricoid

membrane.

• Oxygenate using jet insufﬂ ation until a formal airway can be established.

Equipment

• Minitracheostomy, size 6.0 ET tube or 12G cannula in emergencies.

• Artery forceps.

• 10mL 1% lidocaine.

• 10mL syringe.

• Blue needle and a green needle.

• 20mL saline.

• 2 or 3/0 silk on a large handheld needle.

• 11-blade scalpel.

• Skin prep.

• Sterile drape.

• Sterile gloves and gown.

• Gauze swabs.

Preparation

• Explain procedure to the patient where appropriate.

• The trauma patient’s C-spine should be immobilized in the neutral

position.

Landmarks

The cricoid membrane is a small diamond-shaped membrane, palpable just

below the prominence of the thyroid cartilage.

Technique (see Fig. 4.6)

• Prep and drape, put on sterile gloves.

• If the patient is conscious and maintaining their own airway, inﬁ ltrate

local anaesthetic using aseptic technique.

• Stabilize the thyroid cartilage with the left hand.

• With your right hand, make a 2cm transverse incision (smaller for

minitracheostomy) through the skin overlying the cricothyroid

membrane and then straight through the cricothyroid membrane.

• Now turn the scalpel blade 90° within the airway so that it acts as a

temporary retractor.

CRICOTHYROIDOTOMY

207

• Place an artery forceps through the incision and open it, remove the

scalpel, and insert a size 6.0 ET tube.

• Suction the tube, secure, and connect to a source of oxygen.

• Some minitracheostomy kits use the Seldinger technique; aspirating air

freely is a sign that the needle is in the trachea and that a guidewire

can be gently passed down the lumen.

Complications

• Bleeding.

• Loss of airway.

• Recurrent laryngeal nerve injury.

• Vocal cord injury.

(a)

)c()b(

(d)

Cricoid cartilage

Cricoid membrane

Thyroid gland

Fig. 4.6 Technique of cricothyroidotomy. (a) Structures involved. (b) Incision.

CHAPTER 4 Practical procedures

208

Nasogastric tube insertion

Key facts

• Nasogastric tubes (NGT) are used to decompress the stomach and to

administer enteral feeding and drugs in patients that cannot manage

oral intake. Enteral feeding is covered on b p. 136.

• Inadvertent placement of an NGT into the bronchial tree can cause

aspiration pneumonia or even respiratory arrest if it is then used

to administer feeds or other ﬂ uids; placement must always be

systematically checked (see b p. 209) on a CXR prior to use.

• Never replace an NGT in an oesophagectomy patient without

discussing it with a senior; you risk pushing the tube through the fresh

anastomosis.

• It is worth learning how to place these; usually you will get a call when

the person who normally places them has failed.

Indications

• Intestinal obstruction (wide bore or Ryle’s tube).

• Paralytic ileus.

• Perioperative gastric decompression.

• Enteral feeding (ﬁ ne bore tube).

Equipment

• NGT (sizes 10–12 French).

• Gloves.

• Lubricating gel.

• Lignocaine throat spray.

• NG collection bag.

• Litmus paper.

• Stethoscope.

• Sticky tape.

Preparation

• Chill NGT in fridge prior to passing. This stiffens the tube and makes it

easier to pass.

• Explain the procedure to the patient where appropriate.

• Position the patient, preferably in a sitting position, with the head tilted

slightly forward.

Method

• Wash hands and put on sterile gloves.

• Lubricate the tip of the NGT with gel.

• Pass the tube horizontally along the ﬂ oor of the nasal cavity, aiming

towards the occiput.

• As the tube engages in the pharynx, ask the patient to swallow and the

tube should pass into the oesophagus.

• Some advise getting the patient to take a sip of water, hold it in their

mount while you introduce the tube and then swallow; this introduces

an aspiration risk and many patients are not able to cooperate to this

extent because of pain, nausea, confusion, etc.

NASOGASTRIC TUBE INSERTION

209

• Advance the tube approximately 40–60cm.

• Check the position of the tube as follows:

Aspirating gastric contents which will turn blue litmus red; • and

Insufﬂ ate 20mL air down the tube; if in stomach, should produce •

bubbling which can be heard on auscultation over the stomach; and

All feeding tubes • must be X-rayed prior to use to exclude

inadvertent bronchial intubation; you must be able to follow the

NGT all the way down to the fundus of the stomach on the CXR.

Always double-check you cannot see the tube in the bronchial

tree or pleura. This is the only true conﬁ rmation that NGT is in

stomach.

• Tape tube securely to nostril and attach end to bag/suction.

Tips and pitfalls

• Patient has problems swallowing. Ask the patient to swallow sips of

water as the tube is passed.

• Constant coiling in the mouth. Tube may be soft; cool in the fridge.

• Resistance to passing. There may be an anatomical reason for this, e.g.

oesophageal stricture. The tube may need to be passed under X–ray

control.

• Tube migration. Just because the tube was in the correct position

yesterday does not mean it is today; patients pull at these, work them

out of the oesophagus with their tongue into a coil at the back of

the throat. If called to assess, always look at the back of the pharynx

(‘Open your mouth and say Ah’) and get a CXR.

• Aspiration of tube feeds. In the hypoxic or obtunded patient on NGT

feeds, think of aspiration. Stop the feeds. Sit the patient up and give O

Assess the tube position. If you suspect aspiration (tube feeds visible in

mouth, coughing up feeds, tube in bronchus on CXR), call for senior

help; the patient may need a bronchoscopy and/or intubation.

CHAPTER 4 Practical procedures

210

Urethral catheterization

Key facts

• Foley catheters are useful to monitor urine output hourly (renal

failure, ﬂ uid balance) and in immobile patients.

• Catheterization of female patients is usually performed by nursing staff;

it is useful to learn the technique as you will be asked to try if they fail!

Indications

• Perioperative monitoring of urinary output.

• Acute urinary retention.

• Chronic urinary retention.

• Aid to abdominal or pelvic surgery.

• Incontinence.

Male catheterization

Equipment

• Foley catheter (size 12–20G, 14G most commonly used).

• Dressing/catheter pack containing drapes.

• Cleansing solution, sterile gloves (two pairs).

• Lidocaine gel.

• Gauze swabs, drainage bag and/or universal specimen pot for

midstream urine (MSU).

Preparation

• Consent the patient, explaining the procedure.

• Lay patient supine.

• Expose the genital area and cover with a sterile drape with a hole in it.

Method

• Clean hands and put on sterile gloves.

• Pick up the glans penis with your non-dominant ‘dirty’ hand through

the hole in the drape; the other hand will be your ‘clean’ hand.

• Holding a swab soaked in sterile saline with your clean hand, retract

the foreskin and clean the urethral oriﬁ ce and glans thoroughly so your

gloved ﬁ ngers only touch the swab, not the glans penis.

• Without letting go of the penis, discard the swab and pick up the

sterile lidocaine gel with your clean hand and inject into the urethra.

• Still holding the penis in a vertical position, introduce the catheter with

the clean hand and advance gently for approximately 10cm.

• Lower the penis to lie horizontally and advance the catheter fully

(through the prostatic urethra) up to the hilt.

• Inﬂ ate the balloon now in the bladder via the smaller catheter channel

with the 10mL sterile water; some catheters have an integral bulb of

air which, when squeezed, inﬂ ates the balloon.

• 2 NEVER inﬂ ate the balloon until the catheter is fully inserted as this risks

inﬂ ating the balloon within the prostatic urethra, causing urethral rupture;

ideally you should see urine before inﬂ ating the balloon.

• Attach a catheter bag ﬁ rmly to the catheter.

• 2 Replace the foreskin to avoid paraphimosis.

URETHRAL CATHETERIZATION

211

Tips and pitfalls

• Difﬁ culty identifying urethral oriﬁ ce. Sometimes oriﬁ ce is located in the

glans penis. If just difﬁ culty retracting foreskin, use plenty of gel.

• No urine immediately.

The bladder has just been emptied; insert a 2mL syringe into the •

end of the catheter and aspirate any residual urine.

The catheter tip may be blocked with lidocaine gel; try gently •

instilling 15–20mL of sterile water and gently aspirating.

• Still no urine. The patient may be anuric or a false passage may have

been created; palpate to see if the bladder is empty or if you can feel

the catheter balloon (which should not normally be palpable).

Treat anuria appropriately (see • b p. 112).

Consult a senior colleague if a false passage may have been created.•

• Inability to insert. Try a smaller catheter or a silastic (ﬁ rmer). If

unsuccessful, ask a senior for help; suprapubic catheterization may be

needed (see b p. 212).

• Decompression of grossly distended bladder. Rapid decompression of a

distended bladder (e.g. from chronic retention) may result in mucosal

haemorrhage. Empty the bladder by 250–500mL every 30min until

empty. Then monitor urine output closely as a brisk diuresis and

dehydration may follow.

• Bypassing catheter. Usually due to catheter blockage. Check urine output,

ﬂ ush the catheter, and observe. If urine is ﬂ owing down the catheter and

bypassing it, the catheter may be too small; try a slightly larger size.

• Catheter stops draining. The catheter may be kinked or blocked. Flush

as above; if unsuccessful, try inserting a new catheter. Is the patient

oliguric or anuric? Treat appropriately (see b p. 64).

Female catheterization

2 In many hospitals, males are not allowed to catheterize awake females.

Check before doing do and request a female chaperone.

Equipment As for male catheterization.

Preparation Lie patient on back with knees bent. Ask the patient to place

heels together and allow knees to fall apart as far as possible.

Method

A similar technique is employed here to male catheterization, but note

the following:

• Separate the labia minora with the left hand and ensure the whole

genital area is adequately cleaned using the right hand.

• Identify the external urethral oriﬁ ce. If this proves difﬁ cult in obese

patients, an assistant may help by retracting the dependent fat from

the pubic area.

• Lubricate the tip of the catheter with sterile water or lidocaine gel and

pass gently into the urethra.

Tips and pitfalls

• Difﬁ culty identifying urethral oriﬁ ce. After warning the patient, place

an index ﬁ nger in the vagina to elevate the anterior vulva. Guide the

catheter along the ﬁ nger into the urethra.

CHAPTER 4 Practical procedures

212

Suprapubic catheterization

Indications

Urinary retention with failed or contraindicated urethral catheterization.

Cautions

• Do not perform suprapubic catheterization on a patient with known

bladder tumour or previous bladder surgery; seek expert advice.

• Ensure by clinical examination (and if available, ultrasound bladder

scanning) that the bladder is full and distended.

Equipment

• Dressing pack.

• Gloves.

• Cleansing solution.

• Two 10mL syringes.

• 25G and 21G needle.

• 10mL 1% lidocaine.

• Prepacked suprapubic catheter set (usually containing catheter, trocar,

and scalpel).

• 1/0 silk suture.

• Catheter bag.

Preparation

• Explain the procedure and consent the patient.

• Lie patient supine and expose abdomen.

• Conﬁ rm clinically an enlarged, tense bladder.

• Identify catheterization site, 3–4cm (two ﬁ nger breadths) above the

symphysis pubis (see Fig. 4.7).

Method

• Clean the skin thoroughly around the site and apply drapes.

• Inject lignocaine into skin and subcutaneous tissues, injecting and

aspirating in turn until urine is withdrawn.

• Two systems for introducing a suprapubic catheter are available.

‘Nottingham’ introducer (uses trocar)

• Make a 5mm incision at the identiﬁ ed site.

• Advance the catheter, with trocar in place, through the incision and

subcutaneous tissues. A ‘give’ will be felt as the bladder is entered.

• Withdraw the trocar and ensure that there is free ﬂ ow of urine from

the catheter.

• Inﬂ ate the catheter balloon and suture the ﬂ ange of the catheter to

the skin.

• Attach a catheter bag.

Bonnano (modiﬁ ed Seldinger technique)

• Make a 5mm nick in the skin.

• Take the introducer needle and advance it, aspirating until urine is

withdrawn.

SUPRAPUBIC CATHETERIZATION

213

• Remove the syringe and pass the guidewire down the needle into the

bladder, then remove the needle, holding the guidewire in place.

• Pass the dilator ﬁ rmly over the wire into the bladder.

• Remove the dilator and pass the catheter into the bladder, securing it

as above.

Tips and pitfalls

• Bypassing urine. With some types of catheter and trocar, urine may

initially bypass the catheter. This will cease with full advancement of

the catheter and decompression of the bladder.

• No urine or faeculent matter in catheter. Obtain help; you may have

entered the peritoneum or bowel.

Fig. 4.7 Site of typical suprapubic catheter insertion.

CHAPTER 4 Practical procedures

214

Paracentesis abdominis

Key facts

This is a useful technique in some patients for the diagnosis and manage-

ment of ascites, often in a patient with malignancy.

Indications

• Diagnostic evaluation of ascites.

• Therapeutic drainage of ascites.

Equipment

• Dressing pack.

• Gloves.

• Cleansing solution.

• 10mL syringe and 21G and 25G needles.

• 10mL 1% lidocaine.

• 60mL syringe with 16G aspiration needle for diagnostic ‘tap’.

• Bonano catheter or paracentesis catheter, three-way tap, and

collecting bag for therapeutic drainage.

• Specimen container if appropriate.

• Dressing.

Preparation

• Explain the procedure and consent the patient.

• Position the patient supine and expose the abdomen.

• Percuss out and identify the position of ascites.

• Identify a suitable tap site; the right lower quadrant is the commonest

with the patient turned semilateral to ensure the ascites ﬁ lls this area

(see Fig. 4.8).

Method

• Prepare the skin at the appropriate site and place sterile drapes.

• Inﬁ ltrate local anaesthetic into skin and subcutaneous tissues down to

the peritoneum. Aspirate as the needle is advanced to avoid accidental

vessel puncture.

Diagnostic tap

• Introduce the aspiration needle through the skin and subcutaneous

tissues while aspirating. A ‘give’ should be felt and ﬂ uid freely aspirated

as the peritoneal cavity is entered.

• Withdraw 15–20mL of ﬂ uid for a diagnostic evaluation.

• Remove the aspiration needle carefully and apply an occlusive dressing.

Therapeutic drainage

• Introduce catheter into abdominal wall until a ‘give’ is felt. Trial

aspirate with a syringe to ensure ascites returned.

• Slide catheter over the needle into the peritoneal cavity. Stop if

resistance is encountered.

• Allow up to 1000mL of ascites slowly over 1–2h.

PARACENTESIS ABDOMINIS

215

Tips and pitfalls

• Unable to aspirate adequate quantity of ﬂ uid. The ascites may be

loculated. Drainage under ultrasound guidance may be helpful.

• Blood or faeculent material. Continual staining of the ascitic ﬂ uid

with fresh blood or any staining with faeculent material may indicate

puncture of a vessel or viscus. This is potentially serious; inform a

senior colleague.

• Peritoneal catheter. Some patients who require repeated ascitic taps

might beneﬁ t from placement of a temporary intraperitoneal catheter

to allow daily drainage of ascites for symptomatic relief. There is a

risk of peritonitis with these devices and only a short period of use is

usually recommended, e.g. 2–3 days.

The volume of ascites drained should be closely monitored along with the

patient’s serum albumin and overall ﬂ uid balance. A maximum drainage of

2L/day is usually advised.

Target areas

Fig. 4.8 Target areas for ascitic tap at the level of the umbilicus, 3–4cm lateral to

the mid-inguinal line.

CHAPTER 4 Practical procedures

216

Rigid sigmoidoscopy

Key facts

This is a useful skill to learn. It is usually performed in the outpatient depart-

ment as part of the investigation of lower GI complaints, but may have to be

performed on the ward, e.g. acute admissions with rectal bleeding.

Indications

• Investigation of anorectal symptoms.

• Visualization of the rectum.

Equipment

• Rigid sigmoidoscope with obturator and light source.

• Lubricating jelly.

• Gloves.

• Gauze swabs.

Preparation

• Explain the procedure and consent the patient.

• Position the patient in the left lateral position with the hips ﬂ exed as

fully as possible and knees partially extended.

• Carry out a digital examination of the rectum to identify low-placed

lesions or faecal loading, which may prevent safe insertion or obscure

a useful view.

Method

• Lubricate the sigmoidoscope with jelly.

• With the obturator in place, introduce the scope gently through the

anal sphincter in the direction of the umbilicus for approximately 5cm.

• Remove the obturator; attach light source, insufﬂ ator, and eyepiece.

• Introduce small amounts of air to open up the lumen.

• Advance the instrument slowly under direct vision, ensuring that a

patent lumen is identiﬁ ed prior to advancing the scope further.

• Note the appearance of the mucosa and the presence of any mucosal

lesions. The level of any lesion should also be noted using the marked

scale on the outer casing of the sigmoidoscope.

• If the patient experiences signiﬁ cant discomfort, do not persist.

• Withdraw the scope slowly, again under direct vision.

• Clean the area around the patient’s anus.

Tips and pitfalls

• Biopsy. Unless experienced in the skill, do not attempt biopsy of

lesions. Note and document their position and inform a senior

colleague.

• Unable to see the upper rectum. Remember that the rectum has a

sacral curvature, often pronounced in women; GENTLY use the tip of

the scope as a ‘lever’ to push the anterior wall of the rectum forward

to open to lumen. If this isn’t easy and painless, don’t persist; it may

represent pathology.

RIGID SIGMOIDOSCOPY

217

• Rectosigmoid junction. Negotiation of the rectosigmoid junction can be

difﬁ cult. The best view that can be hoped for is to see the last sigmoid

fold above the junction. Do not attempt to pass the scope into the

distal sigmoid; this is the role of ﬂ exible sigmoidoscopy.

Key revision points—anatomy of the rectum

• The rectum is said to start at the level of S2, but a distance of 15cm

from the anorectal junction is used to deﬁ ne pathology which is

termed ‘rectal’.

• The rectum has two main angles.

The ﬁ rst is the • acute anorectal angle which slopes posteriorly

and is formed in part by the pull of the sling of levator ani.

The second is the • sacral curvature which runs throughout the

rectum, sloping progressively anteriorly up to the level of the

rectosigmoid junction.

• Three ‘lateral valves’ are commonly described, but are only the

mucosal folds of the rectum equivalent to the colonic folds.

• The peritoneal-lined ‘pouch of Douglas’ (or rectovesical pouch in

males) extends a variable distance down the anterior wall of the

rectum. Its contents (e.g. sigmoid colon) may be easily palpable,

particularly in elderly females.

• The upper third is covered by peritoneum anterolaterally, the middle

third just anteriorly, and the lower third is entirely extraperitoneal.

• The rectum has a complete outer longitudinal muscle coat (thus

diverticular disease does not occur in the rectum).

• The rectum and associated mesorectal fat, blood vessels, and lymph

nodes are enclosed and separated from the ‘true’ pelvic organs by a

fascial sheet—the mesorectum.

CHAPTER 4 Practical procedures

218

Local anaesthesia

Local anaesthesia is used in a variety of settings and is easy to deliver. It is

essential to become familiar with the different agents, their relative merits,

and potential dangers.

Indications

• Minor procedures requiring anaesthesia, e.g. insertion of a chest drain,

CV access, suprapubic catheterization, etc.

• Excision of skin or subcutaneous lesions.

• Inﬁ ltration of surgical wounds post-operatively.

Cautions

• Allergy. Do not use local anaesthesia if there is a history of allergy to

local anaesthetic.

• Infection at site of inﬁ ltration. Injection may spread infection. The

effect of the local anaesthetic will be diminished (due to an acidic

environment) and injection may be more painful.

• Increased risk of toxicity. Heart block, low cardiac output, epilepsy,

myasthenia gravis, hepatic impairment, porphyria, B-blocker, or

cimetidine therapy.

• Epinephrine. Causes vasoconstriction, reducing bleeding locally and

prolonging anaesthetic effect. It should not be used for injections into

ﬁ ngers, toes, ears, or penis (all supplied by end arteries) or where skin

ﬂ aps are involved to reduce the chance of ﬂ ap necrosis.

Agents The two most commonly used agents are lidocaine and bupi-

vacaine. Other agents, e.g. prilocaine, are less commonly used.

Lidocaine (previously known as lignocaine)

Used for local inﬁ ltration for minor procedures.

• Concentrations. 0.5%, 1%, and 2%. Plain solutions (with no added

adrenaline) or solutions containing adrenaline.

• Duration of action. Rapid onset (2–3min), lasts 30–90min.

• Maximum dose.

Plain solutions• . 3mg/kg, 20mL 1% or 10mL 2% for 70kg adult.

Solutions with adrenaline• . 7mg/kg as systemic absorption is much

slower, 50mL 1% or 25mL 2% for 70kg adult.

Bupivacaine

Useful in some prolonged procedures, wound inﬁ ltration, and regional

blocks as it has a longer duration of action than lidocaine.

• Concentrations. 0.25–0.75% plain solutions or with adrenaline.

• Duration of action. Slower onset than lidocaine; effects last 3–8h.

• Maximum dose. 3mg/kg for an adult, 2mg/kg for a child.

Equipment

• Syringe.

• Needles 21G–25G.

• Alcohol swabs.

LOCAL ANAESTHESIA

219

Preparation

• Identify site of inﬁ ltration and check for any sign of infection or

obvious subcutaneous blood vessels.

• Calculate maximum dose of anaesthetic for each individual patient.

• Draw up anaesthetic and check details of drug and dose.

Method

• Clean area with alcohol swabs.

• Inject anaesthetic slowly with a ﬁ ne needle to area required, aspirating

before each delivery to prevent accidental IV injection.

• Injecting local anaesthetic in a fan-shaped area subcutaneously from a

single injection is often more comfortable for the patient.

• Field block. Injecting anaesthetic into the tissues surrounding the

area which is to be anaesthetized (e.g. a cutaneous lesion) will often

produce a ﬁ eld block, including the area itself.

Toxicity

This is caused by an overdose of local anaesthetic with systemic absorp-

tion or by accidental IV injection.

Symptoms and signs

• Neurological. Drowsiness, confusion, slurred speech, light-headedness,

tinnitus, numbness of tongue or mouth, convulsions, and coma.

• Cardiovascular. Early tachycardia and hypertension, late bradycardia,

hypotension, cardiac arrhythmias, and cardiac arrest may ensue.

• These features usually will occur at a peak of 10–25min after

subcutaneous injection, but occur immediately with IV injection.

Treatment

• Stop procedure.

• Maintain the patient’s airway and provide oxygen.

• Ensure IV access.

• Perform an ECG.

• Convulsions. Diazepam 5–10mg IV, slowly.

• Hypotension. Raise end of bed and initiate IV ﬂ uids.

• Bradycardia. Usually resolves, atropine is rarely needed.

Tips and pitfalls

• 2 You are more likely to achieve good anaesthetic block with a

large volume of less concentrated local than a small volume of more

concentrated local anaesthetic; generally use 1%, rather than 2%.

• Allow 2–3min for the local to take effect; spend this time setting up

your instruments and draping the patient.

• Accidental IV injection. See toxicity section above.

• Inadequate analgesia. Inﬁ ltrate more anaesthetic up to the patient’s

maximum calculated dose. If the patient is still not tolerating

the procedure, alternative anaesthetic methods may have to be

considered, e.g. regional anaesthesia (note maximum local anaesthetic

dose), sedation, or general anaesthetic.

• The smaller the needle and the more slowly you inject initially, the less

painful it is for the patient.

CHAPTER 4 Practical procedures

220

Intercostal nerve block

This may be a useful skill to learn, although it is usually performed by

anaesthetists.

Indications

• Pain due to fractured ribs.

• Post-thoracotomy pain relief.

Equipment

• Dressing pack.

• Skin antiseptic.

• Gloves.

• 20mL syringe and needle.

• 20mL of local anaesthetic, e.g. bupivacaine.

Preparation

The patient is positioned as for pleural aspiration (see ‘Pleural aspiration’,

b p. 635) and the site of inﬁ ltration is identiﬁ ed.

• Broken ribs. Medial to the site of fracture on the posterior aspect of

the chest wall.

• Post-thoracotomy. Medial to the posterior edge of the scar on the

posterior chest wall.

Method

• Ensure that the skin is prepared thoroughly with antiseptic. Drapes are

placed appropriately.

• Insert the needle and syringe containing anaesthetic through the skin,

inferior to the rib (unlike pleural aspiration) associated with the nerve

to be blocked.

• Aspirate the syringe to ensure that the needle has not entered a blood

vessel or the pleural space. If no blood or air is withdrawn, the site is

inﬁ ltrated with 4–5mL of anaesthetic.

• This is repeated at various sites.

• Obtain a CXR to ensure a pneumothorax has not complicated the

procedure.

Note

• Multiple blocks. Ensure that the patient does not receive a toxic dose

of local anaesthetic.

• Air or blood is aspirated. Withdraw the needle slowly, get a CXR.

Mechanism of action of local anaesthetics

Local anaesthetic works by blocking Na channels in the nerve mem-

brane, preventing propagation of the action potential. Small, non-myeli-

nated pain ﬁ bres are blocked ﬁ rst. Large, myelinated ﬁ bres that conduct

impulses from pressure senses are the last to be blocked.

221

Head and neck surgery

Thyroglossal cyst, sinus, and ﬁ stula 222

Branchial cyst, sinus, and ﬁ stula 224

Salivary calculi 226

Acute parotitis 228

Salivary gland tumours 230

Head and neck cancer 232

Facial trauma 234

Neck space infections 236

Chapter 5

CHAPTER 5 Head and neck surgery

222

Thyroglossal cyst, sinus, and ﬁ stula

Key facts

• Thyroglossal cyst is a ﬂ uid-ﬁ lled sac resulting from incomplete closure

of the thyroglossal duct.

• Thyroglossal sinus results from persistence of the whole duct.

• Incidence <1%; ♂:♀, 1:1.

Anatomy (see Fig. 5.1)

The thyroglossal duct arises embryologically between the ﬁ rst and sec-

ond pharyngeal pouches. It runs as a hollow tube from the foramen

caecum on the dorsal surface of the tongue, becoming a solid cord of

cells migrating through the tongue and into the midline of the neck. The

tract usually passes in front of the hyoid bone and then loops up behind

it before descending in the midline of the neck where the cells divide to

form the two lobes of the thyroid gland either side of the midline. The

duct normally atrophies in the sixth week of gestation.

Clinical features

• Usually presents in children or young adults.

• Ninety per cent present as a painless midline cyst.

• Ten per cent appear on one side of the midline, usually the left.

• Seventy-ﬁ ve per cent appear in front of the hyoid bone and the

majority of the rest at any point to the root of the neck.

• The cyst elevates on protruding tongue if attached to hyoid or if

attached to isthmus of thyroid elevates on swallowing.

• Five per cent become infected presenting as a painful, red neck

swelling.

• Fifteen per cent have a ﬁ stula to the skin (due to infection or

incomplete excision).

• Papillary carcinoma of the thyroglossal ductal cells is rare. Treatment is

by excision.

Diagnosis and investigations

• Ultrasound scan is investigation of choice.

• CT scan will often reveal a well circumscribed cyst related to the

midline of the hyoid bone.

• Fine needle aspiration may reveal a cloudy infected ﬂ uid or a straw-

coloured ﬂ uid.

Treatment

Infected thyroglossal cyst

• Majority respond to antibiotics.

• Surgical drainage if abscess formed or failure to respond to antibiotics.

• Elective excision of the cyst once acute infection has resolved.

Surgery

• Excision is recommended for most cysts.

• Remove through a transverse midline incision in a skin crease.

THYROGLOSSAL CYST, SINUS, AND FISTULA

223

• Divide the platysma muscle and excise the cyst using sharp and blunt

dissection.

• On the deep surface, it is attached to the hyoid bone; excise

approximately 1cm of the bone in midline, removing any underlying

thyroglossal duct epithelium. This is Sistrunk’s procedure.

• Close the wound in layers with a suction drain.

• If there is a ﬁ stula or sinus in the neck, excise it through a transverse

elliptical incision. Again use blunt dissection and remove the middle

part of the hyoid bone (‘Sistrunk procedure’).

Complications These are usually very few. Remove the drain the next

day and discharge the patient.

The important structures that must be considered when operating on

the thyroid gland include:

• Recurrent laryngeal nerve.

• Superior laryngeal nerve.

• Parathyroid glands.

• Trachea.

• Common carotid artery.

• Internal jugular vein (not depicted).

Posterior

Lateral

Superior

Thyroid

cartilage

laryngeal

nerve

Superior

laryngeal

nerve

Vagus nerve

Recurrent

laryngeal

nerve

Recurrent

laryngeal

nerve

Superior

parathyroid

glands

Superior

hyroid artery

Inferior

thyroid artery

Inferior

parathyroid

glands

Right lobe of

thyroid gland

Left lobe of

thyroid gland

Fig. 5.1 The anatomy of the region of the thyroid gland. Reproduced with

permission from Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine,

7th edn. Oxford University Press, Oxford.

CHAPTER 5 Head and neck surgery

224

Branchial cyst, sinus, and ﬁ stula

Key facts

• Disputed aetiology. Theories include:

Cystic degeneration of epithelial derivatives of the ﬁ rst, second, or •

third branchial clefts.

Cystic degeneration of epithelial elements in a cervical lymph node.•

• A branchial ﬁ stula is a tract running from the neck skin through to the

posterior pillar of the fauces; these are very rare.

• A branchial sinus occurs when the lower part of this tract remains

open on to the neck skin surface.

• A branchial abscess is an infected branchial cyst.

Clinical features

• Presents as a neck lump, usually painless.

• They typically present in early adulthood.

• Sixty to seventy per cent are anterior to the upper third of the

sternomastoid muscle with the posterior border lying beneath the

sternomastoid. Other sites include:

Parotid gland.•

Anterior to the lower two-thirds of the sternomastoid.•

Anterior to the pharynx.•

In the posterior triangle of the neck.•

• Two-thirds occur on the left side; 2% are bilateral.

• May present with an acute branchial cyst abscess causing pain,

increased swelling, and occasionally, pressure symptoms (difﬁ culty

swallowing or breathing).

Diagnosis and investigation

For branchial cyst or abscess

• Ultrasound scan is ﬁ rst investigation of choice. CT/MRI for complex

cases.

• Fine needle aspiration biopsy:

Abscesses• . Purulent ﬂ uid is obtained that may culture organisms.

Cysts• . Straw-coloured ﬂ uid containing cholesterol crystals.

Treatment

Branchial abscess

• Drain via a transverse incision in the neck at the point of maximum

convexity.

• Suture a Yeates type drain.

• Give antibiotics and make no attempt to remove the cyst until the

infection has resolved completely.

Branchial cyst

• Most cysts are excised to achieve a diagnosis and prevent symptoms

or complications.

• Place a transverse incision over the cyst, preferably in a transverse skin

crease, long enough to match the size of the cyst.

BRANCHIAL CYST, SINUS, AND FISTULA

225

• Divide the platysma and the deep fascia over the anterior border of

the sternomastoid and retract the muscle posteriorly.

• Remove the cyst, usually by blunt/sharp dissection.

• Use suction drainage and close the wound in layers.

• If the cystic lesion is in the parotid gland and cannot be distinguished

from any other parotid lesion, extend a preauricular incision into the

neck as for a superﬁ cial parotidectomy.

Branchial ﬁ stula

• Excise a sinus of ﬁ stula through a horizontal elliptical incision around

the neck opening.

• Blunt and sharp dissection of sinus tract as far as possible.

• If the upper end of the tract cannot be reached, make a further

transverse incision at a higher level (‘stepladder’ incisions).

• Sometimes the tract runs between the internal and external carotid

arteries and sometimes up to the pharyngeal wall in the region of the

middle constrictor.

• Close the wounds in layers with suction drainage.

Complications

A branchial cyst at any site often lies near important nerves. Previous

infections causing ﬁ brosis will increase the risk of damaging them. The

following nerves are at risk:

• Hypoglossal nerve (tongue deviates to affected side on protrusion).

• Mandibular branch of the facial nerve (movement of lower lip).

• Great auricular nerve (numb ear).

• Accessory nerve (paralysis of trapezius: weakness of arm abduction,

asymmetry, and chronic pain).

CHAPTER 5 Head and neck surgery

226

Salivary calculi

Key facts

• Salivary gland calculi occur most commonly within the submandibular

ductal tree (80%), 20% in the parotid.

• Composed of calcium phosphate and carbonate; may be related to

sialadenitis (inﬂ ammation of a salivary gland).

• Most common in adults.

• No proven relationship with other calculi, e.g. renal.

Clinical features

• Pain and swelling of the affected gland on eating and drinking.

• If there is partial obstruction of the duct, the swelling can last minutes

to several hours.

• Complete obstruction leads to persistent swelling and infection.

• The patient may also experience colicky pain in the duct when eating.

Points in the examination of the submandibular gland

• Examine the gland from behind and feel the swelling by running the

ﬁ nger backwards under the jaw. If you cannot feel a lump, ask the

patient to suck a sour sweet and re-examine them

• Examine the duct oriﬁ ce from the front. Ask the patient to open

their mouth wide and point their tongue upwards. The ducts lie near

the midline at the root of the tongue. Are they red? Is there pus?

Can you see an impacted stone?

• Examine the gland bimanually from the front. Wear gloves and place

the ﬁ nger of one hand over the gland. The index of the other hand is

placed in the mucosal surface of the mandible and the gland palpated

between the two.

Diagnosis and investigations

• Radiographs of the submandibular gland, parotid gland, and ducts are

helpful. Twenty per cent of submandibular and 80% of parotid calculi

are radiolucent.

Lower occlusal X-ray of the teeth will show a stone in the distal •

portion of submandibular duct.

A lateral oblique X-ray or orthopantomogram (OPT) of the •

mandible will show a calculus in the submandibular gland.

• Submandibular duct radiography (sialography) is technically difﬁ cult

and rarely done.

• Parotid sialography may show a ﬁ lling defect. Sialectasis is often seen.

May provide therapeutic beneﬁ t due to ﬂ ushing out of debris in the

ductal tree.

• Ultrasound scanning of parotid and submandibular glands is often the

choice of investigation by head and neck radiologists.

SALIVARY CALCULI

227

Treatment

• Stones in the intra-oral part of the ducts can be removed under local

anaesthesia. Steady the stone with a Babcock’s forceps and incise

directly over it. Remove the stone; leave the duct marsupialized.

• Stones within the submandibular gland require removal of the gland

itself.

• Removal of a calculus from the parotid gland is a rare operation. Most

calculi are at the distal end of parotid duct (as it does an ‘S’ bend

through buccinator muscle) and can be released by intra-oral incision

of parotid duct papilla.

• Most parotid gland obstructive/inﬂ ammatory disease is treated

conservatively with sialogogues and intermittent massage of the gland

towards the duct. Duct dilation using lacrimal probes is useful as most

strictures/obstruction occur at the ‘S’ portion noted above.

Key revision points—anatomy and physiology of

salivary glands

• Salivary glands produce: saliva-containing water; electrolytes

(especially K

and HCO

–

); varying amounts of mucus and enzymes.

• The parotid is a pure serous gland. It responds to salivary stimuli, e.g.

food in mouth, smell. There is little resting ﬂ ow. The submandibular

is mixed with serous and mucous acini, responds to salivary stimuli,

and has a resting ﬂ ow, which contributes along with sublingual and

minor glands to maintain mouth moisture.

• Saliva functions to lubricate, aid mastication, aid taste, suppress oral

bacteria, initiate starch digestion.

• Submandibular duct is palpable in the ﬂ oor of the mouth and enters

mouth from gland on the sublingual papilla near the midline.

• Parotid duct is palpable over the anterior border of masseter and

enters the mouth on the medial wall of the cheek after passing

through buccinator muscle via an ‘S’ bend.

• The facial nerve trunk lies between the deep and superﬁ cial parts of

the parotid gland and divides into ﬁ ve branches (pes anseris) within

the superﬁ cial portion.

CHAPTER 5 Head and neck surgery

228

Acute parotitis

Key facts

• Parotitis is inﬂ ammation of the parotid gland. Causes include:

Acute or chronic obstruction (now commonest cause).•

Bacterial (ascending parotitis), less common.•

Viral infection, e.g. paramyxovirus (mumps), HIV.•

Inﬂ ammatory disorders, e.g. Sjögren’s syndrome, sarcoidosis.•

Any cause of inﬂ ammation of lymph nodes within the parotid gland.•

• Most patients develop this condition as an acute episode of a chronic

obstructive sialadenitis.

Clinical features

• Obstructive parotitis occurs more commonly in adults.

• Presents as an acutely painful preauricular swelling.

• There is often a history of recurrent, intermittent swelling of the gland.

• The gland is usually tender on palpation.

• The patient may be toxic with fever and raised WCC, and pus may

exude from the opening of the parotid duct opposite the crown of the

second upper molar tooth.

• Elderly, debilitated, dehydrated patients with poor oral hygiene or who

are on anticholinergic drugs are at greatest risk.

Diagnosis and investigations

• Plain X-rays to determine whether radio-opaque calculi are present in

the duct or gland.

• Ultrasound or CT scanning may help differentiate between stones,

inﬂ ammation, and tumour.

• If pus is present, take a bacteriology swab and send it to the lab. The

commonest infecting organism is Staphylococcus aureus.

Treatment

Acute parotitis

• Most patients respond to antibiotics:

Give amoxicillin 500mg tds, IV if necessary.•

Rehydrate dehydrated and debilitated patients.•

Good oral nursing care with chlorhexadine mouth rinses.•

• Review patients by clinical examination after the infection has subsided

to make sure that the obstruction was not due to a parotid tumour.

• If a parotid abscess develops, it should be drained surgically:

Make an incision over the abscess under general anaesthetic where •

it appears to be pointing, parallel to the branches of the facial nerve

to avoid damaging them.

Open the abscess with sinus forceps and place a Yeates drain in the •

wound.

Recurrent parotitis

• Teach patients with recurrent parotitis to massage the gland in order

to express saliva from the duct.

• Dilatation of the duct with lacrimal probes can assist drainage.

ACUTE PAROTITIS

229

• Remove radio-opaque calculi, if possible.

• Advise the patient to keep an emergency supply of antibiotics at home.

• If recurrent parotitis persists for months or years, a total

parotidectomy is curative.

CHAPTER 5 Head and neck surgery

230

Salivary gland tumours

Key facts Salivary gland tumours are rare, accounting for 0.4% of all

malignant tumours; 80% arise in the parotid gland.

Clinical features Most patients present with a slow-growing lump in

the affected gland. Pain, paraesthesia (e.g. lingual nerve in submandibular

gland), facial palsy (parotid gland) imply malignancy. Salivary tumours of

minor glands in upper aerodigestive tract (UADT) present as a lump. Fifty

per cent of these are malignant.

Clinicopathological features

Pleomorphic adenoma

• Eighty per cent of benign parotid tumours.

• ♂:♀, 1:1.

• Peak incidence 30–50y.

• Composed of epithelial and mesothelial cells that form a mucous

matrix, often with chondromatous components.

• The tumour grows slowly and has no true capsule so that strands of

tumour cells protrude into normal surrounding tissue. Local extension

may be widespread with recurrence if excision is incomplete.

• Malignant change (adenocarcinoma) occurs in 20% after 10y and is

seen in asymptomatic deep lobe parotid tumours.

Warthin’s tumour (adenolymphoma)

• Usually affects men >50y; 10% are bilateral.

• Benign and presents as a slow-growing soft swelling.

• Successfully treated by wide local excision.

Malignant tumours

Mucoepidermoid tumour

• Low grade malignancy, though variable behaviour.

• Most grow slowly, invading locally and eventually metastasizing to neck

lymph nodes, lung, and skin.

Adenoid cystic carcinoma

• A slow growing malignant tumour with indolent behaviour.

• Perineural invasion propensity and facial palsy common with extension

through stylomastoid foramen. Lung metastasis common.

• Often regarded as incurable, but individuals can lead a normal life over

20–30y before succumbing.

• Treatment is extensive wide local excision, with nerve/organ

preservation where possible. Post-operative radiotherapy has a role.

Radiotherapy also has a role in controlling lung symptoms if they arise.

Acinic cell carcinoma

♀ > ♂; slow-growing, but may metastasize unexpectedly. Surgery is the

treatment of choice.

Squamous cell carcinoma, adenocarcinomas, and undifferentiated

carcinomas

• Generally high grade malignant tumours.

SALIVARY GLAND TUMOURS

231

• Often rapid local invasion into extraparotid tissues and infratemporal

fossa, leading to pain and trismus.

• There may be skin ﬁ xation or ulceration with facial nerve palsy

and invasion of the external auditory canal; incurable; palliative

radiotherapy.

Diagnosis and investigations

• Clinical examination is still of great importance in assessing extent.

• CT scanning may help differentiate between stones, inﬂ ammation, and

tumour.

• MRI scanning offers the most sensitive investigation for assessment of

local invasion and involvement of surrounding structures.

• PET CT is useful for assessing metastases.

Treatment

Benign parotid tumours

• Excise the parotid gland superﬁ cial to the facial nerve (superﬁ cial

parotidectomy). Deep lobe tumours should have a facial nerve-sparing

total parotidectomy.

• Enucleation is inadequate and often leads to local recurrence that is

difﬁ cult to manage.

Benign tumours in other salivary glands

Excision of the entire gland (e.g. simple submandibulectomy).

Malignant tumours

• Radical local excision (to sacriﬁ ce or preserve the facial nerve in

parotid tumours is controversial).

• May be accompanied by neck dissection, especially in parotid tumours.

Complications of parotid surgery

• Facial nerve injury (risk varies according to procedure: lowest in

primary surgery for benign tumours < redo surgery < surgery for

malignancy). Seventy-ﬁ ve per cent neurapraxia with complete or

extensive recovery of function; 25% neurolysis with little or no

recovery (may be treated by nerve interposition grafting).

• Frey’s syndrome:

Late complication of surgery in up to 25% of patients.•

Facial ﬂ ushing and sweating of the skin innervated by the •

auriculotemporal nerve when the patient salivates.

Caused in this case by division of the parasympathetic •

secretomotor ﬁ bres that innervate the parotid gland: they may

regenerate erratically to control cutaneous secretomotor functions.

Subcutaneous botox injection is useful.•

Prognosis

• Recurrence of benign tumours. May develop 20y after surgery,

especially in the patient where enucleation, rather than superﬁ cial

parotidectomy has been performed.

• Five-year survival rate for all malignancies approximately 60%.

CHAPTER 5 Head and neck surgery

232

Head and neck cancer

Key facts

• Head and neck cancer refers to cancer of UADT; 90% are squamous

cell carcinomas (SCC).

• UK incidence 8–15 in 100 000 and rising. Wide geographical variation,

e.g. Indian subcontinent: 40% of all cancers.

• ♂:♀, 2:1, female incidence rising.

• Predisposing factors:

Carcinogens• . Tobacco, alcohol, betel nut chewing;

Infection• . Hyperplastic candidiasis, human papilloma virus (HPV) 16;

Extrinsic factors• . UV light in lip cancer;

Intrinsic factors• . Diet poor in fruit, vegetables, and ﬁ sh oils,

immunodeﬁ ciency/suppression.

Clinical features

• Peak incidence 40+y (increasing incidence in younger patients).

• Persistent oral ulcer with induration, bleeding, often painful.

• Persistent oral swelling, e.g. large tonsil, unexplained loose teeth.

• Unexplained earache: common in tongue, oropharyngeal tumours.

• Dysphagia, odynophagia occur in oro/hypopharyngeal cancer.

• Hoarseness lasting >3 weeks.

• Persistent unilateral serosanguineous nasal discharge.

• Unresolved head or neck swellings of >3 weeks.

• Examination of the neck is mandatory and should include all levels of

neck lymph nodes. Bilateral nodal spread common.

• Six per cent of patients have a synchronous SCC present in the

aerodigestive tract (mouth, larynx, lungs, oesophagus).

Diagnosis, investigations, staging, assessment

• Fibre optic nasendoscopy to examine nasopharynx, base of tongue,

hypopharynx, larynx.

• Fine needle cytology for neck mass.

• Imaging. CT of head and neck and chest with MRI in selected cases.

PET CT for unknown primary tumours, metastatic disease assessment.

• Haematology, biochemistry, ECG, lung function tests as patients

usually have high comorbidities.

• Examination under anaesthetic (EUA). Measure tumour size, biopsy.

Panendoscopy to exclude synchronous tumours of UADT.

• Extraction of any diseased teeth, especially if in possible radiotherapy

treatment ﬁ eld to prevent osteoradionecrosis.

• All patients should be seen by dietician, speech and language therapist,

clinical nurse specialist, and restorative dentist.

Treatment

• Surgery, radiotherapy ± chemotherapy, or combination of all and may

be done with curative intent or palliation.

• In TNM system, T1–4 stage is complex and depends on anatomical

site; N1–3 stage applies to all sites.

HEAD AND NECK CANCER

233

• Function and quality of life are important outcomes. Gastrostomy/

NGT feeding often required during treatment.

Treatment of primary tumour

• Approximately equal cure rate for T1, T2 tumours with surgery

or primary radiotherapy. Surgery is usually offered for oral

cancer, sometimes for T1 larynx (laser surgery). Radiotherapy ±

chemotherapy have better functional outcome in pharyngeal, posterior

one-third tongue cancers.

• Larger T3, T4 tumours involving bone/cartilage are best managed

surgically, e.g. laryngectomy, and often require adjuvant radiotherapy.

Treatment of the neck

• N0 necks may have occult nodal metastases, depending on tumour

site, e.g. >50% for pharynx, and should have either a selective neck

dissection or radiotherapy.

• Single node disease (N1) should have either a neck dissection or

radical radiotherapy.

• Bulky nodal disease (N2, N3) should have a comprehensive neck

dissection followed by radiotherapy or vice versa.

Neck dissections

These are either comprehensive or selective. Selective dissection removes

groups of nodes likely to have occult metastases. Comprehensive includes

radical neck dissection (removal of all ﬁ ve levels of lymph nodes, acces-

sory nerve, internal jugular vein, and sternomastoid muscle) and modiﬁ ed

or functional neck dissection:

• Type 1 preserves the accessory nerve.

• Type 2 preserves the accessory nerve and internal jugular vein.

• Type 3 preserves the accessory nerve, internal jugular vein, and

sternomastoid muscle.

Reconstruction of surgical defect

• Good functional outcome (speech, eating, swallowing) is aim of

reconstruction of surgical defect in the UADT.

• Options include:

Primary closure, e.g. small tongue tumour.•

Local ﬂ ap, e.g. nasolabial to ﬂ oor of mouth.•

Regional ﬂ ap, e.g. pectoralis major to retromolar region.•

Free microvascular transfer ﬂ aps offer great versatility, e.g. radial •

forearm for lining, ﬁ bula for bone, anterior thigh for bulk.

Prosthesis, e.g. obturator for palatal defect.•

Prognosis

• Crude overall 5y survival is 30–40% and of those deaths, 50% die from

other causes, usually tobacco-related.

• HPV 16 positive cancers appear to have better outcome.

CHAPTER 5 Head and neck surgery

234

Facial trauma

Key facts

• Eighty-ﬁ ve per cent of facial injuries are from assault, often with

alcohol/drugs involved; the remaining from falls, sports, road accidents,

industrial injuries.

• Ten to twenty per cent have associated head injury, 2% cervical spine

injury.

• Fracture incidence: nose > zygoma > mandible > maxilla. Panfacial

fractures indicate high energy impact or multiple blows.

Emergency situations in facial injuries

As part of 1° and 2° survey, pay special attention to:

• Airway. Severely displaced fractures, tissue swelling (which may get

worse), blood, dislodged teeth can compromise airway, especially with

associated head injury; intubate if in doubt.

• Bleeding. Profuse bleeding can occur in midface fractures or deep

tongue wounds, requiring early theatre for suturing, nasal packing/

fracture stabilization. Swallowed blood is often vomited.

• Retrobulbar bleed. May follow even minor injury. Orbital swelling can

mask it. Cardinal signs are pain, proptosis, and falling visual acuity.

Treatment is lateral canthotomy under LA, then theatre for orbital

drainage via infra-orbital incision to open ocular muscle cone; 90min

window before blindness sets in.

Key clinical examination points

• Examine the eye even if it means opening swollen eyelids: check visual

acuity. Any diplopia indicates orbital fat/muscle entrapment in orbital

complex fracture. Orbital blow-out fracture may have enophthalmos.

• Dental occlusion (bite): ask patient if bite feels normal. If not, then a

fracture is likely. Manually check continuity of mandible. Fractures in

teeth-bearing segment are compound fractures. In maxilla, grasp upper

incisor teeth and any movement suggests maxillary fracture.

• Mental nerve or infra-orbital nerve paraesthesia indicates mandibular

or orbital ﬂ oor/zygoma fracture, respectively.

• Look for deformity, e.g. nose deviation, ﬂ attened cheek, forehead

hollow.

Investigations

• Imaging. Plain X-rays, OPT, and PA skull for fractured mandible;

occipitomental 30°, 45° views for zygoma fracture. For complex

fractures, CT with 3D reconstruction. Coronal CT/MRI is useful in

orbital complex injuries.

• Clinical photographs as a record which may be used in court.

• Other tests, e.g. ECG, Hb, U&Es for falls in the elderly.

Treatment

• Head injuries, soft tissue lacerations, and direct trauma to the eye take

precedence.

FACIAL TRAUMA

235

• Fractures involving the teeth are compound and antibiotics are

required, e.g. amoxicillin or erythromycin if allergic to penicillin.

• Timing: mandibular fractures involving tooth-bearing segments and any

soft tissue lacerations should be treated within 24h. Uncomplicated

fractures of orbit/malar/frontal bone/nose/maxilla are best treated

when facial swelling has settled. Optimum time is 5–10 days.

• All patients with orbital/malar/maxilla fractures must not blow their

nose for 10 days to prevent surgical emphysema of soft tissues.

• Undisplaced fractures may be treated conservatively. Advise soft diet if

tooth-bearing fragments involved.

• The aim of active treatment is to restore function and correct any

deformity, e.g. diplopia from orbital complex fracture; decompression

of any nerves involved in fracture line (infra-orbital, inferior dental,

frontal nerves); restoration of dental occlusion to correct bite

(mandibular/maxillary fractures); correct deformity (fractured nose/

zygoma).

• Fractures may be treated by closed reduction, e.g. intermaxillary

ﬁ xation with wires or open reduction using mini-fracture plates.

Surgical access to fractures may be intra-oral, incisions around the eye

for orbit, submandibular for mandible, bicoronal to frontal bone.

• Patients who have had an unprovoked assault may experience

post-traumatic stress disorder and beneﬁ t from referral to clinical

psychologist.

CHAPTER 5 Head and neck surgery

236

Neck space infections

Key facts

• Ninety per cent of neck space infections are of dental origin, especially

lower molar teeth.

• Ten per cent are from tonsils and infected epidermoid, branchial, and

thyroglossal cysts.

• Their importance is risk of airway obstruction, septicaemia, and

mediastinitis; mortality risk from overwhelming sepsis.

Anatomy

The investing layer of cervical fascia is attached to mastoid, superior

nuchal line, lower border of mandible, hyoid and descends to the clavicle.

It splits to enclose sternomastoid and trapezius muscles and thus forms a

structural collar to the neck. Medially lie the pharynx, larynx, trachea, and

upper oesophagus which is in direct continuity with the mediastinum. As it

splits to enclose parotid gland, a deep layer is formed attached to base of

skull, merging with the upper end of the carotid sheath and pharyngobasi-

lar fascia posteriorly. It also splits to enclose the submandibular gland with

deep layer attached to mylohyoid line. As a result, a number of important

anatomical compartments or potential spaces exist (see Fig. 5.2).

• Sublingual. Floor of mouth above mylohyoid.

• Submental. Anterior upper neck below mylohyoid.

• Submandibular. Below mylohyoid around submandibular gland.

• Parapharyngeal. Deep to parotid, lateral to pharynx.

• Pterygoid. Pterygomaxillary ﬁ ssure.

These are all interconnected and continue inferiorly down the neck fol-

lowing outside the tough carotid sheath into the mediastinum. Related are

buccal and submasseteric spaces that are not connected.

Clinical features

• Infection may present as a localized ﬂ uctuant swelling or it may

present as a spreading cellulitis with a brawny, hard, tender, hot,

erythematous mass. Often it is a mixture of both. Necrotizing faciitis is

rare and has high mortality.

• There is usually a history of toothache, sore throat, previous neck

swelling, e.g. branchial cyst.

• Cardinal signs of severity include: fever, trismus, hot potato speech,

dysphagia, stridor, tachycardia, and respiratory rate increase.

• Bilateral sublingual/submental/submandibular swelling (Ludwig’s angina)

is particularly aggressive.

Investigations

• Temperature, HR, BP, respiratory rate.

• WCC.

• Imaging. OPT if dental cause expected. Ultrasound scan can localize

any deep space collection. CT, including chest, is useful in severe cases.

NECK SPACE INFECTIONS

237

Treatment

• Admit if systemically unwell or any cardinal signs of severity as above.

• IV antibiotics. Co-amoxiclav or clindamycin if allergic to penicillin.

• Contact anaesthetist as may need ﬁ bre optic intubation.

• Theatre before sunset if systemic sepsis.

Surgical management

• Remove cause of infection, e.g. extract offending teeth, incise quinsy of

tonsil.

• Incise and drain at dependent point any localized abscess.

• Send pus sample for culture and sensitivity.

Exploration of neck spaces

Use a submandibular incision, incise platysma and cervical fascia. Using

Hilton’s method, ﬁ nd lower border of mandible, then explore medially;

this is the submandibular space; go anteriorly to open up sublingual space.

To open parapharyngeal space and pterygoid space, push forceps up

medial ramus of mandible and open forceps. If there is swelling extend-

ing to root of neck, make a second incision above clavicle and medial to

sternomastoid. Suture in a corrugated type drain.

If intubation difﬁ cult or airway compromised, e.g. unrelieved trismus

on induction, do a tracheostomy. The swelling often gets worse before

it gets better. You may need to re-explore the neck. Book ITU bed in

severe cases.

Posterior auricular

nodes

Parotid nodes

Submental nodes

Inferior deep

cervical nodes

Sternohyoidmuscle

Internal jugular

vein

Submandibular

nodes

Buccal nodes

Superior deep

cervical nodes

Posterior belly of

digastric muscle

Omohyoid muscle

Superficial cervical

nodes

Tonsillar node

Occipital nodes

Sternocleidomastoid

muscle

Fig. 5.2 The distribution of lymph nodes in the neck. Reproduced with permission

from Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine, 7th edn.

Oxford University Press, Oxford.

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239

Breast and endocrine

surgery

Breast cancer 240

Surgical treatment of breast cancer 242

Breast cancer screening 244

Benign breast disease 246

Acute breast pain 248

Goitre 250

Thyrotoxicosis 252

Thyroid tumours—types and features 254

Thyroid tumours—diagnosis and treatment 256

Post-thyroid surgery emergencies 258

Primary hyperparathyroidism 260

Multiple endocrine neoplasia 262

Cushing’s syndrome 264

Conn’s syndrome 266

Phaeochromocytoma 268

Chapter 6

CHAPTER 6 Breast and endocrine surgery

240

Breast cancer

Key facts

• Total of 35 000 new cases per year; 1 in 9 lifetime risk for women.

• Commonest in Western Europe; least common in Japan and Africa.

• Incidence increases with age.

• One per cent occurs in men.

• Five per cent related to identiﬁ able genetic abnormality (BRAC1,

BRAC2, ataxia–telangectasia genes.)

• Sixty per cent present as symptomatic disease; 40% during screening.

Pathological features

Eighty per cent ductal adenocarcinoma; 20% lobular, mucinous tubular or

medullary adenocarcinoma. Most carcinomas believed to originate as in

situ carcinoma before becoming invasive; 70% express oestrogen or pro-

gesterone receptors.

Clinical features

Breast lump

• Commonest presenting symptom.

• Usually painless (unless inﬂ ammatory carcinoma).

• Hard and gritty feeling.

• May be immobile (held within breast tissue), tethered (attached to

surrounding breast tissue or skin), or ﬁ xed (attached to chest wall).

• Ill-deﬁ ned; irregular with poorly deﬁ ned edges.

Nipple abnormalities

• Nipple may be the prime site of disease (Bowen’s disease), presenting

as an eczema-like change.

• Nipples may be affected by an underlying cancer:

Destroyed.•

Inverted.•

Deviated.•

Associated bloody discharge.•

Skin changes

• Carcinoma beneath skin causes dimpling, puckering, or colour changes.

• Late presentation may be with skin ulceration or fungation of the

carcinoma through the skin.

• Lymphoedema of the skin (peau d’orange) suggests local lymph node

involvement or locally advanced cancer.

• Extensive inﬂ ammatory changes of the skin are associated with

inﬂ ammatory carcinoma (aggressive form).

Systemic features

• Systemic features include weight loss, anorexia, bone pain, jaundice,

malignant pleural, pericardial effusions, and anaemia.

BREAST CANCER

241

Diagnosis and investigation

Diagnostic tests

Tissue diagnosis

• Core biopsy or ﬁ ne needle aspiration cytology (FNAC) of the breast

lesion 9 axillary nodes.

• Core biopsy also ﬁ nds oestrogen receptor status, differentiates between

invasive carcinomas and in situ carcinoma (ductal carcinoma in situ, DCIS).

Staging investigations

Systemic staging is usually reserved for patients following surgical treat-

ment with a tumour who are at risk of systemic disease.

• Staging CT scan (chest, abdomen, and pelvis).

• Liver ultrasound.

• Chest X-ray.

• Bone scan.

• LFTs, serum calcium.

• Speciﬁ c investigations for organ-speciﬁ c suspected metastases.

Treatment Surgical treatment is described on b p. 242.

Medical treatment

In non-metastatic disease, medical therapy is adjuvant to reduce the risk of

systemic relapse, usually after primary surgery. It is occasionally used as a

treatment of choice of elderly or those unﬁ t/inappropriate for surgery.

• Endocrine therapy.

Used in (o)estrogen receptor (ER) +ve patients.•

Anti-oestrogens like tamoxifen or aromatase inhibitors (letrozole).•

Post-menopausal patients—letrozole (caution osteoporosis).•

Premenopausal patients—tamoxifen.•

Herceptin—given in Her-2 receptor +ve patients.•

• Chemotherapy (e.g. anthracyclines, cyclophosphamide, 5-FU,

methotrexate). Offered to patients with high risk features (+ve nodes,

poor grade, young patients).

In metastatic disease, medical therapy is palliative to increase survival time

and includes:

• Endocrine therapy. As above.

• Chemotherapy (e.g. anthracyclines, taxanes, herceptin).

• Radiotherapy. To reduce pain of bony metastases or symptoms from

cerebral or liver disease.

• All breast lumps or suspected carcinomas are investigated with triple

assessment.

• Clinical examination (as above).

• Radiological assessment:

Mammography usual• , particularly over age 35y.

Ultrasound scan• used to assess the presence of involved lymph

nodes; sometimes used under age 35 because increased tissue

density reduces sensitivity and speciﬁ city of mammography.

MRI • used in lobular carcinoma to assess the extent of the disease,

multifocality, and the opposite breast.

• Younger women with dense breast tissue. For screening purpose in

patients with strong family history.

CHAPTER 6 Breast and endocrine surgery

242

Surgical treatment of breast cancer

Surgery is the mainstay of non-metastatic disease. Options for treatment

of the primary tumour are as follows.

Wide local excision

• To ensure clear margins.

• Commonest procedure.

• Breast-conserving, provided breast is adequate size and tumour

location appropriate (not central/retro-areolar).

• Usually combined with local radiotherapy to residual breast to reduce

risk of local recurrence.

Simple mastectomy

• Best local treatment and cosmetic result for large tumours (especially

in small breast), central location, late presentation with complications

such as ulceration.

• Also used for multifocal tumours or where there is evidence of

widespread in situ changes.

• Adjuvant breast radiotherapy is very rarely necessary.

• Performed with reconstruction at the same time or later stage

including:

Latissimus dorsi ﬂ ap;•

TRAM ﬂ ap;•

Prosthesis (see • b p. 618).

Surgical management of regional lymph nodes

Axillary node sampling

• Minimum of four nodes should be retrieved.

• Avoids complete disruption to axillary lymph drainage, reducing risk of

lymphoedema.

• Is inadequate for treatment of the axilla. If nodes are +ve, they require

adjuvant radiotherapy to axilla or axillary node clearance.

Axillary node clearance

• Optimizes diagnosis and treatment of axilla.

• Increases risk of lymphoedema greatly.

Sentinel node biopsy

• One or two nodes primarily draining tumour identiﬁ ed by radioactive

tracer or dye injected around tumour and node(s).

• Identify positive nodes, then require a full axillary clearance.

• Avoids major axillary surgery where not necessary.

Surgery for metastatic disease

Surgery in metastatic disease is limited to procedures for symptomatic

control of local disease (e.g. mastectomy to remove fungating tumour).

Ductal carcinoma in situ (DCIS)

• Precancerous condition.

• Ten to ﬁ fty per cent develop invasive ductal cancers.

SURGICAL TREATMENT OF BREAST CANCER

243

• Mammograms show microcalciﬁ cation.

• Pathologically graded to low grade, intermediate grade, and high grade.

• DCIS is treated with wide local excision with clear margin.

• Mastectomy needed in larger breast lesions or multifocal disease.

• High grade DCIS treated by post-operative radiotherapy after wide

local excision.

• Axillary surgery is not needed as there is no potential for lymph node

metastasis.

CHAPTER 6 Breast and endocrine surgery

244

Breast cancer screening

Aims

• To identify asymptomatic (hopefully early) invasive breast cancer.

• To identify asymptomatic carcinoma in situ.

• Features looked for on screening mammography include: spiculated

calciﬁ cation; microcalciﬁ cation.

What is offered?

• Since 1988, population-based screening has been offered.

• Arranged regionally with centrally activated postal invitation.

• Starts age 50 and continues to age 70 (cover peak ages of incidence

of new diagnoses and excludes low risk younger women—‘prevents

psychological morbidity of screening the well’); plans to extend screening

age group from 47–74y.

• Two view (lateral and oblique) mammography of both breasts.

• Suspicious or malignant-looking lesions invited for clinical assessment

by standard triple assessment.

Results

• Seventy per cent of women offered it will accept screening (lowest

take-up in socio-economic groups and those difﬁ cult to contact, e.g.

rapidly changing addresses or no ﬁ xed address).

• Ten per cent of invasive carcinoma is not radiologically detectable

(false negative rate).

• Risk of a false positive screening is approximately 25% over 10y of

screening.

• For every 1000 women screened over 10y, around 200 are recalled

because of an abnormal result.

Sixty (6%) will have at least one biopsy.•

Fifteen (1.5%) will have invasive cancer.•

Five (0.5%) will have DCIS.•

• Absolute reduction in cancer deaths due to screening over 10y are:

0.5 per 1000 at age 40.•

2 per 1000 at age 50.•

3 per 1000 at age 60.•

2 per 1000 at age 70.•

• Studies suggest up to a 30% reduction in mortality from screen-

detected early breast cancer.

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CHAPTER 6 Breast and endocrine surgery

246

Benign breast disease

Most benign breast conditions arise from pathology related to abnor-

malities of the normal development and involution of the breast (ANDI).

Other benign diseases are related to infection or trauma.

Fibroadenoma

Benign overgrowth of one lobule of the breast. Usually isolated, may be

multiple or giant, especially in Afro-Caribbeans. Commonest under age 30,

but may occur at any age up to menopause.

• Features. Painless, mobile, discrete lump.

• Diagnosis. Ultrasound usually conclusive.

• Treatment. Excision if concern over diagnosis, cosmesis, or symptoms.

Cysts

Almost always benign, ﬁ lled with green-yellow ﬂ uid. Often associated with

ﬁ brocystic disease (below).

• Features. Round, symmetrical lump(s); may be discrete or multiple.

Occasionally painful.

• Diagnosis. Aspiration—typical ﬂ uid returned; residual mass or

recurrent cysts—mammography to exclude associated tumour.

• Treatment. Repeated aspiration; hormone manipulation occasionally

useful for multiple recurrent cysts.

Fibrocystic disease

Combination of localized ﬁ brosis, inﬂ ammation, cyst formation, and hor-

mone-driven breast pain. Occurs almost exclusively between menarche

and menopause (15–55y).

• Features. Cyclical pain and swelling, ‘lumpy’ breasts, multiple breast

cysts.

• Diagnosis. Lumps usually require triple assessment (even once a

diagnosis of ﬁ brocystic disease is made—any woman may develop a

carcinoma).

• Treatment. Reassurance, anti-inﬂ ammatories, hormone or ‘cellular’

manipulation (e.g. G-linoleic acid/evening primrose oil, combined oral

contraceptive (COC) pill, cyst aspiration).

Breast infections

Lactational mastitis

Due to acute staphylococcal infection of mammary ducts. May degenerate

into an acute lactational abscess. Treat with oral antibiotics and (repeated)

aspiration if abscess occurs. No need to stop lactating.

Recurrent mastitis/mammary duct ectasia

Due to dilated, scarred, chronically inﬂ amed subareolar mammary ducts.

Associated with smoking. Present with recurrent yellow-green nip-

ple discharge or recurrent breast abscesses. Infection is usually mixed

anaerobic based. Treatment with metronidazole and drainage of acute

abscesses. Surgery is rarely necessary.

BENIGN BREAST DISEASE

247

Traumatic fat necrosis

Post-traumatic disorder of breast tissue caused by the organization of

acute traumatic injury by:

• Fibrosis.

• Organized local haematoma.

• Occasionally calciﬁ cation.

Presents with new, painless or painful breast lump, often poorly deﬁ ned.

History of trauma is often absent.

Diagnosis may be difﬁ cult even on triple assessment. Failure to resolve

or doubt about diagnosis after assessment is an indication for excision

biopsy.

CHAPTER 6 Breast and endocrine surgery

Acute breast pain

Causes and features

Breast origin

• Breast abscess. Acute severe, localized pain in the breast, associated

with swelling, redness, and sometimes purulent nipple discharge. Most

common in breastfeeding women. May be due to chronic mastitis/

mammary duct ectasia (see b p. 246)—occasionally recurrent.

• Mastitis. Recurrent intermittent breast pain with swelling, tenderness,

seropurulent nipple discharge. Most common in smokers; associated

with mammary duct ectasia (see b p. 246).

• Fibrocystic disease (see b p. 246). Usually recurrent or chronic

breast pain, but may be acute isolated episode. Often multifocal and

associated with tender vague swelling or ‘lumpiness’.

Non-breast origin

• Musculoskeletal. Often onset after exercise, coughing, or straining,

but not always. No associated breast symptoms. Pain usually sharp

and precipitated by movement or breathing. Often tender deep to

breast tissue and over other chest wall areas (e.g. costochondral

junctions in costochondritis (Tietze’s disease)). May be due to pleural

disease (post-pneumonic, post-pulmonary embolism, viral pleurodynia

(Bornholm’s disease)).

• Visceral. May be due to atypical angina or acute coronary syndrome.

• Skin pathology. Such as infected sebaceous cysts, cellulitis, skin abscess.

Emergency management

Establish a diagnosis

• Good inspection and careful history taking is usually all that is required.

• Imaging is rarely necessary and is often painful if the pathology is

primary breast. Mammography should be avoided due to the breast

compression required. Breast ultrasound may help, particularly in the

diagnosis of breast abscess.

• Consider specialist referral or opinion if PE, cardiac ischaemia, or

pneumonia suspected. CXR is simple, but often unhelpful.

Early treatment

• Give adequate analgesia. NSAIDs (diclofenac (Voltarol

) 50mg PO or

100mg PR) are effective in most causes. Opiates may be necessary.

• Breast abscesses may be effectively aspirated for relief of pressure

symptoms under local anaesthetic. Formal incision and drainage is

often avoided, especially in lactational abscesses.

248

ACUTE BREAST PAIN

Deﬁ nitive management

• Breast abscess. If lactational, oral antibiotics (including ﬂ ucloxacillin

500mg tds) and aspirational drainage (often repeated several times on

a daily or alternate day basis). If associated with chronic mastitis, oral

antibiotics (to include metronidazole 400mg PO tds or co-amoxiclav

750mg tds PO).

• Fibrocystic disease. NSAIDS (e.g. ibuprofen 400mg prn), G-linoleic acid,

danazol, occasionally tamoxifen.

249

CHAPTER 6 Breast and endocrine surgery

250

Goitre

Key facts

• Goitre refers to an enlarged thyroid gland (from the Latin guttur,

meaning throat).

• For clinical practice, ‘enlargement’ is taken to mean a thyroid gland

that is easily visible or palpable with the neck in neutral position.

Pathological features

• Goitres result from follicular cell hyperplasia at one or multiple sites

within the thyroid gland.

• The mechanism is multifactorial—genetic, environmental, dietary,

endocrine, and other factors.

On the basis of clinical and pathological features, goitre can be subclassi-

ﬁ ed as follows.

• Epidemiology.

Endemic.•

Sporadic.•

Familial.•

• Morphology.

Diffuse.•

Nodular.•

Multinodular. —

Solitary nodules. —

• Thyroid function status.

Toxic.•

Non-toxic.•

• Location.

Cervical.•

Retrosternal.•

Intrathoracic.•

Clinical features

Sporadic nodular goitre

• Commonest surgical presentation of thyroid disease.

• Generally asymptomatic and usually present with a neck mass or

compressive symptoms.

• Present as a small, diffuse, or nodular goitre and is generally euthyroid.

Compressive symptoms

• More likely to occur in patients with a retrosternal extension (at the

thoracic inlet, the bony structures create a limited space that cannot

expand).

• Growth of the goitre may cause:

Dyspnoea (worse when lying ﬂ at) due to tracheal displacement.•

Dysphagia due to oesophageal compression.•

Voice changes due to recurrent laryngeal nerve (RLN) pressure.•

GOITRE

251

Distended neck veins, facial plethora, swelling, and stridor due to •

superior vena caval compression (worse with arms raised above

the head—‘Pemberton’s sign’).

Cosmesis May or may not be a signiﬁ cant problem—varies widely.

Hyperthyroidism or hypothyroidism

• The vast majority of patients with goitre will be euthyroid.

• May be apparent clinically or biochemically (hyper = i free T

, d TSH;

hypo = d free T

, i TSH).

Diagnosis and investigations

• Thyroid function tests ((TFTs) for TSH and free T

). Usually normal,

especially outside endemic areas.

• CXR. Look for tracheal deviation and a retrosternal shadow.

• Thoracic CT. Used to deﬁ ne the anatomy in patients with large

intrathoracic extension.

• Preoperative laryngoscopy. To assess the possibility of pre-existing RLN

palsy.

Treatment

Surgical treatment

• Indications include:

Relief of local compressive symptoms.•

Cosmetic deformity.•

Prevention of progressive thyroid enlargement.•

• Thyroid lobectomy is feasible if there is asymmetric enlargement with

only the one lobe creating the obstructive symptoms. This avoids the

need for long-term thyroxine replacement (important mainly in areas

where medical facilities are limited).

• Total thyroidectomy offers immediate improvement of obstructive

symptoms, minimal morbidity in experienced hands, less risk of

recurrent symptoms, particularly in large or retrosternal goitres.

Medical treatment

• Oral levothyroxine (

). Used to reduce the size of goitres in patients

with iodine deﬁ ciency or subclinical hypothyroidism (i.e. when a raised

TSH stimulates the enlargement of the thyroid gland).

• Radioactive iodine (

131

I). Induces a gradual destruction of thyroid tissue,

with a decrease in goitre volume up to 50% in 2y. Large (or repeated)

doses of

131

I are needed. Used for non-toxic goitres (more in Europe

than UK or USA).

• The risks of radioactive iodine are:

Radiation thyroiditis (acute thyroid swelling can potentially be •

dangerous in patients with large substernal goitres).

Temporary thyrotoxicosis (due to rapid release of preformed •

hormones from the destroyed follicles).

Late hypothyroidism due to over-destruction of the gland.•

CHAPTER 6 Breast and endocrine surgery

252

Thyrotoxicosis

Key facts

• Hyperthyroidism occurs in 27 in 1000 women and 3 in 1000 men in the

UK.

• Graves’ disease is the most common cause of hyperthyroidism.

Causes and pathological features

• TSH-secreting pituitary adenoma.

• Autoimmune stimulation (Graves’ disease) (Fig. 6.1).

Thyroid-stimulating antibodies (IgG) bind to TSH receptors and •

stimulate the thyroid cells to produce and secrete excessive

amounts of thyroid hormones.

Thyroid gland hypertrophies and becomes diffusely enlarged.•

The autoimmune process leads to mucopolysaccharide inﬁ ltration •

of the extra-ocular muscles and may lead to exophthalmos.

• T

, T

secreting site in the thyroid.

Nodule in a multinodular goitre (‘Plummer’s syndrome’).•

Adenoma or (very rarely) carcinoma.•

• Thyroiditis (large amount of preformed hormones are released

after the destruction of follicles, with transient thyrotoxicosis).

• Exogenous intake of thyroid hormones (factitious thyrotoxicosis).

Ant pituitary Blood

TSH

del

Thyroid cell

Globulin

Follicle centre

Thyroglobulin

MIT

DIT

–

Fig. 6.1 Physiology of thyroid hormone secretion. AA, amino acids; del,

deiodination (especially of liver and kidney); DIT, di-iodotyrosine; MIT, mono-

iodotyrosine; TSH, thyroid-stimulating hormone.

THYROTOXICOSIS

253

Clinical features (any cause)

• Weight loss, heat intolerance, sweating (due to stimulated metabolism

and heat production).

• Tremor, nervousness, irritability, emotional disturbance, tiredness,

and lethargy (due to CNS overactivity).

• Cardiac features are caused by beta-adrenergic sympathetic activity:

Palpitations, tachycardia, and arrhythmias.

• Eye signs can be:

Minimal/mild (soft tissue oedema, chemosis).•

Very prominent (severe exophthalmos, corneal ulcers, diplopia).•

Ophthalmopathy is usually bilateral, but may only involve one eye.•

• Pretibial myxoedema, thyroid acropachy, vitiligo, and alopecia are rare.

Thyroid storm (thyrotoxic crisis)

• Rare presentation of extreme signs of thyrotoxicosis and severe

metabolic disturbances.

• Precipitated by non-thyroid surgery, major trauma, infection, imaging

studies with iodinated contrast medium in patients with unrecognized

thyrotoxicosis.

• Features are insomnia, anorexia, vomiting, diarrhoea, marked sweating,

fever, marked tachycardia.

• Early clinical diagnosis of the condition and immediate treatment

decrease the risk of fatal outcome.

Diagnosis and investigations

• TFTs. d TSH level, i free T

, and free T

(in all causes, but pituitary).

• Positive serology for thyroid autoantibodies.

• Radioactive iodine scan (or technetium scan).Helpful in distinguishing the

diagnosis of Graves’ disease, thyroiditis, toxic nodule (unilateral uptake

with negative scan on the contralateral side), or toxic multinodular goitre.

Treatment

Medical treatment

• Antithyroid drugs block hormone synthesis:

Carbimazole 20mg bd, then reducing dose (especially in UK).•

Propylthiouracil 200mg bd (especially in USA): blocks the peripheral •

conversion of T

to T

• Beta-blockers (propranolol 40–120mg/day) are used to control

tachycardia and tremor.

• Radioactive iodine (

131

I; see b p. 251 for risks). Contraindicated in

severe eye disease (could worsen after

131

I treatment), young women

(risk of teratogenicity in pregnancy), patients who are main carers of

small children.

Surgical treatment

• Total thyroidectomy (for Graves’ disease). Indicated in patients who are

not candidates for

131

I therapy. It is the treatment of choice in those with

eye disease and patients where control of symptoms has been difﬁ cult

on medication. Slightly higher risk of RLN injury and hypoparathyroidism

(due to increased vascularity of the gland and the local ﬁ brosis).

• Thyroid lobectomy. For isolated nodules or adenomas.

CHAPTER 6 Breast and endocrine surgery

254

Thyroid tumours—types and features

Key facts

• Solitary thyroid nodule is the most common thyroid disorder.

• Ultrasound studies show that up to 50% of patients have thyroid

nodules by the age of 50.

• Although thyroid nodules are common, malignant nodules are rare

(incidence of 4 in 100 000 individuals per year).

Pathological features

• Colloid nodule.

The most commonly encountered solitary thyroid nodule.•

Ultrasound examination may reveal numerous other small nodules •

as part of a multinodular gland.

Nodules are formed mainly of collagenous material interspersed •

with benign thyroid cells with little or no malignant potential.

• Follicullar adenoma.

Benign tumour that grows in a glandular or follicular pattern.•

Tends to develop slowly with a pseudocapsule of compressed •

normal thyroid tissue.

• Papillary carcinoma.

Most common malignant neoplasm of the thyroid.•

Malignant cells show typical cytological features (nuclear ‘grooves’, •

intranuclear inclusions, or ‘optically clear nuclei’—‘Orphan Annie

cells’).

Spread tends to be via lymphatics to local lymph nodes.•

• Follicular carcinomas. Malignant tumours divided into two histologically

distinct groups.

Minimally invasive• . Usually small, encapsulated neoplasms that

show invasion only into the tumour capsule; vascular and lymphatic

invasion is normally absent; associated with an excellent prognosis.

Widely invasive• . Invasion through the capsule into the surrounding

thyroid tissue; they can replace the entire thyroid, invade local

structures, and display haematogenous metastases.

• Medullary thyroid cancer. Rare, derived from calcitonin-secreting C-cells

of the thyroid.

Sporadic• . Single, unilateral, and presenting in isolated patients with a

neck mass and often cervical lymphadenopathy.

Familial• . Either as part of the multiple endocrine neoplasia (MEN)

type 2 (see b p. 262) or non-MEN familial tumours when cancers

may be multiple and multifocal, arising in a background of diffuse

C-cell hyperplasia.

• Anaplastic thyroid cancer. Very rare and extremely aggressive tumour,

characteristically occurring in older women.

• Thyroid lymphoma.

Tumour of mucosa-associated lymphoid tissue (MALToma).•

Classiﬁ ed as diffuse B-cell non-Hodgkin’s lymphomas.•

Rarely associated with longstanding Hashimoto’s thyroiditis.•

THYROID TUMOURS—TYPES AND FEATURES

255

Clinical features

Most thyroid nodules are asymptomatic, presenting as a chance ﬁ nding by the

patient or during a routine general examination. Clinical assessment should

include an assessment of risk factors related to malignancy (see Table 6.1).

Retrosternal extension should be assessed.

Differential diagnosis of neck swellings (see Table 6.2)

Table 6.1 Clinical features

Sex Thyroid nodules—females > males.

A solitary nodule in a man is more likely to

represent a cancer.

Age Nodules in children and old patients are

more likely to represent a cancer.

Family history MEN2A and MEN2B (medullary Ca).

Geographic

Previous neck irradiation

Solitary versus multiple

nodules

Nodule characteristics Firm/hard or ﬁ xed nodules are more likely to

be a cancer. Rapid increase in size of a

previously static longstanding nodule is

worrying (particularly in an elderly patient).

Local lymphadenopathy

Voice changes RLN palsy is a sign of invasive cancer.

Table 6.2 Differential diagnosis

Congenital conditions Thyroglossal tract abnormalities

Branchial cyst

Cystic hygroma

Cervical rib

Tumours Thyroid

Salivary glands

Chemodectoma (carotid body tumour)

Sarcoma

Lipoma, ﬁ broma

Lymph nodes Primary malignancy (lymphomas, leukaemias)

Secondary malignancy (skin, nasopharynx, mouth,

oesophagus, thyroid, breast, or occult)

Inﬂ ammatory conditions (tonsillitis, dental,

mononucleosis, toxoplasma, HIV, cat scratch fever)

Diverticulae Oesophagus

Traumatic Sternocleidomastoid ‘tumour’

CHAPTER 6 Breast and endocrine surgery

256

Thyroid tumours—diagnosis and

treatment

Diagnosis and investigation

• TFTs (free T

, TSH levels).

• Thyroid autoantibodies.

• Fine needle aspiration biopsy (FNAB). Mandatory for all thyroid nodules.

An 18G needle is used to obtain a sample for cytological analysis. The

results are presented on a 5-point scale.

Thy1, non-diagnostic sample (though this may be expected if the •

nodule contains cystic ﬂ uid).

Thy2, benign colloid nodule.•

Thy3, follicular lesion (i.e. either an adenoma or a carcinoma, the •

distinction being possible only after excision biopsy and histological

analysis).

Thy4, suspicious, but not diagnostic of papillary cancer.•

Thy5, diagnostic for thyroid cancer.•

• Neck ultrasound. Sometimes used to assess the size and characteristics

of a nodule and to determine whether the nodule is solitary or part of

multinodular goitre.

Treatment

Surgical treatment

• Thyroid lobectomy, including the isthmus and pyramidal lobe (if

present), is the minimum operation for thyroid tumours. It is curative

for colloid nodule (alleviating pressure symptoms), enables full

histological diagnosis in suspicious (Thy3) follicular lesions, whilst

being considered curative for minimal papillary cancers (<1cm) and for

minimally invasive follicular cancers.

• Total thyroidectomy at initial operation is indicated for cytologically

proven cancers. Completion total thyroidectomy (following thyroid

lobectomy) is deemed necessary for papillary thyroid cancers larger

than 2cm in diameter or histologically proven widely invasive follicular

cancer after initial lobectomy.

• Total thyroidectomy plus cervical nodal dissection. A modiﬁ ed

(selective) functional neck dissection is performed in patients

presenting with palpable lymphadenopathy and in patients with

medullary thyroid cancer.

Medical treatment for patients with thyroid cancer

• T

substitution (levothyronine, 20 micrograms tds) is used in the

immediate post-operative period in patients due to undergo

131

I-whole

body scan. The shorter half-life of T

means it can be stopped for only

2 weeks to allow a rise in TSH that would favour uptake of

131

I in any

remaining thyroid cells.

•

131

I is administered to patients with thyroid cancer following total

thyroidectomy. The

131

I is extremely effective in killing any residual

thyroid cells or metastatic cells that may be present.

THYROID TUMOURS—DIAGNOSIS AND TREATMENT

257

• T

replacement in slightly higher doses (thyroxine, 100–200 micrograms

od) is used to maintain a suppressed TSH. This has been shown to

decrease the possibility of contralateral disease in patients undergoing

lobectomy for thyroid cancer and to reduce the risk of local

recurrence or metastatic disease in patients who underwent total

thyroidectomy.

• Recombinant human TSH (rhTSH) has recently become available as a

means of inducing

131

I uptake without having to stop thyroid hormone

replacement therapy (therefore avoiding the distressing symptoms of

hypothyroidism in the weeks before and after the

131

I scan).

Key revision points—anatomy of the thyroid gland

• The thyroid consists of two lateral lobes that make up 90% of the

gland substance and a central midline isthmus with a small pyramidal

lobe.

• Each lobe contains lobules that comprise follicles containing colloid

and lined by thyroid epithelial cells with parafollicular C (calcitonin-

secreting) cells.

• The arterial supply is from superior thyroid arteries (2) from the

external carotid (related to the external laryngeal nerves in their

course), and the inferior thyroid arteries (2) from the subclavian

artery (related to the recurrent laryngeal nerves).

• Four parathyroid glands are usually found posteromedial to the mid-

upper and inferior poles of the lateral lobes.

CHAPTER 6 Breast and endocrine surgery

258

Post-thyroid surgery emergencies

Neck bleeding

May occur immediately (in recovery) or late (on the ward, sometimes due

to infection).

• Symptoms. Usually due to the pressure of a haematoma on neck

structures: dyspnoea, pain, sensation of neck swelling.

• Signs. Stridor, neck swelling, bleeding from wound, cyanosis (if high

pressure compression of neck).

Resuscitation

• If the patient is at all unwell, call for senior help—acute bleeding can be

rapidly life-threatening.

• If possible, establish large calibre IV access. Give crystalloid ﬂ uid up to

1000mL if tachycardic or hypotensive.

• Give high ﬂ ow O

(8L/min via non-rebreathing mask).

• Consider opening the wound immediately. If the patient is cyanosed

or unconscious, cardiorespiratory arrest may be imminent and loss of

blood from opening the wound will be trivial in comparison.

Early treatment Returning to theatre to deal with the cause is the deﬁ ni-

tive treatment and the patient may be transferred while resuscitation and

emergency treatment are continuing.

Acute bilateral recurrent laryngeal nerve injury

• Extremely rare; due to surgical technique.

• Causes acute paralysis (and therefore adduction) of both vocal cords,

leading to acute airway obstruction.

• Usually noticed immediately after extubation.

• Signs. Acute severe stridor, falling O

saturations, and cyanosis.

Resuscitation

• Usually conducted by the anaesthetist.

• Reintubation or, if not possible, immediate cricothyroidotomy.

• Usually recovers as the nerve injuries are rarely both complete.

Acute thyrotoxic crisis

• Rare due to improved medical pre-conditioning of patients prior to

surgery for thyrotoxic conditions.

• May occur due to handling of the gland.

• Has features similar to those of acute severe thyrotoxicosis (see b

p. 252).

• Features. Sweating, fever, tachycardia (may include tachydysrrhythmias

such as AF or atrial ﬂ utter), hypertension.

Resuscitation

• Ensure the patient has large calibre IV access. Crystalloid may be

required if there is marked vasodilatation with hypotension, but

tachycardia may not represent ﬂ uid depletion.

• Give high ﬂ ow O

(8L/min via non-rebreathing mask).

POST-THYROID SURGERY EMERGENCIES

259

• Catheterize and monitor urine output.

• Severely ill patients may need transfer to critical care due to the

need for control of adrenal amine release and the cardiac effects of

excessive thyroid hormones.

CHAPTER 6 Breast and endocrine surgery

260

Primary hyperparathyroidism

Key facts

• Primary hyperparathyroidism (PHPT) is a common endocrine disease.

• Prevalence is highest among post-menopausal women, with 1 in 500

possibly being affected.

• Most patients are identiﬁ ed by an incidental ﬁ nding of raised serum

calcium during investigations for another condition.

Pathological features

• Eighty-ﬁ ve per cent have a single parathyroid adenoma. Most of these

tumours are small, less than 1g (normal glands are 30–50mg).

• Ten to ﬁ fteen per cent have multigland hyperplasia, either as a

sporadic disease or in association with familial disease (e.g. MEN

syndromes, see b p. 262).

• Parathyroid cancer is rare, representing less than 1% of patients.

Clinical features

• Classical symptoms are described as:

Moans.• Psychological/psychiatric symptoms (lethargy, depressed

mood).

Groans.• Non-speciﬁ c GI symptoms (abdominal pain, constipation).

Bones.• Aches/pains localized in large joints.

Stones.• Calcium-based renal stones.

• Polyuria, polydipsia, and nocturia are also common features.

• More than half of patients report no speciﬁ c symptoms and accept

most of the symptoms as part of ‘generally getting older’.

• Hypercalcaemic crisis can occur in patients with PHPT exposed to

severe dehydration (e.g. diarrhoea/vomiting). In severe cases, patients

can present in coma.

Diagnosis and investigations

• i Corrected serum calcium is highly suggestive if unexplained, but not

diagnostic.

• i Serum parathyroid hormone concentration (PTH) in the presence

of hypercalcaemia conﬁ rms the diagnosis (e.g. bone metastases

(breast, renal, thyroid carcinoma) have a low (i.e. inhibited) PTH

concentration).

• High resolution neck ultrasound may identify tumours.

• Sestamibi (radioisotope) scanning used to localize adenomas

(accurate in 50%) and allows a focused approach (minimally invasive

parathyroidectomy).

Treatment

Surgical treatment

• Bilateral neck exploration, visualization of all four parathyroid glands

with excision of the enlarged one(s), has, for many years, been the

standard treatment. It remains the treatment for those with negative

localization scans.

PRIMARY HYPERPARATHYROIDISM

261

• When imaging studies identify reliably the position of the adenoma,

patients can undergo minimally invasive parathyroidectomy (MIP). This

is a focused neck exploration through a lateral cervical scar, aiming to

remove the adenoma visualized on scanning and not to explore the

other parathyroid glands.

Medical treatment

• Hypercalcaemic crisis needs aggressive rehydration.

• Establish large calibre IV access. Give 1L in ﬁ rst hour, further 4–6L in

ﬁ rst 24h.

• Monitor urine output and CVP until normalized.

• Furosemide can be added to increase urinary excretion of calcium

once rehydration is adequate.

• Bisphosphonates (e.g. IV pamidronate) should be avoided in PHPT

when parathyroidectomy is anticipated since they impair the ability

to maintain normocalcaemia after the excision of an overactive

parathyroid adenoma.

CHAPTER 6 Breast and endocrine surgery

262

Multiple endocrine neoplasia

Key facts

• Familial endocrine diseases constitute a group of rare conditions.

• Familial syndromes are autosomal dominant diseases involving tumours

of several endocrine glands in a synchronous or metachronous pattern.

Clinicopathological features

Multiple endocrine neoplasia type I (MEN-1)

A syndrome of the ‘3Ps’.

• Parathyroid gland tumours. By age 40, 95% of patients have

hypercalcaemia which is the commonest manifestation.

• Pancreatic islet cell tumours.

Prevalence of 30–75%.•

Usually multicentric, slow-growing.•

Secrete multiple polypeptides (insulin and gastrin commonest).•

Gastrinoma leads to Zollinger–Ellison syndrome (recurrent and •

multiple peptic ulcers, severe reﬂ ux oesophagitis, and diarrhoea).

Rarer tumours are VIPoma, glucagonoma, somatostatinoma.•

• Anterior pituitary tumours.

Detected in 15–40%.•

Commonest is prolactinoma.•

Rarer are GH- (causes acromegaly) or ACTH- (causes Cushing’s •

disease) secreting tumours.

Carcinoid tumours (thymus, lungs, foregut), adrenal tumours, lipomas, and

pinealomas have also been reported to appear in MEN-1 patients.

MEN-1 gene, Chr11, encodes a nuclear protein, menin (role unclear).

Multiple endocrine neoplasia type II (MEN-2) Has two forms.

MEN-2A Syndrome with the following features.

• Medullary thyroid carcinoma (MTC).

Originates in the calcitonin-secreting parafollicullar C-cells •

(derivatives of the neuroectodermal tube);

Commonly multicentric and bilateral and appear on a background •

of C-cell hyperplasia;

Presents as unilateral or bilateral thyroid nodules with/without •

associated cervical lymphadenopathy;

Associated secretion of other (some unidentiﬁ ed) peptides can •

lead to severe diarrhoea.

• Phaeochromocytoma (in 50% of patients; see b p. 268 for features).

• Primary hyperparathyroidism (15% of patients).

MEN-2B Syndrome with the following features.

• MTC.

• Phaeochromocytoma.

• ‘Marfanoid-speciﬁ c body habitus’ (tall, slender, high arched palate, and

long extremities), 90% of patients.

MEN-2B is associated with mucosal neuromas and intestinal ganglioneuro-

matosis and characteristic facial appearance.

MULTIPLE ENDOCRINE NEOPLASIA

263

MEN-2 gene, Chr10, encodes a cell surface glycoprotein member of

receptor tyrosine kinases (RET proto-oncogene). Point mutations in spe-

ciﬁ c parts of the RET gene lead to speciﬁ c clinical syndromes (genotype–

phenotype correlation). Because of near complete penetrance, all gene

carriers are likely to be affected.

Familial MTC A syndrome of isolated familial with MTC.

Diagnosis and investigations

MEN-1

• Biochemical screening from second decade in known families (serum

calcium, PTH, prolactin, and insulin growth factor-1 (IGF-1) for

pituitary lesions, and serum glucose, insulin, gastrin, and chromogranin

for pancreatic tumours).

• Genetic screening can be used for offspring of known index cases.

Because 10% of menin mutations are de novo, siblings of an index case

are not necessarily at risk.

MEN-2

• Genetic screening for point mutations of the RET gene has 100%

accuracy for identifying carriers (before biochemical abnormalities).

• Affected children are offered total thyroidectomy at an age related

to the individual risk of each mutation (as early as 3y old for some

aggressive mutations).

• Biochemical screening with 24h urine excretion of catecholamines and

metanephrines and serum calcium and PTH are measured annually.

Treatment

Surgical treatment

MEN-1

• Parathyroidectomy.

• Pancreatic tumours. Enucleation of individual tumours in the head of

the pancreas and distal pancreatectomy for tumours in the tail/body.

• Hypophysectomy and external beam irradiation are considered for

pituitary tumours.

MEN-2

• Total thyroidectomy (TT) indicated in patients identiﬁ ed by genetic

screening. Symptomatic patients need TT and cervical nodal dissection

for the lymph nodes on the involved side.

• Laparoscopic adrenalectomy for phaeochromocytoma.

• Parathyroidectomy for MTC in patients belonging to families in which

hyperparathyroidism is frequently associated.

Medical treatment

MEN-1 Prolactinomas can be treated with dopamine agonists (bromo-

criptine/cabergoline).

CHAPTER 6 Breast and endocrine surgery

264

Cushing’s syndrome

Key facts

A syndrome of excess levels of plasma cortisol and associated clinical

features.

Causes

• Commonest cause is iatrogenic administration of steroids.

• Primary adrenal disease (50% of patients).

Unilateral. Cortical adenoma or cortical carcinoma.•

Bilateral. ACTH-independent macronodular adrenal hyperplasia or •

pigmented nodular adrenal cortical disease.

• Secondary adrenal disease.

ACTH-secreting pituitary adenoma (Cushing’s disease, 25%).•

Ectopic ACTH secretion (25%) from other malignant tumours (e.g. •

small cell lung carcinoma).

Clinical features

• Weight gain. Obesity is predominantly truncal with a protuberant

abdomen and a ‘buffalo hump’.

• Muscle weakness, especially thigh and upper arms (add to the overall

appearance, likened to a ‘lemon on sticks’).

• Menstrual irregularities, headache, and backache are common

presenting symptoms.

• Psychological changes are commonly overlooked: lethargy/depression,

paranoid ideas, hallucinations, and a tendency to suicide.

• Plethora, acne, striae, and multiple bruising are common, as is

hirsutism.

• Hypertension, osteoporosis, and impaired glucose tolerance/diabetes.

All these symptoms and signs are non-speciﬁ c and not exclusively related

to Cushing syndrome.

Diagnosis and investigations

Diagnosis is by proving cortisol excess and then by establishing the cause.

• Loss of normal circadian rhythm of cortisol secretion. Samples taken

at 9 a.m. and midnight demonstrate a loss of the normal morning peak

and night nadir.

• Persistent increase in cortisol levels. 24h urine cortisol levels are

elevated, but false positive results can appear in obese patients,

athletes, and patients suffering stress.

• Overnight dexamethasone test. After administration of 1mg

dexamethasone in the evening, the morning cortisol is inhibited in

normal patients, but not in Cushing’s syndrome. It is a very valuable

outpatient screening test.

• Low dose dexamethasone test. Administration of 0.5mg dexamethasone

qds for 48h fails to inhibit plasma cortisol and urine cortisol and

metabolites.

• ACTH levels are inhibited in primary adrenal disease (see above)

and are increased in patients with pituitary adenomas and ectopic

secretion.

CUSHING’S SYNDROME

265

• High dose dexamethasone test. Administration of 2mg dexamethasone

qds for 48h inhibits ACTH secretion from pituitary tumours and leads

to a drop in cortisol levels in such patients. The test is negative in

primary adrenal disease and in ectopic ACTH secretion.

• Imaging.

Abdominal CT or MRI scanning demonstrates whether there is a •

solitary adrenal tumour (with an atrophic contralateral gland) or

whether both adrenals are enlarged. Cancer should be strongly

suspected in tumours greater than 7cm.

Pituitary MRI usually demonstrates tumours over 10mm; small •

microadenomas may need conﬁ rmation by measuring ACTH

concentrations in the inferior petrosal sinuses (to demonstrate

laterality of the tumour).

Treatment

Surgical treatment

• Unilateral adrenalectomy (may be laparoscopic). For patients with

primary adrenal disease.

• Bilateral adrenalectomy. For patients with pituitary ACTH-secreting

adenomas who failed pituitary surgery or gamma-knife treatment. It

is also needed for the very rare patients with ACTH-independent

bilateral adrenal hyperplasia.

Medical treatment

• Metyrapone and ketoconazole can be used preoperatively to decrease

cortisol synthesis, but their efﬁ cacy is limited.

• Cortisol replacement after unilateral or bilateral adrenalectomy is vital.

Patients with solitary adrenal tumours have the contralateral •

adrenal gland atrophied and it may take up to 1y for a return

to normal function. Start on 50–100mg IV tds hydrocortisone

post-operatively. Maintenance dose is usually prednisolone orally

long-term.

Patients should be informed about the possibility of an Addisonian •

crisis triggered by any illness that could impair their ability to

continue medication (e.g. severe diarrhoea/vomiting episodes).

They should wear a bracelet and carry a card with details of their

condition.

• Mineralocorticoid replacement (ﬂ udrocortisone 0.1mg) is also

necessary after bilateral adrenalectomy.

CHAPTER 6 Breast and endocrine surgery

266

Conn’s syndrome

Key facts

• Syndrome of hypertension, severe hypokalaemia, and aldosterone

hypersecretion with suppression of plasma renin activity.

• Originally described in 1954 by Dr Jerome Conn; caused by a benign

adrenocortical tumour.

Causes and pathological features

• Aldosterone-producing adenomas are usually solitary tumours

involving only one adrenal gland. Most adenomas are small (<2cm in

diameter). Aldosterone-producing adenomas (APA) account for about

50–75% of cases of primary hyperaldosteronism (PAL).

• Other causes are idiopathic bilateral adrenal hyperplasia (25–30% of

cases) and familial hyperaldosteronism (very rare cases).

Type I familial hyperaldosteronism.• Autonomous aldosterone

hypersecretion that is suppressible by dexamethasone (mutation

in the ACTH-responsive regulatory portion of the 11b-hydroxylase

gene).

Type II familial hyperaldosteronism.• Autosomal dominant

autonomous aldosterone hypersecretion that is not suppressible by

dexamethasone.

Clinical features

PAL is characterized by:

• Hypertension. Moderate to severe and indistinguishable from other

forms of hypertension (up to 10% of new diagnoses of hypertension);

• Hypokalaemia. Signs include muscle weakness, cramping, intermittent

paralysis, headaches, polydipsia, polyuria, and nocturia.

Diagnosis and investigations

• Serum and urinary K

levels. PAL suspected if serum K

<3mmol/L

and urinary K

excretion >40mmol/L per day. (Spironolactone or

ACE inhibitors should be stopped prior to testing and any K

deﬁ cit

corrected).

• Ratio of plasma aldosterone concentration to plasma renin activity,

PAC/PRA (i.e. aldosterone/renin ratio, ARR).

Aldosterone is elevated in all cases (normal 2.2–15ng/dL).•

In PAL, plasma renin activity is suppressed.•

PAC:PRA ratio of >50 is diagnostic for PAL.•

False positive due to beta-blockers, clonidine, NSAIDS, renal •

impairment, and the contraceptive pill.

False negative due to diuretics, ACE inhibitors, renovascular •

hypertension, malignant hypertension, calcium blockers, and very

low Na

diets.

• Aldosterone suppression test.

Inability to suppress aldosterone with a high Na•

diet.

Oral Na•

(9g/day for 3 days) and 0.5mg of ﬂ udrocortisone are given

and a 24h urine sample obtained.

CONN’S SYNDROME

267

Na+ values >200mEq with aldosterone levels >12micrograms/L are •

diagnostic.

Normokalaemia should be ensured prior to testing as the test •

may precipitate hypokalaemia. The test is positive in only 3 of 10

patients with Conn’s syndrome.

• Posture test.

• i PAC after standing for 4h in bilateral adrenal hyperplasia.

• d PAC after standing for 4h in unilateral disease (i.e. adrenocortical

adenoma, Conn’s syndrome).

APAs are unresponsive to angiotensin, but still follow the circadian •

rhythm of ACTH/cortisol.

• Adrenal imaging.

CT scan. To localize the cause.•

If a solitary unilateral macroadenoma (>1cm), no other localization •

studies are necessary and treatment is unilateral adrenalectomy.

• Adrenal venous sampling (AVS) is useful when CT localization has

failed.

Patients in whom localization is not achieved may have bilateral adrenal

hyperplasia and should be treated medically.

Treatment

Surgical treatment

Laparoscopic adrenalectomy for aldosterone-secreting adenomas.

Hypokalaemia should be corrected before the operation by the use

of spironolactone, oral potassium, or both. Normalization of BP after

treatment with spironolactone is a good predictor of the successful treat-

ment of hypertension after unilateral adrenalectomy.

Medical treatment Spironolactone can control hypertension and correct

levels in the preparation for surgical treatment.

CHAPTER 6 Breast and endocrine surgery

268

Phaeochromocytoma

Key facts

• Rare—incidence of 2–8 cases per million population/year.

• Many cases probably remain undiagnosed.

Clinicopathological features

• Said to follow the ‘10% rule’:

10% are multifocal.•

10% are bilateral.•

10% are extra-adrenal.•

10% are malignant.•

10% occur in children.•

• Originate from the neural crest tissue that forms the adrenal medulla,

sympathetic chain, and visceral autonomic tissue.

• Most common active products are catecholamines (adrenaline,

dopamine, and noradrenaline), but vasopression, somatostatin, ACTH,

and oxytocin may also be secreted.

• Excess catecholamine secretion leads to characteristic episodes

(‘attacks’) of:

Headache.•

Sweating.•

Palpitations.•

Paroxysmal hypertension, tachydysrrhythmias, and a feeling of •

‘impending doom or death’ may also occur.

• Attacks can be triggered by activities causing mechanical pressure

on the tumour (e.g. physical exercise, defecation, intercourse),

by ingestion of alcohol, labour, general anaesthesia, and surgical

procedures.

• Only 50% of patients have persistent hypertension. The other 50%

have normal BP or are hypotensive between the acute episodes.

Diagnosis and investigations

Consider the diagnosis in patients with characteristic paroxysmal episo-

des, those with unusually labile or intermitted hypertension, those with

a family history of phaeochromocytoma or related conditions (see MEN

syndromes), and in hypertensive children.

• 24h urine collection and assessment for vanillylmandelic acid (VMA)

and noradrenaline is most accurate for diagnosis (97% sensitive).

• Clonidine suppression test (failure of urine levels to fall after clonidine

dose) conﬁ rms the diagnosis where urine levels are borderline.

• Provocative testing (e.g. stimulation with bolus IV glucagon) is rarely

necessary and not without risk.

Localizing studies

• Thoraco-abdominal CT or MRI scanning. First-line test, especially for

adrenal and sympathetic chain tumours.

• MIBG (meta-iodo-benzyl-guanidine) scanning localizes extra-adrenal

sites not seen on CT or MRI.

PHAEOCHROMOCYTOMA

269

Treatment

Medical treatment

• It is imperative to control BP prior to contemplating any surgical

intervention.

• Alpha-blockade (e.g. phenoxybenzamine 10mg bd/tds up to the

maximum dose tolerated) until hypertension controlled.

• Beta-blockade (e.g. propranolol) can be added after hypertension

controlled to control the beta-adrenergic effects (tachycardia).

• Alternative treatments with doxazosin (alpha-/beta-blocker) or calcium

channel blockers have been described, but are not widely used.

Surgical treatment

• The principle of surgery is complete resection of the tumour (with

clear negative margins if suspected of malignancy).

• Laparoscopic adrenalectomy is the treatment of choice for smaller

adrenal tumours (<8cm); open adrenalectomy for larger tumours.

• Local or radical excision is appropriate for extra-adrenal tumours.

Key revision points—anatomy of the adrenal gland

• Two main regions—cortex (steroid producing) and medulla

(catecholamine-producing).

• Three cortical zones.

Glomerulosa (outer)—mineralocorticoids (aldosterone).•

Fasciculata (middle)—glucocorticoids (cortisol).•

Reticularis (inner)—sex hormones (andosterone).•

• Blood supply.

Arterial supply is triple—mainly suprarenal artery, some from •

renal artery and inferior phrenic artery.

Venous drainage—usually single vein to the vena cava (right •

suprarenal vein is very short).

• Innervation.

Autonomic—sympathetic from greater splanchnic nerve (T12), •

parasympathetic from vagus (X) via coeliac plexus.

Somatic—from pudendal nerve (S2, 3, 4) to supply external •

urethral sphincter.

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271

Upper gastrointestinal

surgery

Upper gastrointestinal endoscopy 272

Oesophageal motility disorders 274

Pharyngeal pouch 276

Hiatus hernia 278

Gastro-oesophageal reﬂ ux disease 280

Oesophageal tumours 282

Peptic ulcer disease 284

Gastric tumours 286

Chronic intestinal ischaemia 288

Surgery for morbid obesity 290

Small bowel tumours 292

Acute haematemesis 294

Acute upper GI perforation 296

Acute appendicitis 298

Acute peritonitis 300

Acute abdominal pain 302

Gynaecological causes of lower abdominal pain 306

Intra-abdominal abscess 308

Chapter 7

CHAPTER 7 Upper gastrointestinal surgery

272

Upper gastrointestinal endoscopy

There are four types of endoscopy looking at the upper gastrointestinal

(GI) and pancreaticobiliary tracts.

Gastroscopy

Correctly termed oesophago-gastro-duodenoscopy (OGD). Allows direct

visualization of pathology, small channel biopsies to be taken, and minor

interventions (e.g. injection).

Indications

• Investigation of dysphagia.

• Investigation of dyspepsia, reﬂ ux disease, upper abdominal pain.

• Investigation of acute or chronic upper GI bleeding.

• Investigation of iron deﬁ ciency anaemia (with colonoscopy).

• Therapeutic interventions for upper GI pathology:

Balloon dilatation of benign strictures.•

Endoluminal stenting of malignant strictures.•

Injection, coagulation, or banding of bleeding sources, including •

ulcers, varices, tumours, and vascular malformations.

Resection of early neoplastic lesions in stomach and oesophagus •

(endoscopic mucosal resection (EMR)).

Preparation and procedure

• Patient should be starved for 4h (except in emergency indications).

• IV access may be used.

• Always performed with local anaesthetic throat spray (lidocaine).

• Often performed with IV sedation (e.g. midazolam 3mg).

Risks and complications

• Perforation (usually of the oesophagus). Median risk approximately

1 in 3000; highest in elderly, with oesophageal pathology, during

therapeutic interventions.

• Bleeding. Commonest after biopsies or therapeutic procedures.

• Respiratory depression and arrest. Related to overmedication with

sedative; commonest in frail, low body weight, elderly patients.

Endoscopic ultrasound (EUS)

Utilizes a video endoscope with an ultrasound scanner in its tip.

Indications

• Staging of oesophageal, gastric, or pancreatic cancers.

• Investigation of pancreatic cysts/tumours.

• Investigation of possible distal common bile duct stones/sludge.

• Guided biopsy of pancreatic, peri-oesophageal, or perigastric masses/

lymph nodes.

• Guided drainage of pancreatic (pseudo)cysts.

• Guided coeliac plexus blockade.

UPPER GASTROINTESTINAL ENDOSCOPY

273

Endoscopic retrograde cholangiopancreatography (ERCP)

Indications

• Investigation of possible biliary disease (common bile duct stones,

biliary strictures, biliary tumours, biliary injuries, intrahepatic biliary

disease) only where non-interventional imaging (e.g. magnetic

resonance cholangiopancreatogram (MRCP), CT cholangiography) is

not possible.

• Investigation of pancreatic disease (pancreatic duct strictures,

pancreatic duct abnormalities).

• Therapeutic interventions for pancreatico-biliary disease:

Stenting for common bile duct stones, strictures, and tumours, •

post-operative bile leak.

Sphincterotomy for the extraction of biliary stones.•

Preparation and procedure

• Patient should be starved for 4h (except in emergency indications).

• IV access required.

• Always performed with local anaesthetic throat spray (lidocaine).

• Always performed with IV sedation (e.g. midazolam 5mg) and

occasionally, analgesia (pethidine 50mg, fentanyl).

• Performed under X-ray screening guidance, often in X-ray department.

• May be performed under GA.

• LFTs and INR needed prior to procedure.

Risks and complications

• Perforation (of the oesophagus or of the duodenum). Median risk

approximately 1 in 1000; highest in elderly, with pathology, during

therapeutic interventions, especially sphincterotomy.

• Bleeding. Commonest after biopsies or therapeutic procedures,

especially sphincterotomy; usually controlled by balloon pressure, may

require open surgery.

• Post-ERCP pancreatitis.

• Post-ERCP cholangitis. Particularly in jaundiced patient in whom

procedure has been unsuccessful.

• Respiratory depression and arrest. Related to overmedication with

sedative; commonest in frail, low body weight, elderly patients.

Ileoscopy

Often termed ‘push endoscopy’. Performed with long length thin calibre

endoscope, aiming to intubate past the duodenojejunal junction and visual-

ize the ﬁ rst loops of the upper small bowel.

Indications

• Investigation of undiagnosed upper GI bleeding (possibly due to

proximal small bowel pathology).

• Investigation of abdominal pain.

• Investigation of upper small bowel Crohn’s disease.

Preparation and procedure As for gastroscopy.

Risks and complications As for gastroscopy.

CHAPTER 7 Upper gastrointestinal surgery

274

Oesophageal motility disorders

Key facts A spectrum of diseases involving failure of coordination or

contraction of the oesophagus and its related muscular structures.

Pathological features In some cases, degeneration of the inner and

outer myenteric plexuses can be demonstrated, but often no structural

abnormality is seen.

Clinical features

Achalasia

• Peak ages of incidence in young adulthood (idiopathic) and old age

(mostly degenerational).

• Slowly progressive dysphagia. Initially worse for ﬂ uids than solids.

• Frequent regurgitation of undigested food common late in the disease.

• Secondary recurrent respiratory infections due to aspiration.

Diffuse oesophageal spasm

• Commonest in young adults; ♂ > ♀.

• Characterized by acute pain along the length of the oesophagus

induced by ingestion, especially of hot or cold substances

(odynophagia).

Diagnosis and investigations

Achalasia

• Video barium swallow. A characteristic failure of relaxation of the lower

oesophagus with a smooth outline ‘rat’s tail’ or ‘bird beak’.

• Oesophageal manometry. Hypertonic lower oesophageal high pressure

zone with failure of relaxation normally induced by swallowing; in

chronic cases, the proximal oesophagus may be adynamic.

• Oesophagoscopy. To exclude benign and malignant strictures.

Diffuse oesophageal spasm

• Video barium swallow. ‘Corkscrew’ appearance of the oesophagus

caused by discoordinated diffuse contractions.

• Oesophageal manometry. Diffuse hypertonicity and failure of relaxation;

little or no evidence of coordinated progressive peristalsis during

episodes, but normal peristalsis when asymptomatic.

• Oesophagoscopy. Required to exclude underlying associated

malignancy.

Treatment

Achalasia

• Endoscopically guided controlled balloon dilatation (ﬁ xed pressure).

Successful in up to 80% of patients; low complication rates

(perforation); may need multiple procedures over time.

• Botulinum toxin injections. Success in some patients failing dilatation.

OESOPHAGEAL MOTILITY DISORDERS

275

• Surgical myotomy (Heller’s cardiomyotomy). Usually performed

laparoscopically with division of the lower oesophageal circular muscle

ﬁ bres; highly successful in resistant cases; mostly applicable to young

patients. Speciﬁ c complications include reﬂ ux, obstruction of gastro-

oesophageal junction, oesophageal perforation.

Diffuse oesophageal spasm

• Oral calcium channel blockers or relaxants, e.g. benzodiazepines.

• Long-acting nitric oxide donors (smooth muscle relaxant).

• Widespread oesophageal pneumatic dilatations (often repeated).

• Long surgical open myotomy, rarely undertaken.

Key revision points—anatomy and physiology of the

oesophagus

• Upper two-thirds. Stratiﬁ ed squamous epithelial-lined (develops

squamous carcinoma), striated skeletal muscle, lymphatic drainage

to neck and mediastinal nodes, somatic innervation of sensation (e.g.

moderately accurate location of level of pathology).

• Lower third. Transition to columnar epithelium (develops

adenocarcinoma), transition to smooth muscle, lymphatic drainage to

gastric and para-aortic nodes, visceral innervation (poor localization

of pathology).

• Gastro-oesophageal junction is site of portosystemic anastomosis

(between left gastric and (hemi)azygous veins)—may develop gastric

or oesophageal varices.

• Upper oesophageal sphincter (UOS) = cricopharyngeus.

• Lower oesophageal sphincter (LOS) = functional zone of high

pressure above the gastro-oesophageal junction. Relaxants include

alcohol.

• Swallowing requires intact and coordinated innervation from vagus

(UOS, oesophagus, LOS) and intramural myenteric plexus.

CHAPTER 7 Upper gastrointestinal surgery

276

Pharyngeal pouch

Key facts

• An acquired ‘pulsion’ diverticulum arising in the relatively ﬁ brous tissue

between the inferior constrictor and cricopharyngeus muscle—

‘Killian’s dehiscence’.

• Arises primarily as a result of failure of appropriate coordinated

relaxation of the cricopharyngeus, causing increased pressure on the

tissues directly above during swallowing.

• Typically occurs in the elderly.

• Associated with lower cranial nerve dysfunction (e.g. motor neuron

disease, previous CVA).

Pathological features

• Acquired diverticulum (ﬁ brous tissue and serosa without muscle ﬁ bres

in most of the wall).

• Tends to lie to one side of the midline due to the cervical spine

directly behind.

Clinical features

• Upper cervical dysphagia.

• Intermittent ‘lump’ appearing to the side of the neck on swallowing.

• Regurgitation of food—undigested.

• Nocturnal aspiration—‘waking up coughing’.

Diagnosis and investigations

• Diagnosis may be made on observed swallowing with a transient neck

swelling appearing.

• Video barium swallow will show ﬁ lling of pouch.

2 Gastroscopy should be avoided unless there is a question of associated

pathology since the pouch is easily missed and easily damaged or perfo-

rated by inadvertent intubation.

Treatment

Endoscopic stapled pharyngoplasty—side-to-side stapling of pouch to the

upper oesophagus, which also divides the cricopharyngeus muscle.

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CHAPTER 7 Upper gastrointestinal surgery

278

Hiatus hernia

Key facts

The presence of part or all of the stomach within the thoracic cavity,

usually by protrusion through the oesophageal hiatus in the diaphragm

(see Fig. 7.1).

• Very common; ♀ > ♂; majority are asymptomatic.

• May or may not be associated with gastro-oesophageal reﬂ ux disease

(GORD).

• Predisposing factors include obesity, previous surgery.

Clinico-pathological features

Sliding hernia

• Results from axial displacement of upper stomach through the

oesophageal hiatus, usually with stretching of the phrenico-

oesophageal membrane.

• By far, the commonest form; may result in GORD.

Rolling (para-oesophageal) hernia

Results from the displacement of part or all of the fundus and body of the

stomach through a defect in the phrenico-oesophageal membrane such

that it comes to lie alongside the normal oesophagus.

• Much less common.

• Symptoms include hiccough, ‘pressure’ in the chest, odynophagia.

• May result in volvulus or become incarcerated and cause obstruction.

Diagnosis and investigations

• Upper GI endoscopy (OGD). To exclude oesophageal mucosal

pathology

• Video barium swallow. Usually identiﬁ es the type and extent.

• CT scanning of the thorax. Investigation of choice in acute presentations.

Treatment

Medical (mainly for GORD symptoms)

• Reduce acid production. Stop smoking, lose weight, reduce alcohol

consumption.

• Counteract acid secretion. Proton pump inhibitors (PPIs), symptomatic

relief with antacids, mucosal protectants.

• Promote oesophageal and gastric emptying. Promotilants, e.g.

metoclopramide.

Surgical

Rarely required. Indicated for:

• Persistent symptoms despite maximal medical therapy;

• Established complications of rolling hernia such as volvulus or

obstruction.

HIATUS HERNIA

279

Elective procedure of choice is laparoscopic (or occasionally open) reduc-

tion of the hernia and ﬁ xation (gastropexy), usually with plication of the

oesophageal opening (cural plication), occasionally with a fundoplication

(e.g. Nissen’s operation) if GORD symptoms predominate. Acute presen-

tations may rarely require a partial gastrectomy.

Sliding hernia

Peritoneal sac

Diaphragm

Rolling hernia

Fig. 7.1 Hiatus hernia—sliding and rolling. Reproduced with permission from

Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine, 7th edn.

Oxford University Press, Oxford.

CHAPTER 7 Upper gastrointestinal surgery

280

Gastro-oesophageal reﬂ ux disease

Key facts

• Pathologically excessive entry of gastric contents into the oesophagus.

• Reﬂ ux occurs in ‘normals’ up to 5% of the time.

• Commonest in middle-aged adults.

• Usually due to gastric acid, but also due to bile reﬂ ux.

• Contributory factors include:

Reduced tone in the lower oesophageal sphincter. • Idiopathic, alcohol,

drugs, previous surgery, secondary to existing peptic stricture.

Increased intragastric pressure. • Coughing, delayed gastric emptying,

large meal.

Pathological features

Oesophagitis

• Results in inﬂ ammatory changes in the squamous-lined oesophagus.

• Varies in severity from minor mucosal erythema and erosions to

extensive circumferential ulceration and stricturing (graded I to IV).

Stricture

• Chronic ﬁ brosis and epithelial destruction may result in stricturing.

• Eventually shortening and narrowing of the lower oesophagus.

• May lead to ﬁ xation and susceptibility to further reﬂ ux.

Oesophageal metaplasia (‘Barrett’s oesophagus’)

• May develop as a result of gastro-oesophageal reﬂ ux; possibly more

commonly in biliary reﬂ ux.

• Normal squamous epithelium is replaced by columnar epithelium

(metaplasia).

• Dysplasia and premalignant change may occur in the columnar

epithelium.

Clinical features

• Dyspepsia may be the only feature; may radiate to back and left of

neck.

• True reﬂ ux may occur with acid in the pharynx.

• Commonly worse at night, after large meals, and when recumbent.

• Dysphagia may occur if there is associated ulceration or a stricture.

Diagnosis and investigations

Under the age of 45 Symptoms are relatively common and can be treated

empirically. Investigation is only required if symptoms fail to respond to

treatment.

Over the age of 45 Reﬂ ux can be conﬁ rmed by 24h continuous pH moni-

toring. Peaks of pH change must correspond to symptoms. OGD should

be performed in all new cases over the age of 45 to exclude oesophageal

malignancy.

GASTRO-OESOPHAGEAL REFLUX DISEASE

281

Treatment

Medical

• Reduce acid reﬂ ux. d Smoking, d weight, d alcohol consumption.

• Counteract acid secretion. PPI (e.g. omeprazole 20mg od), symptomatic

relief with antacids (e.g. Gaviscon

10mL PO od).

• i Gastric and oesophageal emptying. Promotilants, e.g. metoclopramide

10mg tds PO.

Surgical

Procedure of choice is laparoscopic fundoplication, ‘Nissen’s operation’

(wrapping fundus of the stomach around the intra-abdominal oesophagus

to augment high pressure zone).

Rarely required. Indicated for:

• Persistent symptoms despite maximal medical therapy.

• Large volume reﬂ ux with risk of aspiration pneumonia.

• Complications of reﬂ ux, including stricture and severe ulceration.

Uncertain role in the prevention of progressive dysplasia in Barrett’s

oesophageal metaplasia in the absence of symptoms.

CHAPTER 7 Upper gastrointestinal surgery

282

Oesophageal tumours

Key facts and pathological features

There are several types of oesophageal tumours.

Adenocarcinoma

• Rapidly increasing incidence in western world; ♂:♀, 5:1.

• Commonest in Western Europe.

• Associated with dietary nitrosamines, GORD, and Barrett’s metaplasia.

• Most commonly occurs in the lower third of the oesophagus.

Squamous carcinoma

• Incidence slightly reducing in western world. Commonest in Japan,

northern China, and South Africa; ♂:♀, 3:1.

• Associated with smoking, alcohol intake, diet poor in fresh fruit and

vegetables, chronic achalasia, chronic caustic strictures.

• May occur anywhere in the oesophagus.

Rhabdomyo(sarco)ma Malignant tumour of skeletal muscle wall of the

oesophagus; very rare.

Lipoma and gastrointestinal stromal tumours (GIST, see b p. 292) Rare.

Clinical features

• Dysphagia. Any new symptoms of dysphagia, especially over the age

of 45, should be assumed to be due to tumour until proven otherwise.

• Haematemesis. Rarely the presenting symptom.

• Incidental/screening. Occasionally identiﬁ ed as a result of follow-up/

screening for Barrett’s metaplasia, achalasia, or reﬂ ux disease. Presence

of high grade dysplasia in Barrett’s is associated with the presence of

an occult adenocarcinoma in 30%.

• Features of disseminated disease. Cervical lymphadenopathy,

hepatomegaly due to metastases, epigastric mass due to para-aortic

lymphadenopathy.

• Symptoms of local invasion. Dysphonia in recurrent laryngeal nerve

palsy, cough and haemoptysis in tracheal invasion, neck swelling

in superior vena cava (SVC) obstruction, Horner’s syndrome in

sympathetic chain invasion.

Diagnosis and investigations

• Diagnosis usually by ﬂ exible oesophagoscopy and biopsy.

• Barium swallow only indicated for failed intubation or suspected post-

cricoid carcinoma (often missed by endoscopy).

Staging investigations

• Local staging. Endoluminal ultrasound scan to assess depth of invasion.

• Regional staging. CT scanning to evaluate local invasion, locoregional

lymphadenopathy, liver disease; laparoscopy to assess for peritoneal

disease in junctional tumours.

• Disseminated disease. PET scanning may be used to exclude occult

disseminated disease in patients otherwise considered for potentially

curative treatment.

OESOPHAGEAL TUMOURS

283

Treatment

Palliative

Most patients present with incurable disease and require palliation.

• Dysphagia can be treated by endoluminal self-expanding metal stenting

(SEMS), external beam radiotherapy; surgery is very rarely indicated

for palliation.

• Metastases. Systemic chemotherapy if symptomatic.

Potentially curative

• Squamous carcinoma. Radical external beam chemoradiotherapy or

neoadjuvant chemotherapy followed by surgery (radical resection).

• Adenocarcinoma (large). Neoadjuvant chemotherapy followed by

surgery (radical resection).

• Adenocarcinoma (small) or high grade dysplasia in Barrett’s. Surgical

resection/EMR/ablation.

CHAPTER 7 Upper gastrointestinal surgery

284

Peptic ulcer disease

Key facts

• Peptic ulceration develops when a breakdown in the mucosal defence

of the stomach or duodenum leads to a mucosal breach.

• May be acute and transient (e.g. stress ulceration after surgery, in

acutely unwell ITU patients).

• If the repair system fails to deal with the breakdown of the mucosa, it

may become chronic.

• The term ‘peptic’ refers to ulcers in columnar mucosa in the lower

oesophagus, stomach, duodenum, or small bowel, usually due to the

action of acid.

Classiﬁ cation

Peptic ulcers can be broadly classiﬁ ed into:

• Gastric ulcers (type I, body and fundal).

• Duodenal and gastric ulcers (type II, prepyloric).

• Atypical ulceration.

Gastric ulceration

• ♂:♀, 3:1; peak age of incidence 50y.

• Associated with Helicobacter (H.) pylori in 45% of cases and with high

alcohol intake, smoking, NSAID use, normal or low acid secretion.

Duodenal and type II gastric ulceration

• ♂:♀, 5:1; peak age of incidence 25–30y.

• Associated with H. pylori in 85% of cases and with high acid secretion,

smoking, NSAID use.

Atypical ulceration

• Usually due to either atypical sites of gastric acid secretion (e.g.

ectopic gastric mucosa in a Meckel’s diverticulum) or abnormally high

levels of acid secretion (e.g. Zollinger–Ellison syndrome; see b p. 285).

• Associated with ulceration that fails to respond to maximal medical

therapy, multiple ulcers, ulcers in abnormal locations (e.g. distal

duodenum or small bowel).

Clinical features

• Nausea and epigastric pain.

• Duodenal ulceration typiﬁ ed by hunger pains with central back pain

relieved by food; pain is often cyclical and occurs in the early hours of

the morning.

• Gastric ulceration typiﬁ ed by pain precipitated by food with associated

weight loss and anorexia; pain less cyclical.

• Vomiting and upper abdominal distension suggest gastric outlet

obstruction.

Diagnosis and investigations

• Gastroscopy. Commonest diagnostic test.

• Barium meal. May be used if gastroscopy contraindicated.

PEPTIC ULCER DISEASE

285

• Urease testing. To assess for presence of H. pylori can be performed on

antral biopsies from gastroscopy or as a CO

breath test.

• Fasting serum gastrin levels. If hypergastrinaemia suspected.

Complications

• Acute upper GI bleeding (see b p. 294).

• Iron deﬁ ciency anaemia due to chronic low level bleeding.

• Perforation (see b p. 296).

• Gastric outlet obstruction due to chronic scarring at or around the

pylorus.

Treatment

Medical

• Advice to reduce alcohol intake, stop smoking, avoidance of NSAIDs.

• PPIs (e.g. omeprazole 20mg PO od, lansoprazole) or H

blockers (e.g.

ranitidine 150mg PO bd, cimetidine 400mg PO bd) if intolerant to PPI.

• Topical antacids (e.g. Gaviscon

, sucralfate, colloidal bismuth),

especially for acute ulceration post-operatively or in ITU patients.

• H. pylori eradication therapy (usually triple therapy of metronidazole,

PPI, and clarithromycin).

Surgical

Rarely necessary with the very highly effective acid-reducing drugs and

eradication therapy. Indications include the following.

• Gastric outlet obstruction not responsive or suitable for endoscopic

dilatation. Usual procedure is pyloroplasty (with or without highly

selective vagotomy) or type II partial gastrectomy (Bilroth II or polya).

• Failure to respond to maximal medical treatment with severe

symptoms or due to habitual recidivism. Procedure is type I partial

gastrectomy for type I gastric ulcer or type II partial gastrectomy for

duodenal ulcer.

• Emergency indications include:

Perforation (see • b p. 296);

Bleeding (see • b p. 294).

Zollinger–Ellison syndrome

• Due to hypergastrinaemia causing extensive, persistent, or typical

ulceration.

• Commonest cause is benign secretory gastrinoma (usually

intrapancreatic); occasionally cause is malignant gastrinoma (associated

with MEN syndromes).

• Diagnosed by raised serum gastrin level, tumour located by CT

scanning, angiography, selective pancreatic venous cannulation at

surgery.

• Treatment. Resection of pancreatic tissue containing tumour.

CHAPTER 7 Upper gastrointestinal surgery

286

Gastric tumours

May arise from the tissues of the mucosa (adenocarcinoma), connective

tissue of the stomach wall (previously known as leiomyoma or leiomyosa-

rcoma, but part of the spectrum of disease called gastrointestinal stromal

tumours (GISTs); see b p. 292), the neuroendocrine tissue (carcinoid

tumours; see b p. 292), or the lymphoid tissue (lymphomas).

Key facts

Adenocarcinoma; commonest age of incidence >50y; ♂:♀, 3:1. Predis-

posing factors include:

• Diet rich in nitrosamines (smoked or fresh ﬁ sh, pickled fruit);

• Chronic atrophic gastritis;

• Blood group A;

• Chronic gastric ulceration related to H. pylori.

Clinical features

Symptoms

• Dyspepsia (any new onset of dyspepsia over the age of 45 should be

considered to be due to adenocarcinoma until proven otherwise).

• Weight loss, anorexia, and lethargy.

• Anaemia (iron deﬁ ciency due to chronic blood loss).

• Occasionally presents as acute upper GI bleeding (see b p. 294).

• Dysphagia uncommon unless involving the proximal fundus and

gastro-oesophageal junction.

Signs

• Weight loss.

• Palpable epigastric mass.

• Palpable supraclavicular lymph node (Troisier’s sign) suggests

disseminated disease.

Diagnosis and investigation

• Diagnosis usually by gastroscopy (barium meal may be required if

gastroscopy contraindicated).

• Staging (see Table 7.1) investigations include:

Thoraco-abdominal CT scan to assess for distant metastases and •

local lymphadenopathy.

Endoluminal ultrasound to assess for local disease.•

Laparoscopy (for patients considered for potential resection) to •

exclude small volume peritoneal metastases.

Treatment

Unfortunately, in the UK, the majority of tumours are metastatic or unre-

sectable due to local extension and so not suitable for consideration of

surgical treatment for cure. The majority of treatment is directed at symp-

toms and palliation. When a tumour is considered potentially curable, the

treatment offered is based on the extent of disease at staging.

GASTRIC TUMOURS

287

Early gastric cancer (T1 or 2, N0/1, P0, H0)

• Suitable for attempted curative resection if patient medically ﬁ t enough.

• Surgery. Radical gastrectomy usually preceded by neoadjuvant

chemotherapy in patients ﬁ t.

• Patients now frequently offered preoperative and post-operative

chemotherapy.

• Local resection or ablation has an uncertain place in treatment.

Advanced gastric cancer (T3 or more or any of N2/P1+/H1+)

• Patients will be offered pre- and post-operative chemotherapy.

• Surgical intervention unlikely to be curative.

• May be undertaken for palliative treatment.

• Local ablation for symptom control occasionally possible.

• Palliative chemotherapy occasionally effective for disseminated disease.

Key revision points—anatomy and physiology of the

stomach

• The fundus is predominantly a storage zone with few active cells.

• The body contains mostly chief cells (secrete pepsinogen; stimulated

by gastrin and local ACh release) and oxyntic cells (secrete H

;

stimulated by gastrin, histamine, and ACh; inhibited by H

, secretin,

and GIP).

• The antrum contains G cells (secrete gastrin; stimulated by ACh

from vagus, stretch; inhibited by VIP, secretin, H

• The pyloric sphincter is a functional sphincter of circular muscle.

• Arterial supply is profuse (gastric ischaemia is rare) via coeliac

axis—left gastric, splenic, and common hepatic arteries.

• Lymphatic drainage follows arteries and is profuse (signiﬁ cant lymph

node metastases are usually fatal).

Table 7.1 TNM staging of gastric cancers

T (tumour) N (nodes) M (metastases)

Tis, in situ within

mucosa

N0, no lymph nodes P (peritoneal metastases)

T1, conﬁ ned to

submucosa

N1, involved nodes

within 3cm of primary

P0, no peritoneal

metastases

T2, conﬁ ned to

muscle wall

N2, involved nodes

more than 3cm from

primary

P1/2/3, peritoneal

metastases in increasing

extent

T3, involvement of

serosal surface

H (hepatic metastases)

T4, involvement of

other organs

H0, no hepatic metastases

H1/2/3, hepatic metastases

in increasing extent

CHAPTER 7 Upper gastrointestinal surgery

288

Chronic intestinal ischaemia

Caused by chronic reduction in blood supply to the intestine without

acute threat to the viability of the bowel.

Key facts

Chronic intestinal ischaemia is uncommon. Usually presents with vague

symptoms and diagnosis is often prolonged. Causes include:

• Progressive atherosclerosis affecting the visceral vessels; usually

requires more than one vessel to be affected (e.g. superior mesenteric

artery occlusion and coeliac artery stenosis).

• Obliterative small vessel disease (e.g. thromboangiitis obliterans,

systemic sclerosis, severe diabetic vasculopathy).

Clinical features

Symptoms

• Commonest symptom is mesenteric angina, chronic central abdominal

pain brought on by eating; associated with nausea and vomiting.

• May present with weight loss, general anorexia, and malnutrition.

• Often associated with other features of extensive vascular disease such

as renal impairment, coronary disease, claudication.

Signs

Weight loss, central abdominal tenderness.

Diagnosis and investigations

• Usually diagnosed by imaging of the visceral arteries in combination

with clinical symptoms. Methods of imaging visceral vessels include:

CT angiogram.•

MR angiogram.•

Transfemoral digital subtraction angiogram/aortogram.•

• Other investigations should include:

Assessment of renal function.•

Assessment of coronary circulation.•

Exclusion of aneurysmal disease.•

• Small vessel disease may require autoimmune screen.

Complications

• Acute intestinal ischaemia is less common due to the development of

collaterals although, if undiagnosed, loss of all visceral vessels results in

eventual pan-intestinal infarction.

• Chronic ischaemic strictures due to focally severe ischaemia.

Treatment

Medical

• Stop smoking.

• Control of hypertension; treatment of any hyperlipidaemia.

• Aspirin 75mg od to prevent thromboembolic events.

• Control diabetes if present.

• Treatment of autoimmune disease if present.

CHRONIC INTESTINAL ISCHAEMIA

289

Interventional

Commonest treatment for large vessel stenosis is radiologically guided

stenting. Risks converting stenosis to acute occlusion with the risk of pre-

cipitating emergency surgery. Not possible if the stenosis is at the aortic

ostium of the vessel affected.

Surgical

• Rarely indicated. Commonest procedure is external iliac to ileocolic

artery side-to-side bypass.

• Overall prognosis is poor as the underlying disease process is often

widespread and progressive.

Key revision points—anatomy and physiology of the

small intestine

• Duodenum is a secretory and digestive organ; described in four parts

(second part admits the common bile and pancreatic ducts via the

ampulla of Vater on the medial wall).

• Jejunum is a secretory and digestive organ. Typical features include:

thick, red-purple wall; prominent plicae circulares; single arterial

arcades with long mesenteric vessels.

• Ileum is predominantly an absorptive organ. Typical features include:

thin blue-purple wall; prominent lymphoid aggregates; multilayered

mesenteric arterial arcades.

• Terminal ileum is a specialized area of ileum, particularly concerned

with absorption of bile salts, vitamin B12/IF complex.

CHAPTER 7 Upper gastrointestinal surgery

290

Surgery for morbid obesity

Key facts

• Approximately 25% of UK adult population are classiﬁ ed as obese, a

body mass index (BMI) of greater than 30kg/m

• Admissions to hospital due to obesity-related disease have increased

eightfold in the last 10y.

• Obese patients are exposed to an increased risk of chronic diseases,

particularly type 2 diabetes, hypertension, hyperlipidaemia, and

arthritis.

• Increased risk of some forms of cancer (colon and endometrial).

Clinical features

Symptoms

• The symptoms of obesity are generally related to the underlying

condition that develops in association with it.

• Commonly, patients ﬁ nd their physical capacity is reduced and they

become short of breath more easily on exertion

Signs

• Examination of obese patients can be challenging as their size can

reduce the ability to elicit clinical signs.

• Assess for signs of respiratory disease, dyspnoea at rest.

• Investigation of possible biliary disease (common bile duct stones,

biliary strictures, biliary tumours, biliary injuries, intrahepatic biliary

disease).

• Investigation of pancreatic disease (pancreatic duct strictures,

pancreatic duct abnormalities).

• Therapeutic interventions for pancreatico-biliary disease:

Stenting for common bile duct stones, strictures, tumours.•

Sphincterotomy for the extraction of biliary stones.•

Diagnosis and investigations

Exclude underlying endocrine disorders—Cushing’s disease, hypothy-

roidism, polycystic ovarian syndrome.

Treatment

Medical

• Diabetic control. Oral hypoglycaemics and insulin, if necessary.

• Medication for anti-hypertensive and cardiovascular disease.

• Psychological and dietetic support for weight loss programme.

• Anti-obesity medication. Orlistat (reduces fat absorption) is the

commonest.

Surgical

• Should only be considered after non-surgical treatments have failed

and patient has been through a preoperative assessment to ensure

they are able to make the necessary post-operative dietary and

lifestyle changes.

• Procedures have either a restrictive or malabsorptive effect.

SURGERY FOR MORBID OBESITY

291

• Adjustable gastric banding is the commonest restrictive operation

(the band is placed around the cardia of the stomach and restricts the

volume of food, but not liquid that can be ingested at one time).

• Gastric bypass involves a restrictive element (division of the stomach

to create a small remnant) and a malabsorptive element (division and

re-anastomosis of small bowel to reduce its ability to absorb food).

• These procedures are most commonly performed laparoscopically.

CHAPTER 7 Upper gastrointestinal surgery

292

Small bowel tumours

Key facts

The small bowel is a rare location for tumours. Tumours may arise from:

• Mucosa small bowel—adenocarcinoma (<5% of all GI malignancies).

• Neuroendocrine tissue, e.g. carcinoid tumours.

• Connective tissue of the bowel wall, e.g. GIST, lipoma.

• Lymphoid tissue (lymphoma).

Adenocarcinoma of small bowel

• Forty per cent of all small bowel tumours.

• Commonest in the duodenojejunal junction and proximal jejunum;

least common in the mid- and distal ileum.

• Associations:

Familial adenomatous polyposis (third commonest location of •

adenocarcinoma after colorectum and duodenum).

Peutz–Jegher’s syndrome.•

Crohn’s disease.•

Untreated longstanding coeliac disease.•

Carcinoid tumours

• Twenty-ﬁ ve per cent of all small bowel tumours.

• Commonest in the distal small bowel; may arise in the appendix or

Meckel’s diverticulum.

• Majority are benign (non-metastatic).

• May produce enteric hormones (e.g. 5-HT, kallikrein, substance P);

hormone effects only occur when the primary is able to secrete

hormones into the systemic circulation or when hepatitic metastases

secrete into the caval circulation (carcinoid syndrome; see b p. 293).

GIST (gastrointestinal stromal tumours)

• Ten per cent of small bowel tumours.

• Arise from the mesenchymal tissues of the bowel wall and mesentery

(smooth muscle cells, ﬁ broblasts, lipocytes).

• Previously called variously leiomyo(sarc)oma, lipo(sarco)ma.

• Tumours of myenteric plexus tissues are a variant called GANT

(gastrointestinal autonomic nerve tumours).

Primary lymphoma

• Twenty per cent of small bowel tumours.

• Arise from the lymphoid tissue of the small bowel wall.

• Almost always non-Hodgkin’s; commonest are B-cell lymphomas

arising from the mucosa-associated lymphoid tissue (MALTomas).

Clinical features

• Adenocarcinoma of small bowel. Often presents late with metastases;

may present with small bowel obstruction, recurrent abdominal pain,

or recurrent/occult GI bleeding.

• Carcinoid tumours. Commonest presentation is incidental ﬁ nding after

appendicectomy or Meckel’s diverticulectomy.

SMALL BOWEL TUMOURS

293

• Carcinoid syndrome. Rare (typiﬁ ed by ﬂ ushing, tachycardia, colicky

abdominal pain, diarrhoea, wheezing).

• GIST. Often present with slow-growing abdominal mass, vague

abdominal pain; may present with occult GI bleeding due to tumour

ulceration.

• Primary lymphoma. Presents with malaise, abdominal pain, diarrhoea;

may present with acute perforation or small bowel obstruction.

Diagnosis and investigations

Common diagnostic tests for all are:

• CT chest and abdomen. Identiﬁ es primary tumour, assesses extent of

involvement of other tissues, assesses possible metastatic disease.

• CT angiography. For assessment of particularly vascular tumours or

GISTs lying close to major visceral vessels to establish resectability.

• Small bowel contrast study. Rarely required for identiﬁ cation of primary

tumours.

• Ileoscopy. May demonstrate proximal lesions presenting with occult,

recurrent upper GI bleeding.

Complications

• Bleeding. Common with adenocarcinoma and some GISTs.

• Obstruction. Especially adenocarcinoma, GISTs, GANTs, and lymphoma.

• Perforation. Commonest with lymphoma, especially shortly after

starting chemotherapy (due to bowel wall replacement by tumour);

also occurs with adenocarcinoma.

• Malabsorption. Often with lymphoma if widespread.

Treatment

Surgery

• Primary surgical resection with macroscopic clearance of tumour for

adenocarcinoma, carcinoid, GISTs, GANTs.

Potentially curative for non-metastatic disease.•

Palliative to prevent complications if disease is metastatic.•

• Surgical resection may be indicated for primary lymphoma prior to

chemotherapy if there is a high risk of perforation of primary.

• Surgical resection of metastases is uncommon.

Medical

• Chemotherapy. Lymphoma and metastatic adencarcinoma.

• Hepatic abalation/embolization. Used to treat carcinoid metastases to

treat symptoms of carcinoid syndrome.

• Imatinib (Glivec

) (anti-CD113). Treatment for GISTs that are positive

for c-Kit.

CHAPTER 7 Upper gastrointestinal surgery

294294

Acute haematemesis

Key facts

See Table 7.2 for predicting mortality of acute upper GI bleeding.

• Incidence 1 in 1000 adults per year in UK.

• Twenty per cent require intervention because of ongoing bleeding or

rebleeding.

• Haematemesis is vomiting of blood, usually due to bleeding proximal

to the duodenojejunal junction.

• Melaena is the passage of altered blood (dark purple, pitch black, or

‘tarry’, usually due to bleeding below the gastro-oesophageal junction.

Causes and features

• Peptic (gastric or duodenal) ulceration (benign, 50%). Fresh red blood

with clots, occasionally mixed with food.

• Oesophageal varices. Copious dark red venous blood with little mixing

with food; features of portal hypertension (e.g. caput medusa).

• Oesophageal ulceration. Small volumes of bright red blood/streaks

typical.

• Oesophageal trauma (‘Mallory–Weiss tear’). Small volumes of fresh

bright blood preceded by violent or prolonged vomiting or retching.

• Vascular malformations/lesions (e.g. ‘Dieu la Foy’).

• Gastric carcinoma, leiomyoma.

• Aortoenteric ﬁ stula. Copious bright red blood (often rapidly fatal).

Associated or predisposing conditions

• Agents affecting mucosal health—NSAIDs, steroids, alcohol, major

trauma, or massive burns.

• Agents worsening risk of bleeding—anticoagulants.

Emergency management

Resuscitation

• Establish large calibre IV access; give crystalloid ﬂ uid up to 1000mL if

tachycardic or hypotensive. Only use O –ve blood if the patient is in

extremis; otherwise wait for cross-matched blood if transfusion needed.

• Catheterize and place on a ﬂ uid balance chart if hypotensive.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), cross-

match (at least 3U if haematemesis large), clotting.

• Always consider alerting HDU/ITU if very unwell.

• Monitor pulse rate, BP, and urine output (urinary catheter).

• Insertion of a Sengstaken–Blakemore gastro-oesophageal tube may be

a life-saving resuscitation manoeuvre.

Establish a diagnosis

• Urgent OGD is the investigation of choice (at least within 24h).

May require ongoing resuscitation with anaesthetist present.•

Allows diagnosis and biopsy if appropriate.•

May allow therapeutic interventions including adrenaline injection, •

heater probe coagulation, banding of varices, clipping vessel.

ACUTE HAEMATEMESIS

295295

• Angiography.

Occasionally suitable for active bleeding due to invasive •

intervention done in radiology department.

May allow selective embolization in some patients with recurrent •

bleeding.

Early treatment

• Give IV PPI (e.g. omeprazole 40mg IV); stop all NSAIDs.

• Blood transfusion if large volume haematemesis or drop in Hb.

• Ensure the appropriate surgical team knows of the patient in case

surgical intervention is required.

• Known or suspected liver disease—consider FFP to correct clotting.

• Surgery may be required if:

Massive haemorrhage requiring ongoing resuscitation.•

Failed initial endoscopic treatment with ongoing bleeding.•

Rebleeding not suitable for repeated endoscopic treatment.•

Deﬁ nitive management

Varices (see b p. 322)

• Endoscopy coagulation or banding/interventional radiology/surgery.

• IV vasopressin or analogues.

Gastric/duodenal ulcer

• Endoscopic coagulation or injection; may be repeated if suitable ulcer.

• Surgery for failed primary management or rebleeding that is unsuitable

for attempted repeat endoscopic treatment.

• Surgical options—local excision of gastric ulcer or partial gastrectomy;

under-running of duodenal ulcer.

• H. pylori eradication (triple therapy).

Gastric carcinoma

• Endoscopic treatment often not effective.

• Partial or subtotal gastrectomy (often palliative, rarely curative).

Oesophageal trauma Oral antacids.

Aortoenteric ﬁ stula Surgery if the patient survives beyond diagnosis.

Table 7.2 Rockall score for predicting mortality of acute upper GI

bleeding*

Rockall score

0 1 2

Age (y) <60 60–79 >80

Shock None HR

>100bpm

Systolic BP

<100mmHg

Comorbidities None Cardiac Hepatorenal

disease

Carcinoma

* Percentage mortality for scores: 0, <1%; 1, 3%; 2, 6%; 3, 11%; 4, 25%; 5, 40%; 6, >80%.

CHAPTER 7 Upper gastrointestinal surgery

296296

Acute upper GI perforation

Causes and features

• Duodenal ulceration.

• Gastric ulceration (usually anterior prepyloric; less commonly anterior

body).

• Gastric carcinoma.

• Traumatic, e.g. ﬁ sh bone perforation.

• Ischaemic (usually secondary to gastric volvulus).

Symptoms

• Acute onset upper abdominal pain. Severe, constant, worse with

breathing and moving; may radiate to back or shoulders.

• Prodrome of upper abdominal pain (in benign or malignant ulceration).

• Copious vomiting and upper abdominal distension suggest volvulus.

• Prodrome of weight loss, dyspepsia, and anorexia suggests carcinoma.

Signs

• Generalized peritonism common (‘board-like’ generalized rigidity with

marked guarding and tenderness).

• Localized upper abdominal peritonism may occur, especially

with previous surgery where adhesions may act to contain the

contamination.

• Mild fever, pallor, tachycardia, and hypotension (often profound due

to autonomic reaction); typically respond quickly to modest ﬂ uid

resuscitation.

Emergency management

Resuscitation

• Establish large calibre IV access; give crystalloid ﬂ uid up to 1000mL if

tachycardic or hypotensive.

• Catheterize and place on a ﬂ uid balance chart.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group

and save, clotting.

Establish a diagnosis

• Erect CXR (looking for free gas). If the CXR is non-diagnostic, a lateral

decubitus abdominal ﬁ lm can be performed, although a CT is more

common.

• CT scan if diagnosis unclear on CXR; may demonstrate presence of

gastric carcinoma.

Early treatment

• Once the diagnosis of perforation is conﬁ rmed on clinical or

radiological grounds, the treatment is surgical unless:

The patient declines.•

The patient is considered unlikely to survive and supportive care is •

deemed more appropriate.

• Conservative management. IV PPI, limited oral intake, active

physiotherapy—has a very limited role in management; it offers an

outcome similar to that of surgery only in cases where the perforation

ACUTE UPPER GI PERFORATION

297297

has sealed at the time of presentation, there is no haemodynamic

instability, and there are no signs of peritonism.

Deﬁ nitive management

Duodenal ulcer

• Sutured closure with omental patch.

• Empirical oral triple therapy for H. pylori.

• Deﬁ nitive surgery (partial gastrectomy, vagotomy, and drainage

procedure) should only be performed for recurrent perforation, failed

fully compliant medical therapy, recidivist non-compliant patient.

Gastric ulcer

• Sutured closure with omental patch if prepyloric.

• Local excision and sutured closure if body.

Gastric carcinoma Partial gastrectomy (usually palliative).

Traumatic Sutured closure.

Volvulus with ischaemia Usually subtotal gastrectomy.

CHAPTER 7 Upper gastrointestinal surgery

298298

Acute appendicitis

Causes and features

2 Commonest cause of urgent abdominal surgery and the common provi-

sional diagnosis of all emergency surgical admissions in the UK.

• Can affect any age, but uncommon under the age of 4 and over the age

of 80. Peak age of incidence is early teens to early twenties. Three types:

Mucosal.• Mildest form usually diagnosed by pathology reporting.

Phlegmonous.• Typiﬁ ed by slow onset and relatively slow progression.

Necrotic.• Often due to acute bacterial infection with ischaemic

necrosis; leads to perforation unless treated by surgery.

Differential diagnosis

• Children.

Non-speciﬁ c abdominal pain, including ‘mesenteric adenitis’.•

Meckel’s diverticulitis.•

Ovarian cyst/menstrual symptoms (peri-menarchal girls).•

• Adults.

Terminal ileal pathology• . Crohn’s, Meckel’s diverticulitis,

gastroenteritis.

Retroperitoneal pathology• . Pancreatitis, renal colic.

Ovarian pathology• . Ectopic pregnancy, cyst, infection, menstrual pain.

• Older adults.

Ileocaecal pathology• . Caecal diverticulitis, caecal tumours.

Colonic pathology• . Sigmoid diverticulitis.

Ovarian pathology• . Cysts, infection, tumours.

Clinical features

• Symptoms.

Malaise, anorexia, and fever.•

Diarrhoea common and may be mistaken for acute (gastro)•

enteritis.

Abdominal pain starts centrally and localizes to the right iliac fossa •

(RIF).

Abdominal pain caused by coughing and moving.•

• Signs.

Fever, tachycardia.•

Abdominal tenderness. Peritonism suggests perforation (local or •

generalized). Often maximal over ‘McBurney’s point’ (see opposite),

but only if appendix is in conventional anatomical position.

Palpation of left iliac fossa (LIF) causes pain worse in RIF (• Rovsing’s

sign).

• Investigations may be normal and none are diagnostic or exclusive (see

b p. 299).

Complications

• Perforation (localized or generalized).

• RIF ‘appendix’ mass (usually appendicitis with densely adherent caecum

and omentum, forming a ‘mass’).

• RIF abscess (usually 2* to perforated retrocaecal appendicitis).

• Pelvic abscess (usually 2* to perforated pelvic appendicitis).

ACUTE APPENDICITIS

299299

Emergency management

Resuscitation

• Establish IV access.

• Catheterize and place on a ﬂ uid balance chart only if d BP or septic.

• Request FBC (Hb, WCC), U&E (Na, K), CRP (usually i WCC, CRP).

Establish a diagnosis

• The diagnosis is a clinical one in all but exceptional cases and

investigations are usually unnecessary.

• CT is appropriate in adults, especially over the age of 65 or if the

diagnosis is unclear since the differential diagnosis is much wider and

appendicitis relatively less likely above this age.

• CT is the best investigation in suspected appendix mass or abscess.

• Ultrasound scan (pelvic) is indicated in young women of childbearing

age if ovarian pathology is suspected.

• Laparoscopy is a useful surgical diagnostic manoeuvre, allowing

diagnosis of pelvic pathology, e.g. pelvic inﬂ ammatory disease (PID)

without a major abdominal incision.

Early treatment Avoid giving IV antibiotics without a clear diagnosis.

Deﬁ nitive management

2 Acute appendicitis

• Open or laparoscopic appendicectomy.

• IV antibiotics on induction; continued antibiotics only indicated for

perforation.

Appendix mass or appendix abscess

• IV antibiotics (e.g. cefuroxime 750mg tds + metronidazole 500mg tds).

• If symptoms settle, delayed (interval) appendicectomy after 6 weeks.

• If symptoms fail to settle, may need acute appendicectomy.

• Appendix abscess may be amenable to CT-guided drainage.

Key revision points—anatomy of appendicectomy

• Commonly retrocaecal, but may be pelvic, retroileal, or retrocolic.

• Taenia coli of caecum converge at base of appendix and aid

location, especially in difﬁ cult locations.

• Small mesentery with sole blood supply from appendicular artery

(a terminal branch ileocolic) which may thrombose causing gangrene.

• Principles of appendicectomy are as follows:

Muscle splitting gridiron• incision centred at McBurney’s point.

Lapararoscopic approach• increasingly popular.

Appendix is carefully located and delivered into the wound.•

The mesentery of the appendix is divided and ligated.•

The appendix is clamped and tied at the base and excised.•

Some surgeons invaginate the stump using a purse-string in the •

wall of the caecum round the base of the appendix.

CHAPTER 7 Upper gastrointestinal surgery

300300

Acute peritonitis

Deﬁ ned as acute inﬂ ammation in the peritoneal cavity.

Causes

May be primary (rare) or secondary (common).

• Primary peritonitis. Typically streptococcal with probable portal of

entry via bloodstream rather than intra-abdominal organs.

• Commonest causes of secondary peritonitis are:

Acute perforated appendicitis • (see b p. 298)—commonest cause of

peritonitis especially in under 45s).

Acute perforated diverticular disease • (see b p. 404)—commonest

cause in elderly.

Upper GI perforation • (see b p. 296).

Perforated tumours (colonic or gastric).•

Perforated ischaemic bowel, e.g. due to adhesions.•

Acute pancreatitis (usually inﬂ ammatory rather than infective).•

Peritoneal dialysis-related—often atypical or cutaneous organisms •

gaining entry via contaminated dialysate bags or catheter.

Post-surgical intervention, e.g. anastomotic leak, enteric injury.•

Clinical features

There are features common to all causes. Additional features suggestive of

an underlying cause should also be sought, particularly in the history.

Symptoms

• Anorexia and fever.

• Severe generalized abdominal pain radiating to shoulders and back.

• Abdominal pain worse with movement, coughing, sneezing.

Signs

• Fever, tachycardia.

• Generalized abdominal tenderness with guarding and rigidity.

• Differential maximal tenderness may indicate the possible underlying

cause.

• Gentle palpation may allow identiﬁ cation of an underlying mass.

Emergency management

Resuscitation

• Establish large calibre IV access.

• Catheterize and place on a ﬂ uid balance chart.

• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, amylase, group

and save.

• ABGs if shocked or ischaemic bowel/pancreatitis suspected.

Establish a diagnosis

Most causes of acute peritonitis require surgery to correct them, but sur-

gery is contraindicated in most cases of acute pancreatitis.

Diagnostic investigations are indicated if the patient would otherwise be

a candidate for surgical intervention.

ACUTE PERITONITIS

301301

• Blood investigations may show neutrophilia, i CRP.

• Raised amylase may suggest pancreatitis.

• Abdominal CT scanning is the investigation of choice for diagnosis.

It should reliably exclude acute pancreatitis and often locate the

probable source of the pathology.

• Laparoscopy is occasionally useful in patients where a formal

laparotomy should be avoided if possible.

Early treatment

IV antibiotics are appropriate without a clear diagnosis, especially if surgery

is likely (e.g. metronidazole 500mg IV tds + cefuroxime 750mg IV tds).

Deﬁ nitive management

Acute appendicitis See b p. 298.

Upper GI perforation See b p. 296.

Perforated diverticular disease

• IV antibiotics (e.g. cefuroxime 750mg tds + metronidazole 500mg tds).

• Surgical treatment involves resection of the affected segment.

Depending on the length of time from perforation, extent of the

contamination, and extent of inﬂ ammation in the affected segment, the

bowel may be anastomosed (primary anastomosis) or the proximal

end brought out on to the abdominal wall as an end colostomy

(‘Hartmann’s type’ resection).

Perforated tumour Surgical resection is required even if palliative. Ends of

bowel may be re-anastomosed or exteriorized as stomas, depending on

the circumstances (degree of contamination, underlying pathology).

Primary peritonitis or continuous ambulatory peritoneal dialysis

(CAPD)-related peritonitis

• A diligent and systematic search is necessary to ensure there is no

occult source of perforation as a cause.

• Primary treatment is extensive lavage of all quadrants and treatment

with appropriate antibiotics (guided by culture results from peritoneal

ﬂ uid).

CHAPTER 7 Upper gastrointestinal surgery

302302

Acute abdominal pain

Acute abdominal pain is the commonest emergency presentation to hos-

pitals in the UK. It is often a daunting challenge to the admitting team

because of the huge differential diagnosis possible, and the wide range

of tests available to try and establish a diagnosis. Be methodical and

remember some simple rules.

• Take a proper history and examination; do not work to the diagnosis

given to you by the referring doctor.

• Resuscitate the patient properly and give adequate analgesia; this often

helps to clarify the diagnosis. There is no reason to withhold analgesia

prior to ‘senior’ clinical examination.

• Try to clarify if you think the patient has signs of peritonitis (localized

or generalized); this will narrow the differential and may require

surgery as part of the diagnostic work-up.

Causes

Causes approximate to the fact that pathology of underlying structures

in each region tend to give rise to abdominal pain maximal in that

region (see Box 7.1). Although a good guide, it is wise to remember that

viscera are often mobile and pain often radiates to adjacent sections of

the abdomen.

Clinical features

Each condition has its own clinical features, but here are some rules to

follow.

Symptoms and signs

• Constant pain, gradual in onset, but progressive worsening suggests an

underlying inﬂ ammatory cause.

• Intermittent pain that is poorly localized suggests colic arising from a

visceral structure.

• Central and lower abdominal pain in children (under the age of 12) is

self-limiting (non-speciﬁ c) in 70%, from benign gynaecological causes in

25% (girls), and only pathological in 10–20%.

• Severe pain out of proportion to the clinical signs suggests ischaemic

bowel until proven otherwise.

• Pain in the loin or back arises from (at least partially) retroperitoneal

structures; consider the pancreas, renal tract, and abdominal aorta.

Emergency management

Resuscitation

• Establish IV access.

• Catheterize and place on a ﬂ uid balance chart only if hypotensive.

• Give adequate analgesia. If renal pathology is suspected, diclofenac

(Voltarol

) 100mg pr is very effective (avoid in asthma and renal

disease). If intra-abdominal pathology is suspected, 5–10mg morphine

iv is reasonable. Morphine IV never hides established clinical signs; it

often helps to clarify the diagnosis by its anxiolytic effect on patients.

• Send blood for FBC (Hb, WCC), U&E (Na, K), amylase, LFTs, CRP,

group and save.

ACUTE ABDOMINAL PAIN

303303

Establish a diagnosis

The time frame for the diagnosis of acute abdominal pain varies according

to the presentation. It is not uncommon for 12–24h of ‘masterful inac-

tivity’ to be used to allow the diagnosis to be clariﬁ ed. Young patients

with central and mild RIF pain are typical of this sort of management. Do

not assume this is normal. Some causes of acute abdominal pain require

diagnosis and management immediately upon admission or within 6–8h or

less. Try to be thoughtful in diagnostic tests; many may be requested, but

usually only one or two are really useful.

• Blood investigations are very rarely diagnostic. Serum amylase more than

3x normal maximum is very highly suggestive of acute pancreatitis.

• Plain abdominal radiographs are very rarely diagnostic.

• Always request a plain erect chest radiograph; it is the ﬁ rst-line test of

choice for free abdominal air.

• Upper abdominal ultrasound is an excellent investigation for suspected

hepatobiliary pathology.

• Pelvic ultrasound (transabdominal or transvaginal) is a good test for

suspected tubo-ovarian disease.

• CT scanning may well be indicated and is a good ‘general survey ‘

of the abdomen, but exposes the patient to signiﬁ cant radiation and

should not be routinely requested.

Box 7.1 Causes of acute abdominal pain arranged

according to abdominal region

Right hypochondriac Epigastric Left hypochondriac

• Right lower lobe

pneumonia/

embolism

• Cholecystitis

• Biliary colic

• Hepatitis

• Pancreatitis

• Gastritis

• Peptic ulcer

• Myocardial

infarction

• Left lower lobe

pneumonia/

embolism

• Large bowel

obstruction

Right lumbar Umbilical Left lumbar

• Renal colic

• Appendicitis

• Intestinal

obstruction

• Intestinal ischaemia

• Aortic aneurysm

• Gastroenteritis

• Crohn’s disease

• Renal colic

• Large bowel

obstruction

Right iliac Hypogastric Left iliac

• Appendicitis

• Crohn’s disease

• Right tubo-ovarian

pathology

• Cystitis

• Urinary retention

• Dysmenorrhoea

• Endometriosis

• Sigmoid

diverticulitis

• Left tubo-ovarian

pathology

CHAPTER 7 Upper gastrointestinal surgery

304304

Early treatment

• IV antibiotics are inappropriate without a clear diagnosis; they will

suppress, but may not adequately treat, developing infection.

• Until a deﬁ nitive management plan is established, concentrate on ﬂ uid

balance, analgesia, and monitoring vital signs.

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CHAPTER 7 Upper gastrointestinal surgery

306306

Gynaecological causes of lower

abdominal pain

Gynaecological pathologies are a common cause of lower abdominal

pain, not only in women of childbearing age, but they can also affect

post-menopausal women.

Causes

• Complications of menstruation. Retrograde menstruation, mid-cycle

ovulation pain (‘Mittelschmerz’).

• Ovarian cyst. Acute swelling, rupture, torsion.

• Tubo-ovarian infection, including PID, abscess.

• Ectopic pregnancy, including rupture.

Clinicopathological features

Complications of menstruation

• Commonest during development of regular periods.

• Typically cyclical pains, often sharp and sudden in onset.

• May have marked tenderness bordering on peritonitis.

• Normal blood investigations; self-limiting.

Ovarian cyst complications

• Commonest in mid-childbearing years.

• May have severe pain with few clinical signs.

• Normal blood investigations.

Tubo-ovarian infection

• Commonly caused by Escherichia coli, Bacteroides fragilis,

Streptococcus sp.

• Associated with cervical disease or instrumentation.

• Sexually-transmitted infections can cause tubo-ovarian sepsis, which

may be more chronic and recurrent (Neisseria gonorrhoeae,

Chlamydia trachomatis).

• Associated with multiple sexual partners and unprotected intercourse.

• Pyrexia, mild tachycardia, occasional purulent vaginal discharge.

• Often affects both sides causing bilateral pain and tenderness.

Ectopic pregnancy

• May occur at any age.

• Commonest site is the Fallopian tube (ampulla, tube, or isthmus).

• Associated with previous tubal disease or surgery.

• Menstrual irregularity or a ‘late’ period is common, but not uniform.

• May give rise to symptoms whilst enlarging with unilateral pelvic pain.

• Symptoms increase with complications (bleeding into site of

pregnancy, free rupture with bleeding into pelvis and peritoneal cavity).

• Typiﬁ ed by lower abdominal pain without fever.

• Hypotension with tachycardia suggests active intra-abdominal bleeding,

but is fortunately rare at presentation.

GYNAECOLOGICAL CAUSES OF LOWER ABDOMINAL PAIN

307307

Emergency management

Resuscitation

• Establish large calibre IV access if an ectopic pregnancy is suspected.

• Catheterize and place on a ﬂ uid balance chart only if hypotensive.

• Give adequate analgesia (5–10mg morphine IV is reasonable).

• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, group and save.

Establish a diagnosis

• Urine B-HCG (and serum B-HCG where urine test is positive since

this is more reliable). All women of childbearing age should be assumed

to be pregnant until proven otherwise. Pregnancy testing may be

negative in ectopic pregnancy if the fetus is already dead by the time of

presentation.

• High vaginal swabs should be taken if tubo-ovarian sepsis is suspected.

• Pelvic ultrasound (transabdominal or transvaginal) is the diagnostic

investigation of choice unless the patient is acutely unstable. It has a

high sensitivity and good speciﬁ city.

• Laparoscopy is a very common diagnostic investigation. It allows a ﬁ rm

diagnosis of most gynaecological pathology and may be therapeutic

(e.g. pelvic lavage, cyst treatment).

Early treatment

• IV antibiotics for a clear diagnosis of pelvic infection.

• If ruptured or bleeding ectopic pregnancy is seriously considered,

make sure the surgical and gynaecological teams are aware. Direct

transfer to theatre may be necessary.

Deﬁ nitive management

• Complications of menstruation. Conservative management—pelvic

lavage if laparoscopy is performed.

• Ovarian cyst complications. Ovarian preservation if below the age of

menopause; cystectomy or drainage where possible.

• Tubo-ovarian infection. Cephradine 500mg tds PO and metronidazole

400m PO tds for non-sexually transmitted infections; metronidazole

400mg PO for chlamydia; IV penicillin for neisserial infections.

• Ectopic pregnancy. Conservation or reconstruction of the affected

tube/ovary wherever possible. If not salvageable, unilateral salpingo-

oophrectomy.

CHAPTER 7 Upper gastrointestinal surgery

308308

Intra-abdominal abscess

Key facts

Intra-abdominal sepsis can present as an intra-abdominal abscess if the

sepsis is contained by tissues or anatomy. Common locations are:

• Alongside the organ of origin (e.g. paracolic in diverticulitis,

parapancreatic after infected pancreatitis).

• Pelvic (especially after pelvic sepsis such as appendicitis or after

generalized peritoneal infection).

• Subphrenic (e.g. after upper GI perforation).

Causes

• Sigmoid diverticulitis (see b p. 404).

• Acute appendicitis (see b p. 298).

• Severe acute cholecystitis (see b p. 316).

• Upper GI perforation (see b p. 296).

• Post-anastomotic leakage (see b p. 420).

• Infected acute pancreatitis (see b p. 332).

• Post-trauma.

Clinical features

Depending on the source, the preceding pathology may have speciﬁ c clini-

cal features, but the development of an abscess gives rise to certain com-

mon features independent of the origin.

Symptoms

• Malaise, anorexia.

• Localized abdominal pain—constant.

Signs

• Swinging fever, typically peaks in excess of 38.5*C occurring twice a

day.

• Tachycardia tends to follow the temperature.

• Localized abdominal tenderness with a possible mass if abscess in an

accessible position (e.g. paracolic).

Emergency management

Resuscitation

• Establish large calibre IV access if the patient is unwell.

• Catheterize and place on a ﬂ uid balance chart only if hypotensive.

• Give adequate analgesia (e.g. 5–10mg morphine IV).

• Send blood for FBC (Hb, WCC), U&E (Na, K), CRP, group and save.

Establish a diagnosis

• Helical CT scanning is the diagnostic investigation of choice.

• Pelvic ultrasound (transabdominal or transvaginal) is occasionally

useful if a pelvic abscess is suspected and CT scanning is to be avoided

due to age.

INTRA-ABDOMINAL ABSCESS

309309

Early treatment IV antibiotics are appropriate if the patient is septic and

should be given according to the most likely underlying diagnosis and

organisms.

Deﬁ nitive management

• Radiologically guided drainage by ultrasound or CT scanning wherever

possible. Limitations include retroperitoneal or intermesenteric

abscesses with dangerous access or complex multiloculated abscesses.

• Open surgical drainage usually only indicated if:

Radiological drainage not possible or safe.•

Radiological drainage fails to deal with the clinical symptoms or •

abscess recurs.

Surgical treatment is required for the primary underlying pathology.•

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311

Liver, pancreatic, and

biliary surgery

Jaundice—causes and diagnosis 312

Jaundice—management 314

Gall bladder stones 316

Common bile duct stones 318

Chronic pancreatitis 320

Portal hypertension 322

Cirrhosis of the liver 324

Pancreatic cancer 326

Cancer of the liver, gall bladder, and biliary tree 328

Acute variceal haemorrhage 330

Acute pancreatitis 332

Chapter 8

CHAPTER 8 Liver, pancreatic, and biliary surgery

312

Jaundice—causes and diagnosis

Key facts

Jaundice is clinically apparent at serum bilirubin levels above 40mmol.

Key revision points—physiology of bile

• Unconjugated bilirubin formed mainly in spleen by the breakdown

of haemoglobin.

• It is insoluble and is transported in the plasma bound to albumin.

• Taken up by the liver by active transport, it is converted in the

hepatocytes into conjugated bilirubin (water-soluble).

• It is excreted into the bile canaliculi and via the main bile ducts into

the duodenum.

• Ten per cent of the unconjugated bilirubin is reduced to

urobilinogen by small intestinal bacteria, reabsorbed in the terminal

ileum, and then excreted in the urine (enterohepatic circulation).

• Ninety per cent is converted by colonic bacteria to stercobilinogen

which is excreted in faeces.

Causes and features

Pre-hepatic jaundice (haemolytic)

• Congenital abnormalities of red cell structure or content (e.g.

hereditary spherocytosis, sickle cell disease).

• Autoimmune haemolytic anaemia.

• Transfusion reactions.

• Drug toxicity.

Hepatic jaundice (hepatocellular)

• Hepatic unconjugated hyperbilirubinaemia.

Gilbert’s syndrome. Deﬁ ciency or abnormalities of unconjugated •

bilirubin uptake system.

Crigler–Najjar syndrome. Abnormality of conjugation process •

enzymes.

• Hepatic conjugated hyperbilirubinaemia.

Infection. Viral (e.g. hepatitis A, B, C, EBV, CMV); bacterial (e.g. liver •

abscess, leptospirosis); parasitic (e.g. amoebic).

Drugs, e.g. paracetamol overdose, antipsychotics, antibiotics.•

Non-infective hepatitis, e.g. chronic active hepatitis, alcohol-related.•

Post-hepatic jaundice (obstructive)

• Intraluminal abnormalities of bile ducts.

Gallstones.•

Blood clot.•

Parasites (e.g. ﬂ ukes).•

• Mural abnormalities of bile ducts.

Cholangiocarcinoma.•

Congenital atresia.•

Sclerosing cholangitis.•

JAUNDICE—CAUSES AND DIAGNOSIS

313

Biliary cirrhosis (primary (autoimmune) or secondary to sepsis).•

Traumatic/post-surgical stricture.•

• Extrinsic compression of bile ducts.

Pancreatitis.•

Tumours, e.g. head of pancreas, ampulla of Vater.•

Lymphadenopathy of porta hepatis nodes.•

Diagnosis and investigations

History

Common aspects overlooked in the clinical history of jaundiced patients.

• Family history of blood disorders.

• Recent foreign travel and work (exposure to infective agents).

• Recent drugs or changes in medications.

• Recent surgery or anaesthesia.

• History of gallstones.

• Alcohol intake, cholangitis (pain, fever, rigors), and carcinoma,

especially the head of the pancreas.

Basic tests

• Reticulocytosis, abnormal blood ﬁ lm (haemolysis).

• i Prothrombin time.

• ‘Hepatitis screen’ (viral titres for hepatitis A, B, C, CMV, EBV).

• Immunology (anti-smooth muscle antibodies (chronic active hepatitis)

and anti-mitochondrial antibodies (primary biliary cirrhosis)).

• LFTs (see Table 8.1).

Advanced tests

• Ultrasound scan (liver, gall bladder, bile ducts, and pancreas).

Excludes the presence of extrahepatic obstruction (dilated •

common bile duct).

May locate cause and site of obstruction.•

Examines hepatic parenchyma in possible hepatitis.•

• Magnetic resonance cholangiopancreatography (MRCP) for suspected

extrahepatic obstruction with no cause seen on ultrasound.

• Liver biopsy (ultrasound-guided) for suspected hepatitis.

Table 8.1 Liver function tests in jaundice

Haemolytic Hepatocellular Obstructive

Unconjugated

bilirubin

Increased Increased Normal

Alkaline

phosphatase

Normal Normal Much increased

γ glutamyl

transferase

Normal Increased Much increased

Transaminases Normal Increased Normal

Lactate

dehydrogenase

Normal Increased Normal

CHAPTER 8 Liver, pancreatic, and biliary surgery

314

Jaundice—management

Complications of jaundice

• Renal failure (hepatorenal syndrome). Caused by a combination of

infection, dehydration, and a direct effect of high levels of bilirubin and

other toxic products of metabolism on the kidney; mortality is highest

when the patient is over 65 with an elevated blood urea.

• Biliary infection (cholangitis). Commonest in obstructive jaundice or

with previously damaged biliary tree; commonly due to Gram –ve

bacteria (e.g. Escherichia coli, Pseudomonas).

• Deranged coagulation. Due to decreased synthesis of vitamin K

dependent clotting factors (III, VII, IX, X) and impaired platelet

function.

• Relative immunosuppression. Predisposes to systemic infections (e.g.

chest infection) and reduces wound healing due to combinations of

jaundice, infection, and reduced proteosynthesis.

Acute presentation—general treatment

Fluid balance

• Correct dehydration. Give up to 1000mL IV crystalloid if there is no

pre-existing liver disease; sodium input should be carefully monitored

in pre-exisisting liver disease—ask for senior advice.

• Monitor hourly urine output—urethral catheter.

• Treat infection. Take blood cultures if the patient is pyrexial. Give IV

antibiotics according to local protocol (e.g. cefuroxime 750mg IV tds,

IV gentamicin, PO or IV ciproﬂ oxacin (500mg IV)); treatment of bile

duct obstruction may be required urgently (e.g. radiologically-guided

drainage, ERCP, or rarely, surgery); consider prophylactic antibiotics.

• Check clotting times (APTT, PT). Give vitamin K 10mg IV stat if PT is

prolonged.

• Ensure adequate nutrition. Ensure the patient has a dietetic review;

enteral feeding is optimum, but may require a ﬁ ne bore NGT or, very

occasionally, a surgical gastrostomy or jejunostomy.

• Preoperative biliary decompression has not been proven to reduce

post-operative complications.

Acute presentation—speciﬁ c treatments

• Endoscopic procedures (ERCP).

Sphincterotomy. Used for common bile duct stone extraction, •

treatment of ampullary strictures due to tumours or inﬂ ammation.

Stent insertion (plastic or expanding metal). Used for bile duct •

stones that cannot be removed easily, post-operative or benign

strictures, malignant strictures, external compression of bile duct.

• Percutaneous transhepatic cholangiogram (PTC). Used for stent

insertion (often in combination with ERCP), temporary external

drainage of obstructed biliary system.

• Surgical drainage (e.g. choledochoduodenostomy). Very rarely used

if other interventions failed due to very high morbidity and mortality.

JAUNDICE—MANAGEMENT

315

Elective presentation—speciﬁ c treatments

• Haemolytic jaundice.

Steroids for autoimmune case.•

Splenectomy (laparoscopic). Rarely used for hereditary causes and •

failed medical treatment.

• Obstructive jaundice.

ERCP and PTC may be used as above for stones, strictures, •

compression.

Surgical drainage (e.g. choledochoduodenostomy or •

cholecystojejunostomy) used for failed interventional treatments.

Surgical resection, e.g. Whipple’s pancreaticoduodenectomy. Used •

for very selected cases where pancreatic or distal bile duct tumours

are benign or malignant, but potentially curable on staging; staging

of potentially suitable patients may include endoscopic ultrasound,

CT scan, ERCP or MRCP, visceral arteriography, laparoscopy.

• Hepatocellular jaundice.

Remove causative agent and support liver function.•

Consider transplantation in speciﬁ c circumstances.•

• Selective arteriography of the hepatic, coeliac, and superior mesenteric

arteries gives information about anatomical variants, vessel invasion,

tumour operability.

Prognosis in acute jaundice

Adverse risk factors include:

• Age >65y.

• Elevated plasma urea.

• Elevated plasma bilirubin (>200g/L).

• Uncontrolled sepsis and multiple organ dysfunction (typically acute

tubular necrosis).

• Underlying malignant disease.

CHAPTER 8 Liver, pancreatic, and biliary surgery

316

Gall bladder stones

Key facts Present in 10% of people >50y in the UK.

Pathological features

Bile has three major constituents:

• Bile salts (primary—cholic and chenodeoxycholic acids; secondary—

deoxycholic and lithocholic acids).

• Phospholipids (90% lecithin).

• Cholesterol.

Bile containing excess cholesterol relative to bile salts and lecithin predis-

poses to gallstone formation.

Types of gallstones

• Pure cholesterol (10%). Often solitary, large (>2.5cm), round.

• Pure pigment (bile salts 10%). Pigment stones are of two types:

Black (associated with haemolytic disease).•

Brown (associated with chronic cholangitis and biliary parasites).•

• Mixed (80%). Most common; usually multiple.

Predisposing conditions

• Increasing age.

• Female (pregnancy and use of the oral contraceptive).

• Obesity.

• Multiparity.

• Chronic haemolytic disorders (only for pigment stones).

• Long-term parenteral nutrition (alteration of bile constituents).

• Previous surgery (e.g. vagotomy or resection of the terminal ileum)

or disease involving the distal small bowel (e.g. Crohn’s disease)—

alteration of bile constituents.

Clinical features (common presentations)

Biliary colic Intermittent severe epigastric and right upper quadrant pain;

usually associated with nausea and vomiting. Resolves after few hours;

tenderness over gall bladder during acute episodes.

Acute cholecystitis

Severe continuous right upper quadrant pain; often radiates to right ﬂ ank

and back associated with anorexia and pyrexia. Tenderness over gall blad-

der during inspiration (Murphy’s sign).

Complications of acute cholecystitis include:

• Formation of an empyema or abscess of the gall bladder (rare).

Indicated by high swinging fever and severe localized pain;

• Perforation with biliary peritonitis (very rare).

• Cholecystoenteric ﬁ stula formation (may lead to a gallstone entering

and obstructing the distal ileum (‘gallstone ileus’; see b p. 302);

• Jaundice due to compression of the adjacent common bile duct by

pressure (‘Mirizzi syndrome’).

Chronic cholecystitis Repeated episode of infection causes thickening and

ﬁ brosis of gall bladder.

GALL BLADDER STONES

317

Mucocele Stone in neck of gall bladder; bile is absorbed, but mucus secre-

tion continues, producing a large, tense globular mass in right upper

quadrant.

Empyema Abscess of gall bladder.

Diagnosis and investigations

• FBC, U&E, LFTs, blood culture, serum amylase—in acute

presentations

• Abdominal X-ray. Only 10% of calculi are radio-opaque.

• Oral cholecystogram (Graham–Cole test). Rarely used.

• Ultrasound. Procedure of choice; identiﬁ es stones, determines wall

thickness, and assesses ductal dilatation.

• Hepatobiliary iminodiacetic acid (HIDA) scan. Useful when ultrasound

ﬁ ndings are equivocal.

Surgical treatment

Cholecystectomy

Majority done laparoscopically; often done as a day case. This is the treat-

ment of choice for all patients ﬁ t for GA. Indicated for:

• Patients with symptoms deemed to be due to gall bladder stones.

• Asymptomatic patients with gall bladder stones at risk of complications

(diabetics, porcelain gall bladder (15–20% associated with carcinoma),

history of pancreatitis, long-term immunosuppressed).

Risks of laparoscopic cholecystectomy

• Conversion to open operation, 5–10%.

• Bile duct injury, <1%.

• Bleeding, 2%.

• Bile leak, 1%.

Non-surgical treatments

Percutaneous drainage of gall bladder

• Done under ultrasound or CT guidance.

• Used for empyema of the gall bladder in patients unsuitable for

emergency cholecystectomy.

• After resolution of the infection, the calculi may be removed

percutaneously.

Dissolution therapy

• Rarely used. Requires a functioning gall bladder, small stones.

• Problems—requires prolonged treatment, <70% response, high rate of

recurrence of stones, side effects of medication (diarrhoea, pruritus).

Extracorporeal shock wave lithotripsy Hardly ever used; risk of visceral

injury and high risk of stone recurrence.

CHAPTER 8 Liver, pancreatic, and biliary surgery

318

Common bile duct stones

Key facts

• Types of stones as per gall bladder stones (see b p. 316).

• Common bile duct (CBD) stones present in 10% of patients with

gallstones.

• Most pass from the gall bladder into the CBD (secondary duct stones).

• Rarely form within the CBD (primary duct stones); almost always

associated with partial duct obstruction.

Clinicopathological features

Asymptomatic Usually found incidentally on ultrasound for gall bladder

stones.

Obstructive jaundice

• Usually due to CBD stone causing obstruction; rarely due to stone-

induced CBD stricture.

• Anorexia, nausea, itching.

• Dark urine and pale stools.

• Epigastric pain and fever more common with CBD stones than other

cause; due to associated low grade bile infection.

• A palpable, distended gall bladder is rare with CBD stones.

Courvoisier’s law

‘If in the presence of jaundice, the gall bladder is palpable, then the cause

of the jaundice is unlikely to be due to stone.’

This is due to the fact that CBD stones originate in the gall bladder

which is usually scarred and ﬁ brotic, preventing distension.

Ascending cholangitis Constant severe right upper quadrant pain, obstruc-

tive jaundice, and high swinging fever (‘Charcot’s triad’).

Acute pancreatitis Sixty per cent of acute pancreatitis in adults in the UK

is due to gallstones (see b p. 316).

Diagnosis and investigations

Basic tests

FBC (i WCC in cholangitis and pancreatitis), U&E, creatinine, LFTs

(i conjugated bilirubin and alkaline phosphatase), serum amylase

(i in pancreatitis), clotting studies.

Advanced tests

Ultrasound (transabdominal)

• Best ﬁ rst-line investigation.

• Accuracy low for distal CBD stones, in acute presentations, obesity,

with extensive overlying bowel gas.

COMMON BILE DUCT STONES

319

MRCP

• Investigation of choice for inconclusive ultrasound result.

• Non-invasive, avoids radiation exposure, highly accurate.

ERCP

• Used diagnostically for patients unable to tolerate MRCP

(claustrophobia).

• Mainly reserved for therapeutic interventions:

Endoscopic sphincterotomy (ES) and stone extraction or •

destruction (lithotrypsy).

Stent insertion for unextractable stones.•

• Risks of ERCP (i with ES):

Haemorrhage.•

Acute pancreatitis.•

Ascending infection.•

Perforation (usually retroduodenal, may cause peritonitis).•

PTC

• Used for failure of ERCP as therapeutic procedure (often in

combination with ERCP).

• Risks include sepsis, tube movement, leakage around the tube, and

dehydration.

Treatment

Principles of treatment of CBD stones are as follows.

Emergency treatment of CBD stones

• Indicated in unresolving gallstone pancreatitis, unresolving ascending

cholangitis.

• Usually ERCP with stone extraction or stent insertion.

• Occasionally PTC required.

Elective treatment of CBD stones

• Indicated for:

All patients having had complications (pancreatitis, cholangitis, •

obstructive jaundice).

All patients with gall bladder stones due for cholecystectomy.•

• Usually by ERCP or combined ERCP/PTC.

• Common bile duct exploration required at time of cholecystectomy

(laparoscopic or open) if ERCP/PTC fail or impossible or as surgeon’s

preference. Open CBD exploration may require a T-tube to be left in

the CBD.

Treatment of persistent CBD stones after cholecystectomy

• Rarely necessary with more accurate preoperative diagnosis and more

effective preoperative treatments.

• Stones can be extracted via a T-tube track if present (6 weeks after

surgery with radiologically guided basket extraction).

• Post-operative ERCP is rarely required.

CHAPTER 8 Liver, pancreatic, and biliary surgery

320

Chronic pancreatitis

Key facts

• Characterized by recurrent or persistent abdominal pain arising from

the pancreas.

• Often associated with exocrine or endocrine pancreatic insufﬁ ciency.

• Characterized by irreversible destruction and ﬁ brosis of pancreatic

parenchyma.

• May arise following one or more episodes of acute pancreatitis or may

be a chronic progressive process de novo.

Pathological features

• The process may affect the whole or part of the gland (focal).

• The head tends to be the most severely involved part in chronic

alcohol disease.

• Features of acute pancreatitis may occur—oedema, acute

inﬂ ammatory inﬁ ltrate, focal necrosis, intraparenchymal haemorrhage.

• Chronic inﬂ ammatory changes cause progressive disorganization of the

pancreas:

Glandular atrophy and duct ectasia.•

Microcalciﬁ cation and intraductal stone formation with cystic •

changes secondary to duct occlusion.

Causes and clinical features

Causes

• Recurrent acute pancreatitis of any cause, especially alcohol.

• Secondary to pancreatic ductal obstruction:

Pancreatic head cysts, tumours.•

Pancreatic duct strictures—post-surgery, ERCP, parasitic infestation.•

Congenital pancreatic abnormalities (pancreas divisum, annular •

pancreas).

Cystic ﬁ brosis.•

• Associated with autoimmune diseases (primary biliary cirrhosis,

primary sclerosing cholangitis).

• Congenital idiopathic chronic pancreatitis.

Features of chronic inﬂ ammation

• Recurrent or chronic abdominal pain:

Typically epigastric, radiating to the back and requiring opiates.•

Worse with food, alcohol.•

Features of exocrine failure

• Anorexia and weight loss (due to protein malabsorption).

• Steatorrhoea (due to fat malabsorption); soft, greasy, foul-smelling

stools that typically ﬂ oat on water.

Features of endocrine failure Insulin-dependent diabetes mellitus (due to

loss of β islet cells).

CHRONIC PANCREATITIS

321

Diagnosis and investigations

Basic tests

• Plain abdominal X-ray may show pancreatic calciﬁ cation.

• Abdominal ultrasound may show cystic change and duct dilatation

within the pancreas.

Advanced tests

• Pancreatic CT scan.

May identify a cause, e.g. anatomical variants, tumours, cysts.•

May show extent of disease. Pancreatic atrophy, disorganization of •

pancreatic ducts, altered acinar pattern with ﬁ brosis, calciﬁ cation,

and cystic change.

• MRI scan. May show the same changes as CT.

• ERCP. Demonstrates irregularity of the pancreatic duct strictures,

calculi, dilated segments (‘chain of lakes’), and changes in ﬁ rst and

second order branches and cyst formation; a secondary effect from

involvement of the head is stricture of the bile duct, leading to an

‘obstructive’ pattern of LFTs.

Treatment

• Prevention of cause/progressive damage.

Stop alcohol, deal with gallstones, treat autoimmune disease.•

Encourage a diet rich in antioxidants (vitamins A, C, E, selenium).•

• Control symptoms/complications.

Dietary modiﬁ cations. Adequate carbohydrates and protein, •

reduced fat.

Pancreatic exocrine enzyme supplements (e.g. Creon•

Analgesia. May require opiates (e.g. MST) or coeliac plexus block.•

Control of diabetes mellitus often requires insulin; control is often •

difﬁ cult due to variable pancreatic function.

Surgical treatment Indications include the following.

• Treatment of reversible cause (anatomical abnormalities, tumours,

cysts, ductal strictures and stones). Operations used include those to

remove causes and those to drain an obstructed pancreatic duct:

Pancreaticoduodenectomy (Whipple procedure).•

Partial pancreatectomy of the head (Frey procedure) or tail (distal •

pancreatectomy).

Pancreaticojejunostomy (Peustow or Duval procedure).•

• Treatment of severe intractable pain or multiple relapses. Operations

are usually to resect affected portion:

Partial pancreatectomy of the head (Frey procedure) or tail (distal •

pancreatectomy).

Total pancreatectomy.•

• Complications (pseudocyst, obstruction, ﬁ stula, infections, portal

hypertension).

Resectional surgery is associated with increasing risk of exocrine and

endocrine pancreatic failure and high risk of complications. All surgery

is associated with a risk of symptom recurrence due to recurrent or pro-

gressive disease.

CHAPTER 8 Liver, pancreatic, and biliary surgery

322

Portal hypertension

Key facts Normal portal vein pressure is 5–10mmHg. Portal hyperten-

sion (PH) develops when the portal pressure is greater than 12mmHg.

Causes and pathological features

Causes

• Prehepatic. Congenital portal vein atresia or portal vein thrombosis

due to neonatal umbilical sepsis, phlebitis of the portal vein from

abdominal infection (e.g. acute appendicitis or diverticulitis), trauma, or

a thrombosed portocaval shunt.

• Hepatic. Cirrhosis (e.g. alcoholic most frequently in the UK), chronic

active hepatitis, and parasitic diseases (e.g. schistosomiasis).

• Post-hepatic. Budd–Chiari syndrome (hepatic vein thrombosis),

constrictive pericarditis, or tricuspid valve incompetence (rare).

Features and complications

• Decreased or reversed portal blood ﬂ ow to the liver promotes the

development of portosystemic anastomosis between the portal system

and systemic circulation:

Left gastric vein into the oesophageal veins at the gastro-•

oesophageal junction—oesophageal and gastric varices.

Superior rectal into inferior rectal veins at the lower rectum—•

rectal varices.

Obliterated umbilical vein into the epigastric veins—‘caput •

medusae’.

• Oesophageal or gastric varices may bleed torrentially.

• Liver cell dysfunction/liver failure occurs in hepatic and post-hepatic

causes.

• Ascites. In part due to portal hypertension, but may be due to

associated liver dysfunction.

• Splenomegaly (hypersplenism may result).

• The Child–Pugh classiﬁ cation is used to assess the severity of portal

hypertension (see Table 8.2).

Diagnosis and investigations

Many investigations may be used at different times in PH.

• FBC, U&Es, LFTs, and clotting.

• Screening tests for causes of cirrhosis (see b p. 324).

• CT and ultrasound scan to assess liver morphology, diagnose PH, and

assess cause.

• Transabdominal Doppler ultrasound to assess blood ﬂ ow in the portal

vein and hepatic artery.

• Gastroscopy in acute variceal bleeding (see b p. 272).

Treatment

Cause

• Anticoagulation for Budd–Chiari syndrome.

• Treatment for hepatic causes.

PORTAL HYPERTENSION

323

Chronic complications

• Oesphago-gastric varices.

Beta-blockers (e.g. propranolol or nadolol) reduce portal venous •

pressure.

Repeated injection sclerotherapy or variceal ligation.•

Elective portosystemic shunts (e.g. splenorenal anastomosis).•

Liver transplant may be considered for treatment if associated with •

severe liver disease.

• Rectal varices. Injection sclerotherapy.

• Symptomatic splenomegaly or hypersplenism. Splenectomy (laparoscopic

or open).

• Ascites. Oral spironolactone; in cases of tense ascites, paracentesis may

be required with IV albumin replacement.

Acute complications Bleeding oesophago-gastric varices.

Key revision points—anatomy of portal circulation

• The hepatic portal circulation carries blood from the GI tract (from

the distal oesophagus to the anorectal junction) to the liver.

• Portosystemic anastomoses occur in ‘junctional’ areas of venous

drainage.

Left gastric veins (portal) and oesophageal veins (hemi/azygous •

veins) at the gastro-oesophageal junction.

Superior rectal veins (portal) and inferior rectal veins (pudendal •

veins) in the lower rectum.

Pancreatic and duodenal veins (portal) and retroperitoneal (hemi/•

azygous) veins in the upper retroperitoneum.

Umbilical vein (portal) into the epigastric veins at the umbilicus.•

• Portal venous blood drains into liver venous sinusoids and hence

into the hepatic veins.

Table 8.2 The Child–Pugh classiﬁ cation of portal hypertension

1 point 2 points 3 points

Bilirubin (μmol/L) <34 34–51 >51

Albumin (g/L) >35 28–35 <28

PT (s) <3 3–10 >10

Ascites None Moderate Moderate–severe

Encephalopathy None Moderate Moderate–severe

Grade A: 5–6 points; Grade B: 7–9 points; Grade C: 10–15 points.

CHAPTER 8 Liver, pancreatic, and biliary surgery

324

Cirrhosis of the liver

Key facts

• Commonest cause of liver failure in the UK.

• Commonest cause is alcohol-related.

Causes

• Congenital.

Haemochromatosis.•

Wilson’s disease.•

Other metabolic disorders (e.g. • α1-anti-trypsin deﬁ ciency).

• Acquired.

Alcohol intake.•

Chronic hepatitis (autoimmune, infective types B, C, and D, •

drug-induced).

Primary biliary cirrhosis.•

Secondary biliary cirrhosis (gallstones, strictures, cholangitis).•

Hepatic vein obstruction, e.g. Budd–Chiari syndrome.•

Idiopathic.•

Pathological features

Cirrhosis is characterized by ﬁ brosis of the liver parenchyma, nodular

regeneration, and hepatocellular necrosis.

• Micronodular form. Small and uniform nodules (<4mm in diameter),

separated by thin ﬁ brous septa uniformly throughout the liver.

• Macronodular form. Larger nodules separated by wider scars and

irregularly distributed throughout the liver.

• Mixed.

Clinical features

• One-third of cirrhosis patients are compensated, i.e. do not produce

any clinical symptoms, and are incidentally discovered during a medical

examination, at operation, or at autopsy.

• Two-thirds are decompensated, i.e. have features of liver cell

dysfunction or complications.

Features fall into three broad groups.

Portal hypertension See b p. 322.

Hepatocellular failure

• Jaundice.

• Spider naevi.

• Ascites.

• Hypoalbuminaemia.

• Clotting disorders.

• Encephalopathy.

• Gynaecomastia and testicular atrophy.

• Hepatorenal syndrome (renal failure in the setting of hepatic failure

due to renal vasoconstriction of unknown aetiology).

CIRRHOSIS OF THE LIVER

325

Malignant change

• Hepatatocellular carcinoma (particularly chronic hepatitis B infection).

• Often indicated by sudden rapid decrease in hepatocellular function.

Diagnosis and investigation

Diagnosis of cause

• Metabolic screen (e.g. serum copper).

• Hepatitis screen (A, B, C, D, E; EBV, CMV).

• Autoimmune screen (anti-mitochondrial antibodies, anti-smooth

muscle antibodies).

• Abdominal ultrasound and CT may show type of cirrhosis, intra- or

extra-hepatic biliary dilatation, extrahepatic obstructive causes.

• Liver biopsy to conﬁ rm diagnosis and establish type, activity, evolution,

and cause.

Investigation of severity or complications

• LFTs (transaminases, γGT, albumin, bilirubin).

• Clotting studies (PT).

• Transabdominal ultrasound or CT scan (splenomegaly and ascites).

Treatment

Removal of the cause/prevent progression

• Abstinence from alcohol.

• Interferon α. Chronic hepatitis B, response rate <50%.

• Combination therapy (interferon A and ribavirin for 6 months.

Moderate to severe hepatitis C.

• Immunosuppression for autoimmune causes.

Treatment of complications

• PH (see b p. 322).

• Encephalopathy. Treatment aims to lower the amount of nitrogen

absorbed from the gut.

Administration of oral lactulose.•

Oral, non-absorbable antibiotics.•

Careful IV ﬂ uid replacement to prevent sodium overload.•

Diet of high carbohydrate, low salt, moderate protein.•

• Ascites. Oral spironolactone; in cases of tense ascites, paracentesis may

be required with IV albumin replacement.

• Decompensated hepatocellular failure. Consider liver transplant.

CHAPTER 8 Liver, pancreatic, and biliary surgery

326

Pancreatic cancer

Key facts

• Fourth commonest solid organ cancer in the UK.

• Incidence is increasing rapidly.

• Eighty per cent of cases occur between the sixth and seventh decades.

• Risk factors include cigarette smoking, increasing age, high fat diet,

diabetes mellitus, excessive alcoholism, and chronic pancreatitis.

• Occupational hazards, e.g. exposure to naphthylene and benzidine.

• There may be hereditary factors involved as 1 in 20 patients with

pancreatic cancer have a family history of pancreatic cancer.

Pathological features

• Ninety per cent ductal adenocarcinoma.

• Seven per cent mucinous cystic neoplasms (mucinous cystadenoma/

cystadenocarcinoma), serous cystadenoma, and papillary cystic tumour.

• Three per cent islet cell tumours.

Clinical features

Carcinoma of the head of pancreas (65%)

• Obstructive jaundice (90%). Due to compression or invasion of the

CBD. Gall bladder is typically palpable.

• Pain (70%). Epigastric or left upper quadrant, often vague and radiates

to the back.

• Hepatomegaly. Due to metastases.

• Anorexia, nausea and vomiting, fatigue, malaise, dyspepsia, and pruritus.

• Acute pancreatitis. Occasionally the ﬁ rst presenting feature.

• Thrombophlebitis migrans (10%). Presents as emboli; splenic vein

thrombosis may lead to splenomegaly in 10% of patients.

Carcinoma of the body (25%) and tail (10%)

• Usually asymptomatic in the early stages.

• Weight loss and back pain (60%).

• Epigastric mass.

• Jaundice suggests spread to hepatic hilar lymph nodes or metastases.

• Thrombophlebitis migrans (7%).

• Diabetes mellitus (15%).

Diagnosis and investigations

• FBC, LFTs, blood sugar.

• Elevated serum CA 19–9 (sensitivity 90%; speciﬁ city 70% for diagnosis).

Level correlates with the tumour volume.

• Transabdominal ultrasound scan (sensitivity 70%; 30% in lesions <2cm).

• Doppler ultrasound images blood ﬂ ow in the portal vein and superior

mesenteric vessels.

• Helical CT scan of pancreas with dual phase IV contrast assesses size

of the primary lesion, vascular invasion, and distant metastasis.

PANCREATIC CANCER

327

• FNAC. Usually CT or ultrasound-guided (speciﬁ city 99%; sensitivity

50–70%).

• EUS more accurate than CT in detecting pancreatic lesions <3cm in

diameter and peripancreatic lymph node involvement.

• PET may help differentiate neoplastic from non-neoplastic lesions and

may be used to exclude extra-pancreatic spread that would preclude

surgical resection.

• ERCP is 85% accurate; can provide cytology as well as achieving biliary

drainage via insertion of a stent.

• Selective angiography or CT angiography used to assess resectability

based on encasement of the major vessels.

• Laparoscopy used to rule out peritoneal disease and liver metastasis

<2cm prior to offering surgical resection.

Treatment

Palliative treatment

The majority of tumours (95%) are not suitable for surgical resection due

to presence of metastases, local invasion, involved lymph glands, age, or

comorbidity of patient.

Relief of jaundice

Obstructive jaundice is associated with pruritus, coagulopathy, immuno-

logical and nutritional derangement, deterioration in liver function, risk of

acute renal failure (hepatorenal syndrome), and increased susceptibility to

infection. Relief of jaundice is achieved by:

• Endoscopic biliary stenting by ERCP.

• Percutaneous biliary drainage by PTC and internal stenting or insertion

of an internal-external drainage catheter.

• Surgical biliary drainage by cholecystojejunostomy or choledoco-

jejunostomy.

Relief of duodenal obstruction Surgical gastric bypass (gastrojeju nostomy).

Relief of pain

• Oral morphine (oramorph or MST).

• Chemical ablation of the coeliac ganglia (percutaneous coeliac

nerve block or thoracoscopic division of the splanchnic nerves are

alternatives).

Curative treatment Radical surgical resection is the only hope of cure if

patient is suitable.

• Pancreatoduodenectomy (Whipple’s operation) for periampullary

tumours and cancer of the pancreas conﬁ ned to the head.

• Total pancreatectomy for extensive tumour.

• Distal pancreatectomy for tumours in the tail.

Adjuvant therapy For advanced disease, adjuvant chemotherapy (e.g. 5-ﬂ u-

orouracil) improves prognosis.

Prognosis Poor; even in patients with resectable disease, the 5y survival

is 12%.

CHAPTER 8 Liver, pancreatic, and biliary surgery

328

Cancer of the liver, gall bladder,

and biliary tree

Key facts

• Commonest tumours of the liver are metastatic (pancreas, colon,

stomach, oesophagus, and breast).

• Thirty-ﬁ ve per cent of patients who die of malignant disease have

hepatic metastases.

Clinicopathological features

Hepatocellular carcinoma (HCC)

• Ninety per cent of primary liver tumours, but <1% of all new cancers

in UK.

• Common in Africa and Asia; commoner in men than women.

• Risk factors:

Cirrhosis, especially due to chronic viral hepatitis (HBV/HCV) or •

alcohol.

Aﬂ atoxin exposure, contraceptives, and androgens.•

• Arises from liver parenchymal cells, spreads via local invasion, via

portal vein invasion to other sites in the liver, or via hepatic vein

invasion to distant metastases (e.g. lung).

• Commonest presentation—rapid deterioration in pre-existing

cirrhosis.

Cholangiocarcinoma

• Usually arises in the extrahepatic biliary tree, but may be intrahepatic.

• Typical sites are distal CBD, common hepatic duct, conﬂ uence of

hepatic ducts (‘Klatskin tumour’).

Adenocarcinoma of the gall bladder

• Gallstones are found in 70% of cases.

• Associated with ulcerative colitis and primary sclerosing cholangitis.

• Often diagnosed incidentally as unexpected ﬁ nding during or after

cholecystectomy for ‘benign’ disease causing right upper quadrant pain.

• May present as a gall bladder mass or obstructive jaundice due to local

invasion of the common hepatic duct.

• Spread is direct into liver tissue (possibly resectable), to hilar lymph

nodes, or blood-borne (incurable).

Ampullary carcinoma

• Typically small and presents relatively early due to the early onset of

painless obstructive jaundice.

• Best prognosis of all hepatobiliary cancers due to early presentation

before local or lymphatic spread.

Other primary liver cancers

• Fibrolamellar carcinoma (FLC).

Usually affects younger patients (3rd and 4th decades).•

Does not occur on a background of liver disease.•

Presents as a large vascular mass.•

CANCER OF THE LIVER, GALL BLADDER, AND BILIARY TREE

329

• Angiosarcoma.

Less than 1% of liver tumours (most common sarcoma of the liver).•

Associated with exposure to arsenicals, vinyl chloride, anabolic •

steroids, and contraceptives.

Diagnosis and investigations

• AFP >500ng/mL highly suggestive of HCC, even in cirrhosis.

• Ultrasound scan often identiﬁ es site and cause of biliary obstruction;

good assessment of liver parenchyma.

• Needle biopsy to conﬁ rm diagnosis of HCC.

• ERCP. Diagnosis of ampullary and bile duct carcinoma; allows biopsy

or brush cytology of distal tumours; allows therapeutic stenting.

• MRCP. Diagnosis of proximal tumours or where ERCP not possible.

• PTC. Diagnosis of intrahepatic biliary tumours, therapeutic stenting, or

external drainage of proximal biliary tumours.

• CT scan. Assessment of local spread (including blood vessels), lymph

nodes, metastases.

Treatment

Curative

• Surgery offers the only cure for primary liver or biliary cancers.

• Patients suitable for resection must:

Be ﬁ t for major surgery.•

No evidence of metastases or involved lymph nodes (rare).•

Tumours technically suitable for complete resection (rare).•

• Surgical options for resection include:

Partial hepatectomy (HCC).•

Liver transplantation (HCC associated with chronic hepatitis).•

Radical cholecystectomy (adenocarcinoma of gall bladder).•

Radical excision of bile duct with reconstruction •

(cholangiocarcinoma).

Pancreaticoduodenectomy (Whipple procedure) (distal •

cholangiocarcinoma or ampullary carcinoma).

Palliative

• Endoscopic or percutaneous stenting for unresectable

cholangiocarcinoma or ampullary carcinoma.

• Chemotherapy is of minimal beneﬁ t in any primary liver or biliary

cancers.

• Embolization. Percutaneous thermal or radiofrequency ablation

(HCC).

Prognosis

• HCC. 5y survival 44% if surgically resectable.

• Cholangiocarcinoma. Median survival 9 months.

• Adenocarcinoma of gall bladder. 5y survival <5%.

About 20% of these tumours are resectable at the time of diagnosis.

CHAPTER 8 Liver, pancreatic, and biliary surgery

330330

Acute variceal haemorrhage

Key facts Mortality rate of ﬁ rst variceal bleed with established PH

is 30%.

Causes and features

See b p. 294 for differential diagnosis. Typical variceal bleeding is:

• Rapid onset, copious dark red venous blood with little mixing with

food.

• Features of established PH, e.g. caput medusa.

• Features of developing hepatic encephalopathy (ingested blood

provides an extremely protein-rich ‘meal’).

Emergency management

Resuscitation (see Fig. 8.1)

• Establish large calibre IV access. Give crystalloid ﬂ uid up to 1000mL

if tachycardic or hypotensive. Only use O –ve blood if the patient

is in extremis; otherwise wait for cross-matched blood if transfusion

needed.

• Catheterize and place on a ﬂ uid balance chart.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), cross-

match (at least 3U if haematemesis large), clotting.

• Always consider alerting HDU/ITU; variceal bleeds can deteriorate

extremely rapidly.

• Monitor pulse rate, BP, and urine output (urinary catheter).

• Insertion of a Sengstaken–Blakemore gastro-oesophageal tube may be

a life-saving resuscitation manoeuvre. Usually only inserted without a

prior gastroscopy if the patient is known to have varices and has life-

threatening bleeding. Key points are the following.

If the patient needs a ‘Sengstaken’ tube, they need to be on ITU.•

Most patients need sedation or a GA for the tube to be inserted.•

The tube is inserted and the gastric balloon blown up ﬁ rst and •

traction applied gently until the tube becomes ﬁ xed; this alone may

stop the bleeding if the varices are gastric.

If bleeding continues, the oesophageal balloon is blown up to a •

pressure around 20–30mmHg.

The oesophageal balloon must be deﬂ ated regularly to prevent •

oesophageal necrosis.

Establish a diagnosis

• Urgent OGD is the investigation of choice (at least within 24h).

May require ongoing resuscitation with anaesthetist present.•

Never• biopsy suspected varices.

Therapeutic interventions, including sclerotherapy and banding, are •

up to 90% successful at controlling acute bleeds and preventing

further interventions.

ACUTE VARICEAL HAEMORRHAGE

331331

Early treatment

• Give IV PPI (e.g. omeprazole 40mg); stop all NSAIDs.

• Give IV vasopression, somatostatin, or octreotide to lower

oesophageal variceal pressure.

• Blood transfusion if large volume haematemesis or drop in Hb.

• Ensure that the appropriate surgical team knows of the patient in case

surgical intervention is required.

• Consider giving FFP to correct clotting abnormalities.

Deﬁ nitive management

Considered for failed endoscopic treatment and ongoing bleeding.

• Transjugular intrahepatic portosystemic shunt formation (TIPS)

(intrahepatic shunt). May be performed to rapidly reduce the portal

pressure, but has the risk of inducing portal encephalopathy.

• Extrahepatic shunt. In portacaval shunts, encephalopathy occurs in 50%

of survivors and the procedure is now seldom performed.

• Oesophageal transaction.

Left gastric vein devascularization.•

Extremely high mortality.•

Low incidence of encephalopathy, but high incidence of recurrent •

bleeding.

Variceal bleed (Dx by Hx & Ex)

Active bleeding

Emergency OGD ± endotherapy

Active bleeding

despite endotherapy

Insert Sengstaken tube

Continue terilipressdin IV

Failure to control bleeding

Consider repeated endotherapy

Consider TIPS

Bleeding controlled

by endotherapy

Grossly unstable

Insert CVL

Admit to critical care

Consider Sengstaken tube

If INR > 1.4 give 2U FFP & Vit K 10mg IV

Start IV terilipressin 4mg stat IV bolus & 1mg IV qds

Give ciprofloxacin 1g IV

Fig. 8.1 Management of acute variceal haemorrhage.

CHAPTER 8 Liver, pancreatic, and biliary surgery

332332

Acute pancreatitis

Causes and features

Inﬂ ammatory process with cascade of release of inﬂ ammatory cytokines

(TNFA, IL2, IL6, platelet-activating factor (PAF)) and pancreatic enzymes

(trypsin, lipases, co-lipases) initiated by pancreatic injury, but which may

develop into full blown MODS or SIRS (see b p. 138).

Causes

• Gallstones (60%).

• Alcohol (30%).

• Hyperlipidaemia.

• Hypercalcaemia (hyperparathyroidism, multiple myeloma).

• Direct damage (trauma, ERCP, post-surgery, cardiopulmonary bypass).

• Toxins:

Drugs, e.g. azathioprine, oestrogens, thiazides, isoniazid, steroids, •

NSAIDs.

Infection, e.g. viral (mumps, CMV, hepatitis B), mycoplasma.•

Venom (scorpion, snake bites).•

• Idiopathic.

Classiﬁ cation/complications

• Oedematous (70%). May be simple or associated with phlegmon

formation; transient ﬂ uid collections common.

• Severe/necrotizing (25%). Necrosis may be sterile or infected.

Persistent large peripancreatic ﬂ uid collections may form

(‘pseudocyst’), which may become infected.

• Haemorrhagic (5%).

See b p. 138 for complications of SIRS.

Clinical features

• Severe epigastric pain radiating to the back.

• Severe nausea and vomiting.

• Fever, dehydration, hypotension, tachycardia (may be frankly shocked).

• Epigastric tenderness associated with guarding and in severe cases,

rigidity which may be generalized.

• Left ﬂ ank ecchymosis (Grey–Turner’s sign) and periumbilical

ecchymosis (Cullen’s sign), 1–3% of cases haemorrhagic pancreatitis.

Emergency management

Resuscitation

• Establish large calibre IV access. Give crystalloid ﬂ uid up to 1000mL

if tachycardic or hypotensive; may require ongoing ﬂ uids IV.

• Catheterize and place on a ﬂ uid balance chart.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (bilirubin,

albumin), amylase, group and save, clotting.

• Monitor pulse rate, BP, and urine output (urinary catheter).

• Consider insertion of a central line and manage patient in HDU if

haemodynamically unstable or fails to respond to early resuscitation.

• Assess the severity of the attack by the Glasgow Imrie criteria

(see Box 8.1).

ACUTE PANCREATITIS

333333

Establish a diagnosis

• Serum amylase >1000U. Diagnostic, but may be normal even in

severe cases; elevated amylase may occur in a wide range of other

acute abdominal events (intestinal ischaemia, leaking aneurysm,

perforated ulcer, cholecystitis).

• Serum lipase. Remains elevated longer than serum amylase; more

speciﬁ c, but less sensitive.

• AXR (non-speciﬁ c ﬁ ndings). Absent psoas shadows, ‘sentinel loop sign’

(dilated proximal jejunal loop adjacent to pancreas because of local

ileus’), ‘colon cut-off sign’ (distended colon to mid-transverse colon

with no air distally); may show gallstone, pancreatic calciﬁ cation.

• CT may be required. Shows pancreatic oedema, swelling, loss of fat

planes; may show haemorrhagic or necrotic complications.

• Ultrasound scan. Must be done within 48h of admission to identify

gallstones in the bile duct.

Early treatment Urgent ERCP and stone extraction are indicated for

proven bile duct stones causing obstruction and pancreatitis.

Deﬁ nitive management

Identify/prevent complications

• IV antibiotics (e.g. IV imipenem tds), sometimes started in

moderate to severe cases even without evidence of infected necrosis.

• CT scan identiﬁ es development of pancreatic phlegmon, early ﬂ uid

collections, necrosis, or haemorrhage.

• CT-guided pancreatic aspiration to identify infected necrosis.

• Early low volume enteral feeding is increasingly used to reduce the risk

of stress ulceration and bacterial translocation causing sepsis.

Treatment of early complications

• Consider treating all severe cases on HDU/ITU for optimized ﬂ uid

balance, respiratory, cardiovascular, and renal support.

• Proven infected necrosis. Surgical debridement may be required, but is

associated with a poor prognosis.

• Acute pseudocysts rarely need drainage unless very large.

Box 8.1 Glasgow Imrie criteria

Three or more positive criteria within 48h of admission = severe attack

(mnemonic: PANCREAS):

- PaO

<8kPa.

- Age >55y.

- Neutrophils/WCC >15 000

× 10

/L.

- Corrected calcium <2mmol/L.

- Raised blood urea >16mmol/L.

- Elevated Enzymes, AST>200U/L, LDH >600U/L.

- Albumin <32g/L.

- Sugar, blood glucose >10mmol/L.

CHAPTER 8 Liver, pancreatic, and biliary surgery

334

Overall outcome Mortality is associated with pancreatic necrosis and

the presence of sepsis, including MODS.

Reference

1 UK Working Party on Acute Pancreatitis (2005). UK guidelines for the management of acute

pancreatitis. Gut 54, iii1–iii9.

335

Abdominal wall

Abdominal wall hernias 336

Inguinal hernia 338

Femoral hernia 340

Umbilical and epigastric hernias 342

Incisional hernias 344

Other types of hernia 346

Rectus sheath haematoma 347

Groin disruption 348

Acute groin swelling 350

Chapter 9

CHAPTER 9 Abdominal wall

336

Abdominal wall hernias

No disease of the human body, belonging to the province of the surgeon,

requires in its treatment a better combination of accurate anatomical knowl-

edge with surgical skill than hernia in all its varieties.

Sir Astley Paston Cooper (1804)

Deﬁ nition of a hernia The abnormal protrusion of a viscus or part

of a viscus through a weakness in its containing wall.

Aetiology

• Congenital. Associated with a developmental disorder, such as

persistent processus vaginalis (infantile inguinal hernia) or failure of

complete obliteration of umbilical opening (infantile umbilical hernia).

• Acquired. Weakness of the abdominal wall due to ageing or previous

surgery; risk increases in conditions where there is i intra-abdominal

pressure, such as heavy lifting, chronic cough, straining on urination or

defecation, abdominal distension, ascites, pregnancy, etc.

Composition of a hernia

• Sac. Peritoneal lining of a hernia; may be complete or incomplete as in

sliding hernia (b p. 346).

• Neck of the sack. At the level of the defect in the abdominal wall

where the hernia emerges.

• Contents. Bowel or omentum.

Behaviour

• Reducible. Contents can be fully restored to the abdominal cavity,

spontaneously or with manipulation.

• Incarcerated. Part or all of the contents cannot be reduced due to a

narrow neck and/or adhesions; there is a risk of strangulation.

• Obstructed. Contains an obstructed bowel loop due to kinking; usually

goes on to strangulation.

Groin hernias rank third, after adhesive obstruction and cancer, as

the most common cause of bowel obstruction in the west. In tropical

Africa, strangulated external hernia is the commonest cause of intestinal

obstruction.

• Strangulated. Blood supply to the contents of the sac is cut off; the

tight neck of the peritoneal sac is the usual site of strangulation.

Pathological sequence Venous and lymphatic occlusion l oedema and

i venous pressure l impeding arterial ﬂ ow l bowel necrosis and

perforation.

2 If not diagnosed and managed early, bowel infarction can result and lead

to serious complications like peritonitis and septic shock.

ABDOMINAL WALL HERNIAS

337

Key revision points—general considerations in assessing

a patient with a hernia

History

- Is it a hernia? (history of reducibility)

- Site?

- Simple or complicated? Complicated if:

Incarcerated: patient can’t reduce it anymore.

Obstructed: symptoms of bowel obstruction.-

Strangulated: acute and severe pain, bowel obstruction, and -

patient is generally unwell.

- Any risk factors? (heavy lifting, COPD, constipation, BPH, previous

surgery).

Physical examination

- Conﬁ rm the diagnosis and type (reducibility, cough impulse,

anatomical location).

- Always examine both sides in suspected groin hernias.

- Any scars? (recurrent or incisional hernia)

- General examination is essential to look for predisposing factors like

bowel pathology and BPH.

Decision making

Is surgery warranted? (symptomatic, i risk of strangulation as with nar-

row neck, patient mobility and ﬁ tness for surgery).

CHAPTER 9 Abdominal wall

338

Inguinal hernia

Key facts

• It has been estimated that worldwide, >20 million repairs of inguinal

hernia are carried each year and in the UK 100 000.

• Commonest type of abdominal hernia; ♂:♀, 8:1.

• Abdominal contents protrude through the inguinal canal.

• Classiﬁ ed to indirect and direct according to its (surgically determined)

relationship to the inferior epigastric artery (see Table 9.1).

• Coexistence of direct and indirect hernias descending either side of

the epigastric artery produces a ‘pantaloon hernia’.

Clinical features

• Most have no symptoms until a lump is noticed in the groin.

• Ache or dragging sensation, especially towards the end of the day.

• Some can relate the onset of the pain and bulge to a speciﬁ c activity

(e.g. lifting).

Diagnosis and investigations

If the diagnosis is uncertain, investigations are of some help.

• Ultrasound. Least invasive and cheap, but may lead to false results.

• CT and MRI. Highly accurate, but CT involves substantial radiation.

• Herniography (intraperitoneal contrast injection and subsequent X-ray).

Aids in the diagnosis in cases of groin pain when no hernia can be felt;

rarely performed.

Treatment

• Patients with symptoms or have had episodes of irreducibility or bowel

obstruction documented should be offered repair.

• Elderly, immobile patients or those with high morbidity for operation

may be safely observed if asymptomatic or mildly symptomatic (annual

risk of incarceration is 2–3 per 1000 patients per year).

• A groin truss is of limited symptomatic beneﬁ t for non-surgical

patients.

Technical aspects

• Repair may be performed by open surgery or via the laparoscopic

approach (either transperitoneal or in the pre-peritoneal space).

• General or local anaesthesia if done via the open approach.

• Tension-free reinforcement of the transversalis fascia (TVF) layer

(usually with non-absorbable mesh); in open repairs, this lies in front of

the TVF and in laparoscopic, behind it).

• Mesh may be ﬁ xed in place by sutures (open) or ‘tacking’ devices

(laparoscopic approach).

• Avoid heavy lifting and straining for ﬁ rst to second week post-op.

• Lifetime recurrence of combined mesh repairs is approximately

1–2%.

• Laparoscopic approach is recommended for recurrent and bilateral

hernias and should be carried out by experienced surgeons in well-

equipped units (NICE guidelines).

INGUINAL HERNIA

339

Table 9.1 Comparison between indirect and direct inguinal hernias

Indirect Direct

Age Any age, but usually

young

Uncommon in children

and young adult

Aetiology Congenital (patent

processus vaginalis)

Acquired weakness in

abdominal wall

Relationship to inferior

epigastric artery

Lateral Medial

Descending to

scrotum

Often Rarely

Occluding the internal

ring

Controls it Does not control it

Neck Narrow Wide

Strangulation More likely Rare

Treatment Infant—herniotomy

(ligation and excision of

the sac)

Adult—open mesh repair,

laparoscopic repair

Open mesh repair,

laparoscopic repair

Key revision points—anatomy of the inguinal canal

- The inguinal canal is the oblique passage through the lower

abdominal wall. It runs from deep to superﬁ cial, from the internal to

the external inguinal rings.

- The inguinal canal transmits the spermatic cord (round ligament in

the female) and the ilioinguinal nerve.

- Contents of the spermatic cord are:

Three vessels (testicular artery, cremasteric artery, artery to the

vas).

Three nerves (genital branch of genitofemoral, autonomic supply

to the testicle, ilioinguinal nerve).

Three structures (vas, pampiniform venous plexus, testicular

lymphatics).

Three coverings (external spermatic fascia, cremasteric fascia,

internal spermatic fascia).

- The deep ring is formed through the transversalis fascia and lies

1–2cm above the inguinal ligament, midway between the symphysis

pubis and the anterior superior iliac spine.

- The superﬁ cial ring is a V-shaped defect in the aponeurosis of

external oblique, above and medial to the pubic tubercle.

- Direct inguinal hernias pass through a weakness in the transversalis

fascia in the Hesselbach’s triangle area (bounded by inguinal

ligament inferiorly, inferior epigastric artery laterally, and lateral

border of the rectus muscle medially).

CHAPTER 9 Abdominal wall

340

Femoral hernia

Key facts

• Commoner in women than men.

• Occurs through tissues of femoral canal.

• Has a high risk of strangulation due to the neck of the sac having bony

and ligamentous structures limiting it on three sides.

• Approximately 30% of femoral hernias present as emergencies; 50% of

these require bowel resection for strangulation and ischaemia.

Clinical features

• Appears below and lateral to pubic tubercle, medial to femoral pulse.

• May be asymptomatic until incarceration or strangulation occurs.

• May be mistaken for an upper medial thigh swelling.

Diagnosis and investigations

• Differential diagnosis includes:

Low presentation of inguinal hernia.•

Femoral canal lipoma.•

Femoral lymph node.•

Saphena varix (compressible, disappears when lying ﬂ at, palpable •

thrill on coughing or percussion of the saphenous vein).

Femoral artery aneurysm (pulsatile).•

Psoas abscess (ﬂ uctuant and lateral to femoral artery).•

• Ultrasound scanning may help with the differential diagnosis. If there is

signiﬁ cant doubt, exploration is usually indicated due to the high risk of

complications in untreated femoral hernia.

Treatment

• All should be repaired because of great risk of strangulation; truss has

no place in the management.

• Once the hernia is reduced, the femoral canal should be narrowed by

interrupted sutures to prevent recurrence; care must be taken not to

narrow the adjacent femoral vein. There are two main approaches.

Low approach (infrainguinal)

• Incision below inguinal ligament approaching femoral canal from below.

• Has the advantage of not interfering with the inguinal structures, but

provides little or no scope for resecting any compromised small bowel

and so is best reserved for elective surgery.

High approach (inguinal)

• Incision above the inguinal ligament approaching femoral canal from

above by dissecting through the posterior wall of the inguinal canal.

• Requires repair of the inguinal canal on closure, but offers excellent

access to the peritoneal cavity should small bowel surgery be required

and is the usual approach in emergency presentations.

FEMORAL HERNIA

341

Key revision points—anatomy of the femoral canal

- Lies medial to femoral vein within femoral sheath.

- Contains loose areolar tissue and a lymph node known as the lymph

node of Cloquet.

- The femoral ring is the abdominal opening of the femoral canal.

The increased diameter of the true pelvis in females proportionally

widens the femoral canal.

- Boundaries to the femoral ring are:

Anteriorly, inguinal ligament.

Medially, lacunar ligament.-

Posteriorly, pectineal ligament.-

Laterally, femoral vein.-

- An aberrant obturator artery branch of inferior epigastric may cross

the lacunar ligament and can cause haemorrhage during surgical

repair.

- Femoral hernia repair (open) involves suture-plication of the inguinal

and pectineal ligaments or placement of a mesh plug that is ﬁ xed in

position in the defect with non-absorbable sutures.

CHAPTER 9 Abdominal wall

342

Umbilical and epigastric hernias

Key facts

These hernias are sometimes referred to collectively as ventral hernias.

• Umbilical hernias can be divided into:

True umbilical hernias• . Occur through the umbilical cicatrix and

are almost always congenital in origin; those present at birth may

close spontaneously before the age of 3; more common in Afro-

Caribbean races.

Paraumbilical hernias• . Occur through the periumbilical tissues and

are always acquired; common in obese and parous women.

• Epigastric hernias are defects in the linea alba somewhere between the

xiphisternum and umbilicus at sites of penetration of the linea alba by

nerves and vessels; they may be small or extensive.

Clinical features

Umbilical hernia

• Small, centrally placed within the umbilicus.

• Often contains pre-peritoneal fat and rarely contains bowel/omentum.

• May be painful, but rarely strangulates.

Paraumbilical hernia

• Variable in size, up to moderate.

• Paced eccentrically and distorts the shape of the umbilicus.

• May contain bowel or omentum.

• Often painful and occasionally strangulate.

Epigastric hernia

• Variable, up to large defects.

• Always placed in the midline although when large, may lie to one side.

• Most frequently contains only pre-peritoneal fat.

• Moderate risk of strangulation.

Diagnosis and investigations The diagnosis is rarely in doubt. If there

is concern that a palpable lump may be a lipoma or subcutaneous tissue

growth, then a CT scan can usually conﬁ rm the diagnosis.

Treatment

• Congenital umbilical hernias should only be repaired if they persist

beyond the age of 2–3y.

• Surgical repair is offered for symptomatic hernias or those with a high

risk of complications.

Principles of repair

• Identify edges of hernial sac and reduce hernia.

• Small defects are usually repaired by an overlapping sutured repair

using non-absorbable suture, e.g. 0 Prolene, without reinforcements;

larger defects or recurrent hernias may be repaired with mesh (usually

polypropylene-based, e.g. Prolene).

• Laparoscopic repair is increasingly being used.

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CHAPTER 9 Abdominal wall

344

Incisional hernias

Key facts

• Incisional hernias are very uncommon outside the abdomen.

• Up to 10% of midline laparotomy wounds suffer herniation to some

degree. Factors that predispose to incisional herniation include:

Wound infection.•

Steroid use, anaemia, or malnutrition at the time of original surgery.•

Incisional hernias are probably slightly less common after muscle •

splitting or transverse incisions, compared to midline laparotomies.

Poor surgical techniques in abdominal closure increase the risk.•

• The peak time of presentation is up to 5y after surgery.

Pathological features

The hernia occurs through the tissues in which the incision is made.

Typically, the sac is made up of peritoneum, eventrated scar tissue, and

subcutaneous scar tissue.

Clinical features

• The hernia may vary from a few cm to a near complete defect in the

anterior abdominal wall through which all the mobile viscera regularly

protrude.

• The risk of strangulation is maximal in small- to medium-sized defects.

In large and very large defects, the viscera are often permanently herni-

ated and if this has been the case for a long period, they ‘lose the right of

abode’ within the true abdominal cavity. This means that the remaining

lateral abdominal wall tissues chronically retract and there may be insuf-

ﬁ cient room for all the viscera within the revised abdominal cavity when

the tissues are re-approximated.

Diagnosis and investigations

When assessing incisional hernias, ask yourself the following.

• What is the risk of complications/strangulation?

• Is it likely that the contents of the hernia can be reduced fully?

• Is the patient able to undergo the anaesthesia necessary for the

surgery required?

• Is there a risk of compromise to respiratory function if a very large

incisional hernia is reduced and repaired?

Treatment

• Small defects (<4cm). Simple sutured repair.

• Medium and large defects (>4cm). A mesh is placed between the

posterior rectus sheath and the rectus muscle ﬁ bres. If below the

umbilicus, the mesh is placed in the pre-peritoneal space. After the

mesh is ﬁ xated, the anterior rectus sheath is closed.

• Laparoscopic repair is increasingly being used. The use of an

‘underlay’ intraperitoneal mesh enhances the repair, but also

creates the potential for bowel adhesions or ﬁ stula formation.

INCISIONAL HERNIAS

345

Polytetraﬂ uoroethylene (PTEF) mesh is recommended to reduce

adhesive complications.

• Unﬁ t patients or patients unwilling to have surgery. A custom-made

support corset is often useful.

CHAPTER 9 Abdominal wall

346

Other types of hernia

These types are rare, but clinically signiﬁ cant.

Spigelian

• Occurs under the lower edge of the linea semilunaris and protrudes

along the lateral border of the rectus sheath.

• Typically difﬁ cult to diagnose in the supine position.

• Ultrasound and CT scan may help to conﬁ rm the diagnosis.

• Has a high risk of complications.

• Repair is via direct sutured repair of the rectus sheath.

Obturator

• Occurs through the obturator canal from the lateral wall of the pelvis

with the sac protruding into the medial upper thigh.

• Symptoms include pain or abnormal sensations in the distribution of

the obturator nerve in the skin of the inner medial thigh.

• Diagnosis is often very difﬁ cult and is usually made by CT scan.

• A high proportion present with complications of bowel obstruction

due to the sac being hidden within the adductor muscles

compartment.

• The neck is narrow and prone to strangulation.

• Repair can be via exposure of the sac in the medial thigh or, more

commonly, at laparotomy for complications.

Lumbar

• Occurs through either the inferior or superior lumbar triangles

(bounded by the lumbar muscles, lumbosacral fascia, and bony features

of the posterior abdominal wall) or, rarely, through lumbar incisions.

• Usually contain retroperitoneal fat and rarely bowel.

• May be repaired by direct suture or mesh repair for larger defects.

Perineal

• Spontaneous perineal hernias occur through the greater or lesser

sciatic foramina and are exceptionally rare.

• Present with acute complications and are diagnosed only at surgery.

• Post-operative perineal hernias occur through the pelvic ﬂ oor muscles

and do so usually as a result of surgical procedures (particularly after

abdominoperineal resection of the rectum).

• Repair may be via sutured closure of the defect or, more commonly,

ﬁ lling of the defect with prosthetic material (mesh) or biological tissue

(muscle ﬂ ap).

Sliding

• The sac is formed partly by a retroperitoneal structure.

• It is thought that the structure slides down the canal pulling its

overlying peritoneum with it hence the name ‘hernia-en-glissade’.

Littre’s hernia The hernia sac contains a Meckel’s diverticulum.

Richter’s hernia Only part of the circumference of the bowel is

strangulated.

RECTUS SHEATH HAEMATOMA

347

Rectus sheath haematoma

Key facts

Result from haemorrhage from any of the vascular network within the

rectus sheath that is formed by terminal branches of the superior and

inferior epigastric arteries.

Clinical features

• Presents with a sudden localized abdominal pain ± a tender mass.

• A history of major or minor blunt trauma may be elicited.

• Some patients report events that cause sudden contraction of the

rectus muscle, such as coughing, sneezing, or any vigorous physical

activity; it may also develop spontaneously in anticoagulated patients.

• Pain typically increases with contraction of the rectus muscles and a

tender mass may be palpated and remains unchanged when the rectus

muscle is contracted.

Diagnosis and investigations

• Can be confused with conditions that present with unilateral

abdominal pain like appendicitis.

• Hb level and coagulation proﬁ le should be checked.

• Ultrasonography may help in the diagnosis; CT is diagnostic.

Treatment

• Small and stable haematomas may be observed without patient

hospitalization.

• Bilateral or large haematomas need hospitalization; blood transfusion

and reversal of coagulation may be needed.

• Angiographic embolization is required infrequently, but may be

necessary in case of haematoma enlargement, free bleeding, or clinical

deterioration.

• Surgical ligation of bleeding vessels is indicated if angiographic

treatment fails or the patient becomes haemodynamic unstable.

CHAPTER 9 Abdominal wall

348

Groin disruption

Key facts

• Also called ‘Gilmore’s groin’ or ‘sports hernia’ (although hernia is

rarely present).

• An overuse syndrome that results in muscular imbalances of the pelvis

and abdominal wall muscles.

• Common in male athletes, especially in sports that require repetitive

twisting and turning at high speeds (e.g. soccer, tennis, ice hockey).

Pathological features

It has distinctive features that include a torn external oblique aponeurosis,

a torn conjoined tendon, a dilated superﬁ cial inguinal ring, and a dehis-

cence between inguinal ligament and conjoined tendon.

Clinical features

• Unilateral groin pain that is often insidious and gradually worsens and

is felt ‘deep’ in the groin area.

• Some patients may identify a distinct provocative event like kicking or

a sudden change in direction while playing.

• Pain is almost always absent at rest.

• Physical ﬁ ndings are non-speciﬁ c. The external inguinal ring may be

dilated and tender. Valsalva manoeuvres and resisted adduction may

elicit pain and are useful provocative tests.

Diagnosis and investigations

• The differential diagnosis includes osteitis pubis, adductor

tendinopathy, and pubic instability or fracture.

• Radiographic ﬁ ndings are usually normal, but helpful in ruling out other

conditions. Therefore, it is a clinical diagnosis that is conﬁ rmed intra-

operatively.

Treatment

• These patients are managed conservatively initially due to the difﬁ culty

in making a diagnosis.

• If symptoms persist, surgical repair is indicated and should be carried

out by a surgeon who is experienced in managing groin disruption.

• Mesh reinforcement is often utilized during the repair.

• This is followed by 2–4-week rehabilitation programme.

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CHAPTER 9 Abdominal wall

350350

Acute groin swelling

Causes of chronic testicular swelling are discussed on b p. 366.

Causes and features

• Incarcerated groin hernia (inguinal or femoral). May or may not be

associated with intestinal obstruction; often red, hot, and tender.

• Acute epididymo-orchitis (in males). Tenderness is particularly over the

spermatic cord and the epididymis.

• Torsion of the testis. May present with pain in the groin, but unless the

testicle is undescended, the tenderness is primarily over the scrotum

(and testis). Testicle is tender, swollen, and high riding. Elevation of the

scrotum, unlike epididymitis, makes the pain worse.

• Iliopsoas abscess. Tenderness primarily below the inguinal ligament;

may be ﬂ uctuant, associated tenderness in the RIF due to underlying

pathology.

• Acute iliofemoral lymphadenopathy (e.g. from infected toenail). Tender

diffuse swelling; often multiple palpable lumps (nodes).

• Acute saphena varix. Compressible, cough thrill.

• Acute complications of femoral artery aneurysm.

Emergency management

Resuscitation

• Establish IV access; consider giving crystalloid ﬂ uid if there is a

suspicion of a complicated hernia or an iliopsoas abscess.

• Catheterize and place on a ﬂ uid balance chart if hypotensive.

• Send blood for FBC (Hb, WCC), U&E (Na, K).

• Group and save and clotting if arterial disease or abscess formation is

suspected.

Establish a diagnosis

2 Torsion of the testis is a true surgical emergency and should not wait

for a diagnosis short of exploration.

Colour ﬂ ow Doppler assessment may be able to conﬁ rm the presence

of a hyperaemic testis, but unless it is immediately available, it should not

delay operation.

2 If there is a strong clinical history in a young male, immediate operation

remains the diagnostic investigation of choice.

• If an iliopsoas abscess is suspected, abdominopelvic CT scanning is the

investigation of choice.

• Rigid sigmoidoscopy and biopsy only if not unstable.

• Flexible endoscopy may be indicated, but carries a risk of perforation.

Deﬁ nitive management

Incarcerated groin hernia

• Repair is indicated for all patients except those considered unﬁ t for

any surgical procedure or those declining treatment.

• It may not be possible to establish if the hernia is inguinal or femoral

preoperatively; if so, it is safest to approach as if for an inguinal hernia.

ACUTE GROIN SWELLING

351351

• Femoral hernias may be approached via an infrainguinal or transinguinal

dissection (see b p. 342).

Infrainguinal approaches may be limited in exposure if there is •

necrotic bowel within the hernia requiring resection.

A transinguinal approach will involve repair of the inguinal canal as •

well, but offers an almost unlimited exposure of the femoral canal

from above and allows plenty of exposure for bowel resection.

• Inguinal hernias should be approached through a conventional incision.

Repair may require a mesh although there is an increased risk of

infection if there is an associated bowel resection.

• Anaesthesia may be general or local with sedation.

Psoas abscess The underlying cause should be identiﬁ ed as a matter or

priority. Incision and drainage of the groin collection may be indicated, but

only as part of the overall treatment.

Torsion of the testis

• Once identiﬁ ed, the affected testis should assessed; if non-viable, a

simple orchidectomy is performed and if viable, an orchidopexy.

• If the diagnosis is conﬁ rmed, the contralateral testicle should be ﬁ xed

by orchidopexy to prevent subsequent torsion.

Epididymo-orchitis Antibiotics PO (e.g. ciproﬂ oxacin 500mg od) for 14 days

or IV if severe.

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353

Urology

Symptoms and signs in urology 354

Investigations of urinary tract disease 356

Urinary tract stones 358

Obstruction of the ureter 360

Benign prostatic hyperplasia 362

Stricture of the urethra 364

Scrotal swellings 366

Disorders of the foreskin 368

Common conditions of the penis 370

Erectile dysfunction 372

Adenocarcinoma of the kidney 374

Transitional cell tumours 376

Adenocarcinoma of the prostate 378

Carcinoma of the penis 380

Testicular tumours 382

Haematuria 384

Acute urinary retention (AUR) 386

Acute testicular pain 388

Chapter 10

CHAPTER 10 Urology

354

Symptoms and signs in urology

Symptoms

Pain

• May be located over the site of pathology, e.g. testes.

• May radiate in accordance with innervation of the structure involved.

Kidney pain• . In the renal angle (between the lower border of the

12th rib and the spine).

Ureteric pain• . Between the renal angle and the groin.

Bladder pain• . In the suprapubic region.

Prostatic pain• . In the perineum, but may radiate along the urethra to

the tip of the penis.

• May be related to function, e.g. suprapubic pain exacerbated by

bladder ﬁ lling.

Haematuria (macroscopic)

• Frequently a sinister symptom of malignant disease, especially the

bladder when it is normally painless.

• When associated with painful voiding, it is usually due to bladder

infection or stones.

Lower urinary tract symptoms

• Refers to a group of symptoms that typically affect the ageing male.

• Often caused by bladder outﬂ ow obstruction related to prostatic

enlargement.

• Includes symptoms related to both voiding and storage.

• Voiding symptoms. Poor urine ﬂ ow, hesitancy, post-micturition

dribbling.

• Storage symptoms. Frequency, nocturia, urgency, urge incontinence.

• International prostate symptom score (IPSS) is a validated

questionnaire to estimate the patient’s perception of severity of

symptoms.

Urinary incontinence

• Affects women more commonly than men.

• Stress incontinence. Urine leakage that occurs at times of increased

intravesical pressure, e.g. during coughing, sneezing, lifting.

Results from incompetence of urethral sphincter and bladder neck •

mechanism; usually related to pregnancy and childbirth.

• Urge incontinence. Urine leakage that occurs in association with a

strong desire to void.

Urine leaks from the bladder before the patient is able to reach a •

toilet.

Usual cause is overactivity of the detrusor muscle.•

May be idiopathic or secondary to other bladder disease.•

Stress and urge incontinence frequently coexist.•

• Insensible urine leakage. Occurs without any associated symptoms.

Urine leaks from the bladder continuously and the patient is •

sometimes unaware.

SYMPTOMS AND SIGNS IN UROLOGY

355

Causes• . Overﬂ ow incontinence from chronic retention, ﬁ stulation

(commonly between bladder and vagina), gross sphincter

disturbance resulting from surgery or neurological disease.

Male sexual dysfunction

• Erectile dysfunction (ED), commonly known as impotence.

Inability to attain and maintain an erection adequate for satisfactory •

sexual intercourse.

There are degrees of ED.•

Men with incomplete ED respond more satisfactorily to treatment.•

The majority of cases have an organic basis.•

All cases have a degree of psychogenic involvement.•

Twenty per cent of cases are primarily psychogenic.•

• Premature ejaculation.

More common in younger men.•

Invariably has a psychogenic basis.•

Often associated with performance anxiety.•

• Loss of libido.

Loss of normal sex drive.•

Either psychogenic or related to hypogonadal states.•

Haemospermia

• Presence of blood in ejaculate.

• Rarely associated with signiﬁ cant pathology.

Signs

Inspection

Examination of the penis must include retraction of the foreskin (if pos-

sible) and inspection of the glans and external meatus for signs of infection,

inﬂ ammation, or tumour.

Palpation

• Tenderness in the renal angle or a palpable loin mass may indicate

renal pathology.

• Suprapubic dullness to percussion is an indication of a bladder mass or

full of urine.

• Check for testicular asymmetry, masses, or tenderness

(underdevelopment, tumours, and infection).

• Intrascrotal mass may include the testis (e.g. hydrocele) or be separate

from it (e.g. epididymal cyst).

• Do a digital rectal examination to determine the size, consistency,

regularity, and symmetry of the prostate.

CHAPTER 10 Urology

356

Investigations of urinary tract disease

Laboratory investigations

Urinalysis

• Dipstick analysis for blood, leucocytes, protein, nitrites, and glucose.

Nitrites, blood, and leucocytes—infection.•

Blood—microscopic haematuria.•

Protein, leucocytes—intrinsic renal disease.•

• Microbiology, cytology for presence of urinary infection or

malignant cells. Midstream urine (MSU) specimens are required for

bacteriological culture; take care to avoid contamination

particularly in women.

• Matched urine and serum biochemistry to assess glomerular function,

e.g. matched osmolarities, sodiums, and potassiums.

Blood

• Serum creatinine levels. Provides a crude assessment of overall renal

function.

• Creatinine (Cr) clearance (requires 24h urine collection and

measurement of serum creatinine).

Cr clearance (mL/min) = u x v/p

where u is urine Cr concentration, v is 24h urine volume, p is plasma Cr

concentration.

• Serum prostate-speciﬁ c antigen (PSA). Indicator of prostate disease.

Interpreted according to age-speciﬁ c reference range.•

High levels are found in benign prostatic hyperplasia, prostate •

cancer, acute retention, and urinary infection.

• Sex hormone measurements. Occasionally useful in the assessment of

male sexual dysfunction and infertility.

Radiology investigations

Ultrasound

• Renal and bladder scans. For haematuria and urinary tract infection

(UTI).

• Transrectal ultrasound scan. Measures prostate accurately and allows

systematic biopsy for detection of cancer.

• Scrotal ultrasound. Evaluates acute scrotum from a suspected testicular

cancer.

Intravenous urogram (IVU)

• Provides greater functional information than ultrasound.

• Provides superior imaging of the ureter.

• Pre- and post-contrast scans provide some functional information with

regard to arterial and venous blood ﬂ ow and excretory function of the

kidneys.

• Vital for the staging of renal, bladder, and testicular cancers.

INVESTIGATIONS OF URINARY TRACT DISEASE

357

MRI

• Provides greater accuracy than CT in assessment of the prostate

capsule and seminal vesicles.

• Sensitive test for the presence of bone metastases.

Isotope bone scan

• Demonstrates abnormal area of bone turnover.

• A useful screening test for the presence of bone metastases.

• Plain ﬁ lms are taken to aid interpretation if the site or pattern of hot

spots is indeterminate.

Isotope renography

• Provides anatomical and functional information about the kidneys.

• Dimercaptosuccinate (DMSA) scan provides an image of functioning

renal parenchymal tissue.

• 99m

Tc-mercaptoacetyltriglycine (MAG3) renogram provides dynamic

information regarding excretion from the kidneys and determines

whether or not obstruction is present.

Endoscopy

Flexible cystoscopy

• Examines urethra and bladder.

• Performed using local anaesthetic gel.

• There is limited potential for intervention.

Rigid cystoscopy Under GA, permits biopsy and resectoscope allows

resection of tissue.

Ureteroscopy

• Rigid and ﬂ exible ureteroscopes provide access to the ureter and

pelvicalyceal system.

• Allows the passage of instruments and laser ﬁ bres for the treatment of

stones and upper tract tumours.

CHAPTER 10 Urology

358

Urinary tract stones

Key facts

• Prevalence of stones in the population is around 3%; ♂ > ♀.

• The commonest reason for emergency urological admissions.

• Peak presentation in the summer months.

• Most common age of presentation of urinary calculi is 20–50y.

• Ninety per cent of urinary calculi are radio-opaque.

Aetiology

• Metabolic. Hyperparathyroidism, idiopathic hypercalciuria,

disseminated malignancy, sarcoidosis, hypervitaminosis D.

• Familial metabolic causes. Cystinuria, errors of purine metabolism,

hyperoxaluria, hyperuricuria, xanthinuria.

• Infection.

• Impaired urinary drainage, e.g. medullary sponge kidney, pelviureteric

junction (PUJ) obstruction, ureteric stricture, extrinsic obstruction.

Pathological features

Calcium stones

• Seventy-ﬁ ve per cent of all urinary calculi.

• Usually combined with oxalate or phosphate, are sharp, and may cause

symptoms, even when small.

Triple phosphate stones (‘struvite stones’)

• Compounds of magnesium, ammonium, and calcium phosphate.

• Fifteen per cent of all calculi.

• Commonly occur against a background of chronic urinary infection and

may grow rapidly.

• ‘Staghorn’ calculi (ﬁ ll the calyceal system) are a form of struvite.

Uric acid stones

• As a consequence of high levels of uric acid in the urine.

• Five per cent of all urinary stones; radiolucent.

Cystine stones

• Relatively rare; 1–2% of all cases.

• Difﬁ cult to treat due to extremely hard consistency.

Other stones Xanthine, pyruvate, and other stones; 1% of all calculi.

Clinical features

• ‘Ureteric/renal colic’. Severe, intermittent, stabbing pain radiating from

loin to groin.

• Microscopic or, rarely, frank haematuria.

• Systemic symptoms such as nausea, vomiting, tachycardia, pyrexia.

• Loin or renal angle tenderness due to infection or inﬂ ammation.

• Iliac fossa tenderness if the calculus has passed into the distal ureter.

Investigations

• Basic tests.

Raised WCC and CRP suggest superadded infection (should be •

conﬁ rmed by MSU); raised Cr suggests renal impairment.

URINARY TRACT STONES

359

Stones often visible on plain abdominal X-ray (‘kidneys/ureters/•

bladder’ (KUB)).

Serum calcium, phosphate, and uric acid.•

24h urine for calcium, phosphate, oxalate, urate, cystine, and •

xanthine.

• Advanced tests.

Non-contrast spiral CT is the gold standard for locating stones and •

assessing evidence of complications.

IVU will locate stones and show any proximal obstruction.•

Renal ultrasound scan for hydronephrosis.•

Treatment

Acute presentations (renal colic, ureteric obstruction)

• Analgesia, e.g. diclofenac 100mg PR; antiemetic, e.g. metoclopramide

10mg IV; IV ﬂ uids.

• Small stones (<0.5cm) may be managed expectantly as most will pass

spontaneously.

• Emergency treatment with percutaneous nephrostomy and/or ureteric

stent insertion is necessary if either pain or obstruction is persistent.

Elective presentations

• Extracorporeal shock wave lithotripsy (ESWL).

Focused, externally generated electrohydraulic or ultrasonic shock •

waves.

Targeted onto the calculus using ultrasound, X-ray, or a •

combination.

Causes stone disintegration and the fragments are then voided.•

• Percutaneous nephrolithotomy (PCNL).

For stones in the renal pelvis or calyces and occasionally for stones •

in the upper ureter.

Percutaneous track into the renal pelvis using ﬂ uoroscopic •

guidance.

Nephroscope is inserted and the calculus visualized.•

Removed either in total or, if large, following fragmentation.•

• Endoscopic treatment.

Ureteroscope is inserted and the stone visualized.•

Stone is fragmented using ultrasound, electrohydraulic •

intracorporeal lithotripsy, or laser.

• Open nephrolithotomy/ureterolithotomy. For large staghorn calculi or

complex stones, e.g. above ureteric stricture.

Prevention of recurrence

• Increase oral ﬂ uid intake and reduce calcium intake.

• Correct metabolic abnormalities.

• Treat infection promptly.

• Urinary alkalization, e.g. sodium bicarbonate 5–10g/24h PO in water

(mainly for cystine and urate stones).

• Thiazide diuretics (for idiopathic hypercalciuria).

CHAPTER 10 Urology

360

Obstruction of the ureter

(See Fig. 10.1)

Key facts

Ureteric obstruction leads to hydronephrosis (ureteric and

pelvicalyceal dilatation).

Pathological features Hydronephrosis can be unilateral or bilateral.

Unilateral

• Extramural.

Aberrant vessels at the PUJ.•

Extrinsic tumour. Carcinoma of the cervix, prostate, large bowel, or •

retroperitoneal endometriosis.

Idiopathic retroperitoneal ﬁ brosis.•

Post-radiation ﬁ brosis.•

Retrocaval ureter.•

Abdominal aortic aneurysm.•

• Intramural.

Transitional cell carcinoma of the renal pelvis or ureter.•

Urinary calculi.•

Ureteric stricture.•

Aperistaltic segment. Almost always congenital.•

Bilateral

• All causes of unilateral obstruction may cause bilateral hydronephrosis.

• Congenital posterior urethral valve.

• Congenital or acquired urethral stricture.

• Benign enlargement of the prostate.

• Locally advanced prostate cancer.

• Large bladder tumours.

• Gravid uterus.

Clinical features

• Loin pain.

• Fever and/or rigors (if complicated by infection).

• Symptoms and signs of renal failure (if obstruction longstanding).

Investigation and diagnosis

• Serum biochemistry and haematology.

• MSU.

• KUB X-ray/IVU.

• Ultrasound scan and/or CT scan.

• Isotope renogram.

• Retrograde pyelogram.

Complications

• Infection, pyonephrosis.

• Hypertension.

• Renal failure.

OBSTRUCTION OF THE URETER

361

Treatment

3 Emergency presentation

• Emergency treatment is indicated if there are signs of infection,

established renal failure, uncontrollable symptoms.

• Treatment is drainage of the kidney via a percutaneous nephrostomy

or retrograde ureteric stent.

Elective presentation

• Deﬁ nitive treatment is directed at the underlying cause. Possible

interventions include:

Treatments of calculi (see • b p. 358).

Ureteric stenting (unilateral or bilateral).•

Ureterolysis and ureteric transfer (for retroperitoneal ﬁ brosis).•

Prostatic resection.•

Bladder drainage using a urethral or suprapubic catheter.•

• In cases where renal function cannot be restored, a nephrectomy is

performed to avoid infective complications.

1. Pelviureteric junction

2. Mid ureter (lower retroperitoneum

and pelvic brim)

3. Vesicoureteric junction

4. Bladder neck

Fig. 10.1 Commonest sites of renal stone impaction. 1, pelviureteric junction;

2, pelvic brim; 3, vesicoureteric junction.

CHAPTER 10 Urology

362

Benign prostatic hyperplasia

Key facts

• Benign prostatic hyperplasia (BPH) is a non-malignant enlargement of

the prostate gland. There is an increase in both stromal and glandular

components.

• Incidence of BPH is about 25% in age 40–60y, 40% in over 60s.

• Commonest cause of lower urinary tract symptoms (LUTS) in

middle-aged and elderly men.

Pathological features

Aetiology is largely unknown. Possible factors include:

• Androgens. No BPH in those who have had early castration.

• Oestrogens. Increased oestrogen:testosterone ratio with age.

• Growth factors, e.g. high concentration of TGFA in BPH.

Clinical features

Symptoms

• Storage symptoms, such as frequency, urgency, nocturia, and

incontinence.

• Voiding symptoms, including hesitancy, poor stream, intermittency,

terminal dribble, and abdominal straining.

• Superimposed infection may cause dysuria and haematuria.

• Incomplete emptying and chronic or acute retention of urine.

Signs

• Smooth enlargement of the prostate detected by digital rectal

examination.

• Possible palpable bladder if chronic retention.

• Always examine for neurological signs in those with LUTS.

Complications of BPH

• Intractable LUTS.

• Haematuria.

• UTI.

• Stone formation.

• Acute retention of urine.

• Chronic retention of urine.

• Overﬂ ow incontinence.

• Obstructive renal failure.

Diagnosis and investigations

• Prostate symptom score to assess severity.

• Digital rectal examination and serum PSA measurement to assess for

features of malignancy.

Basic investigations

• Serum creatinine, urinalysis in all patients.

• Urine ﬂ owmetry and residual volume estimation in those considered

for intervention.

BENIGN PROSTATIC HYPERPLASIA

363

Advanced investigations

• Cystoscopy. To exclude bladder disease.

• Transrectal ultrasound 9 guided biopsy. If concern over underlying

malignancy.

• Renal ultrasound, invasive urodynamic studies.

Treatment

Recommended for those with LUTS that are impacting on quality of life or

those with complications.

Medical treatment

• Patients with mild symptoms and no complications may be observed

(watchful waiting).

• A-adrenergic antagonists. Relax smooth muscle of prostatic urethra

to decrease outlet resistance; side effects include dizziness and

hypotension (especially postural).

• 5A-reductase inhibitors. Block conversion of testosterone to

dihydrotestosterone (DHT) and shown to cause involution of BPH;

side effects include loss of libido and erectile dysfunction.

• Combination drug therapy with both the above agents. May reduce

the clinical progression and decrease the need for surgery.

Surgical treatment

• Reserved for those with any of the complications or symptoms not

responding to medical therapy.

• Surgical options include:

Transurethral resection of the prostate (TURP), the most •

commonly performed procedure for BPH in the UK.

Open retropubic prostatectomy.•

Transurethral incision in the prostate (TUIP).•

Bladder neck incision.•

Laser ‘prostatectomy’.•

Microwave thermotherapy ablation of the prostate.•

Key revision points—anatomy of the prostate

• Three glandular zones:

Peripheral (70%), most prone to carcinoma formation.•

Central (25%), most prone to BPH.•

Transitional (5%), most prone to BPH.•

• Blood supply:

Arterial supply is triple, mainly inferior vesical, some from inferior •

rectal and internal pudendal.

Venous drainage, extensive plexus beneath capsule.•

• Innervation:

Autonomic, extensive from inferior hypogastric plexus as a •

capsular plexus supplying prostate, seminal vesicles, and urethra,

which also supplies the penile structures (glands, corpora, and

urethra).

Somatic, from pudendal nerve (S2, 3, 4) to supply external •

urethral sphincter.

CHAPTER 10 Urology

364

Stricture of the urethra

Key facts

• Classiﬁ ed according to site and aetiology, e.g. post-inﬂ ammatory

bulbar stricture or traumatic membranous stricture.

• Graded according to length and (in the anterior urethra) degree of

ﬁ brosis of corpus spongiosum (spongioﬁ brosis).

• Any part of the urethra may be involved.

• The propensity for stricture recurrence parallels the severity (grade).

Aetiology

• Trauma.

Pelvic fracture.•

Falls astride, e.g. on bicycle crossbar.•

Urinary tract instrumentation/surgery.•

• Infection.

Neisseria gonorrhoea • and Chlamydia trachomatis.

Catheter-associated UTI.•

• Lichen sclerosis et atrophicus.

Pathological features

• Annular narrowing by scar tissue composed of dense collagen and

ﬁ broblasts, which may extend into corpus spongiosum.

• Lichen sclerosus (balanitis xerotica obliterans (BXO)) consists of

dermal sclerosis with epidermal atrophy; urethral lesions are usually

conﬁ ned to the meatus and fossa navicularis.

Clinical features

• History of urethritis, trauma, or urinary tract instrumentation.

• LUTS, divergent or diminished stream, straining to void, urgency,

frequency.

• Haematuria (‘initial’ or ‘terminal’, i.e. at the beginning or end of the

stream).

• UTI (often recurrent).

• Urinary retention, acute or chronic.

• Overﬂ ow incontinence.

Complications

• Urinary tract calculi formation.

• Infection, including UTI, prostatitis, epididymitis, and (rarely) Fournier’s

necrotizing fasciitis.

• Renal failure secondary to chronic obstruction.

Diagnosis and investigations

• Urinalysis (microbiology, biochemistry, and cytology).

• U&E.

• Uroﬂ owmetry and measurement of post-void residual bladder volume.

• Voiding cystourethrogram with or without retrograde urethrogram.

• Endoscopy.

STRICTURE OF THE URETHRA

365

• Ultrasound scan (transperineal or endoluminal) to assess extent of

spongioﬁ brosis.

• Magnetic resonance tomography.

Treatment

Initial

• Treat infection before surgical treatment.

• For acute urinary retention, severe symptoms, or renal failure,

temporary suprapubic catheterization.

Deﬁ nitive

• All urethral reconstructive surgery has an ‘attrition rate’.

• Initial internal urethrotomy may cure up to 30%, but repeat

procedures are rarely successful and may cause progression.

• Urethroplasty may be used for some cases.

Short strictures are excised and the urethra primarily •

re-anastomosed.

For longer or complex strictures, pedicled ﬂ ap reconstruction or •

graft reconstruction is used; the graft or ﬂ ap may be applied as an

onlay (to augment the native urethra) or as a tube.

For free grafts, buccal mucosa is currently favoured.•

More complicated repairs are best managed with staged repairs.•

• Perineal urethrostomy may be required.

CHAPTER 10 Urology

366

Scrotal swellings

Major causes

Intratesticular lesions

• Malignant testicular tumours.

• Benign intratesticular lesions. Simple intratesticular cyst or epidermoid

cysts and benign teratoma (especially in the prepubertal testis).

Inﬂ ammatory lesions

• Acute epididymo-orchitis or viral orchitis.

• Chronic tuberculous epididymo-orchitis, schistosomal epididymitis,

sperm granuloma.

Traumatic lesions

• Scrotal haematoma.

• Haematocele (haematoma within tunica vaginalis).

• Testicular haematoma (within tunica albuginea testis).

Derangement of testicular, adnexal, or cord anatomy

• Epididymal cysts or spermatocele of the epididymis.

• Varicocele (varicosities of the pampiniform plexus).

• Inguinal hernia (patent processus vaginalis in children).

• Hydrocele (vagina = within tunica vaginalis or cordal).

• Late (missed) or prenatal torsion of the spermatic cord.

• Persistence of embryological vestigial structures.

Müllerian duct remnant (appendix testis).•

Wolfﬁ an duct remnants (appendix epididymis, vas aberrans of •

Haller, paradidymis).

Miscellaneous

• Acute idiopathic scrotal oedema.

• Cutaneous lesions, e.g. sebaceous cysts.

• Henoch–Schönlein purpura.

Clinical features/diagnosis

• 2 Testicular tumours:

Firm intratesticular or progressively enlarging lesions are tumours •

until proven otherwise.

Do not be misled by painful testicular swelling following relatively •

trivial trauma; tumours may present this way.

• Tuberculous epididymitis may occur with or without evidence of

pulmonary, systemic, or other genitourinary involvement.

• Hydroceles, patent processus vaginalis, and large spermatoceles are

transilluminable, may be ﬂ uctuant, and are usually conﬁ ned to the

scrotum.

• Varicocele. Often associated with subfertility or dragging discomfort

that worsens on standing and settles when recumbent. More obvious

as a ﬂ uctuant swelling with the patient standing. A cough impulse may

be felt. Ipsilateral testis may be atrophied. Examine the abdomen to

exclude an associated renal tumour.

SCROTAL SWELLINGS

367

• Inguinal hernias tend to be intermittent, associated with groin

discomfort, and when ‘out’, the examining hand cannot ‘get above’

the swelling in the cord/inguinal canal. A history of longstanding

enlargement is typical.

Investigations

• Urinalysis for M,C,&S.

• Blood tests. Consider tumour markers (AFP, β-HCG), inﬂ ammatory

markers (CRP, WCC).

• Ultrasound scanning of the scrotal contents has several important uses.

Distinguishes intratesticular from paratesticular swellings, solid from •

cystic lesions, cellulitis from abscess, etc.

Can examine impalpable testes, e.g. within large hydroceles.•

Can identify rupture of the tunica albuginea testis.•

Examination of the abdomen can identify renal mass associated with •

varicocele or ascites with hydrocele/scrotal oedema, etc.

Colour ﬂ ow Doppler ultrasound can identify hyperaemia, •

underperfusion, and varicocele.

Treatment

Testicular tumours, acute epididymo-orchitis (see b pp. 382, 388).

• Suspected paratesticular tumours are approached surgically in the

same way as testis tumours. Surgery may be conservative with benign

testicular and paratesticular tumours.

• Sperm granuloma may be excised or epididymectomy may be

performed. Reassurance may be all that is required in many cases.

Recurrence rates after surgery are high.

• Epididymal cysts/spermatocele may be aspirated, but recurrence is

common. Excision risks loss of epididymal patency, is associated with

risk of recurrence, and should probably be discouraged in men who

have not completed their family.

• Hydroceles. Treat if symptomatic. Procedures usually reconﬁ gure the

serosal remnant of tunica vaginalis so as to allow lymphatic drainage

via scrotal lymphatics. Reduction, inversion (Jaboulay), or imbrication

(Lord’s) of the tunica vaginalis is used.

• Embryological remnants. No treatment if asymptomatic.

• Varicocele. Treat if symptomatic, associated with infertility, or with

failure of testicular growth. Venous embolization and retroperitoneal

ligation (laparoscopic or open) of the testicular vein have similar

results. Minimally invasive treatments are preferable. Gubernacular

veins and other collaterals may account for failures. Open surgical

ligations via an inguinal incision can deal with these.

• Acute idiopathic penoscrotal oedema of childhood usually settles with

conservative treatment. Antihistamines and antibiotics are frequently

prescribed, but there is little evidence to support this.

CHAPTER 10 Urology

368

Disorders of the foreskin

Phimosis (see Fig. 10.2a)

Key facts

• Narrowness of the preputial opening, preventing retraction and

exposure of the glans.

• May be physiological in infants and young children and will resolve.

• Pathological phimosis is secondary to scarring such as BXO or

following monilial balanoposthitis.

• Pathological phimosis may be associated with discomfort, UTI,

balanoposthitis, and (perhaps) carcinogenesis.

Clinical features

• In childhood, physiological phimosis may be identiﬁ ed by absence of

scarring of the preputial tip and by pouting of the inner layer of the

prepuce when a gentle attempt is made to retract it.

• A whitish sclerotic preputial tip and no pouting characterize BXO.

• Parents may complain of ballooning of their child’s foreskin or of

recurrent balanoposthitis. In adults, the diagnosis is obvious.

Treatment

• Physiological phimosis needs no treatment.

• Early BXO may be treated by application of topical steroid cream.

• Surgical treatment of phimosis includes circumcision and dorsal slit.

Paraphimosis (see Fig. 10.2b)

Key facts/diagnosis

• The retracted foreskin acts as a constricting ring, reducing lymphatic

and venous drainage of tissues distal to the ring (glans, inner layer of

foreskin). Subsequent oedema makes reduction more difﬁ cult.

• Involved tissues typically appear odematous and inﬂ amed with

progression to infection, ulceration, and necrosis if left untreated. Can

occur in normal penises.

3 Treatment

• Early cases. Gentle manual compression of the oedematous tissues

within a saline-soaked swab will allow reduction of the foreskin after a

few minutes without anaesthesia.

• Established cases. LA penile block or anaesthesia may be necessary.

Hyaluronidase can be injected under the constriction.

• Neglected/severe cases. A relaxing dorsal incision may be made through

the constriction and the tissues immediately proximal and distal to it.

Subsequent circumcision is often offered.

DISORDERS OF THE FORESKIN

369

Paraphimosis

Phimosis

(a)

(b)

Manual reduction of

paraphimosis by counter

pressure between

thumbs and fingers

Fig. 10.2 (a) Phimosis. (b) Reduction of an acute paraphimosis.

CHAPTER 10 Urology

370

Common conditions of the penis

Peyronie’s disease

Key facts

• Damage to tunica albuginea penis, forming inelastic penile plaques

mostly in the dorsal midline, causing local pain and deformity.

• Associated with Dupuytren’s contractures, plantar fascial contractures,

and tympanosclerosis.

• One-third of patients have erectile dysfunction.

Clinical features

History and examination

• Gradual or sudden development of palpable penile plaques with

painful distortion of the erect penis in two-thirds of patients.

• Occasional history of penile trauma, urethral instrumentation.

• Erectile dysfunction may involve the whole or part of the penis.

• Pain usually resolves, but deformity does not.

• Penetrative sexual intercourse may be more difﬁ cult or impossible

because of pain, angulation, or buckling.

• The plaque is palpable with the ﬂ accid penis stretched.

• Erection is induced pharmacologically and a photo record kept.

Investigations Plain ﬁ lm soft tissue radiography or grey-scale ultrasound

may demonstrate calciﬁ cation, an indicator of plaque maturity.

Treatment

Medical

Indicated for those able to engage in intercourse and whose disease is

still evolving.

• Oral treatment options. Colchicine, vitamin E, or Potaba

• Intralesional injections. Verapamil or collagenase (investigational).

• Treatment of associated erectile dysfunction.

Surgical

Indicated for those with stable lesions, severe deformity.

• Plication techniques. Plication of the tunica opposite the deforming

plaque.

• Grafting techniques. The plaque is excised and the defect grafted.

• Prosthesis insertion within corpora cavernosa. Generally reserved for

patients with severe erectile dysfunction refractory to medical therapy.

Priapism

Key facts Abnormally sustained erection unrelated to sexual stimulation. It

is classiﬁ ed as high ﬂ ow (arterial) or low ﬂ ow (veno-occlusive).

Low ﬂ ow priapism

• Congestion secondarily reduces arterial blood ﬂ ow, leading to local

hypoxia, acidosis, and hypercapnoea.

• Causes include:

Drugs • (intracavernosal prostaglandin and papaverine, psychotropics,

e.g. trazodone, chlorpromazine).

COMMON CONDITIONS OF THE PENIS

371

Abnormal blood viscosity (sickle cell, myeloma, leukaemia, •

thalassaemia, total parenteral nutrition).

Neurological disease, e.g. spinal or cerebrovascular disease.•

Miscellaneous, e.g. inﬁ ltration by solid tumour.•

• Characterized by painful persistent erection, not involving the glans

and corpus spongiosum.

High ﬂ ow priapism

• Most commonly follows blunt trauma to penis or perineum, but has

been caused by intracavernosal injection or revascularization.

• The mechanism is arterio-cavernosal ﬁ stula with unregulated arterial

inﬂ ow and increased venous outﬂ ow.

• Characterized by partial, painless swelling of the glans and corpus

spongiosum.

Investigation

• Colour Doppler ultrasonography or cavernosal blood gases.

• pH <7.25, pO

<30mmHg, pCO

>60mmHg suggest low ﬂ ow.

• FBC and differentials; Hb electrophoresis.

Treatment—low ﬂ ow

• Correct underlying abnormalities, e.g. sickle cell (rehydration, O

transfusion), myeloma (plasmapheresis).

• Oral B-agonists, e.g. terbutaline 5mg + further 5mg 15min later.

• Intracavernosal phenylephrine.

• Corpora cavernosa aspiration (up to 50mL) + manual pressure.

• Surgical techniques augment venous drainage of the corpora

cavernosa.

Treatment—high ﬂ ow

Selective pudendal arteriography and embolization.

CHAPTER 10 Urology

372

Erectile dysfunction

Key facts

• Erectile dysfunction (ED) is the inability to achieve or maintain an

erection satisfactory for sexual intercourse.

• Distinct from premature, retrograde, or delayed ejaculation.

• Causes include:

Psychogenic. • Anxiety, depression.

Drugs.• Antihypertensives, recreational drugs, tobacco, alcohol.

Vascular. • Hypercholesterolaemia, atheroma, diabetes mellitus (DM).

Metabolic/endrocrine. • Azotaemia, hypercholesterolaemia,

hypogonadism, hyperthyroidism, hyperprolactinaemia, DM.

Neurological.• Parkinson’s disease, CVA, spinal injury, neurological

damage following pelvic surgery, pelvic fracture, autonomic

neuropathies.

Penile. • Cavernositis, Peyronie’s disease, previous priapism.

Clinical features

• Speciﬁ c validated questionnaires have been developed as

investigational tools and can be used in practice.

• The presence of morning erections strongly suggests psychogenic

cause.

• Small testicles, lack of secondary sexual characteristics suggest an

endocrine cause.

• Lack of lower limb pulses suggests possible vascular cause.

• Neurological deﬁ cits in S2, 3, 4 distributions suggest neurological

cause.

Investigations and diagnosis

• Check blood glucose, lipids and serum electrolytes, hormone proﬁ les

(testosterone, FSH/LH, prolactin), thyroid function for underlying

cause.

• Dynamic cavernosometry conﬁ rms if there is a true vasculogenic cause

(venous or arterial).

• Angiography demonstrates arterial anatomy if revascularization is

contemplated.

Treatment

• Psychotherapy or specialist sexual counselling for psychogenic causes.

• Oral phosphodiesterase-5 inhibitors—sildenaﬁ l (Viagra

), vardenaﬁ l,

tadalaﬁ l.

• Apomorphine sublingual.

• Intracavernosal—prostaglandins, A-blockers, papaverine.

• Intraurethral—prostaglandin.

• Vacuum devices-induced pseudoerection.

• Prosthesis.

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CHAPTER 10 Urology

374

Adenocarcinoma of the kidney

Key facts

• Accounts for 2% of all cancers.

• Incidence is 2–5 per 100 population.

• ♂:♀, 3:1.

Clinical features

• May be asymptomatic at presentation, the tumour being detected

during imaging of the abdomen for an unrelated condition (e.g. CT

scan or ultrasound scan).

• Symptoms include painless haematuria, groin pain, awareness of a mass

arising from the ﬂ ank.

• Chest symptoms and bone pain may be present with metastases to

these sites.

• Positive family history or clinical evidence of neurological or ocular

disease should raise the possibility of von Hippel–Lindau disease (VHL).

• Renal carcinomas are often small and may be multiple.

• Local spread often includes spread via intravascular invasion into the

renal vein and inferior vena cava.

Diagnosis and investigations

• Blood tests. Hb and ferritin to check for anaemia (iron-deﬁ cient);

electrolytes and Cr to check for overall renal function. Raised

corrected calcium and alkaline phosphatase suggest possible bony

metastases.

• Diagnostic and staging investigation of choice is a pre- and post-IV

contrast-enhanced CT scan of abdomen and chest (delineates size,

local extent, local invasion, likely sites of possible metastases).

• Isotope bone scan if there is clinical or biochemical evidence of bony

metastases.

Treatment

Surgery

• Recommended as the only curative treatment except in the very

elderly, extensive (inoperable) local invasion, and the presence of

metastases.

• May be via open or laparoscopic approach.

• Radical nephrectomy is recommended for large tumours.

• Partial nephrectomy may be suitable for peripheral tumours <4cm in size.

• Resection of the primary cancer is occasionally appropriate with

the presence of metastasis (the deposit must be solitary and itself

amenable to complete local resection, e.g. in the liver or lungs).

Medical therapy

• Used for metastatic disease.

• Biological therapy can be with immune modulators such as interferons

and interleukins. Partial response rates of 15–20% can be achieved, but

the treatment carries signiﬁ cant morbidity. This is reserved for patients

with a good performance status.

375

ADENOCARCINOMA OF THE KIDNEY

• Chemotherapy is rarely used as the tumours are not chemosensitive.

• Hormonal therapy (androgens and tamoxifen) may have some beneﬁ t.

• Radiotherapy is useful to palliate painful bony metastases.

Prognosis

• The outcome following nephrectomy is unpredictable.

• Tumours that are pathologically conﬁ ned to the kidney confer a good

prognosis. Adverse risk factors include extracapsular spread, invasion

of the renal vein, lymph node involvement.

• Cure is likely if the tumour is <4cm in diameter and if there are no

adverse pathological features.

• Periodic radiological follow-up is recommended in most cases so that

locally recurrent or metastatic disease can be detected at an early

stage.

Key revision points—anatomy of the kidney

Usually ﬁ ve segments (apical, anterior superior, anterior inferior, poste-

rior and inferior), each supplied by its own artery.

- Fascial coverings.

Perirenal, anterior and posterior layers, enclosing kidney and

perirenal fat.

Lateral conal fascia, formed from anterior and posterior perirenal

fascia; fused with transversalis and iliac fascia laterally.

- Blood supply.

Arterial supply, direct from the aorta; renal arteries also give

supply to the renal pelvis and upper ureter and adrenal gland.

Venous drainage, direct to inferior vena cava; left renal vein also

drains the left gonadal vein.

- Common anatomical variants.

Unilaterally absent kidney (1 in 1200).

Pelvic kidney (1 in 2500).-

Joined (horseshoe) kidney (1 in 400).-

CHAPTER 10 Urology

376

Transitional cell tumours

Key facts

• Transitional cell tumours (TCT) may affect any part of the urinary

epithelium (renal pelvis, ureter, bladder, or very rarely, urethra).

• TCT have a spectrum of disease from benign superﬁ cial ‘papilliferous’

growths to frankly invasive transitional cell carcinoma (TCC);

progression may occur from benign to more malignant forms with

time.

• TCC of the bladder. Fifth commonest cause of cancer deaths and the

commonest form of bladder cancer in the UK; ♂:♀,, 3:1.

• TCC of the upper urinary tract is similar in spectrum of disease and

management to bladder tumours, but much less common.

• TCT is associated with:

Exposure to aromatic hydrocarbons, e.g. workers in the •

petrochemical, industrial dye, rubber industries, chimney sweeps.

Smoking (especially in women).•

• Risk is probably due to excretion of carcinogenic products excreted

and concentrated in the urine and tumours are more likely in locations

exposed to urine for the longest periods, i.e. bladder.

Pathological features

• The majority (70%) are superﬁ cial in nature at diagnosis, being

conﬁ ned to the mucosa.

• Invasion into the lamina propria, muscle, and perivesical fat can occur

with lymphatic and distant spread occurring in advanced cases.

• TCC in situ is pre-invasive and associated with a high risk of muscle-

invasive disease if not adequately treated.

• TCC must be differentiated from other forms of bladder cancer.

Squamous cell carcinoma. • Usually caused by chronic irritation due to

schistosomiasis infestation (bilharzia), indwelling catheter, repeated

previous surgical interventions.

Adenocarcinoma. • Rare; presents in middle age and is usually located

in the dome of the bladder in association with the urachus.

Clinical features

• The majority of cases present with painless haematuria.

• Other features are painful micturition, renal colic due to blood clot,

disturbance of urinary stream, retention of urine.

Diagnosis and investigation

Urine cytology May reveal malignant cells; if there are malignant cells, TCC

or carcinoma in situ will probably be present.

Cystoscopy

• Usually carried out using a ﬁ bre optic ﬂ exible cystoscope and local

anaesthetic gel.

• Images the bladder and urethra; suspect lesions usually require

transurethral resection under GA for diagnosis.

TRANSITIONAL CELL TUMOURS

377

Transurethral resection

• Usually carried out using a rigid endoresectoscope under GA.

• Permits resection of all or part of the tumour using a diathermy ‘loop’,

with the tumour resected piecemeal; resection may be carried out into

deep tissue (the muscle wall of the bladder beneath the tumour).

• Subsequent pathological examination will determine the histological

grade and the pathological stage, e.g. depth of invasion.

• Following resection, bimanual examination determines whether or not

a residual mass is present.

Upper tract imaging

• Used to identify and assess pelviureteric tumours.

• IVU or ultrasound scan.

• Ultrasound scan permits examination of the renal cortex and will

detect tumours of 1cm diameter in the pelvicalyceal system, ureter,

and bladder.

• Bladder tumour may show as a ﬁ lling defect in the cystogram phase.

Local staging MRI and CT scanning to detect local or systemic spread.

Treatment

Superﬁ cial TCT

• Remove; completed by endoscopic resection.

• Recurrence is common and regular endoscopic surveillance with check

cystoscopy is performed.

• Intravesical chemotherapy reduces the risk of tumour recurrence

(single dose of mitomycin C instilled after resection of the tumour).

• For multiple or recurrent TCC, six intravesical treatments are given.

Carcinoma in situ

• Requires thorough therapy to prevent invasive TCC.

• Immunotherapy with intravesical BCG is effective in 60% of cases.

• Needs close endoscopic surveillance with regular bladder biopsy.

Invasive TCC

• Muscle-invasive tumours are of high grade and the prognosis is poor.

• Curative therapy can be offered with radical cystectomy (combined

with a urinary diversion via an ileal conduit) or radical radiotherapy.

Squamous cell and adenocarcinoma

• Radical cystectomy provided general condition allows.

• Usually resistant to radiotherapy and chemotherapy.

Prognosis

• Approximately 30% develop muscle-invasive disease.

• The 5y survival rate for muscle-invasive bladder cancer is 40–50%.

• Metastatic TCC is poor prognosis with a median survival of 13 months.

• Systemic chemotherapy with cis-platinum-containing regimes provides

a long-term response in 15% of cases.

CHAPTER 10 Urology

378

Adenocarcinoma of the prostate

Key facts

• Most commonly diagnosed cancer affecting men in the western world.

• Approximately 30 000 new cases diagnosed annually in the UK with

10 000 deaths.

• Peak incidence in eighth decade.

• Approximately 40% of cases present with early disease; 20% of cases

have metastases at presentation.

Clinical features

• The majority of men present with LUTS (b p. 354).

• Bone pain, pathological factures, and features of hypercalcaemia are

occasional presenting features due to metastases.

• May be diagnosed by digital rectal examination; areas of ﬁ rmness or

palpable nodules are suggestive of malignant change.

Diagnosis and investigations

• Serum PSA. Can be used as a screening test; high sensitivity, but low

speciﬁ city; elevated age-speciﬁ c levels are an indication to consider

prostate biopsy.

• Transrectal ultrasound (TRUS). Permits detailed imaging of the prostate.

Systematic needle biopsy is performed guided by the ultrasound

images with antibiotic prophylaxis; graded using the Gleason grading

system which assigns a numerical score to adverse features from a

minimum of 2 to a maximum of 10.

• Pelvic MRI. Used to detect the presence of extracapsular extension or

the presence of pelvic lymphadenopathy (suggests spread).

• Laparoscopic node biopsy. May be performed to sample enlarged nodes

prior to considering radical treatment.

• Isotope bone scan. Will detect the presence of bone metastases.

Treatment

Localized disease (conﬁ ned to prostate)

Patients with a life expectancy of <10y

• Active monitoring with treatment deferred until there is evidence of

disease progression (rising serum PSA).

• Hormonal therapy or A-blocker treatment offered for troublesome

LUTS.

• TURP is considered for severe symptoms with features of obstruction.

Life expectancy of >10y

• Counselled in detail about radical treatment aimed at cure.

• The options are as follows:

Radical prostatectomy• . Operation to remove the prostate and

seminal vesicles; complications include incontinence (severe in 3%)

and ED (40–50% of cases).

External beam radiotherapy• . Radiation is delivered at a radical

dose of 55–70Gy in 20–25 fractions over a 4–5-week period;

complications include cystitis, proctitis, and ED.

ADENOCARCINOMA OF THE PROSTATE

379

Brachytherapy• . Radioactive seeds placed into the prostate using

TRUS guidance; a relatively new technique and long-term follow-up

data are lacking.

Locally advanced disease (spread beyond the prostate)

• Incurable and treatment is therefore palliative.

• Eighty per cent are androgen-dependent. Hormone therapy reduces

androgenic drive to the prostate cancer cell using two methods:

Luteinizing hormone• -releasing hormone (LHRH) agonists. Given by

3-monthly depot injections, suppresses testosterone production by

the testes; side effects include hot ﬂ ushes, lethargy, loss of sexual

function.

Anti-androgens• . Given orally, act as competitive inhibitors at the

level of the androgen receptor, reduce androgenic stimulus to the

prostate cancer cell without reducing serum testosterone levels;

side effects include gynaecomastia and nipple tenderness (60%),

potency is sometimes preserved.

Metastatic disease

Treated with hormonal therapy using LHRH analogues. Addition of an

anti-androgen provides a secondary response in some cases of PSA

relapse. Pain from bone metastases usually responds to radiotherapy.

Hormone-resistant disease

• All prostate cancers will eventually become hormone-resistant.

• Chemotherapy is appropriate for patients who have a good

performance status.

• Palliative radiotherapy and bisphosphonates are used for bony

metastases.

Prognosis

• Localized prostate cancer. Excellent prognosis with 70–90% 10y

disease-speciﬁ c survival ﬁ gures.

• Locally advanced, non-metastatic disease. Median survival of 7y.

• Metastatic disease. Median survival of 2–3y.

• Once the state of hormone-resistant disease has been reached, the

median survival is 6–12 months.

CHAPTER 10 Urology

380

Carcinoma of the penis

Key facts

• Rarest of the urological cancers.

• Occurs primarily in older men.

Clinicopathological features

• Over 95% are squamous cell carcinoma.

• Usually affects the glans, but may involve the shaft.

• Associated with chronic infection of the penis, particularly in the

presence of phimosis.

• Early cases present with a painless ulcer, nodule, or ‘warty’ outgrowth

on the penis that may also involve the foreskin.

• Advanced disease presents with a fungating mass, usually ulcerated.

Inguinal lymphadenopathy may be present on examination. Nodes are

often reactive rather than being metastatic and antibiotics should be

given prior to further assessment.

Diagnosis and investigations

• Biopsy lesion to conﬁ rm the diagnosis.

• Pelvic and abdominal CT scanning provide further evidence of nodular

involvement in cases with positive inguinal nodes.

Treatment

• If primary tumour conﬁ ned to glans, treatment involves either partial

amputation or radiotherapy.

• Superﬁ cial lesions can be treated by excision of the glans followed by

glans reconstruction.

• More advanced carcinomas require total penectomy. Inguinal and iliac

lymph node dissections are considered.

Prognosis

• Early stage penile cancer has a high cure rate with either surgery or

radiotherapy.

• Long-term survival is sometimes seen even in cases of lymph node

involvement.

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CHAPTER 10 Urology

382

Testicular tumours

Key facts

• Commonest malignancy in men between the ages of 18 and 40.

• Annual incidence 6 per 100 000 males per year.

• Associated with testicular maldescent.

• Increased risk is associated with higher levels of exogenous oestrogens,

either prenatally or in childhood.

• Increased level of awareness has led to more tumours being detected

on self-examination, particularly amongst younger men.

Pathological features

• Common types are seminoma and non-seminomatous germ cell

tumours (NSGCT; previously called ‘teratoma’). Lymphoma is a rare

testicular tumour.

• Seminoma.

Peak incidence 30–40y.•

Lymphatic spread more common than haematogenous.•

Lymphatic spreads to iliac and para-aortic nodes.•

• NSGCTs.

Peak incidence 20–30y.•

Haematogeneous spread most common to lungs, brain, and liver.•

• Lymphomas. Peak incidence over 60y.

• Marsden staging (after investigations and treatment).

Stage 1, conﬁ ned to testis.•

Stage 2, abdominal nodal spread.•

Stage 3, nodal disease outside the abdomen.•

Stage 4, extralymphatic spread.•

Clinical features

• The usual presentation is with a painless testicular mass.

• Typical features are irregular, ﬁ rm, ﬁ xed, and does not transilluminate.

• Palpate the abdomen for intra-abdominal masses (either para-aortic

node masses or hepatomegaly).

• Check for supraclavicular lymphadenopathy and signs of lung or

neurological disease.

Diagnosis and investigation

2 Any clinically suspicious mass requires urgent testicular ultrasound scan.

Typical features are a non-homogeneous mass with increased vascularity.

• Serum tumour markers, B-HCG and AFP. Increased levels suggest

metastatic disease in NSGCTs, but may be normal in localized or

metastatic disease; very rarely elevated in seminoma even if metastatic.

• CT scan of abdomen and chest. To assess presence of metastases.

• CT brain, bone scan. Only if clinically indicated.

TESTICULAR TUMOURS

383

Treatment

• Orchidectomy is carried out at the earliest opportunity; this is

performed via an inguinal approach so that the spermatic cord can be

clamped prior to mobilization of testis.

• Seminoma is radiosensitive and even widespread local disease

responds well to radiotherapy.

Stage• 1. May be treated by orchidectomy only, orchidectomy +

prophylactic iliac and para-aortic radiotherapy, or orchidectomy +

prophylactic chemotherapy.

Stages 2/3/4• . Orchidectomy + radiotherapy to involved node

groups 9 chemotherapy.

Visceral metastases are treated with a combination of •

chemotherapy and radiotherapy.

• NSGCT is chemosensitive and even widespread metastatic disease

responds well.

Stage 1• . Orchidectomy.

Stages 2/3/4• . Orchidectomy + chemotherapy; if lymphadenopathy is

still present following chemotherapy, a retroperitoneal lymph node

dissection is performed.

Prognosis

• Cure rates >95% for stage 1 tumours.

• Metastatic disease also has excellent long-time survival rates with

combination therapy.

CHAPTER 10 Urology

384384

Haematuria

Causes and features

May be microscopic or macroscopic.

• UTI. Commonest cause; usually associated with LUTS, particularly

cystitis.

• Renal stones. Often associated with pain (renal colic).

• Malignancy (TCT, renal adenocarcinoma, prostate adenocarcinoma).

Most likely to be macroscopic, often with few other acute symptoms.

• Post-interventional. For example, post-TURP, post-cystoscopy, post-

catheterization.

• Renal disease. For example, glomerulonephritis, vasculitis; usually

causes microscopic haematuria, is often asymptomatic, and rarely

presents as an emergency.

Complications

• Suprapubic colicky pain or acute retention of urine suggests clots in

the bladder/urethra.

• Cardiovascular collapse is rare.

Emergency management

Resuscitation

• Establish large calibre IV access if the bleed is large; give crystalloid

ﬂ uid up to 1000mL if tachycardic or hypotensive.

• Do not catheterize without seeking senior advice if there is any

suggestion of lower urinary tract pathology or post-interventional

bleeding.

• Irrigation (‘3-way’) catheters may be used to relieve acute symptoms

of clot colic or clot retention, but should be placed by experienced

staff.

• Send blood for FBC (Hb, WCC), U&E (Na, K), group and save,

clotting.

Establish a diagnosis

• Full clinical examination. Particularly check the prostate on PR exam.

• Ultrasound kidney. To identify renal tumours, cysts.

• Cystoscopy (usually rigid, may be ﬂ exible). To identify bladder tumours.

• CT scan abdomen. If renal tumour is suspected.

Early treatment

• Ensure all clotting abnormalities are corrected.

• Ensure ﬂ uid balance is correct; promote an active diuresis to prevent

clot formation and retention.

• Transfuse blood only if Hb <8g/dL or the patient is symptomatic or

high risk.

• Start antibiotics according to local protocol if infection is suspected

(before cultures are available).

HAEMATURIA

385385

Deﬁ nitive management

Transitional cell tumours Transurethral resection will control symptoms,

establish a diagnosis, and start treatment (see b p. 382).

Renal stones (see b p. 358)

• May pass spontaneously.

• May need endoscopic removal, lithotripsy, or percutaneous treatment.

Post-interventional Flexible cystoscopy may be required.

CHAPTER 10 Urology

386386

Acute urinary retention (AUR)

Causes and features

Deﬁ ned as a painful inability to pass urine.

Local causes

• Prostatic enlargement (BPH or carcinoma) (see b p. 362). Often

acute-on-chronic retention.

• Post-urological surgery, e.g. post-TURP, clot impaction.

• Bladder or urethral stone impaction.

• Pressure on bladder, e.g. late pregnancy, faecal impaction.

• UTI.

General causes

• Pharmacological, for example:

Anticholinergic side effects of many drugs.•

Anaesthetic drugs.•

Alcohol intoxication.•

A• -sympatheticomimetics.

• Post-non-urological surgery:

Precipitated by recent catheterization.•

Abdominal surgery with lower abdominal pain.•

Epidural or spinal anaesthesia.•

• Loss of normal neurological control:

Spinal injury (trauma, ‘slipped disc’, neurological disease).•

Epidural/spinal anaesthesia.•

Symptoms

• Suprapubic pain, inability to pass urine despite desire.

• May dribble urine in small volumes, especially if there is underlying

chronic retention.

• Palpable/percussible bladder strongly suggests pre-existing chronic

retention/lower urinary tract disease.

Signs

• Prostatic enlargement on PR examination.

• Check for signs of neurological disease.

Emergency management

Resuscitation

• Give analgesia (e.g. morphine 5–10mg IV); it will also help relaxation

and may aid spontaneous micturition.

• A warm bath may aid micturition in drug-induced retention.

• Catheterize if retention persists. 2 Seek senior advice before starting

if there are concerns about local pathology as a cause or if there is a

history of previous surgical instrumentation of the urethra.

• Suprapubic catheterization may be required for known or suspected

urethral disease or failed urethral catheterization (see b p. 210).

• Document initial urine volume passed after catheter inserted; large

volumes suggest underlying chronic retention.

ACUTE URINARY RETENTION (AUR)

387387

• Send urine for M,C,&S.

• Send blood for FBC (Hb, WCC), U&E (Na, K), Cr.

Establish a diagnosis

• Check medications, especially recent changes.

• Cystoscopy may be required.

• Review full clinical examination, including neurological ﬁ ndings and

rectal examination.

Early treatment

• Monitor renal function, especially if there is underlying chronic

retention; renal function may deteriorate even after relief of the

obstruction.

• Monitor ﬂ uid balance in ﬁ rst 48h if there is associated chronic

retention; a secondary diuresis may occur.

• Start antibiotics according to local protocols if there is evidence

of a UTI.

Deﬁ nitive management

Prostatic disease (see b p. 362)

• TURP may be required.

• A-blocker may enable successful trial of voiding.

CHAPTER 10 Urology

388388

Acute testicular pain

Causes and features

This is an acute emergency in men of childbearing age. Torsion of the

testicle must be dealt with immediately to preserve testicular function. It

is the commonest cause for referral for acute testicular pain.

Torsion of the testicle

Key facts

• Occurs due to anatomical variants in testicular anatomy, e.g. ‘bell

clapper’ testicle with pronounced meso-orchium allowing rotation

within the tunica vaginalis.

• Peak age of incidence 12–18y.

• Torsion initially causes venous obstruction, but with prolonged

increased venous pressure, arterial compression occurs and the

testicle rapidly develops irreversible ischaemia and necrosis.

• Testicular salvage depends on the degree of torsion and time spent

torted. Speed of presentation, diagnosis, and treatment are all

important. Torsion greater than 360* lasting longer than 24h results in

near universal complete or severe atrophy.

• Spermatogenic cells are more susceptible to ischaemia than Leydig

cells. Subfertility may occur even if the testicle is macroscopically

normal after treatment.

Features

• Sudden onset of moderate to severe, constant, unilateral scrotal pain,

often with nausea, vomiting, and abdominal pain.

• May have been preceding episodes of intermittent pain that suddenly

resolved.

• The testis is globally tender, high in the scrotum, may have a transverse

axis, and be slightly enlarged. If it is infarcted, scrotal wall oedema and

tenderness may be present. Absence of ipsilateral cremasteric reﬂ ex is

the most reliable sign.

Torsion of the testicular appendages

• Occurs in testicular appendix ‘hydatid of Morgagni’ or epididymal

appendages (e.g. cysts, ductal remnants).

• Similar features and symptoms to testicular torsion.

• The ‘blue dot sign’ is said to be pathognomonic when present.

• The testis and epididymis may be non-tender and the cremasteric

reﬂ ex should be preserved.

Acute epididymo-orchitis

• Peak incidences vary according to cause, ages 35y and >55y.

• Common organisms include Chlamydia trachomatis, Neisseria

gonorrhoea in the young (sexually-transmitted infections (STI)).

• Escherichia coli and Proteus occur in chronic bladder outﬂ ow

obstruction or urinary tract instrumentation.

• One-third of male adolescents with mumps develop orchitis, which is

unilateral in 80%; a third of these testes atrophy.

ACUTE TESTICULAR PAIN

389389

Features

• Gradual onset of pain (hours or days).

• Dysuria, urethral discharge, and pyrexia are common.

• Tenderness and induration are localized to the epididymis and

spermatic cord in epididymitis.

• Cremasteric reﬂ ex is preserved.

• Prehn’s sign (relief of pain with scrotal elevation).

Idiopathic scrotal oedema

• Often less painful and tender than appears.

• Swelling is mostly cutaneous and normal size and texture testicle may

be palpable with care.

Acute inguinal lymphadenopathy

• May occur secondary to lower limb, buttock, or perineal infections.

• Rarely part of systemic infection of lymphatic disorder.

Emergency management

Resuscitation Give analgesia (e.g. morphine 5–10mg IV).

Establish a diagnosis

3 Immediate surgical exploration is indicated for all cases where

the diagnosis of torsion is considered possible and the history is short (i.e.

testicular viability is still at issue).

• Testicular colour duplex ultrasound. May be used if immediately

available or where symptoms have been present for days and testicular

viability is unlikely if torted.

• Send MSU, urethral swab, chlamydia serology if suspected infection.

Deﬁ nitive management

If a torted testicle is found at surgery:

• A viable testicle is detorted and ﬁ xed.

• A clearly non-viable testicle is excised.

• The opposite testicle is ﬁ xed (orchidopexy) to prevent the opposite

side torting in future.

Torsion of testicular or epididymal appendage Excise appendage.

Epididymo-orchitis

• Suspected STI, e.g. ceftriaxone 250mg IM single dose, doxycycline

100mg PO bd 7 days.

• Suspected UTI-related—ciproﬂ oxacin 500mg PO bd 10–14 days.

• Scrotal elevation, local ice therapy, and oral NSAIDs may help.

• Abscess formation may require drainage or orchidectomy.

• Treatment of acute viral orchitis is symptomatic.

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391

Colorectal surgery

Ulcerative colitis 392

Crohn’s disease 394

Other forms of colitis 396

Colorectal polyps 398

Colorectal cancer 400

Restorative pelvic surgery 402

Minimally-invasive colorectal surgery 403

Diverticular disease of the colon 404

Rectal prolapse 406

Pilonidal sinus disease 408

Fistula-in-ano 410

Haemorrhoids 412

Acute anorectal pain 414

Acute rectal bleeding 416

Acute severe colitis 418

Post-operative anastomotic leakage 420

Chapter 11

CHAPTER 11 Colorectal surgery

392

Ulcerative colitis

Key facts

• An acute and chronic inﬂ ammatory disease originating in the colonic

columnar mucosa.

• Precise aetiology is unknown, but an environmental trigger combined

with a genetic predisposition (family history) are factors.

• Often precipitated by an apparent acute GI infection; peak age of

diagnosis is the late teens and twenties, but may present in late

adulthood.

• Commonest in white Anglo-Saxon Caucasians.

Pathological features

• Granular, hypervascular, and mildly oedematous mucosa with loss of

vascular pattern seen at endoscopy.

• Acute neutrophil inﬁ ltration of the colonic mucosa and submucosa;

mucosal crypt abscesses with goblet cell mucin depletion.

• With more severe inﬂ ammation, there are multiple aphthous ulcers,

which may become conﬂ uent with only islands of inﬂ amed mucosa and

granulation tissue remaining (‘pseudopolyposis’).

• Transmural inﬂ ammation may occur in severe disease secondary to the

widespread loss of mucosa and subsequent severe inﬂ ammation.

• Chronic ‘burnt-out’ disease leads to a pale, featureless, ahaustral

pattern to the colon.

• Disease tends to be present in the distal colon and rectum and spread

proximally with increasing extent of disease.

Clinical features

• Proctitis. Commonest presentation. Rectum ‘always’ involved unless

already on topical treatment. Symptoms of urgency and frequency of

defecation due to rectal irritability; bloody mucus mixed with loose

stools (frank bloody diarrhoea rare).

• Left-sided colitis. Disease up to the splenic ﬂ exure. Symptoms of rectal

irritation plus extensive bloody mucus in stools, often leading to

bloody diarrhoea; mild associated systemic features.

• Pancolitis. Disease involving the entire colon. May be associated with

mild secondary inﬂ ammation of the terminal ileum (‘backwash ileitis’).

Diarrhoea predominant feature; systemic features common (fever,

malaise, anorexia, tachycardia). May be associated with anaemia (due to

blood loss), hypoalbuminaemia, and hypokalaemia (due to mucus loss).

Diagnosis and investigations

Basic tests

i WCC and CRP; d Hb and albumin, especially during episodes of inﬂ am-

mation. AXR may show oedematous colonic mucosa (‘thumbprinting’),

but is unreliable for diagnosis or extent of disease. Proctosigmoidoscopy

usually shows erythematous, granular, or frankly ulcerated rectal mucosa

with mucus and blood. Biopsies should be taken before starting treatment.

Always send stool M,C,&S and test for parasites and cysts in any acute

presentation to exclude infectious causes.

ULCERATIVE COLITIS

393

Advanced tests

Extent of disease is best assessed with colonoscopy and biopsies; will also

usually exclude colonic Crohn’s disease.

Treatment

See b p. 418 for management of acute severe colitis.

Medical treatment

Principles are to reduce inﬂ ammation and prevent complications. Acute

derangements in blood results should be corrected (e.g. blood transfusion

for severe anaemia, potassium supplementation, nutritional support for

hypoalbuminaemia).

Proctitis

• Topical steroids—Predsol

suppositories.

• Topical 5-aminosalicyclic acid (5-ASA) suppositories.

Left-sided colitis

• Topical steroids—Predsol

foam enemas (penetrate up as far as the

splenic ﬂ exure).

• Topical 5-ASA foam enemas.

• May require systemic steroid treatment (prednisolone).

Pancolitis

• Topical steroids or 5-ASA treatments for local symptoms.

• Usually need systemic treatment, e.g. oral steroids (prednisolone),

5-ASA treatment.

• Oral immunosuppressives, e.g. azathioprine, 6-mercaptopurine.

• Systemic affectors of lymphocyte function, e.g. cyclosporin A,

anti-TNFα (inﬂ iximab)

Surgical treatment

Surgery is indicated for acute colitis that fails to respond to treatment (see

b p. 418) and for chronic colitis when:

• Chronically symptomatic despite maximal medical therapy.

• Medical therapy controlling symptoms, but associated with

unacceptable side effects, e.g. osteoporosis, immunosuppression.

• Recurrent exacerbations affecting growth or development in

adolescents.

• Conﬁ rmed diagnosis of either high grade dysplasia or dysplasia-

associated lesion or mass (DALM), or carcinoma of colon.

Surgical treatment may be:

• Proctocolectomy (removal of colon and rectum) with ileoanal pouch

formation (see b p. 402).

• Panproctocolectomy (removal of colon, rectum, and anus) with end

ileostomy formation (permanent).

• Total abdominal colectomy (removal of colon) with ileostomy (used

when the patient is too unwell for major pelvic surgery, e.g. for acute

severe colitis).

CHAPTER 11 Colorectal surgery

394

Crohn’s disease

Key facts

• A chronic inﬂ ammatory non-caseating, granulomatous disease affecting

any part of the GI tract.

• Associated with several extraintestinal disorders (see Box 11.1).

• Precise aetiology is unknown, but products from the bacterial ﬂ ora

combined with a genetic predisposition (family history) are factors.

• Peak age of onset of symptoms is the teens and early twenties, but

diagnosis is often several years later.

• Commonest in white Anglo-Saxon Caucasians.

Pathological features

• Commonly focused in the terminal ileum and caecum, but may affect

the anus, colon, or entire small bowel.

• Anal Crohn’s disease is not common, but may be severe and

associated with active small bowel disease.

• Colonic Crohn’s disease is a long-term risk factor for colorectal cancer

formation.

• Affected bowel looks blue-grey, thickened, with spiral surface vessels

and encroachment of the mesenteric fat around the bowel (‘fat

wrapping’).

• Transmural inﬂ ammation in the form of lymphoid aggregates,

particularly in the subserosal tissues (‘Crohn’s rosary’), mucosal crypt

ulceration, and ﬁ ssuring ulceration.

• Mucosal thickening and serpiginous longitudinal ulceration combine to

give the appearance of ‘cobblestoning’.

• Perforation, ﬁ stulation, and abscess formation are occasional

‘ﬁ stulizing’ sequelae of transmural inﬂ ammation.

• Extensive ﬁ brosis and smooth muscle hyperplasia may occur, giving

rise to stenosis.

Clinical features

• Inﬂ ammatory features. Fever, malaise, abdominal pain (often RIF),

change in bowel habit (usually diarrhoea without blood), and weight

loss. Children and adolescents may have failure to thrive or have

retarded growth. Rectal bleeding is rare except in Crohn’s colitis.

• Fistulizing features. Para-enteric abscess formation often with a tender

abdominal mass, ﬁ stula formation (ileocolic, ileoileal, ileocutaneous);

rarely free perforation with features of peritonitis.

• Stenosing features. Colicky abdominal pain, weight loss due to poor

food intake (‘food fear’), palpable or visible distended small bowel

loops.

• Anal disease. Atypical severe anal ﬁ ssures, ﬁ stula in ano, anal mucosal

thickening, and discoloration.

CROHN’S DISEASE

395

Diagnosis and investigations

Basic tests

i WCC and CRP; d Hb and albumin, especially during episodes of

inﬂ ammation.

Advanced tests

• In acute presentations, an abdominal CT may show an inﬂ ammatory

mass, abscess formation, localized or free perforation.

• In subacute or chronic presentations, small bowel disease may be

shown by a small bowel contrast study (shows mucosal irregularity and

narrowing) or a white cell scan showing ileal ‘hot spots’.

• Crohn’s colitis is diagnosed by endoscopy and biopsy.

• Anal disease may require, EUA, anal ultrasound, or MRI scanning for

assessment.

• OGD and biopsies may show features of Crohn’s in gastric mucosa.

Treatment

Medical treatment

Principles are to reduce inﬂ ammation and control complications. Acute

derangements in blood results should be corrected.

• Systemic (5-ASA) drugs are ﬁ rst-line acute and long-term treatment.

• Systemic steroids (hydrocortisone, prednisolone) control acute

exacerbations of inﬂ ammation and steroids with very high ﬁ rst pass

metabolism (budesonide) can be used chronically.

• Immunosuppressives (azathioprine, 6-mercaptopurine) are used as

maintenance therapy and anti-TNFA antibodies (inﬂ iximab) may be

effective in ﬁ stulizing complications.

• Dietary manipulation (elemental diet) may reduce inﬂ ammatory

factors.

Surgical treatment

Principles are to deal with septic complications, relieve signiﬁ cant bowel

obstruction, and remove as little bowel as possible. Indications for

surgery include the following.

• Acute. Free perforation, severe haemorrhage, acute severe colitis,

complete intestinal obstruction.

• Subacute. Inﬂ ammatory mass, subacute obstruction, abscess formation,

symptomatic ﬁ stulation.

• Chronic. Steroid dependency or complications, growth retardation,

cancer treatment or prevention.

Box 11.1 Extraintestinal manifestations of Crohn’s

disease

Associated with disease activity Independent of disease activity

• Pyoderma gangrenosum • Ankylosing spondylitis

• Erythema nodosum • Polyarthritis

• Primary biliary cirrhosis • Chronic active hepatitis

CHAPTER 11 Colorectal surgery

396

Other forms of colitis

Key facts and pathological features

Various insults of widely differing origin may give rise to colitis other then

idiopathic inﬂ ammatory bowel disease.

Acute infective colitis

• Typically caused by pathological variants of normal enteric organisms,

e.g. enteropathogenic E. coli; only rarely progresses to acute severe

colitis.

• Typhoid colitis (Salmonella typhi) (rare in the UK). Typiﬁ ed by acute

bloody diarrhoea, but few if any colonic mucosal neutrophils on biopsy

due to bone marrow suppression.

Clostridium (C.) difﬁ cile-related colitis

Caused by C. difﬁ cile infestation. Associated with antibiotic use, particularly

third generation cephalosporins (even a single dose), prolonged inpatient

stay. Toxin A produced by the organism causes acute severe inﬂ ammation

in the mucosa.

Clinical picture may be varied.

• C. difﬁ cile diarrhoea. Foul green liquid without bloody stools.

• Acute C. difﬁ cile colitis. Caused by progressive rapid mucosal loss, acute

neutrophil inﬁ ltration, and inﬂ ammation

• Pseudomembranous colitis. Exudate and slough forms grey-white

‘plaques’ of material on the denuded colonic surface called

pseudomembranes. May rapidly progress to acute severe ‘invasive’

colitis, especially in the immunocompromised or acutely unwell.

Typiﬁ ed by secondary infections associated with mucosal loss.

Neutropenic colitis

Occurs in the severely immunocompromised with neutropenia and/or

neutrophil dysfunction. Caused by multiple, normally non-pathogenic,

enteric organisms colonizing the colonic mucosa.

Radiation colitis

Acute, transient colitis caused by mucosal injury secondary to external

beam radiotherapy. May progress to chronic mucosal damage, haemor-

rhagic telangectasia, and possible stricturing after months or years.

Ischaemic colitis

Commonest in the upper left colon where the collateral blood supply

between the middle and inferior colic arteries is poorest. Usually pre-

cipitated by an acute occlusion of part or all of the inferior mesenteric

artery. May progress to infarction, but often presents with acute onset

bloody diarrhoea and abdominal pain; may settle spontaneously although

occasionally forms an ischaemic stricture.

Clinical features

Broadly similar, independently of the underlying cause. Typical features are

vague abdominal pain, mild fever (absent in neutropenic colitis), diarrhoea

(may be bloody, especially in ischaemic, radiation, severe pseudomembra-

nous, and typhoid colitis). Cessation of diarrhoea, except with treatment,

OTHER FORMS OF COLITIS

397

suggests acute severe colitis is developing and should be investigated

urgently.

Diagnosis and investigations

Depending on the suspected cause:

• Stool sent for C. difﬁ cile toxin (CDT), three samples.

• Stool for M,C,&S (if atypical infective causes possible, also send for

cysts, parasites, and ova (C,P,&O)).

• Plain abdominal radiograph may show thickened colonic haustrae.

• CT abdomen often shows typical mucosal thickening in colitis and may

be diagnostic for pseudomembranous colitis.

• Flexible endoscopy (usually ﬂ exible sigmoidoscopy) with biopsy.

Treatment

Medical treatment

• Acute infective colitis. Antibiotics only if severely symptomatic.

• C. difﬁ cile diarrhoea/colitis. Oral vancomycin up to 200mg PO

daily or metronidazole 400mg PO tds; treatment may be as for

pseudomembranous colitis if severe.

• Pseudomembranous colitis. Oral vancomycin up to 200mg PO daily or

metronidazole 400mg PO tds; adjuvant systemic treatment may be

added in severe cases, e.g. IV vancomycin or tigicycline.

• Neutropenic colitis. Broad-spectrum antibiotics, bone marrow support.

• Radiation colitis. Symptomatic treatment only; anti-diarrhoeals.

• Ischaemic colitis. Supportive treatment; anticoagulation may be

appropriate if the underlying cause is thromboembolic.

Surgical treatment

Rarely indicated. Any form of colitis may progress to acute severe colitis

and require emergency colectomy (see b p. 418). Indications are:

• Failure to respond to maximal medical therapy with life-threatening

colitis (usually requires perioperative ITU support).

• Complications of colitis. Uncontrollable bleeding, perforation

(especially in ischaemic or neutropenic colitis).

Key revision points—colorectal resections

Anastomosis of the colon/rectum may be in several ways.

• Hand sewn. Either end to end or end to side, usually single layer of

sutures (dissolvable), either interrupted or continuous.

• Stapled colonic. By mechanical stapler (‘linear stapler’), usually side

to side.

• Stapled colorectal. By mechanical stapler (‘endoluminal stapler’), end

to end.

• Defunctioning (loop) ileostomy typically for rectal anastomosis

when:

Below the peritoneal reﬂ ection.•

Comorbidities (diabetes, age, previous DXT, acute illness).•

CHAPTER 11 Colorectal surgery

398

Colorectal polyps

‘Polyp’ is a purely descriptive term and any growth from the lining of the

large bowel can be described as a polyp. Polyps may be predominantly

raised with a stalk attachment (pedunculated), ﬂ at and spreading over

the surface of the bowel wall (sessile), or occasionally a combination of

the two.

Key facts and pathological features

Polyps may arise for many different reasons.

Juvenile polyps

Mucin-ﬁ lled cystic swellings of the lower rectal mucosa. Rarely part of

a hereditary syndrome (juvenile polyposis) with multiple juvenile polyps

throughout the colon; small increased risk of colorectal cancer.

Hamartomatous polyps

Polyps containing excessive amounts of the normal architectural com-

ponents of the bowel wall, usually isolated. May be part of a hereditary

syndrome (Peutz–Jeghers syndrome, with polyps characterized by exten-

sive branched growth of the muscularis mucosa); small increased risk of

colorectal and other GI cancers.

Hyperplastic polyps

Small sessile polyps formed from normal elongated mucosal crypts.

Only associated with risk of colorectal cancer if numerous (‘hyperplastic

polyposis’).

Adenomatous polyps

• True neoplastic polyps formed by excessive growth of the colorectal

epithelium; divided by the morphology of the glandular tissue into

tubular, tubulovillous, and villous types.

• May be sessile, pedunculated, or mixed.

• Thought to be the precursor of most colorectal cancers; the risk of

cancerous change within an adenomatous polyp increases with size

(particularly >1cm), villous morphology, and sessile form.

• Majority are sporadic (either isolated or in small numbers), although

occasionally part of a hereditary syndrome.

Familial adenomatous polyposis (FAP)

Caused by an autosomal dominant defect in the APC gene on chromo-

some 5. Characterized by between dozens and thousands of adenomatous

polyps in the colorectum and an increased risk of polyp formation in the

stomach and duodenum. The risk of cancerous transformation in any given

polyp is similar to that in normal polyps, but the overall risk is very high

due to the vastly increased number present.

Associated with:

• Desmoid formation, particularly in the abdominal tissues.

• Multiple osteomata, ﬁ bromata, and thyroid inﬂ ammation (called

Gardner’s syndrome).

COLORECTAL POLYPS

399

Hereditary non-polyposis colorectal cancer (HNPCC)

A range of abnormalities of the mismatch repair (MMR) genes that

predispose adenomas to acquire multiple genetic defects and so progress

more rapidly than normal to cancer, although the overall rate of

adenoma formation is similar to that in normals.

Clinical features

Most polyps are asymptomatic, although symptoms may occur with increas-

ing size and with proximity to the anus. Typical symptoms are:

• Bleeding. Usually low volume, dark red, often ﬂ ecks or mixed with

stool.

• Mucus discharge. White, clear, or watery; commonest with large villous

adenomas and may cause hypokalaemia and hypoproteinaemia if the

villous adenoma is large with copious mucus discharge.

• Prolapse. If pedunculated and low in the rectum polyps, may prolapse

out of the anus.

Diagnosis and investigations

• Most polyps are diagnosed by colonoscopy.

• Most patients with polyps require further follow-up investigations

to keep them under surveillance for future polyp formation; the

frequency and length of follow-up depends on the number, size, and

histology of the polyp.

• Hereditary polyposis syndromes may be investigated by genetic

mutation analysis.

Treatment

Medical treatment

• Colonoscopic polypectomy (see b p. 36). Simple, is carried out for

pedunculated polyps larger than 1–2mm; others may be removed by

EMR/ESD (see b p. 403).

• Patients with FAP require regular gastroscopy and upper GI

surveillance to identify premalignant polyps.

Surgical treatment

• Surgical excision is required for polyps that are too large or unsuitable

for colonoscopic removal and in which there is a risk of current or

future malignant change; for colonic polyps this means either resection

or open excision.

• Rectal polyps may be removed by transanal microsurgery (see b p. 403).

• FAP is usually treated by proctocolectomy (usually with ileoanal

pouch formation) or colectomy and ileorectal anastomosis before

early adulthood; other polyposis syndromes may also be treated by

prophylactic colectomy.

Reference

1 Atkin WS, Saunders BP (2002). Surveillance guidelines after removal of colorectal adenomatous

polyps. Gut 51 (Suppl. V), v6–v9.

CHAPTER 11 Colorectal surgery

400

Colorectal cancer

Key facts

Colorectal cancer (CRCa) is the second commonest tumour and com-

monest GI malignancy. One in 18 of the population will suffer CRCa; ♂:♀

8 3:1. Peak age of incidence 55–75y, but is increasing in younger ages.

Pathological features

The predominant type is adenocarcinoma (mucinous, signet ring cell, and

anaplastic subtypes). Classiﬁ ed as well, moderately, or poorly differenti-

ated. Predisposing factors include:

• Polyposis syndromes (including FAP, HNPCC, juvenile polyposis).

• Strong family history of colorectal carcinoma.

• Previous history of polyps or CRCa.

• Chronic ulcerative colitis or colonic Crohn’s disease.

• Diet poor in fruit and vegetables.

Morphology

CRCa may occur as a polypoid, ulcerating, stenosing, or inﬁ ltrative tumour

mass. The majority (75%) lie on the left side of the colon and rectum

(rectum, 45%; descending-sigmoid, 30%; transverse, 5%; right-sided,

20%). Three to ﬁ ve per cent have a synchronous carcinoma at time of

diagnosis.

Clinical features

Rectal location

• PR bleeding. Deep red on the surface of stools.

• Change in bowel habit. Difﬁ culty with defecation, sensation of

incomplete evacuation, and painful defecation (tenesmus).

Descending-sigmoid location

• PR bleeding. Typically dark red, mixed with stool, sometimes clotted.

• Change in bowel habit. Typically increased frequency, variable

consistency, mucus PR, bloating, and ﬂ atulence.

Right-sided location

Iron deﬁ ciency anaemia may be the only elective presentation.

Emergency presentations

Up to 40% of colorectal carcinomas will present as emergencies.

• Large bowel obstruction (colicky pain, bloating, bowels not open).

• Perforation with peritonitis.

• Acute PR bleeding.

Diagnosis and investigations

Elective diagnosis By PR examination or rigid sigmoidoscopy for rectal

carcinoma. Colonoscopy is the preferred diagnostic investigation (alterna-

tives are barium enema and CT colonography).

Emergency presentations Commonly diagnosed by abdominal CT scan.

Single contrast enema may be used when the diagnosis of large bowel

obstruction is possible and CT scanning is unavailable. Acute PR bleeding

is sometimes investigated by urgent colonoscopy.

COLORECTAL CANCER

401

Staging investigations

• Assessment of the presence of metastases (liver, lung, or para-aortic).

Thoracoabdominopelvic CT scanning is gold standard; CT PET scan

may be used to evaluate equivocal lesions.

• Assessment of local extent. For colonic carcinoma, CT scanning is

adequate; for rectal cancer, pelvic MRI and TRUS are commonly used.

• Assessment of synchronous tumours. If not diagnosed by colonoscopy

or barium enema, one of these two tests is usually performed to

identify synchronous tumours.

• Tumour marker (CEA) is of no use for diagnosis or staging, but can

be used to monitor disease relapse if raised at diagnosis and falls to

normal after resection.

Treatment

Potentially curative treatment

Suitable for technically resectable tumours with no evidence of metastases

(or metastases potentially curable by liver or lung resection).

• Surgical resection (with lymphadenectomy) is the only curative

treatment. Typical operations:

Right/transverse. Right/extended right hemicolectomy.•

Left. Left hemicolectomy.•

Sigmoid/upper rectum. High anterior resection.•

Lower rectum. Low anterior resection/abdominoperineal resection •

(APER).

Anorectal. APER.•

• Preoperative (neoadjuvant) chemoradiotherapy may be used in rectal

cancer to increase the chance of curative resection.

• Adjuvant chemotherapy (5-FU based) is offered for tumours with

positive lymph nodes or evidence of vascular invasion.

• Hepatic or lung resection may be offered to patients with suitable

metastases and a clear resected/resectable primary tumour.

Palliative treatment

For unresectable metastases or unresectable tumours.

• Chemotherapy may effectively extend life expectancy with a good

quality of life.

• Obstructing tumours may be endoluminally stented with self-

expanding metal stents or transanally ablated if rectal.

• Surgery reserved for untreatable obstruction, bleeding, or severe

symptoms.

Pathological staging

Duke’s (approx. % 5y survival) TNM

• A, conﬁ ned to bowel wall only

(75–90)

• B, through bowel wall (55–70)

• C, any with +ve lymph nodes

(30–60)

• D, any with metastases (5–10)

• T1–4, stages of invasion of

bowel wall

• N0/1/2, no/up to 4/more than

4 lymph nodes involved

• M0/1, metastases not present/

present

CHAPTER 11 Colorectal surgery

402

Restorative pelvic surgery

Low/ultralow anterior resection

Anterior resection = removal of part or all of the rectum and anastomosis

of the left colon to the remaining stump of tissue.

• Low anterior resection refers to a join that takes place below the level

of the peritoneal reﬂ ection. i.e. to a short stump of rectum.

• Ultralow anterior resection refers to a join that takes place on to the

top of the anal canal, i.e. no native rectum remains. The anastomosis

may be stapled or sewn by hand.

The lower the level of the anastomosis, the higher the risk of complica-

tions of anastomosis, particularly anastomotic leakage (see b p. 420).

Most low and almost every ultralow anastomosis will have a temporary

loop ileostomy formed to reduce the risk of major septic complications

and consequences of leakage, but cannot prevent them.

Indications

• Rectal carcinoma.

• Rectal adenoma untreatable by other means (very rare with transanal

endoscopic microsurgery (TEMS).

• Severe or complex anorectal sepsis (including rectovaginal ﬁ stula).

Ileoanal pouch formation

For operations that remove all the colon and rectum, but do not require

removal of the anus, a permanent stoma can be avoided by the formation of

an ileal pouch. Formed from a side-to-side double fold of ileum (‘J’ pouch) or

three folds sewn together (‘W’ pouch), joined either by hand or by staples to

the upper anal canal (ileoanal anastomosis). A temporary loop ileostomy is

often formed for the same reasons as for a low anterior resection (above).

Indications

• Ulcerative colitis not responding to medical management.

• FAP or multiple colorectal polyposis.

• Crohn’s disease of the colon (controversial).

• Multiple colonic tumours including the rectum.

Complications of pelvic anastomosis (anterior resection

and ileoanal pouch)

• Leakage. Occurs in up to 15% of cases; highest in the lowest

anastomosis. Typically presents as fever, abdominal pain, and

tachycardia (see b p. 420).

• Bleeding. Uncommon; usually settles with supportive treatment.

• Ischaemia. The proximal bowel involved in the anastomosis may

become ischaemic. This may present as a leak, bleeding PR, or fever

and tachycardia. Diagnosis is by careful ﬂ exible sigmoidoscopy. May

resolve spontaneously; progressive ischaemia results in perforation and

death if not corrected by surgery.

• Stenosis. Narrowing of the anastomosis or bowel used to form it is

an occasional late complication. Presents with difﬁ culty in defecation

and small volume frequent stools. Treatment is dilatation under

anaesthetic; very rarely requires re-operation.

MINIMALLY-INVASIVE COLORECTAL SURGERY

403

Minimally-invasive colorectal surgery

Transanal endoscopic microsurgery (TEMS)

Large calibre operating protoscope with operating microscope allows

microsurgery within the rectum.

Indications

• Excision of large adenomas of the rectum (up to the rectosigmoid

junction) in a single specimen either by mucosectomy (or occasionally

full thickness).

• Excision of early rectal carcinoma (only if <3cm size, early tumour

(T1), no adverse features or in elderly/comorbid patients) by single

specimen full thickness excision.

• Repair of a rectovaginal ﬁ stula.

Advantages Include entirely endoscopic technique, very low risk of parar-

ectal/pelvic sepsis, single complete specimen for histological assessment,

may avoid more radical surgery.

Complications Include bleeding (rarely requires active treatment), infec-

tion in the pelvic tissues (rare, presents with deep pelvic pain, fever, tachy-

cardia, and disturbance of bowel habit; treat with IV antibiotics).

Laparoscopic surgery

Several variants now exist. All use the same principles: minimal incisions,

avoidance of exposure of viscera, light anaesthetic techniques with mini-

mal opiates, and often enhanced recovery post-operatively.

Typical Indications

• Any colorectal resection can be performed by laparoscopic surgery.

• Rectopexy for prolapse.

• Combined treatment of large/extensive colonic polyps.

• Formation of some stomas.

Two newer variants have been used:

• SILS. Single incision laparoscopic surgery; one larger port for camera

and instruments used at the umbilicus.

• LESS. Combined laparoscopic and endoscopic single site surgery;

combines laparoscopic mobilization and handling with endoluminal

endoscopic techniques to remove very large lesions.

Advanced polypectomy

Several advanced endoscopic techniques are used to remove large and

often sessile colonic polyps.

• EMR. Endoscopic mucosal resection; excision (usually piecemeal)

of (presumed) adenoma with use of submucosal ﬂ uid injection to

facilitate snaring of the polyp.

• ESD. Endoscopic submucosal dissection; attempted complete excision

of (presumed) adenoma using submucosal injection and endoscopic

diathermy ‘knife’.

CHAPTER 11 Colorectal surgery

404

Diverticular disease of the colon

Key facts

Colonic diverticula are acquired outpouchings of colonic mucosa and

overlying connective tissue through the colonic wall.

• Tend to occur along the lines where the penetrating colonic arteries

traverse the colonic wall between the taenia coli.

• Associated with hypertrophy of the surrounding colonic muscle

with thickening of the colonic mucosa. This is probably due to the

underlying pathological process, which is high pressure contractions of

the colon, causing chronic pressure on the colonic wall.

• Peak age of presentation is 50–70y, but diverticular disease is

increasing in frequency and occurring at a progressively younger age.

Clinical and pathological features

Asymptomatic

The majority of diverticular disease is found incidentally on barium enema

examination.

Painful diverticular disease

Intermittent LIF pain may be due to diverticular disease, but irritable bowel

syndrome commonly coexists and may be the cause of symptoms.

Acute diverticulitis

Rapid onset of LIF pain, nausea, fever, frequently with loose stools. Usually

febrile with moderate tachycardia and LIF tenderness. Colonic wall shows

acute neutrophil inﬁ ltration around the inﬂ amed diverticulum and in the

subserosal tissues.

Bleeding diverticular disease

Usually spontaneous in onset with no prodromal symptoms. Presenting

with large volume dark red, clotted rectal blood. Due to rupture of a

peridiverticular submucosal blood vessel. Not typically associated with

inﬂ ammation.

Complications

Pericolic/paracolic mass/abscess

Acute diverticulitis may progress to persistent pericolic infection with

thickening of surrounding tissues and the formation of a mass. If this sup-

purates, a pericolic abscess forms. Enlargement and extension of this into

the paracolic area leads to a paracolic abscess. The features are those of

acute diverticulitis with a swinging fever, ﬂ uctuating tachycardia, unresolv-

ing abdominal pain, and a tender LIF mass.

Peritonitis

Perforation of a pericolic or paracolic abscess usually leads to purulent

peritonitis. Direct perforation of the acute diverticular segment leads to

faeculent peritonitis. The features are of acute diverticulitis with high fever,

severe abdominal pain, and generalized guarding and rigidity.

DIVERTICULAR DISEASE OF THE COLON

405

Diverticular ﬁ stula

Acute infection with paracolic sepsis may drain by perforation into

adjacent structures. This is typically the posterior vaginal vault in women or

the bladder in either sex. Colovesical ﬁ stula leads to recurrent UTI caused

by enteric organisms with bubbles and debris in the urine. Colovaginal

ﬁ stula leads to faeculent per vagina (PV) discharge.

Stricture formation

Chronic or repetitive inﬂ ammatory episodes may lead to ﬁ brosis and nar-

rowing of the colon. A history of recurrent diverticulitis with recurrent col-

icky abdominal pain, distension, and bloating suggests stricture formation.

Diagnosis and investigations

• Elective diagnosis is usually by double contrast barium enema.

Colonoscopy is a relatively poor investigation to assess number and

extent of diverticula.

• Hb, WCC, CRP during acute episodes of inﬂ ammation.

• CT scanning is the test of choice to identify complications, including

abscess formation and perforation.

• Double contrast barium enema is used to assess for possible stricture

formation.

• Colonoscopy is indicated if there is any suggestion of coexistent

malignancy.

Treatment

Medical treatment

• High ﬁ bre diet, high ﬂ uid intake, and stool softeners to reduce

intracolonic pressure.

• IV antibiotics (amoxycillin 500mg IV tds, metronidazole 500mg IV tds,

gentamicin IV od) during acute infective exacerbations.

• Recurrent infective episodes may be prevented by a 6-week course of

oral antibiotics (e.g. ciproﬂ oxacin 500mg PO od).

• Signiﬁ cant paracolic abscesses may be drained by radiological guidance.

Surgical treatment

• Resection is indicated for:

Acute inﬂ ammation failing to respond to medical management.•

Undrainable paracolic sepsis.•

Free perforation.•

The affected region should be resected (segmental colectomy). The ends

may be re-anastomosed if they are healthy and the patient’s general condi-

tion is suitable. If not, a proximal end colostomy and oversewing of the

distal end is usual (Hartmann’s type resection).

• Stricture may be treated by elective resection or balloon dilatation.

• Diverticular ﬁ stula may be treated by elective resection to prevent

recurrent infections.

CHAPTER 11 Colorectal surgery

406

Rectal prolapse

Key facts

Rectal prolapse may be partial thickness (usually just mucosa) or full

thickness involving all the layers of the rectal wall. Full thickness may

be contained within the rectum (internal prolapse also called intussuscep-

tion). Commonest in post-menopausal women, multiple vaginal deliver-

ies, associated with chronic straining and chronic disorders of defecation

(which cause weakness of the pelvic ﬂ oor and sphincter complex), and

slow transit constipation. Occasionally occurs in children suffering consti-

pation (usually self-limiting).

Pathological features

Mucosa involved in prolapse undergoes chronic changes.

• Typically glandular branching and occasional gland misplacement.

• Thickening of the muscularis mucosae and excess submucosal collagen

deposition.

• Mucosal inﬂ ammation and focal ulceration may also occur. Extensive

mucosal ulceration associated with mucosal prolapse may result in an

appearance called ‘solitary rectal ulcer’.

Clinical features

• Mucosal prolapse. Discharge of mucus and small volume faecal staining,

pruritus ani, and occasionally small volume bright red rectal bleeding.

• Internal full thickness prolapse. Sensation of rectal fullness/mass,

incomplete defecation, dissatisfaction after defecation and repeated

defecation.

• External full thickness prolapse. External prolapsing mass after

defecation (usually requiring manual reduction), mucus and faecal

soiling, occasional bright red rectal bleeding (may be large volume if

prolapse becomes ulcerated).

Diagnosis and investigations

• Rigid sigmoidoscopy may show features of mucosal inﬂ ammation,

particularly the anterior rectal mucosa.

• Prolapse may be demonstrable on straining in clinic.

• Defecating proctogram may be performed to conﬁ rm the diagnosis

if it is unclear and surgery is contemplated. Proctogram required

to conﬁ rm the diagnosis of internal prolapse if suspected. May also

demonstrate associated problems of pelvic ﬂ oor and rectocele.

• Colonic transit studies may be used if there is suspected slow transit

constipation and resection is possible.

Treatment

Medical treatment

• Avoidance of straining and adaptation of defecatory habit (bio-

feedback).

• Avoidance of constipation (stool softeners and bulking agents, rather

than stimulants).

RECTAL PROLAPSE

407

Surgical treatment

Mucosal prolapse

• Recurrent banding or dilute phenol injection of excess mucosa.

• Mucosal excision.

• Stapled anopexy (also called procedure for prolapse and haemorrhoids

(PPH)) sometimes used.

Full thickness prolapse (internal or external)

Surgery indicated for failure of control of symptoms. Choice of operation

depends on age and extent of prolapse.

• Delorme’s perineal rectopexy (mucosal excision with sutured plication

of the excessively long rectal muscle tube in an effort to shorten it to

prevent prolapse). Ideal for very frail and elderly, but least successful

with highest recurrence rate of all surgical procedures.

• Altmeier’s perineal rectal resection (mucosal and rectal muscle

tube excision with sutured perineal anastomosis). Avoids abdominal

operation, but has increased morbidity due to perineal anastomosis.

• Transabdominal rectopexy (mobilization of the rectum and suturing to

the presacral fascia). May be done via a laparotomy or laparoscopically.

May be just to ventral surface of the rectum with suspensory mesh

(ventral mesh rectopexy). Highest success rate for prevention of

recurrence of prolapse. May be combined with a sigmoid resection if

there is marked associated constipation on transit studies.

Key revision points—anorectal physiology

• The internal anal sphincter is smooth muscle and under involuntary

control of the pelvic autonomic system. Relaxants include nitric

oxide donors (e.g. GTN) and calcium antagonists (e.g. diltiazem).

• The external anal sphincter is skeletal muscle and under voluntary

control of the pudendal nerve (S2, 3, 4). Relaxation (by temporary

partial paralysis) may be achieved by botulinum toxin injection.

• Defecation is a complex sensorimotor process that requires intact

pelvic autonomics, sacral spinal nerves, and pelvic ﬂ oor muscle

function.

CHAPTER 11 Colorectal surgery

408

Pilonidal sinus disease

Key facts

Single or multiple sinuses (‘pits’) that exist in the midline of the buttock

clefts. Usually contain hair, inspissated secretions, and debris. Commonest

in men, dark-haired, hirsute people, especially eastern Mediterranean

races. Probably caused by local trauma, causing retention of hairs within

initially normal midline pits. May be precipitated by long periods seated,

e.g. lorry drivers, computer operators.

Pathological features

Typiﬁ ed by chronic inﬂ ammation. Once inﬂ ammation has started, sinuses

often extend and may become interlinked. Lateral tracks may run out into

the neighbouring buttock tissue.

Clinical features

• Irritative features. Intermittent discharge and inﬂ ammation with pain

and swelling.

• Acute sepsis. Acute abscess formation is common with swelling, pain,

and erythema; may discharge spontaneously or may cause ﬁ stulation

with sinuses appearing in the lateral buttock tissue.

• Chronic sepsis. Usually follows unresolved acute sepsis either after

spontaneous discharge or surgical drainage.

Diagnosis and investigations

• Ensure the patient is tested for occult diabetes mellitus.

• Very extensive sinus formation and ﬁ stulation may be assessed by MRI

scanning of the natal cleft and buttocks.

Treatment

Medical/non-surgical

• Shaving of local hairs and washing of accessible cavities (usually by a

partner or family member) may control local symptoms.

• Intermittent courses of antibiotics may be required for septic episodes.

• Formed pilonidal abscess or collection requires surgical drainage

(under local or general anaesthetic).

• Recurrent acute sepsis or persistently symptomatic chronic sepsis

usually requires surgical treatment.

Surgical

Principles of surgical treatments are:

• Excision of all sinus openings.

• Obliteration of all infected or chronically inﬂ amed tissue.

• Obliteration of the natal cleft by ﬂ attening (thought to be most

important in the prevention of recurrence by reducing the risk of

further hair implantation).

PILONIDAL SINUS DISEASE

409

Surgical options are:

• Primary excision with laying open of wound and closure by secondary

intention is very rarely used, except in extensive recurrent disease; it

requires daily dressings for many weeks or months.

• Tension-free apposition of the skin edges (may be by lateral ﬂ aps,

e.g. Karyadakis or Bascom procedures, or by plastic surgical ﬂ aps, e.g.

rhomboid, rotational, or Z plasty ﬂ aps).

Key revision points—anatomy of the large bowel

• Main features of large intestine structure:

Complete layer of circular smooth muscle throughout, but •

incomplete bands of longitudinal muscle (taeniae coli) in colon

(complete in rectum).

Fatty appendages along taeniae (appendices epiploicae).•

Folded internal mucosal appearances (haustrations).•

‘Segmented’ external appearances (sacculations).•

• Four main arterial (and lymph node) territories (used for resections):

Ileocolic and right colic arteries (from SMA): last terminal ileal •

loop, caecum, and ascending colon.

Middle colic artery (from SMA): transverse colon up to the •

splenic ﬂ exure.

Left colic (from IMA): splenic ﬂ exure and descending colon.•

Superior rectal artery (from IMA): rectum and upper anal canal.•

• Autonomic nerve supply:

Sympathetic, mainly from greater splanchnic nerves via SMA and •

IMA plexuses.

Parasympathetic, from vagus via SMA and IMA plexus from •

caecum to splenic ﬂ exure and from pelvic parasympathetics (S2,

3, 4) via hypogastric plexuses and retroperitoneal nerves from

splenic ﬂ exure to upper anal canal.

CHAPTER 11 Colorectal surgery

410

Fistula-in-ano

Key facts

A ﬁ stula is an abnormal connection of two epithelial surfaces and the two

surfaces joined in ﬁ stula in ano are the anorectal lining and the perineal or

vaginal skin. Very common, especially in otherwise ﬁ t young adults. May

occur in the presence of Crohn’s disease; minor association with obesity

and diabetes mellitus, very rarely due to trauma or ulceration of anorectal

tumours.

Pathological features

Commonest cause is sepsis arising in an anal gland that forces its way out

through the anal tissues to appear in the perianal or in women, vaginal

skin (cryptoglandular theory of ﬁ stula in ano). Often presents initially as

an acute perianal abscess. The tissues through which the track pushes

determines the classiﬁ cation of ﬁ stulas (see Fig. 11.1).

Clinical features

• Acute perianal abscess. Rapid onset of severe perianal or perineal pain.

Swelling and erythema of the perianal skin with fever and tachycardia.

• Recurrent perianal sepsis. Recurrent intermittent sepsis typiﬁ ed by

gradual build-up of ‘pressure’ sensation and swelling in the perianal skin

and eventual discharge of bloodstained purulent ﬂ uid.

• Chronic perianal discharge. Persistent low grade sepsis of the track with

chronic discharge of seropurulent ﬂ uid via a punctum that is usually

clearly identiﬁ ed by the patient.

Diagnosis and investigations

Diagnosis and investigation should aim to conﬁ rm the presence of

a ﬁ stula and identify the course of the track to determine the type of

ﬁ stula:

• Examination of the perineum and rectal examination may reveal a

palpable ﬁ brous track.

• EUA with probing of any external opening to aid identiﬁ cation of the

course of the track.

• Endoanal ultrasound (sometimes with hydrogen peroxide injected into

the track) identiﬁ es the course of the track.

• MRI scanning is probably the most sensitive method of determining the

course of the track and identifying any occult perianal or pelvic sepsis.

• Flexible sigmoidoscopy if associated colorectal disease, e.g. Crohn’s

disease, is suspected.

Treatment

Medical treatment

• Antibiotics may reduce symptoms from recurrent sepsis, but cannot

treat the underlying ﬁ stula.

• Medical treatment of inﬂ ammatory bowel disease may dramatically

reduce symptoms from associated ﬁ stulas.

FISTULA-IN-ANO

411

Surgical treatment

Principles of surgical treatment are as follows:

• Drainage of any acute sepsis if present.

• Prevention of recurrent sepsis. Usually by insertion of a loose seton

suture, e.g. silastic sling.

• Low ﬁ stula in ano. Lay open track, remove all chronic granulation

tissue, and allow to heal spontaneously (ﬁ stulotomy); little risk of

impairment of continence due to minimal division of sphincter tissues.

• High ﬁ stula in ano:

Remove ﬁ stula track and close the internal opening (core •

ﬁ stulectomy and endorectal ﬂ ap advancement).

Slowly divide the sphincter tissue between the ﬁ stula and the •

perianal skin (cutting seton); low risk of incontinence.

Fill the ﬁ stula with ﬁ brin glue.•

Rectum

Pelvic

floor

Anus

Low

fistulae

High

fistulae

Sphincter

muscle

Low

transphincteric

Submucosal

Intersphincteric

Extrasphincteric

Suprasphincteric

High

transphincteric

Fig. 11.1 Classiﬁ cation of ﬁ stula-in-ano.

CHAPTER 11 Colorectal surgery

412

Haemorrhoids

Key facts

Broad term, often incorrectly used to refer any perianal excess tissue.

True haemorrhoids are excessive amounts of the normal endoanal cush-

ions that comprise anorectal mucosa, submucosal tissue, and submucosal

blood vessels (small arterioles and veins). Commonest age of onset is

in young adulthood. Associated with constipation, chronic straining, obes-

ity, and previous childbirth. May become ulcerated and inﬂ amed if recur-

rently prolapsing.

• If conﬁ ned to the tissue of the upper anal canal, they are referred to

as ‘internal’.

• If extend to the tissues of the lower anal canal, they are referred to

as ‘external’.

• Typically occur in the same location as the main anal blood vessel

pedicles (described as 3, 7, and 11 o’clock positions as seen in the

supine position).

Clinical features

• Features of irritation. Pruritus ani, mucus discharge, and perianal

discomfort.

• Features of damage to mucosal lining. Recurrent post-defecatory

bleeding—bright red, not mixed with stools, on paper or splashing in

the toilet pan.

• Features of prolapse. Intermittent lump appearing at anal margin,

usually after defecation, may spontaneously reduce or require manual

reduction.

Diagnosis and investigations

• Diagnosis is usually by rigid sigmoidoscopy and proctoscopy.

• Flexible sigmoidoscopy or colonoscopy may be appropriate if there

is concern about the cause of symptoms; remember—haemorrhoids

rarely start over the age of 55y and it is often best to assume another

cause until proven otherwise in these cases.

Treatment

Medical treatment Avoidance of constipation and straining; bulking or

softener laxatives.

Surgical treatment

• Banding or excessive tissue. Best for prolapse symptoms (not possible

for external components due to excellent nerve supply of lower anal

canal).

• Dilute phenol injections (5% in almond oil). Best for bleeding

symptoms.

• Haemorrhoidal devascularization procedures (e.g. arterial ligation

‘HALO’ either Doppler ultrasound-guided or blind). For failed topical

treatments and surgery not indicated/desired.

• Stapled anopexy (also called PPH). Sometimes used for circumferential

prolapsing haemorrhoids.

HAEMORRHOIDS

413

• Haemorrhoidectomy for large external haemorrhoids or haemorrhoids

failing to respond to conservative treatment. Associated with a small

risk of impaired continence and anal stenosis.

Key revision points—anatomy of the anus

• Lower third of the anal canal is somatic tissue in origin—stratiﬁ ed

squamous epithelium; very sensitive (pudendal and distal sacral

nerves); relatively poor blood supply and healing.

• Upper third of the canal is visceral tissue in origin—columnar

epithelium; insensitive; excellent blood supply and healing.

CHAPTER 11 Colorectal surgery

414414

Acute anorectal pain

Causes and features

Fissure-in-ano Acute severe, localized, ‘knife-like’ pain in the anus dur-

ing defecation. Often associated with deep throbbing pain for minutes

or hours afterwards due to pelvic ﬂ oor spasm. Blood on the paper when

wiping (small volume, red-pink streaks or spots).

Haemorrhoids Usually acutely prolapsed and inﬂ amed with associated peri-

anal lump, soreness, and irritation. May bleed, often profuse, bright red.

Perianal abscess Gradual onset, constant localized perianal pain. Associated

swelling with tenderness and possible discharge. May have associated sys-

temic features of fever, malaise, anorexia.

Perianal haematoma Usually sudden onset; acutely painful with associated

perianal swelling (dark red coloured).

Rectal prolapse Acute full thickness rectal prolapse, occasionally causes

pain. Obvious large perineal lump, dark red blue with surface mucus and

occasionally some surface ulceration.

Emergency management

Establish a diagnosis

• Good inspection and careful digital rectal examination is usually all that

is required.

• Rigid sigmoidoscopy may be painful and is often unnecessary.

• Flexible sigmoidoscopy is rarely indicated.

Early treatment

• Give adequate analgesia; opiates may be necessary.

• Topical treatment is highly effective; cool pads, topical local

anaesthetic gels.

Deﬁ nitive management

Fissure-in-ano Mainstay of acute treatment is analgesia and anal sphincter

muscle relaxants, e.g. topical GTN 0.2% ointment, diltiazem 2% ointment.

Local anaesthetics are helpful early in treatment.

Haemorrhoids May require bed rest with continued topical treatment

until swelling resolves and spontaneous reduction begins. Acute haemor-

rhoidectomy is almost always best avoided due to the risk of over-excision

of anal tissue. Minimal anal dilatation under GA is rarely necessary.

Perianal abscess Incision and drainage is a surgical emergency, particularly

if the patient is diabetic or immunosuppressed.

Perianal haematoma Incision to allow decompression of acute haematoma

may be necessary, often done under topical LA.

Rectal prolapse Swelling may be reduced by cool packs, elevation, and

sometimes icing sugar applied to the swollen mucosa as a dessicant! Very

rarely requires emergency surgery.

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CHAPTER 11 Colorectal surgery

416416

Acute rectal bleeding

Causes and features

Acute rectal bleeding is broadly divided into regions of the colon from

which it comes and the blood is typically different according to the origin.

Anorectal

Bright red blood, on the surface of the stool and paper, after defecation.

• Haemorrhoids.

• Acute anal ﬁ ssure.

• Distal proctitis.

• Rectal prolapse.

Rectosigmoid

Darker red blood, with clots, in surface of stool and mixed.

• Rectal tumours (benign or malignant).

• Proctocolitis.

• Diverticular disease.

Proximal colonic

Dark red blood mixed into stool or altered blood.

• Colonic tumours (benign or malignant).

• Colitis.

• Angiodysplasia.

• NSAID-induced ulceration.

Upper GI bleeding occasionally produces dark red rectal bleeding, but it

is usually associated with signiﬁ cant haemodynamic instability when

sufﬁ ciently large.

Features (signs)

• Tachycardia and hypotension suggests substantial loss.

• LIF tenderness suggests diverticular inﬂ ammation with bleeding.

Emergency management

Resuscitation

• Establish large calibre IV access; give crystalloid ﬂ uid up to 1000mL

if tachycardic or hypotensive.

• Catheterize and place on a ﬂ uid balance chart if hypotensive.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group

and save, clotting.

Establish a diagnosis

• Rigid proctosigmoidoscopy should be performed in all cases to

exclude a simple anorectal cause.

• Urgent ﬂ exible sigmoidoscopy and colonoscopy may be undertaken. It

is higher risk than elective endoscopy, but may conﬁ rm an origin and

may allow therapeutic intervention (adrenaline injection, heater probe

coagulation, argon plasma coagulation (APC)).

• Urgent selective mesenteric arteriography for obscure or persistent

bleeding; needs active bleeding of 0.5mL/min.

ACUTE RECTAL BLEEDING

417417

• Urgent gastroscopy should be used to exclude massive upper GI

bleeding if suspected.

Early treatment Consider blood transfusion if major bleed (persisting

haemodynamic instability despite resuscitation, Hb <8g/dL).

Deﬁ nitive management

Anorectal causes Most can be controlled by local measures, such as

injection, coagulation, or packing.

Acute colitis

• IV or PO metronidazole if thought to be infective until organism

identiﬁ ed.

• IV hydrocortisone 100mg qds if thought to be ulcerative or Crohn’s

colitis.

• Surgery may be necessary whatever the aetiology if bleeding persists

(subtotal colectomy and ileostomy formation).

Diverticular disease

• IV antibiotics (cefuroxime 750mg tds + metronidazole 500mg tds).

• Angiographic embolization if bleeding fails to stop and patient not

critically unstable for time in radiology.

• Surgery is high risk, but may be unavoidable. If the location is known,

a directed hemicolectomy may be performed (on-table colonoscopy

may be used). If not, a subtotal colectomy is safest.

Angiodysplasia

• Colonoscopic therapy (injection, heater probe, APC) is ideal.

• Angiographic embolization may be possible.

• Right hemicolectomy is occasionally unavoidable.

Undiagnosed source

Rarely, the patient remains unstable with active bleeding and no cause can

be reliably conﬁ rmed. Surgical options to deal with this include:

• On-table colonoscopy with washout via colostomy to locate bleeding

source.

• Formation of mid-transverse loop colostomy and subsequent targeted

hemicolectomy.

• ‘Blind’ hemicolectomy (left if signiﬁ cant diverticular disease present;

right if no other cause obvious and angiodysplasia is likely).

CHAPTER 11 Colorectal surgery

418418

Acute severe colitis

Causes and features

Any cause of colitis may progress to acute severity. Common causes

include:

• Severe ulcerative colitis (UC; usually pancolitis); occasionally, acute

severe colitis is the presentation of UC with no prior history;

• Acute infective colitis (e.g. Salmonella, C. difﬁ cile, amoebae, parasites);

• Neutropenic colitis;

• Pseudomembranous colitis (C. difﬁ cile-related);

• Progressive Crohn’s colitis (usually with a clear prior history).

Symptoms

• Diarrhoea (usually bloody with urgency and frequency). ‘Constipation’

may be an ominous feature, suggesting acute colonic dilatation.

• Abdominal pain (generalized).

• Malaise, anorexia, and fever (systemic inﬂ ammatory features).

Signs

• Fever, tachycardia, possible hypotension.

• Abdominal tenderness; peritonism suggests perforation.

Complications

Any acute severe colitis may develop any of these complications.

• Haemorrhage.

• Hypokalaemia.

• Hypoalbuminaemia;.

• Perforation (localized or generalized).

‘Toxic dilatation’ is a term used to describe the situation of acute severe

colitis with colonic dilatation usually associated with reduced bowel fre-

quency and impending perforation.

Fulminant severe colitis is deﬁ ned as: tachycardia >120bpm or stool fre-

quency >10 times/24h or albumin <25g/dL.

Emergency management

Resuscitation

• Establish large calibre IV access; give crystalloid ﬂ uid up to 1000mL if

tachycardic or hypotensive.

• Catheterize and place on a ﬂ uid balance chart if hypotensive.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group

and save, clotting.

Establish a diagnosis

• Send ‘hot’ stools for M,C,&S as well as microscopy for C,P,&O. Even

known colitics may catch acute infective colitis.

• Plain AXR (looking for colonic dilatation) and erect CXR (looking for

free gas).

• Rigid sigmoidoscopy and biopsy only if not unstable.

• Flexible endoscopy may be indicated, but carries a risk of perforation.

ACUTE SEVERE COLITIS

419419

Early treatment

• Give IV hydrocortisone if the diagnosis of UC is likely; if infective colitis

is suspected, consider withholding steroids until the M,C,&S results are

back.

• Blood transfusion if anaemic.

• Surgery if peritonitis or free gas on CXR (the operation for any

acute colitis is usually total abdominal colectomy and end ileostomy

formation).

Deﬁ nitive management

Acute ulcerative colitis

• IV hydrocortisone 100mg qds, converted to oral prednisolone if

responding to treatment.

• IV cyclosporin if fulminant/not responding to IV steroids.

• Surgery for failure to respond to medical treatment or acute

complications of haemorrhage or perforation.

• Regular blood investigations and plain abdominal radiography to

monitor treatment.

Infective colitis

• IV or PO metronidazole until organism identiﬁ ed.

• Salmonella, C. difﬁ cile—metronidazole.

• Surgery for failure to respond to medical treatment or acute

complications of haemorrhage or perforation.

Neutropenic colitis

• IV antibiotics.

• Bone marrow support.

• Surgery for failure to respond to medical treatment or acute

complications of haemorrhage or perforation.

CHAPTER 11 Colorectal surgery

420

Post-operative anastomotic leakage

Causes and features

Any intra-abdominal anastomosis may leak. Highest risk of leak occurs

with oesophageal and rectal anastomosis and lowest with small bowel

anastomosis (see Table 11.1).

Anastomotic leakage may present as one of several clinical pictures.

3 Peritonitis

Acute severe generalized abdominal pain with generalized guarding and

rigidity. Fever, tachycardia, and tachypnoea are common. Diagnosis is usu-

ally clinical, but may require CT scanning if unsure.

Intra-abdominal abscess (see b p. 308)

Swinging fever and tachycardia, commonly around 5–7 days post-opera-

tively. Localized tenderness related to the anastomosis may be present.

Diagnosis should be sought by CT scanning.

Enteric ﬁ stula

A ﬁ stula between the anastomosis and the wound or another organ may

occur. Usually occurs as a result of a subclinical leak and abscess forma-

tion that discharges through a pathway of low resistance. Often presents

late as an apparent wound infection that discharges with enteric content.

Diagnosis made by CT scanning or occasionally, ﬁ stulography if presents

very late.

2 Cardiovascular complications

 Sepsis originating from an initially subclinical leak may present with

apparent cardiovascular complications, e.g. AF, SVT, chest pain, and sinus

tachycardia. A wise precautionary rule is, ‘Any acute post-operative dis-

turbance of physiology in a patient with an intra-abdominal anastomosis is

due to leak until proven otherwise.’

Emergency management

Resuscitation

• Establish large calibre IV access; give crystalloid ﬂ uid up to 1000mL if

tachycardic or hypotensive.

• Catheterize and place on a ﬂ uid balance chart if hypotensive.

• Send blood for FBC (Hb, WCC), U&E (Na, K), LFTs (albumin), group

and save, clotting.

• Give appropriate analgesia if not on an epidural or PCA.

Establish a diagnosis

• Acute peritonitis needs no diagnostic investigation. Emergency re-look

laparotomy should be organized immediately.

• CT scanning with IV and PO contrast is the investigation of choice for

all other suspected leaks.

• For rectal anastomoses, a water-soluble contrast study may delineate a

leak.

POST-OPERATIVE ANASTOMOTIC LEAKAGE

421

Early treatment

• Give IV antibiotics (e.g. IV cefuroxime 750mg tds + metronidazole

500mg tds).

• Monitor ﬂ uid balance hourly.

Deﬁ nitive management

3 Peritonitis

Always requires surgical intervention unless the patient is deemed unﬁ t.

Prepare for theatre. Ensure blood results from resuscitation are avail-

able. Stoma care review is not always necessary and often not practical

or useful.

Once the leak has been identiﬁ ed, options for management include:

• Dividing the anastomosis, closing the distal end, and forming the

proximal end into a stoma;

• Emptying the bowel (lavage) and forming a proximal defunctioning

stoma;

• Re-forming or repairing the anastomosis (only suitable for ﬁ t patients

with minimal contamination and an otherwise healthy anastomosis);

• Placing a large drain(s) next to the anastomosis.

Intra-abdominal abscess

• Radiologically guided drainage and antibiotics, provided patient does

not become peritonitic or show signs of secondary complications.

• Open surgical drainage if inaccessible or unresponsive to radiological

drainage.

Enteric ﬁ stula

• Usually managed by antibiotics. May close spontaneously; if fails to

close, surgical repair may be required.

• Treat as for abscess or peritonitis if either develops.

Table 11.1 Risk factors associated with increased risk of leak

Patient factors Disease factors Operative factors

Chronic malnutrition

Immunosuppression

Unprepared bowel, e.g.

obstruction

Poor blood supply or

bowel ends

High dose steroid use

Diabetes mellitus

Local or generalized sepsis

Metastatic malignancy

Tension on bowel ends

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423

Paediatric surgery

Principles of managing paediatric surgical cases 424

Acute abdominal emergencies—overview 426

Oesophageal atresia 428

Pyloric stenosis 430

Malrotation and volvulus 432

Intussusception 434

Hirschsprung’s disease 436

Rare causes of intestinal obstruction 438

Abdominal wall defects 440

Necrotizing enterocolitis (NEC) 442

Inguinal hernia and scrotal swellings 444

Other childhood hernias 446

Prepuce (foreskin) and circumcision 448

Undescended testis 450

Solid tumours of childhood 452

Neck swellings 454

Chapter 12

CHAPTER 12 Paediatric surgery

424424

Principles of managing paediatric

surgical cases

Key facts

• Children are not small adults.

• Children come in different sizes; always obtain a weight before starting

treatment.

• Fluids and drug doses depend on body weight.

• Babies and children have different differential diagnoses from adults.

• Children often differ from adults in physiology and anatomy (see

Table 12.1).

• Babies and young children have difﬁ culty communicating symptoms.

Special problems with babies

• Thermoregulation is impaired (immature sweating, high surface area to

body weight increases rate of heat loss). Prone to hypothermia.

• Minimal glycogen stores. Prone to acute hypoglycaemia.

• Principal breathing pattern is diaphragmatic. Prone to breathing

difﬁ culties with abdominal distension.

• Immature body physiology. Much less biological functional reserve than

adults; acute disturbances of physiology more serious with less room

for error.

• May not metabolize drugs as expected.

Intravenous ﬂ uids

Maintenance ﬂ uids (see Box 12.1)

Box 12.1 Paediatric ﬂ uid regimen

• 4mL/kg/h total ﬂ uid for each of the ﬁ rst 10kg of weight (0–10kg).

• 2mL/kg/h total ﬂ uid for each of the next 10kg of weight (11–20kg).

• 1mL/kg/h total ﬂ uid for each subsequent kg of weight (over 21kg)

• Always calculate ﬂ uid and sodium requirements according to weight.

• Remember to add glucose, especially for neonates.

• Adjust the ﬂ uid regimen according to clinical setting for neonates and

premature babies.

Resuscitation ﬂ uids

• Crystalloids or colloids can be given as resuscitation ﬂ uids.

• Mild dehydration—10mL/kg bolus; repeat as necessary.

• Moderate dehydration—20mL/kg bolus; repeat as necessary.

PRINCIPLES OF MANAGING PAEDIATRIC SURGICAL CASES

425

Table 12.1 Basic physiological parameters in children

Neonates Adolescents

Blood volume (mL/kg) 80 30–40

Oral ﬂ uid intake (mL/kg/day) 150 30–40

Daily Na

intake (mmol/kg) 2–3 1–2

Daily K

intake (mmol/kg) 2–3 1

Systolic BP (mmHg) 40–50 100–120

Resting pulse rate (bpm) 120–160 70–80

CHAPTER 12 Paediatric surgery

426426

Acute abdominal emergencies—

overview

Key facts

• Whatever the cause (see Fig. 12.1), these typically present with signs

and symptoms of either peritonitis or intestinal obstruction.

• Features of peritonitis are often difﬁ cult to elicit in babies.

• Cardinal features of obstruction are:

Vomiting.•

Abdominal distension.•

Failure to pass meconium.•

Pain.•

Vomiting in children

• Vomiting is common in newborns and is often entirely benign. May be

due to:

Overfeeding.•

Rapid feeding.•

Air swallowing (inadequate winding).•

• Vomiting may be due to metabolic causes (inborn errors of

metabolism, acidosis) or infections (UTI, chest infection, meningitis).

• Bile-stained vomiting should never be ignored.

Abdominal distension Most pronounced in distal obstruction and less so in

proximal causes of obstruction.

Failure to pass meconium

• Term babies should pass meconium within 36h.

• Babies with proximal obstruction or atresia may still pass meconium.

Pain May be difﬁ cult to assess in babies. Typical features are going off

feeds, lethargy, erratic heart rate.

Diagnostic features

History

• Family/genetic history for cystic ﬁ brosis (CF). Meconium ileus.

• Premature birth. Necrotizing enterocolitis.

• Time of onset related to birth. The more proximal the obstruction,

the earlier the presentation.

Examination

• Blood in vomit or stool may indicate necrotic bowel.

• Degree of distension. Most pronounced with distal obstruction.

Investigations

• Plain AXR may show diagnostic features.

‘Double bubble sign’• . Duodenal atresia or malrotation.

‘Ground glass’• . Meconium ileus.

Multiple loops of small bowel• . Distal obstruction.

Intramural gas• (‘pneumatosis intestinalis’). Necrotizing enterocolitis.

Free air• . Intestinal perforation.

• Abdominal ultrasound. Abdominal mass. Intussusception, tumour,

duplication cyst.

ACUTE ABDOMINAL EMERGENCIES—OVERVIEW

427427

Antral web

Pyloric stenosis (>3wks)

Jejunal atresia

Anorectal

malformation

Ileal adhesion

Meconium ileus

Incarcerated inguinal hernia

Exomphalos

Gastnoschisis

Duodenal atresia

Volvulus

Congenital oesophageal

problems

Hirschsprung’s disease

Meconium plug

Small left colon

syndrome

Fig. 12.1 Causes of acute abdominal emergencies in babies and infants.

CHAPTER 12 Paediatric surgery

428

Oesophageal atresia

Key facts

• Congenital abnormality of the formation of the upper aerodigestive

tract (UADT), resulting in partial or complete interruption of the

oesophageal lumen (see Fig. 12.2).

• Often associated with other congenital abnormalities (VACTERL).

Clinicopathological features

• May be diagnosed on prenatal ultrasound. Features include maternal

polyhydramnios, absent stomach bubble, associated abnormalities.

• Post-natal diagnosis relies on features of persistent salivary drooling,

regurgitation of all feeds, and cyanosis with feeding.

• Failure to pass NGT into stomach.

• Tracheo-oesophageal ﬁ stula in isolation unusual. Presents with

recurrent aspiration/chest infections.

Diagnosis and treatment

• Plain AXR and thorax. NGT coiled in oesophagus.

• Presence of stomach gas suggests tracheo-distal oesophageal ﬁ stula.

• Plain X-ray spine. Associated congenital abnormalities.

• Echocardiography. Associated cardiac abnormalities.

Medical treatment

• Nurse head-up.

• NBM and continuous Replogle (oro-oesophageal) tube.

• Antibiotics for possible aspiration pneumonia.

Surgical treatment

• Isolated atresia.

Gastrostomy for feeding + continuous drainage of upper pouch.•

Delayed closure of defect (may require interposition graft if a long •

segment involved).

• Atresia with tracheo-oesophageal ﬁ stula. Ligation of ﬁ stula and primary

closure of oesophageal defect.

• Isolated tracheo-oesophageal ﬁ stula. Ligation of ﬁ stula (through neck).

OESOPHAGEAL ATRESIA

429

Type C

87%

Type A

Type E

Fig. 12.2 Classiﬁ cation of oesophageal atresia. Type C (III), distal ﬁ stula; type A

(I), atresia without ﬁ stula; type E (V), H-type ﬁ stula.

CHAPTER 12 Paediatric surgery

430

Pyloric stenosis

Key facts (children)

• Incidence 3 in 1000 live births.

• Increased familial risk (family history).

• It typically occurs in ﬁ rst born boys (♂:♀, 4:1).

Pathological features There is hypertrophy of the pyloric smooth

muscle in early infancy, which occurs at about 3–6 weeks.

Clinical features

• Classical projectile, forceful vomiting (secondary gastritis may cause

bloodstaining).

• Persisting vomiting.

• Sometimes a history of excessive positing and gastro-oesophageal

reﬂ ux.

• Baby appears active and hungry, especially after vomiting.

• Small, green, starvation stools passed infrequently.

• Weight gain is poor.

• Dehydration with hypochloraemic alkalosis gradually supervenes in

untreated, established condition.

• Baby usually looks well in early state.

• Dehydration, pallor, underweight only in advanced condition.

• Epigastric fullness with left-to-right gastric peristaltic wave.

• Test feed is usually performed to palpate a pyloric ‘tumour’ (see

Box 12.2).

Diagnosis and investigations

• If pyloric ‘tumour’ is felt, no radiological investigations are necessary

prior to surgery.

• Ultrasound shows thickened (>4mm), elongated (>16mm) pyloric

muscle and increased muscle to lumen ratio with decreased movement

of ﬂ uid through narrow canal (term infants).

• Barium meal (rarely necessary) shows an enlarged stomach, increased

gastric peristalsis, and elongated, narrowed pyloric canal.

• Electrolytes and capillary blood gases (d Na

, d K

, d Cl

–

, base excess,

and pH).

Treatment

• Resuscitation with IV rehydration.

• Correct hypovolaemia with 10mL/kg 0.9% saline.

• Correct hypochloraemic alkalosis and hypokalaemia (may take

24–48h)—0.45% sodium chloride/5% dextrose with added potassium

chloride at a rate of 120–150mL/kg/24h.

• NGT drainage to prevent aspiration of vomited secretions.

Surgical treatment

• Pyloromyotomy (division of pyloric muscle ﬁ bres without opening of

bowel lumen).

Done via right upper quadrant incision, periumbilical, or •

laparoscopically.

PYLORIC STENOSIS

431

Caution not to open mucosa and avoid the prepyloric vein (‘of •

Mayo’).

Start feeding within 4–6h post-operatively and increase to full •

volume by 24h.

Box 12.2 How to perform a test feed

• Undress baby (leaving loose nappy) and place on carer’s lap with

head elevated.

• Sit opposite baby and carer; position baby so head is to examiner’s

right.

• Begin feeding (breast or bottle). With active suckling, the abdominal

wall relaxes.

• Palpate with left hand (middle ﬁ nger).

• Begin above umbilicus and feel into RUQ under liver edge.

• Wait to feel appearance of olive-sized, ﬁ rm, mobile lump in angle

between liver edge and upper right rectus muscle (contracted

pyloric muscles).

• As stomach inﬂ ates with air and milk, pylorus becomes more

difﬁ cult to feel—aspiration of NGT may help.

CHAPTER 12 Paediatric surgery

432

Malrotation and volvulus

Key facts and clinical features (neonates)

Malrotation

• This can present at birth or soon after and symptoms are due to

rotation of the small bowel, leading to duodenal obstruction.

• ‘Ladd’s bands’ are occasionally the cause of the obstruction.

• Proximal duodenal distension leads to bile-stained vomiting.

• The caecum may be in an abnormally high or midline position.

Volvulus

• Twisting, in clockwise direction, of malrotated, non-ﬁ xed midgut loop

on its narrow-based mesentery through 360* or more.

• Results in obstruction of superior mesenteric blood vessels.

• Signs. Sudden onset of abdominal pain, bile vomiting, progression to

shock, passage of blood per rectum.

• May be less dramatic; most dangerous in newborn period because of

delay in diagnosis and rapid development of gut ischaemia.

• Older children may present insidiously or as rapid onset of shock with

less prominent other symptoms.

Diagnosis and investigations

3 If in doubt, operate. Viability of twisted bowel is very time-

dependent—delays in diagnosis can be very serious.

• Plain AXR. ‘Double bubble’ sign with some distal gas.

• Barium meal. Obstruction of second part duodenum, non-rotation

of duodenum/jejunum, and corkscrew appearance of proximal small

bowel loops; absent C loop of duodenum.

• Ultrasound scan. Reversed relation of superior mesenteric artery

and vein.

• Doppler ultrasound. Absent or abnormal small bowel blood.

Treatment

• Resuscitation, including decompression with NGT.

• Prompt surgery to avoid irreversible bowel damage.

• Laparotomy may reveal:

Obstructed, but viable bowel.•

Patchy ischaemic changes.•

Established necrosis.•

• Resection of ischaemic gut may risk ‘short gut syndrome’.

• ‘Second look’ laparotomy (24–48h) allows reassessment prior to

resection.

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CHAPTER 12 Paediatric surgery

434

Intussusception

Key facts (children)

• Incidence approximately 2 per 1000 live births.

• Peak age of presentation at 3–10 months.

• ♂:♀, 2:1.

• Fewer than 10% have a clear focal pathological cause that starts the

intussusception (‘apex’; older children are more likely to have an

apex).

Clinicopathological features

• Invagination/telescoping of the proximal bowel (called the

intussusceptum, e.g. terminal ileum/ileocaecal valve) into the distal

bowel (called the intussuscepiens, e.g. caecum/ascending colon).

• May be due to enlargement of lymphatic patches of Peyer (‘idiopathic’).

• Pathology at the apex may be:

Meckel’s diverticulum.•

Polyp.•

Lymphoma.•

Clinical features

• Classic triad of features is:

Abdominal pain (associated with pallor, screaming, and •

restlessness).

Palpable sausage-shaped mass (mid-abdominal or right upper •

quadrant).

Passage of ‘redcurrant jelly’ stool (rectal examination may reveal •

bloody mucus and the lead point may rarely be palpable).

• Typically, the infant is relatively settled between bouts of pain.

• Signs of shock (lethargy, poor feeding, hypotonia) require urgent ﬂ uid

resuscitation.

• Features of obstruction (distension and vomiting) may occur.

Diagnosis and investigations

• Ultrasound (diagnostic test of choice). Intussusception in cross-section

(‘doughnut’ or ‘target’ sign).

• Plain X-ray. May show soft tissue mass, small bowel obstruction, free

air indicating perforation.

• Air (or rarely gastrografﬁ n) contrast enema. Diagnostic and may be

therapeutic (see below).

Treatment

• Immediate IV ﬂ uid resuscitation to correct ﬂ uid losses and to restore

ﬂ uid, electrolyte, and acid/base balance.

• Maintenance ﬂ uid replacement and replacement of continued losses

(vomiting or nasogastric losses). Reduction only attempted once ﬂ uid

balance restored.

• Analgesia and sedation (morphine 0.2mg/kg) will aid process of

reduction.

• Antibiotics and NGT.

INTUSSUSCEPTION

435

Methods of reduction

Radiological reduction

• Air enema therapeutic in 75% of cases.

• Usually performed in radiology department under screening control.

• Surgeon should be present.

• Evidence of irreducible obstruction or perforation mandates

immediate halt.

• Partial or incomplete reduction may warrant repeat attempt after

4–6h.

• Informed consent includes risk of perforation.

Surgical reduction

• Laparotomy indicated without enema if evidence of peritonitis or

perforation.

• Manual reduction by retrograde squeezing and gentle proximal

traction.

• Resection and anastomosis if bowel viability is in doubt (710% require

resection).

• Post-reduction septic shock may occur with release of bacterial

products from viable, but damaged bowel segment.

• Most recover rapidly with resumption of oral feeding in 24–48h

and discharge home in 4–5 days.

Complications

• Recurrence rate is 5–7% in non-operative cases and about 3% for

operative reduction.

• Morbidity is low, but delayed diagnosis, inadequate resuscitation, and

failure to recognize ischaemic or perforated bowel account for

1% mortality.

CHAPTER 12 Paediatric surgery

436

Hirschsprung’s disease

Key facts (neonates/children)

• Incidence 1 in 5000 live births.

• Commoner in males.

Pathological features

• Due to incomplete migration of neural crest cells into the hindgut,

resulting in distal aganglionosis and failure of coordinated peristaltic

waves, abnormal anorectal relaxation, and loss of recto-anal inhibitory

reﬂ exes.

• May involve:

Just the anorectal junction (ultrashort segment), presents in adult •

life.

The rectum and recto-sigmoid (short segment. 70%), presents in •

infancy or early childhood.

Extensive colonic involvement (long segment), rare.•

• The proximal (normal) bowel becomes progressively distended due to

build-up of faecal matter.

Clinical features

• There is failure to pass meconium within 24–48h, abdominal

distension, and bile vomiting.

• It may be associated with Down’s syndrome.

• It may present late with poor weight gain, offensive diarrhoea, or

enterocolitis.

Diagnosis and investigations

• Radiograph shows dilated colon to level of ‘transition zone’ to

aganglionic bowel.

• Contrast enema shows less distensible rectum and may indicate

transition zone.

• Suction rectal biopsy conﬁ rms diagnosis; thickened nerve ﬁ bres and

aganglionisis (i AChE).

• Anorectal manometry (in older children) shows failure of anal relaxation

on rectal balloon distension (loss of recto-anal inhibitory reﬂ ex).

Treatment

• Resuscitation and analgesia.

• Decompression of the colon with regular saline rectal wash-outs.

• If decompression is not achieved or there is total colonic involvement,

a defunctioning stoma is necessary.

• Deﬁ nitive surgery is to remove the aganglionic bowel and bring

normally innervated bowel to the anus (pull-through technique—

Soave, Swenson, or Duhamel types).

It is usually performed as a one-stage procedure without a covering •

stoma.

The pull-through can be performed transanally or abdominally.•

Laparoscopy assists in establishing a level and mobilizing the •

colon/rectum.

HIRSCHSPRUNG’S DISEASE

437

Complications

• Constipation.

• Enterocolitis can affect 20–50% of children pre- and post-operatively

(uncommon >5y of age unless an obstructive component exists).

Further reading

Langer JC (2004). Hirschsprung’s disease. Curr Probl Surg 41: 949–88.

Swenson O (2002). Hirschsprung’s disease: a review. Pediatrics 109(5): 914–8.

Teitelbaum DH, Coran AG (2003). Primary pull-through for Hirschsprung’s disease. Sem Neonatol

8(3): 233–41.

CHAPTER 12 Paediatric surgery

438

Rare causes of intestinal obstruction

Duodenal atresia

• Caused by failure of development or canalization of the duodenal

canal.

• May be complete (i.e. entirely separate proximal and distal duodenum)

or partial (e.g. an hourglass narrowing or web obstruction in the

second part of the duodenum).

Diagnostic features

• Bile-stained vomiting occurs from birth.

• Epigastric fullness on examination.

• Look for features of associated Down’s syndrome.

• Plain AXR. ‘Double bubble sign’ with no distal gas.

Management

• Resuscitation.

• Surgical bypass (duodenoduodenostomy bypass).

Jejuno-ileal atresia

• Caused by probable in utero vascular insult to mesenteric vessels.

• May occur in a single or multiple segments and may be short segments

or long stretches of small bowel involved.

Diagnostic features

• Bile-stained vomiting from birth.

• Prominent abdominal distension, especially with distal atresia.

• Features of obstruction.

Investigation and management

• Resuscitation.

• Contrast enema may be helpful to exclude other diagnoses.

• Surgical anastomosis between atretic ends.

Meconium ileus

• Caused by the presence of impacted, abnormally thick meconium

within the normal lumen of the small bowel.

• Pathognomonic of CF, but only 15% of CF present as meconium ileus.

Diagnostic features

• May be identiﬁ ed during antenatal ultrasound examination (‘bright

spots’ in bowel) or family history with antenatal testing.

• Presents in neonatal period with features of distal obstruction:

Vomiting, distension, failure to pass meconium, mass in RIF

(meconium-obstructed bowel loops).

Investigation and management

• Resuscitation, IV ﬂ uids, NGT.

• Plain AXR.

• Contrast enema may be diagnostic and therapeutic.

• Surgical removal of meconium (may involve a temporary ileostomy).

• Immunoreactive trypsin and commonly associated CF genes (δF508).

RARE CAUSES OF INTESTINAL OBSTRUCTION

439

Anorectal malformations

Incidence, approximately 1 in 5000 live births. Caused by failure of the cor-

rect septation of the hindgut cloaca or failure of formation of the anorectal

canal (and associated pelvic ﬂ oor structures).

• Low anomalies traverse a normal levator muscle.

• High anomalies end above the levator and are commonly associated

with a ﬁ stula (bladder, urethra, vagina).

• Malformations may be part of a syndrome or linked to chromosomal

abnormalities (VACTERL).

Diagnostic features

Condition should present at the neonatal check with recognition of an

absent or abnormally placed anus and the failure to pass meconium with

associated abdominal distension if a diagnosis has been missed. It may take

up to 24h before meconium passes through the ﬁ stula.

Investigations and management

• Lateral prone X-ray of pelvis at 24h (assists in level assessment and

sacrum).

• Perineal, renal ultrasound, and echocardiography (for associated

abnormalities).

• Contrast loopogram 1 week after stoma formation (position of

ﬁ stula/renal anomalies).

• Prophylactic antibiotics if vesicoureteric reﬂ ux is demonstrated.

Surgical treatment

• Low lesions (perineal ﬁ stula). Single stage perineal approach (anoplasty

or dilatation).

• All other lesions. Defunctioning colostomy.

• Posterior sagittal anorectoplasty (PSARP). At 1–6 months and

colostomy closure thereafter.

Prognosis

• Low anomalies often have relatively good function with a tendency to

constipation in later life.

• High anomalies often have impaired function with up to 80% lifetime

chance of soiling/incontinence.

CHAPTER 12 Paediatric surgery

440

Abdominal wall defects

Exomphalos (omphalocele)

Key facts

• Incidence 1 in 7000 births.

Clinicopathological features

• Herniation of the abdominal viscera through an umbilical defect that is

covered by a membrane (unless ruptured).

• Exomphalos minor. The defect is <5cm and only the bowel is herniated.

• Exomphalos major. The defect is >5cm and bowel, liver, and other

abdominal organs lie in the hernial sac.

• May present antenatally with an abnormal scan or raised maternal

serum alpha-fetoprotein (AFP); in post-natal presentation, there is an

obvious defect.

Diagnosis and investigations

• Investigations directed at identifying the associations (see Box 12.3).

Check blood sugar.

• All newborn babies should have cardiac imaging prior to further

management.

Treatment

• Parents may opt for termination in antenatally detected defects with

associated major cardiac or chromosomal anomaly (mortality 780%).

• Post-natal management involves protection of sac, insertion of NGT,

IV access, and ﬂ uid management.

• Minor exomphalos should be suitable for reduction and primary

closure of umbilical defect.

• Major exomphalos may be associated with underdeveloped abdominal

cavity, precluding primary reduction. Epithelialization of the sac can be

encouraged with application of silver sulphadiazine paste, resulting in a

large ventral hernia that is suitable for delayed closure at 71y of age.

Surgical treatment

• Primary reduction of smaller defects. Excision of sac, closure of

umbilical defect (linear or purse string), and closure of umbilical skin.

• If the sac is ruptured in a larger defect. Application of silo or tissue

ﬂ ap.

Box 12.3 Associations of exomphalos

• Chromosomal abnormality (trisomy 18, 13, 21).

• Cardiac and renal anomalies found in up to 40%.

• Pulmonary hypoplasia caused by abnormal diaphragm function.

• Beckwith–Wiedemann syndrome: exomphalos, macroglossia,

gigantism hyperinsulinism in infancy, renal/hepatic tumours.

• Pentalogy of Cantrell: exomphalos, sternal cleft, ectopia cordis,

anterior diaphragmatic hernia, ventricular septal defect.

ABDOMINAL WALL DEFECTS

441

Gastroschisis

Key facts

• Incidence 1 in 7000 births (increasing).

Clinicopathological features

• There is a defect to the right of the umbilicus with protrusion of the

stomach, small bowel, and large bowel.

• Associated with young maternal age and antenatal smoking or

recreational drug use.

• Most present antenatally with an abnormal scan or raised maternal

serum AFP.

• Antenatal diagnosis allows planned delivery (no evidence to

recommend Caesarean section).

• Extraintestinal associated anomalies are uncommon.

• Intestinal atresia found in 10–20%.

Diagnosis and investigations Associated anomalies are rare. No formal

investigations are required.

Treatment

Management of gastroschisis at birth

• Planned vaginal delivery as close as possible to neonatal surgical unit.

• Standard neonatal resuscitation (clean, dry, stimulate, facial O

, etc.).

• Cling ﬁ lm wrap to protect herniated bowel against trauma,

contamination, heat loss, drying, and ﬂ uid loss (ensure mesentery not

on tension).

• Insertion of NGT to decompress stomach.

• Fluid balance must include considerable evaporative losses from gut.

• Broad-spectrum antibiotics.

Non-surgical treatment Manual reduction and non-sutured closure of

defect.

Surgical treatment

• If possible, the defect is delineated and closed.

• If herniated contents are unable to be reduced, the application of

a ‘silo’ to cover gut and delayed closure once the gut is reduced

(7–10 days).

CHAPTER 12 Paediatric surgery

442

Necrotizing enterocolitis (NEC)

Key facts

• Range of intestinal inﬂ ammation, ranging from mild mucosal injury to

full thickness necrosis and perforation.

• Perforated NEC associated with 40% mortality in neonates.

Clinicopathological features

• Associated with:

Premature delivery.•

Formula milk feeds.•

Hypoxia.•

Systemic sepsis.•

‘Micro-epidemic’ outbreaks in neonatal units.•

• Typically affects premature babies on ventilatory support.

• Features of vomiting, distension, bloody mucus passing PR.

• May shows signs of severe sepsis/shock (tachypnoea, poor perfusion,

temperature instability).

Diagnosis and investigations Plain AXR. Pneumatosis intestinalis,

portal venous gas, free gas if perforation, dilated, thick-walled (oedema-

tous) bowel.

Treatment

Medical

• Fluid resuscitation.

• IV antibiotics.

• Bowel rest and TPN.

Surgical treatment

• Indicated by complications (perforation, failure to respond to medical

treatment, abdominal mass, systemic sepsis).

• May include:

Peritoneal drainage.•

Bowel resection (usually with stoma formation).•

Complications

• Septicaemia.

• Enteric ﬁ stulation.

• Peritonitis.

• Adhesions.

• Enteric stricture.

• Short gut syndrome.

• Death.

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CHAPTER 12 Paediatric surgery

444

Inguinal hernia and scrotal swellings

Inguinal hernia

Key facts

• Childhood inguinal hernias derive from a persistent processus vaginalis

and are invariably indirect.

• ♂:♀, 7:1.

• Right-sided hernias (60%) are commoner than the left (25%); 15% are

bilateral.

• Higher incidence of complications (incarceration) than adult hernias.

Clinical features

• Usually noticed as a painless swelling, variable in size in the

inguinoscrotal or labial area.

• More prominent when the baby cries and may disappear

intermittently.

• Bowel entrapment causes pain and irreducibility leads to strangulation,

intestinal obstruction, perforation, and peritonitis.

• Ovarian entrapment may occur in females.

• Bile vomiting in a young infant should always prompt examination of

the inguinoscrotal area.

• Cardinal feature is a swelling in the groin above which the examining

ﬁ ngers cannot deﬁ ne the inguinal canal (‘cannot get above’).

• Asymmetrical thickening of the spermatic cord in the presence of a

history compatible with a hernia is strongly suggestive of the diagnosis.

Treatment

• Prompt surgical treatment is important in premature/young infants to

avoid risks of complications.

• Herniotomy alone is adequate. No need to repair the walls of the

canal; usually a simple, straightforward day case procedure.

• Acute surgery can be very difﬁ cult when it is irreducible or

strangulated or in very young infants.

Hydrocele

• Congenital ﬂ uid-ﬁ lled processus vaginalis and tunica vaginalis.

• Communicates with the peritoneal cavity in children.

• Scrotum is usually smoothly enlarged and sometimes bluish in colour

and the testis is often surrounded by the hydrocele.

• Occasionally acquired due to trauma, infection, or testicular tumour.

• Simple hydroceles may resolve spontaneously up to age of 18 months;

surgical intervention is deferred until 18 months.

• At operation, ligation of the patent processus vaginalis and drainage of

the ﬂ uid are adequate; there is no need to excise the hydrocele wall.

Varicocele

• Due to a dilated pampiniform venous plexus of the spermatic cord.

• Onset usually after puberty.

• Has the feel of a ‘bag of worms’ during palpation of the cord.

INGUINAL HERNIA AND SCROTAL SWELLINGS

445

• Indications for treatment include discomfort (aching), cosmesis, and

concern about fertility. The procedure is carried out by high ligation of

the plexus, either by open or laparoscopic surgery.

• Beware an acute left varicocele in childhood due to obstruction of the

left renal vein by tumour (nephroblastoma).

• Treatment may be surgical ligation or radiologically-guided

embolization.

Idiopathic scrotal oedema

• Aetiology unknown; possibly due to an acute allergic reaction.

• Characterized by painless, red, unilateral scrotal swelling extending to

the groin and the perineum.

• Rapidly resolves spontaneously; the clinical diagnosis precludes the

need for investigation.

CHAPTER 12 Paediatric surgery

446

Other childhood hernias

Umbilical hernia

Key facts

• Persistence of the physiological umbilical defect beyond birth.

• Usually close spontaneously (especially in premature infants).

• Have a low incidence of complications (incarceration/strangulation).

Clinical features Usually noticed as a painless, intermittent swelling at the

umbilicus.

Treatment

• Delay repair beyond age 4 in Caucasian children; beyond age 8 in

Afro-Caribbean children.

• Simple sutured closure of defect in surgery required.

Epigastric hernia

Key facts

• Defect in the midline linea alba between the umbilicus and the xiphoid

process.

• Very rarely closes spontaneously.

• Have a low incidence of complications (incarceration/strangulation).

Clinical features Usually noticed as a painless, intermittent swelling above

the umbilicus.

Treatment Simple sutured closure of defect required.

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CHAPTER 12 Paediatric surgery

448

Prepuce (foreskin) and circumcision

Key facts

• One of the commonest reasons for referral to a paediatric surgical

clinic.

• Prepuce (foreskin) is initially fused to the glans penis. Preputial

‘adhesions’ lyse spontaneously as part of normal development.

• Separation of the prepuce from the glans is gradual; 80% of newborns,

50% of 1y-olds, and 10% of 5y-olds will have a non-retractable

prepuce.

Non-retractable foreskin

Clinical features

• Only rarely causes problems which include dysuria, frequency, spots

of blood, ballooning, and spraying.

• Very occasionally causes recurrent balanitis with redness, soreness,

and cellulitis. Preputial ‘cysts’ are often present—these are collections

of subpreputial smegma and are part of normal development.

Treatment

• Often only reassurance and advice are needed.

• Leave the foreskin alone if asymptomatic.

• Frequent bathing and hygiene and gentle attempts at retraction.

• Hydrocortisone 1% topically relieves symptoms and may speed

separation.

• Topical or rarely, oral antibiotics only for recurrent balanitis.

• Persisting symptoms warrant retraction and separation using LA or

under GA.

Phimosis

Deﬁ ned as a non-retractable foreskin with associated scarring that will not

resolve spontaneously.

Clinicopathological features

• May be congenital (uncommon) or acquired (usually age 5+) secondary

to inﬂ ammation.

• Commonest cause balanitis xerotica obliterans (BXO); foreskin looks

pale, thickened, and scarred.

• Additional symptoms to those of a non-retractable foreskin are

retention of urine, paraphimosis, obstruction, and back pressure on the

upper urinary tract. Consider an ultrasound scan and ascending urinary

tract infection, in which case antibiotics are indicated.

Treatment

• Circumcision.

• Dorsal slit of foreskin.

• Preputioplasty (prepuceplasty).

• Non-surgical treatment using Plastibel is occasionally used in neonates.

PREPUCE (FORESKIN) AND CIRCUMCISION

449

How to examine a child’s foreskin

• Try to ensure the boy is happy and relaxed, lying on examination

couch or parental knee.

• Normal foreskin often appears long and ‘redundant’.

• Gently hold tip of prepuce between ﬁ nger tips, lift forward, and

spread wide open. Preputial oriﬁ ce usually demonstrated.

• If retraction attempted, perform gently to show pouting of mucosa.

• Blanching of skin below preputial opening—normal.

• Tight, white contracted preputial oriﬁ ce indicates ﬁ brotic phimosis

(‘muzzling’).

CHAPTER 12 Paediatric surgery

450

Undescended testis

Key facts

• Testicular descent from the fetal abdominal site into the scrotum is

normally complete by birth.

• Absence of a scrotal testis (cryptorchidism) may be due to agenesis

(rare), intra-abdominal arrest, incomplete descent (intracanalicular), or

ectopic descent (inguinal, perineal, crural, penile).

• Incidence 2–4% of newborn boys, falling to 1.5% at 6 months.

• Commoner on the right side.

Clinical features

• Undescended testis can be noted at the post-natal check, by parents,

or by the GP.

• Rarely presents acutely as torsion (tender mass in inguinal region).

• A retractile testis is one that can be brought down into the scrotum

with gentle manipulation, but retracts into the superﬁ cial inguinal

pouch, either spontaneously or with minor pressure (see Box 12.4).

Diagnosis and investigations

• No investigations are required in palpable undescended testis.

• Chromosomal studies and HCG stimulation test may be requested in

bilateral impalpable testes.

• Ultrasound may help locate an impalpable testis.

• Diagnostic laparoscopy is deﬁ nitive and allows further management.

Treatment

• Testis should be brought to the scrotum at 1–2y of age to avoid

secondary damage due to trauma, torsion, and increased ambient

temperature.

• Hormone manipulation is ineffective in true undescended testis.

• Intracanalicular or ectopic testis should be managed by one-stage

orchidopexy.

• Intra-abdominal testis can be brought down by one- or two-stage

orchidopexy (50–90% success).

• Laparoscopy for bilateral impalpable testes.

• Scrotal position facilitates self-examination to detect signs of neoplastic

change (74 times normal in an abdominal testis).

Complications

• Post-operative atrophy of the testis (<2%) unless intra-abdominal

position (10–50%).

• Retraction.

UNDESCENDED TESTIS

451

Box 12.4 How to exclude retractile testis

• A cooperative, relaxed little boy is essential. Examine on carer’s

knee or lying down.

• Control inguinal canal with ﬁ nger pressure (prevents retraction of

testis).

• Palpate tissues superﬁ cial to external inguinal ring, working down to

scrotum.

• Try to manipulate testis into scrotum—then release.

• True retractile testis should remain in scrotum brieﬂ y.

• About 95% true retractile testes descend spontaneously before

puberty and require no follow-up (75% apparently retractile testes

become ‘ascending’).

Indications for orchidopexy

• Maximize sperm production.

• Prevent testicular torsion.

• Repair of associated inguinal hernia.

• Cosmesis.

• Reduce chance of malignancy development and improve

self-examination success.

CHAPTER 12 Paediatric surgery

452

Solid tumours of childhood

Neuroblastoma

• Commonest solid abdominal tumour of childhood.

• Spectrum of tumours derived from neuroblasts found in the adrenal

gland, along the sympathetic chain, or extra-adrenal sympathetic

tissues.

• Aggressive tumour with early spread to lymph glands, liver, bone

(cortex or marrow), orbits, and skin.

• Presents as painless large, abdominal mass in children <2y.

• May present as weight loss, hypertension, or metastatic disease.

• Urinary HMMA, HVA elevated.

• CT scan. Optimal investigation for suspected neuroblastoma.

• Treatment by combination of chemotherapy, surgery, and

radiotherapy.

• Survival of between 30 and 90%, depending on the site and stage

at presentation.

Nephroblastoma (Wilms’ tumour) of kidney

• Fast-growing tumour of the kidney.

• Ranges from benign mesoblastic nephroma of infancy to poorly

differentiated, malignant nephroblastoma in the older child.

• Malignant tumours frequently metastasize to regional lymph nodes,

liver, and lungs.

• Usually presents as a large, relatively painless abdominal mass in an

otherwise well child.

• Treatment by combination of chemotherapy, surgery, and radiotherapy

according to histology and spread at diagnosis.

• 5y survival:

Early stage, 90%.•

Disseminated disease, 30%.•

Rhabdomyosarcoma

• Tumour of striated muscle origin from the bladder, vagina, prostate,

parameningeal tissue, and limbs.

• Haematuria, vaginal bleeding, and the appearance of grape-like cysts

(sarcoma botryoides) at the vaginal introitus.

• Variable histology (embryonal is most favourable), which determines

the prognosis.

• Survival of up to 70% from surgery and chemotherapy.

Hepatoblastoma

• This presents as a right hypochondrial mass extending across the

midline.

• Chemotherapy may render initially inoperable tumours resectable.

• Depending on staging, size, and histology, survival of up to 70% is

possible.

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CHAPTER 12 Paediatric surgery

454

Neck swellings

Key facts

• Childhood neck lumps may be due to embryological abnormalities as

well as the same spectrum of conditions in adults (b pp. 222–226).

• Embryological abnormalities may relate to:

Descent of the thyroid from the foramen caecum of the tongue •

l thyroglossal cysts (b p. 222).

Formation of 2nd, 3rd, and 4th branchial arches and clefts •

l branchial cysts (b p. 224).

Formation of lymphatic vessels and veins • l cystic hygroma and

cavernous haemangiomata.

• 2 Lymphadenopathy is very common in children, but typically ‘waxes

and wanes’.

• 3 If lymphadenopathy persists for longer than 2 months and

measures >2cm diameter, it should be biopsied.

Causes and clinicopathological features

Thyroglossal cyst (b p. 222).

Branchial cysts (b p. 224).

Lymphadenopathy

• The neck contains large numbers of lymph glands draining areas of

potential infection in the mouth, nose, fauces, and ears.

• Common causes of lymphadenopathy include upper respiratory tract

infection, middle ear infections, tonsillitis, parotitis, dental abscess,

atypical mycobacterial infection.

• Malignant lymphadenopathy is much less common.

May be primary lymphoma.•

Secondary deposits, e.g. from neuroblastoma.•

Salivary gland swellings

• May be due to duct obstruction (stones or duct stenosis), infection

(mumps), autoimmune disorders (recurrent parotitis), neoplasia

(adenoma).

• Commonest in the submandibular, sublingual, and parotid glands.

Skin lesions

• Dermoid cysts. Usually in the midline above the hyoid bone and are

rarely infected.

• Sebaceous cysts. Epidermal origin with a small central punctum; may

occur anywhere, but most commonly on the scalp or back of the neck.

Lymphovascular lesions

• Haemangiomas. Can be mixed capillary or cavernous haemangiomas or

haemangioendotheliomas within the neck and parotid area; may grow

rapidly in size and lead to high output cardiac failure or even carotid

steal syndrome.

• Cystic hygroma (lymphangioma). Commonly in the posterior triangle of

the neck.

NECK SWELLINGS

455

Treatment

• Excision of dermoid cysts, sebaceous cysts, thyroglossal cysts, thyroid

neoplasms, salivary gland enlargements, lymph gland enlargements

(biopsy).

• Haemangioma. Supportive measures (intubation, steroids, interferon,

and emergency surgical intervention).

• Cystic hygroma. Sclerosant injection (OK 432—streptococcal

derivative), effective in lymphangiomas with few large cysts.

Differential diagnosis of neck lump

Neck lumps may be lateral or midline.

Lateral

• Lymph node

• Branchial sinuses and cyst

• Cystic hygroma

• Sternomastoid tumour

• Haemangioma

• Lymphangioma

• Submandibular gland

• Parotid gland

• Neoplasm

Midline

• Submental lymph nodes

• Thyroglossal cyst

• Thyroid swelling

• Dermoid cyst

Neck swellings by cause

Congenital

• Thyroglossal cysts

• Branchial cyst

• Cystic hygroma

• Haemangioma

• Dermoid cyst

Acquired

• Reactive lymphadenopathy

• Infective lymphadenopathy

• Secondary tumour deposits

Anatomy related to neck lump surgery

• Incisions should be parallel with skin creases (Langer’s lines).

• Subcutaneous closure should be meticulous (e.g. removable 4/0,

5/0, or 6/0 continuous subcuticular monoﬁ lament).

• Facial nerve. Passes between the two lobes of parotid gland.

• Lingual nerve. Swerves around submandibular duct.

• Thoracic duct. Enters junction of left subclavian and jugular veins.

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457

Paediatric orthopaedic

Developmental dysplasia of the hip (DDH) 458

Slipped upper femoral epiphysis (SUFE) 460

The limping child 462

The child with a fracture 464

Non-accidental injury (NAI) 466

Legg–Calvé–Perthes disease 468

Motor development 470

Club foot or congenital talipes equinovarus (CTEV) 471

Flat feet (pes planus) 472

The osteochondritides 474

Chapter 13

CHAPTER 13 Paediatric orthopaedic

458

Developmental dysplasia of

the hip (DDH)

DDH covers a spectrum of abnormalities from a mildly underdeveloped

stable hip to well-established dislocation and/or acetabular dysplasia in

the older child. The incidence is 1–2 per 1000 newborns in the UK. It is

bilateral in 20%. It was previously called congenital dysplasia of the hip

(CDH), but as it may also be acquired after birth, the term was changed.

Early detection is important.

Risk factors

• Family history. First-degree relative.

• Breech presentation at or after 36 weeks of gestation.

• Foot abnormalities. Congenital talipes calcaneovalgus and metatarsus

adductus.

• Oligohydramnios.

• Children with syndromes.

• Torticollis.

Clinical features

• Barlow test (dislocatable hip). It tests if a hip is unstable. Take the baby’s

leg between your thumb and index ﬁ nger and place your other ﬁ ngers

onto the buttock. Flex and adduct the hip. Posterior-directed force

is applied in line with the shaft of the femur. In case of instability, the

femoral head then subluxes or dislocates which you can palpate in the

buttock.

• Ortolani Sign (dislocated hip). Now abduct the leg. If the hip is

dislocated and reducible, you will feel the femoral head moving into

the joint. This often does not produce a palpable clunk.

• Irreducible hip.

Shortened leg.•

Limited hip abduction.•

Asymmetry of skin creases can be present; many children with •

normal hips have asymmetry of thigh and buttock skin creases.

Abnormal ﬁ ndings can prove easy to miss if the dislocations are bilateral.

Screening

All children with risk factors and an abnormal neonatal clinical hip exami-

nation have a hip ultrasound. The majority of hips are fully developed at

full term plus 6 weeks. Therefore, the ultrasounds of those children with

risk factors, but normal clinical ﬁ ndings, are done at that point. Those

children with obvious clinical abnormalities on hip examination have the

ultrasound done earlier.

Paton RW et al. reported in 2009 that there is no association between

postural and ﬁ xed talipes equinovarus and DDH.

Since it can be difﬁ cult

for non-paediatric orthopaedic surgeons to differentiate the different foot

abnormalities, it is continued to scan the hips of children with club feet.

Evidence shows that there is no advantage of universal baby hip screening

over selective at risk screening.

DEVELOPMENTAL DYSPLASIA OF THE HIP (DDH)

459

Radiology

• Ultrasound is the investigation of choice. Baby hip ultrasound

was pioneered by Dr Graf from Austria. It is more accurate than

radiographs. It visualizes the cartilage and allows dynamic testing of the

hip joint. A Graf alpha angle of t60° is classed as normal.

• Radiographs are taken in children who present late, usually after the

age of 6 months.

Treatment

• 0–6 months of age. A Pavlik harness is applied. This is a soft harness

which ﬂ exes the hips and knees and directs the legs away from

the body midline, thereby directing the femoral heads towards the

hip joints. It allows limited hip movements. It is used until the hips

normalize, which can take several months; it works 90% of times.

• 6–18 months. If the harness is unsuccessful or if a child is older than

6 months, they need a closed or open reduction of the hip joint and

hip spica cast immobilization. Some children need a hip adductor

tendon release in the groin and occasionally, a femoral osteotomy. A

removable hip abduction brace is used after spica removal.

• t18 months. These children usually need an open reduction of the hip

joint, a hip adductor release, and a femoral ± pelvic osteotomy and hip

spica immobilization. A hip abduction brace is normally not necessary

after hip spica removal because of the improved bone alignment.

Reference

1 Paton RW, Srinivasan MS, Shah B, et al. (1999). Ultrasound screening for hips at risk in develop-

mental dysplasia: is it worth it? J Bone Joint Surg Br. 81: 255–8.

CHAPTER 13 Paediatric orthopaedic

460

Slipped upper femoral epiphysis (SUFE)

This is reported to have an incidence of 4–7 per 100 000 population. It

is caused by the displacement of the femoral epiphysis (growth plate) in

relation to the femoral neck. It is the commonest cause of a limp in a boy

aged 12–14 or girl aged 11–13 (growth spurt at puberty). In this age group,

it must be actively excluded in a limping child.

Risk factors

• Obesity. Classic is the limping, obese, 13y-old boy with knee pain.

• Rapid growth.

• Hormone disturbances. Hypothyroidism, renal rickets, pituitary

deﬁ ciency, growth hormone deﬁ ciency, and treatment with it).

• Male—♂:♀, 3:1.

• Side affected. Left > right.

Classiﬁ cation

This is usually classiﬁ ed by the ability to weight bear on presentation.

• ‘Unstable’ slips cannot walk due to pain and present like a fracture.

• Diagnosis is easy.

• ‘Stable’ slips can weight bear, though usually with a limp.

• Presentation is usually late, i.e. after 2–3 weeks of limping.

• Fifty per cent will have no pain; pain is commonly referred to the knee.

2 Any child with knee pain must have there hip examined.

A summary of presentation and prognosis can be seen below.

Clinical features

• There will be an obvious limp, usually in an overweight child,

commonly male.

• The affected limb will be shorter and lies in external rotation.

• Abduction is limited; when the hip is ﬂ exed, it will rotate externally—

this sign is almost diagnostic of the condition.

Radiology

Anteroposterior and lateral views of BOTH hips should be insisted on. The

slip is often easier to see on the lateral view. The slip is in an inferior and

posterior direction (down and backwards). Widening of the physis may be

a sign of impending slip (i.e. ‘pre-slip’).

• Klein’s line giving Trethowan’s sign. If you draw a line on the superior

aspect of the femoral neck (called), it should cut through the femoral

head; if it does not, it is diagnostic of a SUFE (see Fig. 13.1).

Management

The acute slip (i.e. <3 weeks history) can be managed by gentle manipula-

tion and cannulated screw ﬁ xation in the reduced position. This is contro-

versial, however, as any manipulation may damage the already damaged

epiphysis and possibly cause avascular necrosis.

Standard treatment is stopping the slip from worsening and the slip is

usually pinned in situ (where it is with no manipulation) with one cannu-

lated screw percutaneously.

SLIPPED UPPER FEMORAL EPIPHYSIS (SUFE)

461

Deformed epiphysis can remodel by up to 60*. Residual deformity can

be corrected via an osteotomy once the epiphysis has fused if there is a

functional deﬁ cit.

The condition can be bilateral in some cases. This is much more likely if

there is an underlying endocrine disorder. Some surgeons advocate pro-

phylactic pinning of the unaffected side, but this is controversial.

Complications

• Avascular necrosis of femoral head.

• Chondrolysis. Rapid progressive loss of cartilage; joint space narrowing

is seen on X-ray.

• Subtrochanteric fracture. If pins entry point placed too low.

• Late osteoarthritis. Estimated 10%.

Further reading

Aronsson D, Loder RT, Breur GJ, Weinstein SL (2006). Slipped capital femoral epiphysis: current

concepts. J Am Acad Orthop Surg 14: 666–79.

Fig. 13.1 Normal (left) and Abnormal, i.e. SUFE (right) Klein’s lines.

CHAPTER 13 Paediatric orthopaedic

462

The limping child

The limping child is the acute abdomen of children’s orthopaedics. It can

be caused by many things, ranging from a stone in the shoe to leukaemia.

History

The most important initial question is, ‘Has the child always limped?’ If so,

the most common causes are:

• DDH (see b p. 458).

• Cerebral palsy.

• Limb length discrepancy from congenital disorders.

• Muscular dystrophy.

If there has been a normal gait and then the child starts to limp, then the

possibilities are highly varied. The main points to glean are:

• How long, what side, and what causes it? Is it constant or intermittent?

• Are there any associated complaints?

• Is there a history of trauma?

• How is the child’s general health?

• What is the child’s past medical and birth history?

Remember, what causes an older child to limp will cause a younger child

to refuse to weight bear. This will be perceived as more serious by the

parents and therefore, these patients will present much earlier.

Examination

• Look at the child walking. Decide on whether there is a limp! This is

often a symptom used by parents (and grandparents) to make sure

that you take their complaint seriously and a limp may not be the

problem at all.

• What type of limp is it?

Short leg• . Limb length discrepancy.

Antalgic• . Less time on affected than unaffected limb due to pain.

Trendelenberg• . Pelvis dips and trunk sways on affected side due to

weak hip abductors.

Bizarre• . Usually psychological, e.g. completely stiff leg.

• Tailor examination to history. Inspect limbs from hips to toes. Skin

discoloration may indicative of infection. Try to use distraction

techniques to get the true picture.

• Tenderness? Bony tenderness with swelling and bruising is a clinical

fracture. Infected areas will be painful and usually red, hot, or swollen.

• Joints. Concentrate joint examination as appropriate, but always

examine hips if knee pain present. Put all joints through full passive

range of motion.

• Limb lengths? Assess individual leg lengths with patient lying on the

couch with legs straight. Look for level of heels and malleoli. If one leg

is short, assess if discrepancy is within femur or tibia by ﬂ exing both

hips and knees together. Look at the legs from the side to see if the

front of the lower legs is at different levels (if yes—femoral shortening)

and/or if the front of the thighs are at different levels (if yes—lower leg

shortening).

THE LIMPING CHILD

463

• Lymphadenopathy? From generalized infection, local infection, or blood

disorder.

• Full systemic examination must also be performed.

Remember common things are common! The age of the patient is a very

useful screen (see Table 13.1).

Investigations

• X-ray. Always X-ray hips if no localizing signs. If one limb appears to

be involved, especially in the younger patient, then X-ray the whole

limb. Otherwise, X-ray bones/joints as appropriate from the clinical

examination.

• Blood tests. FBC, U&E, G, LFTs, CRP, ESR useful as full general screen.

Management Dependent on diagnosis reached.

Further reading

Sawyer JR, Kapoor M (2009). The limping child: a systematic approach to diagnosis. Am Fam Physician

79(3): 215–24. Available at: M http://www.aafp.org/afp/2009/0201/p215.html

Table 13.1 Screening using age of the patient

Young

(0–5y)

Child

(5–10y)

Adolescent

(10–15y)

All ages

DDH Perthes’ disease SUFE Septic arthritis

Septic hip Irritable hip AVN of

femoral head

Cellulitis

Limb length

discrepancy

Juvenile

rheumatoid

arthritis

Overuse

syndromes

Stress fracture

Occult fracture Non-accidental

injury (NAI)

Neoplasia

Neuromuscular

disease

CHAPTER 13 Paediatric orthopaedic

464

The child with a fracture

Accidents are part of normal life! Some, usually the more severe, result in

a fracture. In a city of 1 million inhabitants, there would be around 3000

children’s fractures annually.

Most childhood fractures are minor, almost half affecting the forearm.

They are weather-dependent, increasing in good weather when climbing

(and falling) is common.

Clinical features

• A clear history of trauma and a complaint of pain are present in all,

but a small number of patients. In a young child, however, the pain

may not be localized and instead of crying, they may present with

pseudoparalysis of a limb, limp, or refusal to weight bear.

• Look for external signs of injury. Bruising, due to a thick subcuticular fat

layer is not a constant feature. Palpate for tenderness unless there is a

clear deformity. Remember to examine the normal limb ﬁ rst and when

examining the affected side, start away from the injury. This will gain

the child’s conﬁ dence. If you’re going to do something that hurts them,

tell them rather than saying, ‘This won’t hurt’. If you lie to them, you

will lose their trust and make examination impossible.

• Neurovascular status. Check the distal capillary reﬁ ll and pulses as well

as distal neurology in the form of power and sensation. Document all

ﬁ ndings. It is good practice and also helps if there are any medicolegal

issues about treatment.

• Investigation. Though a fracture is a clinical diagnosis, this can

sometimes be difﬁ cult in the child. A low threshold for X-rays should

always be adopted. The joint above and below any injury must be

visualized with two perpendicular views being standard practice.

• Analgesia. Always splint an obvious fracture and give analgesia before

X-rays. If a limb is clearly deformed (hence fractured), then a plaster

should be applied before the X-ray. Radiographs of deformed limbs

out of splintage are unacceptable. This is also the case for adults!

• Unnecessary X-rays. Try to avoid ‘comparison’ views of the normal

side if you are unsure about radiological features. With growing bones,

ossiﬁ cation centres and epiphysis interpretation can be difﬁ cult. If you

are unsure about a feature, show the X-ray to a senior.

• Fractures. The classical fracture in a child is the greenstick injury. This is

when there is a fracture of one cortex and a plastic deformation (i.e. a

bend, not break) of the other at the same level. Even complete

fractures tend to displace far less in children as the periosteum in

children is highly structural, thick, and strong. It will hold the fracture

in rough approximation. In adults, the periosteum is a very weak

component of bone, hence the wider displacement.

Management

• Fractures usually unite. If there is a minor greenstick fracture with little

symptoms and no risk of displacement, then there is no need to apply

a plaster cast. However, this is not normally acceptable to parents

once they know their child has a broken limb.

THE CHILD WITH A FRACTURE

465

• In undisplaced, stable, greenstick fractures of the forearm, a ﬁ breglass

removable cast can be placed and the parents simply remove this in 4

weeks time with no need to be followed up in a clinic.

• Normally the joint above and below the fracture needs to be

immobilized. Often this is safer in children to ‘slow them down’

anyway. The fracture should be monitored in the fracture clinic. If a

plaster is placed, then clear plaster instructions, in the form of a

printed sheet, should be given to the parents. An example is shown

Box 13.1.

Box 13.1 Plaster instructions

Return to the Accident and Emergency Department or Plaster room if

your child complains of any of the following:

• Numbness or pins and needles in the affected limb.

• Restricted movement or tight swelling of the ﬁ ngers or toes.

• If the ﬁ ngers or toes go white or blue.

• If there is local itching, pain, or burning in the plaster.

• A string foul smell is coming from the plaster.

• The plaster becomes soft or loose.

Also, if the plaster is rubbing or digging in, this will irritate the skin and

cause blistering.

• Do NOT place anything down the plaster if it is itching. This will

cause skin damage or blisters and may cause an infection.

• Do NOT get the plaster wet.

• If the fracture is displaced or angulated, then it may require

manipulation or, less commonly, open reduction and ﬁ xation under

GA.

• Angulation, if close to the joint and in the plane of motion of the joint,

is very well tolerated. Remodelling of the bone will occur; a 15*

angulation in a child <6y old and 10* angulation in a child 6–10y old is

acceptable orthopaedically, though is often not accepted by the

parents! Rotational displacement will not remodel and needs

correction.

CHAPTER 13 Paediatric orthopaedic

466

Non-accidental injury (NAI)

Deﬁ nition

Physical violence towards a baby or child. It is one part of child abuse

which may occur in isolation or in combination with other forms of child

abuse, including neglect, emotional abuse and/or sexual abuse. It denotes

an injury that cannot be explained by an accident and where responsible

adults do not have a viable explanation of how the injury occurred.

Incidence

• The National Society for the Prevention of Cruelty to Children

(NSPCC) reported in 2011 that 46 700 children were at risk of abuse

in the UK.

• It is estimated that 4 million children a year are abused in some

manner in the USA.

• It happens in all socio-economic classes, but is more common in the

deprived. Twins, preterm babies, and special needs children are also at

increased risk.

• The majority of NAI fractures occur under 2y of age (80% of children

with NAI fractures are under 18 months of age). The majority of

accidental injuries occur in children over 5y of age (85%).

Suspicious features

• Inexplicable delay from time of injury to medical advice being sought.

• No convincing explanation of mechanism of injury.

• Patterns of soft tissue injury, e.g. bruising in the shape of ﬁ ngers or

objects (belt, buckles) or in unusual areas (back, away from bony

prominences), bites, and burns.

• Unusual fractures or fracture patterns, e.g. rib fractures, non-linear

skull fractures, transverse fractures of long bones, scapula, lateral

clavicle, and vertebral fractures.

• Fractures of differing ages on a radiograph.

• No fracture in isolation is pathognomonic of NAI.

• Rib, humeral, femoral, and skull fractures have the highest probability

for abuse. Rib fractures are present in 5–27% of children who are

abused. Diaphyseal fractures are four times more common than

metaphyseal fractures in NAI.

• Metaphyseal corner and bucket handle fractures. They are only

present in a minority of children who present with NAI (the reported

rates vary widely, 11–50%). Many references refer to them as

pathognomonic or speciﬁ c for NAI. However, a similar appearance can

occur with other conditions (e.g. severe osteogenesis imperfecta,

rickets, scurvy).

Corner fracture. A small piece of bone is avulsed due to shearing •

forces on the growth plate.

Bucket handle fracture (same as corner fracture). The fragment is •

larger and seen face on as a disc or bucket handle.

• Two or more fractures are present in 66–74% of abused children, but

only in 16% of non-abused children.

NON-ACCIDENTAL INJURY (NAI)

467

• Periosteal reactions are common features in NAI; a very strong grip

may cause such a reaction.

• Always keep NAI in mind when dealing with any child with trauma.

Examination

• A thorough history (this should be witnessed) and total body

inspection and examination from head to toes is mandatory. Enquire

about a history of fractures and deafness and look for blue sclera

(osteogenesis imperfecta). Examination of genitalia should only be

done by experts.

• Note how the child interacts with the carer/parent.

• Good communication and contemporaneous medical note writing is

essential since every case of child abuse will be submitted to court.

Management

• Contact consultant in charge, departmental child protection lead, and/

or hospital child protection team (paediatric consultant on call, child

protection practitioner).

• Hospital admission if NAI is suspected, even if the medical condition

does not require it.

• Skeletal survey (skull, chest, abdomen, upper and lower limbs). This

will be organized by paediatric team if NAI is suspected.

• Blood tests (FBC, clotting screen, bone proﬁ le, calcium, phosphate,

alkaline phosphatase, copper, caeruloplasmin, magnesium, fasting

25-hydroxyvitamin D, and parathyroid hormone).

• Every hospital has a policy dealing with safeguarding of children.

Differential diagnoses

• Osteogenesis imperfecta.

• Haemophilia.

• Birth trauma.

• Rickets.

• Leukaemia.

• Scurvy (mimics NAI).

CHAPTER 13 Paediatric orthopaedic

468

Legg–Calvé–Perthes disease

Deﬁ nition

Idiopathic avascular necrosis of the proximal femoral epiphysis, ﬁ rst

described independently by Legg, Calvé, and Perthes. The cause is

unknown. The epiphyseal changes can lead to permanent deformity and

osteoarthritis in adult life. The diagnosis is made on X-rays.

Key facts

• Age of onset most commonly between 4 and 10y of age. If both hips

look to be at the same stage, consider multiple epiphyseal dysplasia.

• ♂:♀, 5:1.

• 10–12% bilateral; the disease is usually at different stages.

• Females have poorer prognosis.

• Early onset up to age of 7y; late onset from age of 8y. The overall

prognosis is better in the early group.

Pathology/radiology

• Waldenström described four radiographic stages—ischaemia,

fragmentation, reossiﬁ cation, remodelling.

Ischaemia.• Compromise of blood supply of the femoral head. The

articular cartilage still grows as it is nourished by the joint ﬂ uid,

resulting in increased joint space and apparent mild joint subluxation

on X-ray (Waldenström’s sign); the head ceases to enlarge.

Fragmentation/resorption.• New bone is laid down on the dead

trabeculae, causing increased bone density. Subchondral fractures

may occur, causing a black subchondral line (crescent sign). The

hyperaemia and revascularization causes bone lysis and rareﬁ cation,

giving a fragmented appearance on the X-rays.

Reossiﬁ cation (healing phase).• The head is plastic and if it is not

concentrically contained within the acetabulum, it will become

deformed.

Remodelling.• The plasticity is lost and the femoral head shape will

remain. The normal internal architecture will return, but inside an

altered shape if this has occurred. Deformity will lead to arthritis.

• With non-operative treatment, revascularization and reossiﬁ cation

takes 2–3y to complete in most cases.

• Herring’s lateral pillar classiﬁ cation. Now generally used at

presentation (Catterall in the past). Groups A, B, C; a B/C group

added later.

Group A• . The lateral column of the proximal femoral epiphysis is of

normal height.

Group B• . The height is reduced, but >50% of the height on the

other side.

Group C• . The height is reduced to <50% compared to the other

side.

Group B/C• . Lateral pillar is narrowed (2–3mm) or poorly ossiﬁ ed

with approximately 50% height.

LEGG–CALVÉ–PERTHES DISEASE

469

• Stulberg classiﬁ cation. Describes the end stage of the disease at

skeletal maturity.

I. Normal spherical femoral head.•

II. Round femoral head and ﬁ tting within 2mm of a circle on both •

anteroposterior and lateral radiographs.

III. Out of round by >2mm on either radiograph.•

IV. Flat head and matching ﬂ at acetabulum (aspherical congruency).•

V. Flat head with non-matching acetabulum (aspherical •

incongruency).

• Catterall classiﬁ cation (grades 1–4; 1, 25% head involvement; 2, 50%; 3,

75%; 4, >75%). Superseded by lateral pillar classiﬁ cation. He described

ﬁ ve head-at-risk signs (Gage’s sign—V-shaped lucency at lateral

epiphysis, horizontal growth plate, lateral calciﬁ cation, subluxation,

metaphyseal cystic changes). Foster reported poor reliability for

head-at-risk signs.

Clinical features

• Painless limp is common.

• There may be pain in groin, inner thigh, and/or or only in the knee.

• Again, every child with knee pain must have their hip examined.

• Reduced hip abduction and internal rotation might be examined.

Management

• Overall very controversial.

• Annamalai et al. (2007)

showed a great deal of variability in the UK in

the decision-making process and treatment.

• Non-operative symptomatic relief for the majority of patients.

Physiotherapy/exercises; observation and serial radiographs.

• Largest multicentre centre conducted in America by Herring et al.

2,3

comparing non-operative management with operative management (either

femoral varus or pelvic osteotomy) for early and late onset groups.

Early onset group. No difference in outcome between •

non-operative management, femoral varus, or pelvic osteotomy.

Late onset group. Improved outcome for lateral pillar groups B and •

B/C with either femoral varus or pelvic osteotomy over

non-operative group; no difference for groups A and C.

• Containment surgery has been advocated by others when the femoral

head extrudes from the acetabulum irrespective of age (the femoral

head is maintained within the depth of the acetabulum with femoral

osteotomy, pelvic osteotomy, or both combined).

Bracing is not used by the majority of paediatric orthopaedic surgeons as

part of management of Legg–Calvé–Perthes disease.

References

1 Annamalai et al. (2007). Perthes disease: a survey of management amongst members of the

British Society for Children’s Orthopaedic Surgery (BSCOS). J Child Orthop 1(2): 107–13.

2 Herring JA, Kim HT, Browne R. Legg-Calvé-Perthes Disease. (2004). Part I: Classiﬁ cation of

radiographs with the use of the modiﬁ ed lateral pillar and Stulberg classiﬁ cations. J Bone Joint

Surg Am 86-A: 2103–20.

3 Herring JA, Kim HT, Browne R. Legg-Calvé-Perthes Disease. (2004). Part II: Prospective multi-

center study of the effect of treatment on outcome. J Bone Joint Surg Am 86-A: 2121–34.

CHAPTER 13 Paediatric orthopaedic

470

Motor development

Most children develop at roughly the same pace. Development is eas-

ier to understand if you realize that it will spread from head to feet, i.e.

cephalocaudal.

Maturation of the nervous system occurs so that a child is able to do

things more distally, the older they become. Fig. 13.2 summarizes this with

some common ‘milestones’ of development.

Motor milestone

3456789101112

walking alone

Standing alone

Walking with assistance

Hands & knees crawling

Standing with assistance

Sitting without support

Age in months

13 14 15 16 17 18 19 20 21

Fig. 13.2 WHO Multicentre Growth Reference Study Group (2006). WHO

motor development study: windows of achievement for six gross motor

development milestones. Acta Paediatrica Supplement 450: 86–95.

CLUB FOOT OR CONGENITAL TALIPES EQUINOVARUS (CTEV)

471

Club foot or congenital talipes

equinovarus (CTEV)

Club foot is a congenital condition that presents at birth and may be iso-

lated or part of a more widespread congenital disorder. Its incidence is

approximately 1 in 1000 live births in the UK with a ♂:♀ ratio of 2:1. The

cause is unknown.

It occurs with other neuromuscular disorders such as:

• Arthrogryphosis.

• Myotonic muscular dystrophy.

• Myelomeningocele and other spinal dysraphisms (spina biﬁ da).

• Cerebral palsy.

2 Always perform a thorough examination of the hip and back to rule out

other disorders/syndromes that might be associated with a club foot.

Clinical features

The hindfoot is plantar ﬂ exed (equinus) and in varus. There is midfoot and

forefoot cavus and forefoot adduction. The forefoot looks supinated, but

is actually pronated in relation to the midfoot. Overall, the foot is turned

and twisted inwards so that the sole is facing towards the midline and

backwards. In the true clubfoot deformity, the deformity is ﬁ xed to a vary-

ing degree. In the positional clubfoot deformity, the deformity is passively

correctable and usually does not require any treatment.

Management

The cornerstone of treatment is to create a supple foot that is

plantigrade that will allow the child to function well.

Treatment has been revolutionalized by the use of the Ponseti method

of casting which can be performed in the outpatients. This is often run by

specialist nurses/physiotherapy practitioners who work closely with the

paediatric orthopaedic team.

Serial casts are applied that stretch the contracted tissues back to nor-

mal in a deﬁ ned order. First, you correct the adduction and cavus, which

also corrects the hindfoot varus and ﬁ nally, the equines. About 80% of

clubfeet need a percutaneous Achilles tendon tenotomy to correct the

equinus.

The initial casting period goes over about 6 weeks with weekly cast

changes. At the end of this period, the Achilles tenotomy is performed if

necessary, followed by a further 3 weeks in cast. Thereafter, the feet are

immobilized 23h/day with boots on a bar for 3 months and then only dur-

ing the night until the age of 4–5y. Some children require a tibialis anterior

tendon transfer when they are about 4–5y old because of a dynamic supi-

nation deformity. Recurrences are usually the result of non-compliance

or if the child has a syndromic clubfoot.

CHAPTER 13 Paediatric orthopaedic

472

Flat feet (pes planus)

There are always one or two children in every orthopaedic paedi-

atric new patient clinic with ﬂ at feet. The children rarely complain of

symptoms and the appearance and referral is often sparked by the

parents.

Clinical features

Like all paediatric consultations, take an accurate neonatal, birth, and fam-

ily history to look for associated problems. The cornerstone is whether

the foot deformity is ﬂ exible (vast majority) or rigid.

2 Flexible ﬂ at feet correct fully once the big toe is extended and the arch

reforms and when the child stands on tip toes.

Ensure you examine the ankle and Achilles tendon as this often causes

a ‘compensatory’ ﬂ at foot due to the stiffness and is easily remedied by

physiotherapy.

Natural history

The majority of children form normal foot arches by the age of about 3y.

In some, the arches never form and they remain ﬂ atfooted.

Management

Flexible ﬂ at feet generally need simple reassurance and the patient can be

discharged. Some children with more severe ﬂ at feet beneﬁ t at times from

the use of insoles since insoles improve the mechanical leg alignment. This

applies, for example, to children who present with knee pain and moder-

ate to severe ﬂ at feet where the feet are in a pronated position when

standing. Tight Achilles tendons need physiotherapy.

Rigid ﬂ at feet are associated with an underlying abnormality such as:

• Congenital vertical talus (from birth).

• Tarsal coalition. Fusing of some part of the tarsal bones via scar or

bone (often adolescents).

• Inﬂ ammatory joint disease.

Treatment is centred on the underlying disorder, i.e. tarsal coalition

is often treated by ofﬂ oading the area with orthotics and if this fails,

attempts can be made to surgically resect the ﬁ brous or bony coalition.

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CHAPTER 13 Paediatric orthopaedic

474

The osteochondritides

These conditions result in avascular necrosis of epiphyseal bone, similar to

Legg–Calvé–Perthes disease, but less common. In general, they are trou-

blesome rather than serious. Some are self-limiting.

Features

Most lead to aching and muscle spasm. Radiographic changes occur

in the affected epiphysis, with varying degrees of density change and

fragmentation.

Epiphyses commonly affected are:

• Lateral condyle of the humerus (Panner’s disease).

• Carpal lunate (Kienbock).

• Carpal scaphoid (Preiser).

• Head of metatarsal (Freiberg).

• Tarsal navicular (Kohler).

• Patella (Larsen–Johanssen).

• Vertebral epiphyseal plates (Scheuermann).

• Vertebral body (Calvé).

Management

Usually symptomatic with limitation of activities and anti-inﬂ ammatory

medication.

Traction apophysitis

An apophysis is a traction epiphysis which may undergo partial avulsion

with avascular change followed by subsequent repair. These changes can

be the result of trauma, overuse, or rapid growth. The commonest are:

• Osgood–Schlatter’s disease. Apophysitis of the tibial tubercle into which

the patellar tendon inserts.

• Sever’s disease. Apophysitis of the apophysis at the posterior aspect of

the calcaneum where the Achilles tendon inserts.

Clinical features

The patient is usually an adolescent who presents with aching, swelling,

and/or pain.

Radiology

Radiographs show fragmentation of the tibial tuberosity/calcaneal

apophysis.

Treatment

Explanation of the condition; limitation of activities; anti-inﬂ ammatory

medication. Plaster immobilization for 4–6 weeks can be helpful in severe

cases. Temporary use of a cushioned heel support for Sever’s disease can

be helpful.

THE OSTEOCHONDRITIDES

475

Osteochondritis dissecans of the knee

• Avascular necrosis of the subchondral bone, resulting in softening of

the articular cartilage and bone that may become loose and separated

from the rest of the femoral condyle. The cause is unknown, but it is

thought that it might be the result of repetitive minor trauma.

• Most lesions are located on the lateral side of the medial femoral

condyle, but any joint can be affected.

• Children between 5 and 15y of age are most commonly affected with

the majority occurring in teenage boys.

Clinical features

• Non-speciﬁ c knee pain.

• If the fragment has become loose, the patient will report crepitance,

popping, giving way, and/or locking.

Natural history

In children and adolescents, spontaneous healing over about 18 months is

the usual outcome. Patients with more advanced lesions have an increased

risk to develop early osteoarthritis.

Investigations

• Radiographs. The tunnel view will show the lesion the best.

• MRI. The scan shows extent of the lesion and, if there is detachment,

with ﬂ uid interposition between fragment and underlying bone.

Management

• Activity restriction for the majority of cases.

• Unstable lesions require arthroscopic stabilization.

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477

Major trauma

Management of major trauma 478

Thoracic injuries 480

Abdominal trauma 482

Vascular injuries 484

Head injuries 486

Chapter 14

CHAPTER 14 Major trauma

478

Management of major trauma

Key facts

• Trauma is the leading cause of death in the ﬁ rst four decades of life,

but three people are permanently disabled for every one killed.

• Death from injury occurs in one of three time periods (trimodal).

First peak• . Within seconds to minutes. Very few can be saved due

to severity of their injuries.

Second peak• . Within minutes to several hours. Deaths occur due to

life-threatening injuries.

Third peak• . After several hours to weeks. Deaths from sepsis and

multiple organ failure.

• The ‘golden hour’ refers to the period when medical care can make

the maximum impact on death and disability. It implies the urgency and

not a ﬁ xed time period of 60min.

The advanced trauma life support (ATLS) system

• Accepted as a standard for trauma care during the ‘golden hour’ and

focuses on the ‘second peak’.

• Emphasizes that injury kills in certain reproducible time frames in a

common sequence: loss of airway, inability to breathe, loss of

circulating blood volume, expanding intracranial mass.

• The primary survey (ABCDEs) with simultaneous resuscitation is

emphasized.

Prehospital care and the trauma team

• Effort is made to minimize scene time, emphasizing immediate

transport to the closest appropriate facility (scoop and run).

• Hospital is informed of the impending arrival of the casualty.

• Trauma team usually comprises an anaesthetist, ‘general’ surgeon,

orthopaedic surgeon, and A&E specialist, A&E nurses, and

radiographers.

• Information from paramedics should include Mechanism of injury, Injuries

identiﬁ ed, vital Signs at scene, and any Treatment administered (MIST).

• Triage is the process of prioritizing patients according to treatment

needs and the available resources (those with life-threatening

conditions and with the greatest chance of survival are treated ﬁ rst).

Management

Primary survey

Identify and treat life-threatening conditions according to priority (ABCDE).

Airway maintenance with cervical spine protection

• Protect spinal cord with immobilization devices or using manual in-line

immobilization. Protect until cervical spine injury is excluded.

• Access airway for patency. If patient can speak, airway is not

immediately threatened.

• Consider foreign body and facial, mandibular, or tracheal/laryngeal

fractures if unconscious. Perform chin lift/jaw thrust. Consider

nasopharyngeal/oropharyngeal airway.

MANAGEMENT OF MAJOR TRAUMA

479

• If patient unable to maintain airway integrity, secure a deﬁ nitive airway

(orotracheal, nasotracheal, cricothyroidotomy).

Breathing and ventilation

• Administer high-ﬂ ow O

using a non-rebreathing reservoir.

• Inspect for chest wall expansion, symmetry, respiratory rate, and

wounds. Percuss and auscultate chest. Look for tracheal deviation,

surgical emphysema.

• Identify and treat life-threatening conditions: tension pneumothorax,

open pneumothorax, ﬂ ail chest with pulmonary contusion, massive

haemothorax.

Circulation with haemorrhage control

• Look for signs of shock.

• Hypotension is usually due to blood loss. Think: chest, abdomen,

retroperitoneum, muscle compartment, open fractures (‘blood on the

ﬂ oor and four more’).

• Control external bleeding with pressure.

• Obtain IV access using two 12G cannulae. Send blood for cross-match,

FBC, clotting, U&E.

• Commence bolus of warmed Ringer’s lactate solution; unmatched,

type-speciﬁ c blood only for immediate life-threatening blood loss.

• Consider surgical control of haemorrhage (laparotomy, thoracotomy).

Disability

• Perform a rapid neurological evaluation. AVPU method (Alert,

responds to Vocal stimuli, responds only to Painful stimuli,

Unresponsive to all stimuli), Glasgow coma scale (GCS).

• After excluding hypoxia and hypovoleamia, consider changes in level of

consciousness to be due to head injury.

Exposure/environment control

• Undress patient for through examination.

• Prevent hypothermia by covering with warm blankets/warming device.

Use warm IV ﬂ uids.

Adjuncts to primary survey

• Monitoring. Pulse, non-invasive BP, ECG, pulse oximetry.

• Urinary catheter (after ruling out urethral injury).

• Diagnostic studies. X-rays (lateral cervical spine, AP chest, and AP

pelvis), ultrasound scan, CT scan, diagnostic peritoneal lavage.

Secondary survey

Begin only after primary survey is complete and resuscitation is continuing

successfully.

• Take history. AMPLE (Allergy, Medication, Past medical history, Last

meal, Events of the incident).

• Perform a head-to-toe physical examination.

• Continue reassessment of all vital signs.

• Perform specialized diagnostic tests that may be required.

CHAPTER 14 Major trauma

480

Thoracic injuries

Key features

• Thoracic injuries account for 25% of deaths from trauma.

• Fifty per cent of patients who die from multiple injuries also have a

signiﬁ cant thoracic injury.

• Open injuries are caused by penetrating trauma from knives or

gunshots. Closed injuries occur after blasts, blunt trauma, and

deceleration. (Road trafﬁ c accidents (RTAs) are the most common

cause.)

Management—primary survey

Identify and treat major thoracic life-threatening injuries.

Tension pneumothorax

• A clinical diagnosis. There is no time for X-rays.

• Patient has respiratory distress, is tachycardic and hypotensive.

• Look for tracheal deviation, decreased movement, hyperresonant

percussion note, and absent breath sounds over affected hemithorax.

• Treat with immediate decompression. Insert a 12G cannula into the

second intercostal space in the mid-clavicular line. Follow this with

insertion of an underwater seal chest drain into the ﬁ fth intercostal

space between the anterior and mid-axillary line.

Open pneumothorax

• Occlude with a three-sided dressing.

• Follow by immediate insertion of an intercostal drain through a

separate incision.

Flail chest

• Results in paradoxical motion of the chest wall. Hypoxia is caused by

restricted chest wall movement and underlying lung contusion.

• If the segment is small and respiration is not compromised, nurse

patient in HDU with adequate analgesia. Encourage early ambulation

and vigorous physiotherapy. Do regular blood gas analysis.

• In more severe cases, endotracheal intubation with positive pressure

ventilation is required.

Massive haemothorax

• Accumulation of >1500mL of blood in pleural cavity.

• Suspect when shock is associated with dull percussion note and absent

breath sounds on one side of chest.

• Simultaneously restore blood volume and carry out decompression by

inserting a wide bore chest drain.

• Consider need for urgent thoracotomy to control bleeding if there is

continued brisk bleeding and need for persistent blood transfusion.

Consult with a regional thoracic centre.

THORACIC INJURIES

481

Cardiac tamponade

• Most commonly results from penetrating injuries, but blood can also

accumulate in pericardial sac after blunt trauma.

• Recognize by haemodynamic instability. Hypotension, tachycardia,

raised JVP, pulsus paradoxus, and faint heart sounds.

• If critically ill with suspected tamponade, perform ‘blind’

pericardiocentesis and call cardiothoracic or general surgeons to

consider emergency thoracotomy.

• If unwell, but responding to treatment, arrange urgent transthoracic

echo or focused abdominal ultrasound in A&E.

Management—secondary survey

Perform a further in-depth examination. In stab injuries, expose the

patient fully and position them so that you can assess front, back, and sides

of the chest for any wounds missed in the primary survey.

An erect CXR looking for the following injuries.

Simple pneumo-/haemothorax Treat with a chest drain if large or sympto-

matic or in any patient likely to undergo GA.

Pulmonary contusion Most common potentially lethal chest injury. Risk of

worsening associated consolidation and local pulmonary oedema. Treat

with analgesia, physiotherapy, and oxygenation. Consider respiratory sup-

port for a patient with signiﬁ cant hypoxia.

Tracheobronchial rupture

• Suspect when there is persistent large air leak after chest drain

insertion. Seek immediate (cardiothoracic) surgical consultation.

• Thoracic CT scan usually diagnostic.

Blunt cardiac injury (myocardial contusion/traumatic infarction)

• Suspect when there are signiﬁ cant abnormalities on ECG or

echocardiography.

• Seek cardiological/cardiothoracic surgical advice.

Aortic disruption

• Patients survive immediate death because the haematoma is contained.

• Suspect when history of decelerating force and where there is

widened mediastinum on CXR.

• Thoracic CT scan is diagnostic.

• Consider cardiothoracic surgical referral.

Diaphragmatic rupture

• Usually secondary to blunt trauma in restrained car passengers (seat

belt compression causes ‘burst’ injury commonly on the left side).

• Suspect in patient with a suitable history and a raised left

hemidiaphragm on CXR.

• Penetrating trauma below the ﬁ fth intercostal space can produce a

perforation.

• Thoracoabdominal CT scan usually diagnostic.

CHAPTER 14 Major trauma

482

Abdominal trauma

Key features

• Abdominal injuries are present in 7–10% of trauma patients. These

injuries, if unrecognized, can cause preventable deaths.

• Blunt trauma. Most frequent injuries are spleen (45%), liver (40%), and

retroperitoneal haematoma (15%). Blunt trauma may cause:

Compression or crushing, causing rupture of solid or hollow •

organs.

Deceleration injury due to differential movement of ﬁ xed and •

non-ﬁ xed parts of organs, causing tearing or avulsion from their

vascular supply, e.g. liver tear and vena caval rupture.

• Blunt abdominal trauma is very common in RTAs where:

There have been fatalities.•

Any casualty has been ejected from the vehicle.•

The closing speed is >50mph.•

• Penetrating trauma. These may be:

Stab wounds and low velocity gunshot wounds. Cause damage •

by laceration or cutting; stab wounds commonly involve the liver

(40%), small bowel (30%), diaphragm (20%), colon (15%).

High velocity gunshot wounds transfer more kinetic energy and also •

cause further injury by cavitation effect, tumble, and fragmentation;

commonly involve the small bowel (50%), colon (40%), liver (30%),

and vessels (25%).

Management—primary survey

• Any patient persistently hypotensive despite resuscitation, for whom

no obvious cause of blood loss has been identiﬁ ed by the primary

survey, can be assumed to have intra-abdominal bleeding.

• If the patient is stable, an emergency abdominal CT scan is indicated.

• If the patient remains critically unstable, an emergency laparotomy is

usually indicated.

Management—secondary survey of the abdomen

History

• Obtain from patient, other passengers, observers, police, and

emergency medical personnel.

• Mechanism of injury. Seat belt usage, steering wheel deformation,

speed, damage to vehicle, ejection of victim, etc. in automobile

collision; velocity, calibre, presumed path of bullet, distance from

weapon, etc. in penetrating injuries.

• Prehospital condition and treatment of patient.

Physical examination

• Inspect anterior abdomen which includes lower thorax, perineum, and

log roll to inspect posterior abdomen. Look for abrasions, contusions,

lacerations, penetrating wounds, distension, evisceration of viscera.

• Palpate abdomen for tenderness, involuntary muscle guarding, rebound

tenderness, gravid uterus.

ABDOMINAL TRAUMA

483

• Auscultate for presence/absence of bowel sounds.

• Percuss to elicit subtle rebound tenderness.

• Assess pelvic stability.

• Penile, perineum, rectal, vaginal examinations, and examination of

gluteal regions.

Investigations

Blood and urine sampling Raised serum amylase may indicate small bowel

or pancreatic injury.

Plain radiography Supine CXR is unreliable in the diagnosis of free intra-

abdominal air.

Focused abdominal sonography for trauma (FAST)

• It consists of imaging of the four Ps. Morrison’s pouch, pouch of

Douglas (or pelvic), perisplenic, and pericardium.

• It is used to identify the peritoneal cavity as a source of signiﬁ cant

haemorrhage.

• It is also used as a screening test for patients without major risk

factors for abdominal injury.

Diagnostic peritoneal lavage (DPL)

• Mostly superseded by FAST for unstable patients and CT scanning in

stable patients. Useful, when these are inappropriate or unavailable, for

the identiﬁ cation of the presence of free intraperitoneal ﬂ uid (usually

blood).

• Aspiration of blood, GI contents, bile, or faeces through the lavage

catheter indicates laparotomy.

• The investigation of choice in haemodynamically stable patients in

whom there is no apparent indication for an emergency laparotomy.

• It provides detailed information relative to speciﬁ c organ injury and its

extent and may guide/inform conservative management.

Indications for resuscitative laparotomy Blunt abdominal trauma.

Unresponsive hypotension despite adequate resuscitation and no other

cause for bleeding found.

Indications for urgent laparotomy

• Blunt trauma with positive DPL or free blood on ultrasound and an

unstable circulatory status.

• Blunt trauma with CT features of solid organ injury not suitable for

conservative management.

• Clinical features of peritonitis.

• Any knife injury associated with visible viscera, clinical features of

peritonitis, haemodynamic instability, or developing fever/signs of

sepsis.

• Any gunshot wound.

CHAPTER 14 Major trauma

484

Vascular injuries

Key features

• Wounds that involve vascular structures of the extremity are a

signiﬁ cant cause of morbidity and mortality in the traumatized patient.

• Motor vehicle accidents and falls are the most common causes of

blunt injury.

• Stab wounds cause most of the upper extremity vascular injuries,

while gunshot wounds cause the majority of lower extremity vascular

injuries in penetrating vascular injury.

• Blunt trauma causes more morbidity than penetrating injuries due to

associated fractures, dislocations, and crush injuries to muscles and

nerves.

Management—primary survey

• Apply direct pressure to open haemorrhaging wound.

• Carry out aggressive ﬂ uid resuscitation.

• A rapidly expanding haematoma suggests a signiﬁ cant vascular injury.

• Realign and splint any associated fracture. Immobilize dislocated joint.

• Seek surgical consultation.

Management—secondary survey

• Begin only after primary survey is complete and resuscitation is

continuing successfully.

• Identify limb-threatening injuries.

• Look for hard or soft signs of vascular injury:

‘Hard’ signs are massive external blood loss, expanding or pulsatile •

haematoma, absent or diminished distal pulses, and a thrill or

audible continuous murmur.

‘Soft’ ﬁ ndings are history, if active bleeding at the accident scene, •

proximity of penetrating or blunt trauma to a major artery, small

non-pulsatile haematoma, and neurological deﬁ cit.

• Measure distal systolic Doppler pressures of the injured arm or leg and

compare with uninjured brachial systolic pressure. An index of <1.0 is

a predictor of arterial injury.

• Presence of hard signs requires immediate operative intervention or

arteriography when limb is viable and active bleeding is absent.

Intraoperative arteriography helps in planning the operative approach.

Some minimal arterial injuries can be managed non-operatively.

Embolization can be used to manage selected arterial injuries.

Principles of operative management

• Obtain proximal and distal control prior to exposing the injury.

• Inspect the injured vessel and debride as necessary.

• Remove intraluminal thrombus by using Fogarty catheter.

• Flush lumen with heparinized normal saline solution.

• Consider temporary intraluminal shunting if limb is ischaemic and there

is a delay (if revascularization is anticipated).

VASCULAR INJURIES

485

• The type of vascular repair depends on the extent of damage.

Techniques used are lateral repair, patch angioplasty, end-to-end

anastomosis, interposition graft, or bypass graft.

• Use systemic anticoagulation if there is no contraindication.

• Consider intraoperative completion arteriography.

• Ensure completed vascular repair is free of tension and covered with

viable soft tissue.

• In patients with combined vascular and orthopaedic injuries, perform

arterial repair ﬁ rst to restore circulation before orthopaedic

stabilization. Where there is massive soft tissue injury, debride all

non-viable tissue.

• Anticipate development of compartment syndrome. Perform

fasciotomies to decompress all four compartments of the leg.

CHAPTER 14 Major trauma

486

Head injuries

Causes and features

• Most common reasons for head injuries—falls, RTAs, and assaults.

• About 80% of head injuries are mild, 10% moderate, and 10% severe.

• Up to half of the deaths from trauma under the age of 45 are due to

a head injury. Sequelae are common in survivors.

Management—primary survey

• Maintain adequate oxygenation and BP. This avoids potentially

devastating secondary brain injury.

• Determine consciousness level on the AVPU or GCS (see Table 14.1;

use a standard head injury proforma).

• Involve anaesthetist to provide appropriate airway management in

patients with GCS <8 or AVPU = P or U.

• Avoid systemic analgesia until full neurological assessment made.

Management—secondary survey

• Fully assess the head and neck including:

Examination of skull vault.•

Looking for signs of base of skull fractures (haemotympanum,•

‘panda’ eyes, cerebrospinal ﬂ uid (CSF) otorrhoea or rhinorrhoea,

Battle’s sign).

Repeated monitoring of vital signs.•

Repeated assessment of conscious level (GCS or AVPU).•

• Follow guidelines when transferring patients to the neurosurgical unit.

Ensure resuscitation and stabilization of patient is complete before

transfer.

• Give verbal advice and a written head injury advice card to patients

who are being discharged from A&E.

Indications for CT scanning in head injuries

• GCS <13 at any point since the injury; GCS = 13 or 14 at 2h after

the injury.

• Suspected open or depressed skull fracture.

• Any sign of basal skull fracture.

• Post-traumatic seizure.

• Focal neurological deﬁ cit.

• More than one episode of vomiting.

• Amnesia for greater than 30min of events before impact.

• Age t65y, coagulopathy, dangerous mechanism of injury, provided

that some loss of consciousness or amnesia has been experienced.

HEAD INJURIES

487

Indications for neurosurgical referral in head injuries

• Major intracranial injury (extradural haematoma, moderate or larger

subdural haematoma, intracerebral haematoma).

• Progressive focal neurological signs.

• Deﬁ nite or suspected penetrating head injury.

• A CSF leak or base of skull fracture.

• Persisting coma (GCS d8) after initial resuscitation or deterioration

in GCS score after admission.

Indications for admission in head injuries

• Patients with new, clinically signiﬁ cant abnormalities on imaging.

• Patient has not returned to GCS = 15 after imaging, regardless of the

imaging results.

• Patient fulﬁ ls the criteria for CT scanning, but this cannot be done

within the appropriate period, either because CT is not available or

because the patient is not sufﬁ ciently cooperative to allow scanning.

• Continuing worrying signs, e.g. persistent vomiting, severe

headaches.

• Other sources of concern, e.g. drug or alcohol intoxication, other

injuries, shock, suspected non-accidental injury, meningism, CSF leak.

CHAPTER 14 Major trauma

488

Table 14.1 Glasgow coma scale*

Feature Scale Score

Eye opening (E) Nil 1

In response to pain 2

In response to speech 3

Spontaneous 4

Motor response (M) Nil 1

Extension 2

Abnormal ﬂ exion 3

Flexion away from pain 4

Localizes pain 5

Obeys commands 6

Verbal response (V) Nil 1

Sounds 2

Inappropriate words 3

Confused sentences 4

Orientated fully 5

* Minimum score, 3; maximum score, 15.

Reproduced from Teasdale, G. and Jennett, B. (1974). The Lancet, 304: 7872, with kind

permission from Elsevier.

489

Orthopaedic surgery

Examination of a joint 490

Examination of the limbs and trunk 492

Fracture healing 494

Reduction and ﬁ xation of fractures 498

The skeletal radiograph 502

Injuries of the phalanges and metacarpals 504

Wrist injuries 508

Fractures of the distal radius and ulna 510

Fractures of the radius and ulnar shaft 512

Fractures and dislocations around the elbow in children 514

Fractures of the humeral shaft and elbow in adults 518

Dislocations and fracture dislocations of the elbow 522

Fractures around the shoulder 524

Dislocations of the shoulder region 526

Fractures of the ribs and sternum 530

Fractures of the pelvis 532

Femoral neck fractures 536

Femoral shaft fractures 538

Fractures of the tibial shaft 540

Fractures of the ankle 544

Fractures of the tarsus and foot 546

Injuries and the spinal radiograph 550

Spinal injuries 554

Acute haematogenous osteomyelitis 558

Chronic osteomyelitis 560

Septic arthritis 562

Peripheral nerve injuries 564

Brachial plexus injuries 566

Osteoarthrosis (osteoarthritis) 568

Carpal tunnel syndrome 570

Ganglion 572

Bone tumours 574

Low back pain 578

Paget’s disease (osteitis deformans) 582

The great toe 584

Arthroplasty 586

Useful reading 588

Chapter 15

CHAPTER 15 Orthopaedic surgery

490

Examination of a joint

• Applying a systematic approach will avoid missing vital clues.

• Always begin with a history, followed by examination.

• The classical orthopaedic triad of ‘look, feel, and move’ applies.

• Remember to examine the patient as a whole, not just the joint!

Ask

• Is the joint painful?

• Is there a speciﬁ c area of tenderness?

• Does the pain radiate?

• Is the joint swollen?

• Can the joint be moved actively?

• Has there been an injury to the joint?

Look

• Remember, always compare unaffected with affected side.

• Is there any swelling? If so, is it an effusion, synovitis, or bony

deformity?

• Are there any colour changes? Bruising or erythema?

• Is there any skin involvement, i.e. rheumatoid nodules at elbow,

psoriatic plaques?

• Are there any scars? If so, are they traumatic, surgical, or infective?

• Look for muscle wasting, generally around the joint and speciﬁ cally in

the whole limb.

• Examine the patient as a whole for clues to the disease process at the

joint.

Feel

• Always gain verbal consent and explain what you are doing to the

patient.

• Examine the unaffected or least painful side prior to examining the

affected side.

• Is the joint hot, cold, or moist?

• Is there any local tenderness? Look at the patient’s face, not the joint.

• Is the joint swollen? An effusion can occur after trauma

(haemarthrosis) or with infection (septic arthritis). Does the ﬂ uid shift

with sweeping? Is synovitis present (non-movable ﬂ uid feel), or is it a

bony swelling?

Move

• Compare affected with unaffected side.

• Test active movements ﬁ rst before passive. This gives an idea of the

patient’s pain and reduces further discomfort.

• Ask the patient to move the joint through a full range of movement.

• Look for pain (patient’s face) and limitation of movement.

• Is the limitation mechanical (blocked by loose body, meniscal tear,

contracture) or restrictive (resisted by the patient due to pain)?

• Shoulder. Flexion, extension, abduction, internal and external rotation.

EXAMINATION OF A JOINT

491

• Elbow. Flexion, extension, pronation, and supination (ensure humerus

at patient’s side).

• Wrist. Flexion, extension, radial and ulnar deviation, pronation, and

supination.

• Metacarpophalangeal joint (MCPJ). Flexion, extension, abduction, and

adduction.

• Proximal interphalangeal joint (PIPJ) and distal interphalangeal joint

(DIPJ). Flexion and extension.

• Thumb. Flexion, extension, abduction, adduction, and opposition.

• Hip. Flexion, extension, internal and external rotation.

• Knee. Flexion and extension.

• Ankle. Plantar and dorsiﬂ exion, eversion and inversion.

• Cervical spine. Flexion, extension, and lateral rotation and ﬂ exion.

• Lumbar spine. Flexion, extension, and lateral rotation and ﬂ exion.

• Muscle power is graded via the MRC system (see b p. 492).

• Always get the patient to walk to test gait if the problem is lower limb.

Special tests

These depend on the individual joint examined and are numerous for each

joint!

They normally involve either:

• Tests of instability, for example:

Collateral testing in the knee, elbow, or ﬁ nger joints.•

Cruciate ligament testing (anterior draw, Lachmans).•

Apprehension tests (shoulder instability).•

• Or provocation tests that aim to locate the cause of intra-articular

pain, for example:

Grind tests (thumb base osteoarthritis, knee meniscal injury).•

Meniscal provocation tests (McMurray’s test).•

References

1 Soloman L, Warwick D, Nayagam S (Eds) (2010). Apley’s system of orthopaedics and fractures,

9th Edn. Hodder Arnold, London.

CHAPTER 15 Orthopaedic surgery

492

Examination of the limbs and trunk

Develop your own system that you feel comfortable with. Always compare

affected with unaffected side. Make allowances for the dominant side.

Look

Is there any swelling, deformity, asymmetry, muscle wasting, twitching

(fasciculation), scars, skin colour changes, rashes?

Feel

Is there any tenderness, temperature changes, solid or ﬂ uid swellings,

muscle bulk?

Move

• Move each joint through its full active and passive range.

• Is the limb tone normal, reduced (ﬂ accid or ﬂ oppy), or increased

(rigidity)? Is there any spasm? Are there any joint contractures?

• Is the rigidity through whole movement or only initially (spasticity)?

• Is the alteration in movement from a neuromuscular disorder, a

mechanical block, or pain from the joint?

Power (MRC grading)

• Grade 0, no movement.

• Grade 1, ﬂ icker of movement only.

• Grade 2, movement with gravity eliminated.

• Grade 3, movement against gravity.

• Grade 4, movement against resistance.

• Grade 5, normal power.

Test all muscle groups within their relevant myotomes according to the

patient’s history.

Coordination

• Ask the patient to touch their nose with their index ﬁ nger with their

eyes open and then shut. Compare side to side.

• Alternatively, ask the patient to put their right heel on to their left

knee and run it down their shin and vice versa. Note whether these

movements are smooth or jerky.

• Romberg’s test. Stand with feet together and eyes shut. Positive result

will cause the patient to become unstable or fall; be prepared!

Reﬂ exes

• Biceps jerk, C5/6.

• Abdominal, T8–T12.

• Triceps jerk, C6/7.

• Knee jerk, L2/3/4.

• Brachioradialis, C5/6.

• Ankle jerk, S1/2.

• Plantar response. Normal ﬂ exor, abnormal extensor (Babinski’s sign).

• Clonus at ankle (normal two beats or less).

EXAMINATION OF THE LIMBS AND TRUNK

493

Grading

• 0, absent.

• 1, hypoactive.

• 2, normal.

• 3, hyperactive, no clonus.

• 4, hyperactive with clonus.

Sensation

Explain what you are about to do clearly to the patient and perform the

test with their eyes closed. Compare symmetrical sides of the body at the

same time. Map out the abnormalities.

• Pinprick, light touch, and temperature tested in a dermatomal pattern.

• Vibration sense tested with a 128MHz low-pitched tuning fork on a

bony prominence. Start distal and if abnormal, move from proximal.

• Proprioception (joint position sense) tested by moving the

metatarsophalangeal joint (MTPJ) of the hallux, up and down; the

patient conﬁ rms the correct movement.

CHAPTER 15 Orthopaedic surgery

494

Fracture healing

Fracture healing occurs as either primary or secondary bone union.

• Secondary bone healing produces callus. It occurs when fractures

are immobilized with ‘relative stability’ (some minimal movement

at fracture site, e.g. a plaster cast). It involves two simultaneously

occurring, but distinct, processes: intramembranous and endochondral

ossiﬁ cation, producing periosteal bony callus and ﬁ brocartilagenous

bridging callus, respectively.

• Primary bone healing does not produce callus. It occurs when

fracture fragments are reduced ‘anatomically’ and ‘interfragmentary

compression’ is achieved with ‘absolute stability’. There is no motion

between fracture surfaces (e.g. compression plating techniques or lag

screw ﬁ xation).

Secondary bone healing (callus)

Initial phase: haematoma and inﬂ ammation

• Torn vessels at fracture site bleed, producing a haematoma and

subsequent clot.

• The size of the haematoma depends upon the blood supply to the

bone and the violence of the injury; it can continue to expand during

the ﬁ rst 36h.

• Injured tissue and platelet activation causes an inﬂ ammatory cascade

via the release of growth factors and various cytokines.

• Inﬂ ammatory cell migration to the haematoma occurs (macrophages,

ﬁ broblasts, osteoclasts, chondroblasts).

• Fibroblasts and chondroblasts organize the haematoma into collagen

and granulation tissue, with new capillary ingrowth (angiogenesis).

• Osteoclasts and macrophages remove dead bone and tissue,

respectively.

• This stage usually lasts up to 1 week.

Second phase: callus formation (soft and hard)

• Cell (osteoblasts) proliferation and differentiation results in callus

formation.

• Intramembranous (or periosteal) hard callus forms peripherally,

with endochondral (ﬁ brocartilagenous/bridging) soft callus forming

alongside. A third type ‘medullary callus’ forms later if the above fails.

• The amount and type of callus produced is dependent upon local

factors such as the type of fracture, proximity of the bone ends,

amount of haematoma, and is inversely proportional to the amount of

movement present.

• Soft callus is calciﬁ ed by chondroblasts and subsequently resorbed by

chondroclasts.

• New blood vessels invasion into the callus brings osteoblastic type

cells, resulting in ossiﬁ cation into woven bone.

• By this point, the fracture will have united and be pain-free.

• This stage lasts 1 week to 4 months.

FRACTURE HEALING

495

Third phase: remodelling

• Woven bone is resorbed by osteoclasts and osteoblasts replace this

with lamellar bone, which is very hard and dense.

• Final remodelling occurs when swelling around the fracture site

decreases; trabeculae can be seen crossing the fracture site on

radiographs and the medullary canal is recreated.

• Remodelling is most marked in children and follows the mechanical

forces applied to the bone in a physiological environment.

• This process is identical in both primary and secondary bone healing

and can last for several years.

Primary bone healing (absolute stability)

• The inﬂ ammatory response is much reduced.

• Areas of direct contact undergo some activity.

• Any gaps are invaded with blood vessels and cells differentiate into

osteoblasts, laying down woven and lamellar bone (gap healing).

• Osteoclasts acting as ‘cutting cones’ pass directly across the fracture

site, leaving channels that are ﬁ lled with blood vessels and allowing

osteoblasts to ﬁ ll them with lamellar bone.

• No callus is formed and union takes much longer to achieve, with

the strength of the healing process being borne by the mechanical

properties of the ﬁ xation device.

• Remodelling occurs as above.

Factors adversely affecting fracture healing

• Degree of local trauma (bone loss, soft tissue trauma and interposition,

neurovascular injury, open fractures).

• Inadequate reduction and immobilization.

• Infection.

• Location of fracture. Which bone and where on bone i.e. metaphysis

versus diaphysis (see below)?

• Disturbances of ossiﬁ cation, e.g. metabolic bone disease, osteoporosis,

local pathological tumour.

• Age, poor nutrition, smoking, drugs (especially NSAIDs), diabetes.

How long do fractures take to unite?

Perkins rules

• Fractures of cancellous (metaphyseal) bone (e.g. those around joints)

will take 6 weeks to unite.

• Fractures of cortical (diaphyseal) bone (e.g. shafts of long bones) will

take 12 weeks to unite.

• Fractures of the tibia (because of poor blood supply) will take 24

weeks to unite.

• Time to union for children equals the age of the child in years plus 1,

e.g. tibial fracture in a 2y-old child will unite in 3 weeks. Common

sense needs to be applied when applying the rule to fractures of

cancellous bone in older children.

CHAPTER 15 Orthopaedic surgery

496

Delayed union

Deﬁ ned as a failure of union to occur in 1.5x the normal time for fracture

union.

Non-union

Deﬁ ned as a failure of union to occur within twice the normal time to

fracture union. However, expect open fractures to normally take twice

the normal Perkins rule.

• Hypertrophic non-union. Excess mobility or strain at fracture site. There

is a good blood supply with healing potential. Appears as large callus

(elephant’s foot pattern) on X-rays. Usually requires stabilization to

allow callus progression.

• Atrophic non-union. Due to poor blood supply resulting from initial

injury or surgical intervention. There is poor healing potential. Usually

require stabilization and biological augmentation to heal.

Further reading

Soloman L, Warwick D, Nayagam S (Eds) (2010). Apley’s system of orthopaedics and fractures. 9th

Edn. Hodder Arnold, London.

Ramachandran M (2007). Basic Orthopaedic Sciences: The Stanmore Guide. Hodder Arnold,

London.

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CHAPTER 15 Orthopaedic surgery

498

Reduction and ﬁ xation of fractures

Caveat. A fracture is a soft tissue injury with an associated broken bone.

Treat the soft tissues with utmost respect to ensure fracture healing.

Modern fracture reduction and treatment was pioneered by the AO

group and centres around four key principles:

• Fracture reduction and ﬁ xation to restore anatomical relationships.

• Stability by ﬁ xation or splintage as the personality of the fracture and

the injury dictates.

• Preservation of the blood supply to the soft tissue and bone by careful

handling and gentle reduction techniques.

• Early and safe mobilization of the part and patient.

Fracture reduction can be achieved by closed

(indirect) or open (direct

and indirect) methods. Maintenance of the reduction may also be achieved

via closed methods which can be non-surgical (plaster or brace) or surgi-

cal (intramedullary nail, external ﬁ xation, Kershner (K) wires), or via open

methods such as rigid internal ﬁ xation with plates and screws.

Casting

• Application of a plaster of Paris (or modern alternatives) cast over

appropriate padding to stabilize a reduced fracture.

• Typically involves splinting of joints either side of a long bone fracture

to provide additional rotational stability.

• Simplest and cheapest to apply.

• Lowest risk of septic complications.

• It will provide pain relief.

• ‘Half casts’ or ‘backslabs’ can be utilized to immobilize a fracture prior

to deﬁ nitive management.

• Complications include problems with cast (pressure areas, loosening

and breakdown of cast), thromboembolic events, coverage of wounds.

• It is a very involved process, requiring regular follow-up to ensure

maintenance of reduction.

Cast bracing

• Stabilization of a fracture across a joint with a cast, but the joint itself is

left free to move by the incorporation of a hinge across it.

• Has the advantage of allowing early movement of the joint without the

use of weight bearing, e.g. tibial shaft fractures.

Internal ﬁ xation

Indications

• Intra-articular fractures. To prevent or reduce the incidence of

osteoarthrosis.

• Unstable fracture patterns.

• Neurovascular damage. Fracture stability must be achieved before the

delicate repair of vessels or nerves takes place. If not, these repairs

may be damaged.

• Polytrauma. Multiple injuries are better managed by ﬁ xation to facilitate

nursing care and to allow early mobilization.

REDUCTION AND FIXATION OF FRACTURES

499

• Elderly patients tolerate immobilization and prolonged bed rest poorly

(fractured neck of femur).

• Fractures of long bones (e.g. forearm, femur, tibia). Rehabilitation

is facilitated more quickly with internal ﬁ xation after anatomical

reduction.

• Failure of conservative therapy (loss of acceptable alignment).

• Pathological fractures.

Methods

Compression plates and screws, locking plates and screws, Kershner (K)

wires, intramedullary nails, tension band wiring.

Complications

• Infection which increases with the size and increased time of exposure

required.

• Nerve and vessel injury.

• Non-union (increased with iatrogenic soft tissue and periosteal injury).

• Implant failure and subsequent fracture through a bony defect if the

implant is removed.

External ﬁ xation

Indications

Temporizing measure for:

• Open fractures (commonly tibia or femur) associated with signiﬁ cant

soft tissue damage or nerve and vessel injury.

• Highly comminuted or unstable fractures and fracture dislocations.

• Life-saving splintage procedure in pelvic fractures.

• Initial stabilizing device for any fracture where ‘damage limitation’

surgery may be appropriate in the multiply injured patient (damage

control orthopaedics).

• Deﬁ nitive treatment of periarticular fractures (pilon and tibial plateau).

• As a salvage option in the face of mal-union, non-union, or signiﬁ cant

bone loss.

Methods

• Pin-and-rod construct most commonly used (tibia–pelvis).

• Modern systems incorporate ring ﬁ xators with pins and rods (hybrid).

• Circular ﬁ xators (Ilizarov) can be used for deﬁ nitive fracture ﬁ xation

or as a salvage option.

Complications

• Pin site infection and possible osteomyelitis.

• Nerve, vessel, ligament, and tendon injury (good understanding of

cross-sectional anatomy required).

• Over-distraction, resulting in non-union.

Locking plates

• Modern implants in which the screw heads are threaded and engage

and lock into threads in the plate holes.

• These act as ‘internal, external ﬁ xators’ where forces are transmitted

from bone to screw to plate.

CHAPTER 15 Orthopaedic surgery

500

• The locking plate provides angular stability and is much stronger than a

normal plate as all screws act in unison.

• Advantages are:

Excellent holding power as all locked screws have to fail at once for •

construct to fail. Thus, excellent choice of ﬁ xation in osteoporotic

fractures.

Spares periosteal blood supply as does not rely on compression of •

plate on bone.

They can be placed percutaneously (avoiding stripping soft tissue •

and blood supply from a fracture site).

They do not require contouring.•

The screws are usually self-drilling and self-tapping.•

References

1 Ruedi TP, Murphy WM (2000). AO principles of fracture management. Thieme Medical Publishers,

New York.

2 McRae R, Esser M (2008). Practical fracture treatment, 5th edn. Churchill Livingstone, Edinburgh.

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CHAPTER 15 Orthopaedic surgery

502

The skeletal radiograph

This is the most important investigation in orthopaedics, but does not sub-

stitute for accurate history and examination. Always remember a fracture

is a clinical, not a radiological diagnosis.

Evaluation

Have a system. The following is only one example:

• Note the history, race, occupation, handedness, pastimes, age, sex, and

recent laboratory results of the patient.

• Accurate history and clear requests to be documented on X-ray

forms. Always write the side in full, e.g. ‘right’.

• Always take two views at 90° to each other (orthogonal).

• Examine the ﬁ lm carefully.

• Most hospitals use computer-based X-ray viewing systems but if using

a viewing box, have a bright spotlight and magnifying glass available.

• When describing the lesion, think of side, anatomical site, nature,

displacement, and soft tissue components.

• Keep it simple.

A. Adequate views and alignment.•

B. Bones.•

C. Cartilage (soft tissues).•

• Look for cortical/medullary changes, periosteal reactions, deformity,

soft tissue swelling, and cortical breach (deﬁ nition of a fracture).

• Supplement radiological ﬁ ndings with further biochemical

investigations, bone scanning, and biopsy if indicated.

Radiological features

Osteoporosis

• The most common form of bone disease.

• Characterized by low bone mass and deterioration of the

microarchitecture of bone tissue with consequent increase in bone

fragility and susceptibility to low trauma fractures.

• Affects middle-aged and elderly women, predisposing them to

fractures of the distal radius, femoral neck, and vertebral bodies.

• Localized osteoporosis follows disease, e.g. after joint fusion.

• The cortices are thin with reduced medullary trabeculae, i.e. the bone

is essentially normal; there is just too little of it.

Osteomalacia

There is reduced mineralization of osteoid.

• The trabeculae are blurred.

• Symmetrical transverse or oblique cortical defects appear (Looser’s

zones, pseudofractures).

• In children, changes are most marked at the metaphysis (rickets).

Hyperparathyroidism

There is bone resorption. Best place to see it is in the phalanges of the

hands in the subperiosteal cortex. Note generalized cortical striations.

Usually diagnosed with parathyroid hormone levels after incidental ﬁ nding

of raised calcium levels.

THE SKELETAL RADIOGRAPH

503

Diffuse increase in density

Think of neoplasia, ﬂ uorosis, sarcoidosis, bone dysplasia (osteopetrosis).

Abnormalities of bone modelling

Developmental disorders, e.g. osteochondrodysplasia, are often present

from birth. Look for abnormalities of the eyes, heart, and ears. Thorough

assessment by biochemical and genetic specialist required.

Local abnormalities may occur in congenital disorders, e.g. endochon-

dromatosis (Ollier’s disease), ﬁ brous dysplasia, neuroﬁ bromatosis, or

acquired disorders, e.g. Paget’s disease.

Solitary lesions

Always think of sepsis, primary bone tumours, or secondary metastasis.

Location and age are important, e.g. an epiphyseal lesion in a child may

be a chondroblastoma and a subarticular lesion in a young adult may be a

giant cell tumour. The older the patient, the more likely it is a metastasis.

Describing a fracture

• First check details match patient (i.e. date of X-ray, patient age, side,

hospital number).

• Ensure the appropriate X-ray is taken with two views at 90° to each

other (e.g. an X-ray of an ankle, rather than the whole lower leg).

• Which bone is fractured?

• Where is the fracture in the bone? Joint (intra-articular), proximal,

middle, or distal third, or metaphysis (ﬂ ares at end of bones), diaphysis

(shaft), physis (growth plate), and epiphysis (end part of bone) in

children.

• What is the pattern? Transverse, oblique, spiral, comminuted or

multifragmentary, segmental.

• Is there displacement? Quantify this (e.g. 50% of bone width or

completely ‘off ended’ >100%).

• Is there any angulation? Which direction (varus, valgus, recuvartum)?

• If a joint is involved, comment on whether it is ‘in joint’ or dislocated.

• Other things to look for are gas in soft tissues (suggests open fracture

or gas-forming infection), foreign bodies (metal, glass, grit), ﬂ uid in

joints (e.g. lipohaemarthrosis in knee suggests fracture), fat pad signs in

the elbow (suggest fracture and are prominent due to blood in joint).

• A ring-like structure (e.g. the bony pelvis) rarely fractures in only one

place; if you ﬁ nd one fracture, look hard for another one!

• Comment on implants if present and the proximity and involvement

of this to fracture (periprosthetic fractures of a total hip replacement

(THR) or total knee replacement (TKR)).

• Pitfalls. Is it a fracture? Structures that may be mistaken for fractures

include suture lines between bones, vascular channels, and physes

in immature skeletons. Anatomic structures are more likely to be

symmetrical, if not midline.

Further reading

Raby N, Berman L, de Lacy G (2005). Accident and emergency radiology: a survival guide, 2nd edn.

Saunders, London.

Nicholson DA, Driscoll P (1995). ABC of emergency radiology. BMJ Books, Wiley, England.

CHAPTER 15 Orthopaedic surgery

504

Injuries of the phalanges and

metacarpals

Thumb

Mechanism Direct blows to thumb, forced opposition of the thumb.

Extra-articular

• Metacarpal shaft fractures. Undisplaced can be managed in cast. Displaced

fractures require reduction and ﬁ xation, either open or closed.

• Metacarpal base fractures. Often displaced or angulated due to

deforming forces of the tendon attachments. If fractures undisplaced,

can manage with closed reduction and immobilization in cast. For

displaced/signiﬁ cantly angulated fractures, closed reduction with K wire

ﬁ xation or open reduction with internal ﬁ xation (ORIF) is required.

Up to 30° of angulation can be accepted due to the vast range of move-

ments at the base of thumb.

Intra-articular (± fracture dislocation)

• Bennett’s fracture dislocation. Volar/ulnar fragment left behind due to

strong ligament attachments; remaining distal metacarpal dislocates

proximally and dorsally. Treatment involves closed reduction and

K wire ﬁ xation to either carpus (trapezium) and/or index ﬁ nger

metacarpal. Open reduction is rarely needed.

• Rolando fractures. Multifragmentary fracture, at least three parts in

a ‘T’ or ‘Y’ pattern ± dislocation. Treatment depends on degree of

fragmentation. Reduction and K wire ﬁ xation or external ﬁ xation

should be considered. ORIF only if large fragments.

Thumb dislocation

• At the MCPJ, usually results in ulnar collateral ligament (UCL) injury

(gamekeeper’s thumb).

• Tear of the UCL can be partial or complete, with adductor

aponeurosis stuck in the joint (Stener lesion), preventing reduction.

• Partial tears (stable) are immobilized in cast for 6 weeks.

• Complete tears (unstable or Stener Lesion) require surgical repair.

• Chronic tears are treated with tendon reconstruction of UCL or MCPJ

fusion.

Metacarpal fractures

Mechanism Usually ‘punch’ injury (‘Friday night’ or ‘boxer’s’ fracture). The

little ﬁ nger most commonly affected. Remember to check for rotational

deformity as this is not an acceptable deformity.

Metacarpal neck fractures

Accept up to 15° angulation in index/middle and 35° in ring/little ﬁ ngers.

Most treated conservatively (neighbour strapping). Reduction and pinning

or ORIF if signiﬁ cant angulation.

INJURIES OF THE PHALANGES AND METACARPALS

505

Metacarpal shaft fractures

Check for rotation. Transverse or unstable fractures (especially ring and

little ﬁ ngers), treat with ORIF or K wire ﬁ xation. Undisplaced fractures

can be treated conservatively (neighbour strapping). Similar degrees of

angulation to neck fractures can be accepted.

Metacarpal base fractures (± subluxation)

Always get a true lateral X-ray of hand to assess for subluxation. These

are usually stable fractures and can be treated conservatively in cast for

3 weeks. If subluxed (little ﬁ nger akin to Bennett’s fracture), treatment

involves closed reduction and K wire ﬁ xation to carpal bone for 4 weeks.

Distal phalanx fractures

Mechanism Crush injury that is comminuted and often compound. Tuft

type fractures.

Treatment

Wound toilet, simple nail bed repair if needed, and primary suture or Steri-

strip

with pressure dressing. Wound inspection at 48h and as required.

Can be dealt with in A&E department. Antibiotics if open.

Mallet ﬁ nger

• Sudden ﬂ exion injury of distal phalanx (i.e. stubbing ﬁ nger), resulting

in either avulsion of extensor tendon insertion with ﬂ ake or large

fragment of bone, but can be purely tendinous.

• Small fragments or purely tendinous types are treated in ‘mallet

splint’ (extension) for 8 weeks continuously, followed by 2–4 weeks

just at night. If large fragment, ﬁ xation can be undertaken if unable to

maintain in splint.

Proximal and middle phalanx fractures

Mechanism Direct blow or twisting injuries.

Treatment

• Dependent on fracture conﬁ guration. Check for rotational deformity.

• Undisplaced stable fractures are treated with neighbour strapping for

2–3 weeks with early mobilization.

• If unstable, rotated, severely angulated, or involving the joint, consider

closed reduction and K wire ﬁ xation or ORIF with mini-fragment

screws ± plate. Stable ﬁ xation to allow early mobilization is the goal.

PIP joint dislocations

• Dorsal dislocation is the most common. It is associated with avulsion

of volar plate or fracture of volar base of middle phalanx.

• Dislocations require reduction under ring block.

• If stable, they can be treated with extension blocking splint with PIPJ

ﬂ exed for 4–6 weeks.

• If unstable or associated with signiﬁ cant fracture, they require either

manipulation under anaesthesia (MUA) and K wiring, ORIF, or volar

plate arthroplasty.

CHAPTER 15 Orthopaedic surgery

506

Immobilization for hand injuries (Edinburgh position)

To prevent stiffness, the metacarpal joint should be immobilized in 90°

of ﬂ exion and the PIPJ in extension with the wrist extended at 30°. This

places the ligaments on maximal stretch whilst immobilized.

Further reading

Soloman L, Warwick D, Nayagam S (Eds) (2010). Apley’s system of orthopaedics and fractures,

9th edn. Hodder Arnold, London.

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CHAPTER 15 Orthopaedic surgery

508

Wrist injuries

Scaphoid fractures

Mechanism Fall on to the outstretched hand with forced dorsiﬂ exion.

Examination

• Fullness in the anatomical snuffbox means an effusion.

• Tenderness on the volar surface of the scaphoid, i.e. the tubercle, is

more predictive than snuffbox tenderness (dorsal) which is unreliable.

• Wrist movement, particularly pronation followed by ulnar deviation,

may be painful.

• Pain on compression of the thumb longitudinally or on gripping may be

present.

• However, clinical examination is highly variable and skill-dependent.

Investigation (radiographs)

‘Scaphoid series’ ﬁ lms (PA wrist in ulnar deviation, lateral wrist in neutral;

PA in 45° pronation and ulnar deviation; and AP with 30° supination and

ulnar deviation). False negative rate of <5%. Fractures are usually of the

waist, but may be more proximal.

Treatment

• Below elbow, cast in neutral position (RCTs show that the thumb

does not need to be included)

for 8 weeks, but the fracture may

take 12 weeks to unite. At 12 weeks, remove plaster regardless of

symptoms.

• If initial X-rays negative, but clinical suspicion persists, cast the wrist

and repeat ﬁ lms in 2 weeks.

• Displacement of >1mm or angulation requires ORIF with compression

screw.

• Proximal pole fractures are relative indication for ﬁ xation as high

chance of non-union.

Complications

• Non-union. i with proximal fractures due to blood supply running from

distal to proximal in the bone. If not united at 12 weeks, proceed to

ORIF (compression screw) ± bone grafting.

• Avascular necrosis. i with proximal and displaced fractures (see above).

Treatment is by internal ﬁ xation and bone grafting which may need to

be a ‘vascularized’ graft.

• Degenerative change. May occur after non- or mal-union. Treated by

limited wrist fusion (four corner fusion, scaphoidectomy, and radial

styloidectomy).

Other carpal fractures

• The most common is hamate fracture. The hook is fractured by

direct blow to the palm of the hand or repeated direct contact (e.g.

motorcyclists, golfers, racquet sports, and cricketers).

• Treatment is usually excision, but internal ﬁ xation may be attempted if

the fragment is large.

WRIST INJURIES

509

Ligamentous injuries of the wrist

• Common; difﬁ cult to diagnose so easily missed.

• If left untreated, they can cause long-term disability.

• The proximal row of carpal bones forms an intercalated segment, i.e.

they are connected and work together as a unit. Injury may occur to

the ligaments connecting the bones.

Scapholunate ligament

Common in isolation or in association with fractures (especially distal

radius). ‘Terry Thomas’ sign, i.e. increase in the space between scaphoid

and lunate on a clenched ﬁ st PA view. Acute ruptures may be repaired,

but chronic injuries may require reconstruction or fusion.

Lunotriquetral ligament

Less common; acute repair may be successful, but chronic injuries require

lunotriquetral fusion.

Carpal dislocations

Complete ligamentous injury may allow the carpus to dislocate.

• Occurs either with the lunate remaining in place, a perilunate

dislocation, or the carpus staying in place and the lunate moving, a

lunate dislocation.

• On rarer occasions, the scapholunate ligament remains intact and the

scaphoid fractures, resulting in a trans-scaphoid perilunate dislocation.

Treatment Severe injury requires reduction—best open as it allows for-

mal repair of the disrupted ligaments, as well as stabilization of the carpus.

If the scaphoid is fractured, it should be internally ﬁ xed as well.

Carpometacarpal fracture dislocation

• Usually as the result of a punch injury. Affects little or ring ﬁ ngers.

• Commonly missed due to poor history and examination.

• Indicated by tenderness at the carpometacarpal base.

• Diagnosed with a true lateral (not the standard lateral oblique) X-ray

(shows subluxation or dislocation at the carpometacarpal joint).

Treatment Unstable injury—reduce with traction and local pressure, then

stabilize the joint with K wire ﬁ xation for 4 weeks.

Triangular ﬁ brocartilage complex (TFCC) injury

TFCC and the ulnar small ligaments of the hand. An acute tear is usually

peripheral and the result of trauma, including a fracture to the ulna styloid.

It will present with ulna-based wrist pain in ulnar deviation with or without

rotation.

Treatment If associated with a large ulnar styloid fracture, this can be inter-

nally ﬁ xed with a tension band wire technique. Arthroscopic debridement

or repair of the tear has been attempted, but is technically demanding.

References

1 M http://www.eatonhand.com.

2 Clay NR, Dias JJ, Costigan PS, et al. (1991). Need the thumb be immobilized in scaphoid frac-

tures? A randomised prospective trial. J Bone Joint Surg Br 73(5): 828–32.

CHAPTER 15 Orthopaedic surgery

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Fractures of the distal radius and ulna

• Usually caused by a fall on to the outstretched hand.

• Very common. Approximately 1 in 6 of all fractures treated.

• Bimodal incidence. Peaks in childhood (6–10y) and early old age

(60–70y).

• Scaphoid and ligamentous wrist injuries may also be present.

Classiﬁ cation

• Classiﬁ cation systems are the AO system

and the Frykman system.

• Historical eponymous terms (‘Colles’, ‘Smith’s’) are still used.

• To avoid confusion, stick to describing the fracture by anatomical

methods, e.g. dorsally displaced fracture of the distal radius with

shortening and ulnar deviation.

• In children, the fracture usually involves the epiphyseal region and

these fractures are classiﬁ ed by the Salter–Harris system.

Salter–

Harris type II is easily the most common injury of the distal radius.

Important radiological features to assess

• These parameters give an idea of the severity of the injury and thus

the stability of the fracture; the more features, the more unstable.

• Dorsal cortex comminution.

• Intra-articular extension (radiocarpal and distal radioulnar joint

(DRUJ)).

• Ulnar styloid fracture (suggests a TFCC injury which is a strong DRUJ

stabilizer).

• Loss of radial inclination (normally approximately 22°).

• Loss of palmar tilt or dorsal angulation (normal tilt approximately 11°).

• Loss of radial height (approximately 11mm from distal ulna to tip of

radial styloid).

Treatment4

Children

• Fractures of the distal radius. Usually treated by closed reduction

(manipulation) and the application of a well moulded plaster.

• If very unstable in theatre (radial and ulnar complete fractures,

displaced) or if the fracture has slipped position in plaster after

manipulation, then internal ﬁ xation with percutaneous K wires or

more rarely, open ﬁ xation with plates and screws may be used.

Adults

Fractures with dorsal displacement/angulation

• Undisplaced + stable. Below elbow plaster immobilization for 6 weeks.

• Displaced + stable. Closed reduction and plaster immobilization for 6

weeks.

• Displaced + unstable. Closed reduction and either percutaneous K

wire ﬁ xation (two wires), external ﬁ xation, or ORIF with plates and

screws.

• Complex intra-articular fractures or highly unstable patterns can now

be successfully treated with modern anatomic pre-contoured distal

radius locking plates.

FRACTURES OF THE DISTAL RADIUS AND ULNA

511

Traditionally a difﬁ cult area to know the best treatment method.

• Take each case on its own merits. There are many patient and fracture

factors to allow for.

• Dorsal comminution is a common problem and must be taken into

account in the method chosen.

• Bone structural substitutes, e.g. Biobon, lack RCT data to back up their

use and considerable expense.

Fractures with volar displacement (‘Smith’s fracture’)

Unstable and are treated by a volar buttress plate (supports a fracture like

a shelf, propping up or supporting the distal fragment).

Intra-articular fractures with volar displacement (‘Barton’s fracture’)

Internal ﬁ xation is mandatory as it is a highly unstable fracture.

Ulnar styloid fractures

Do not often require ﬁ xation unless the fragment is large in which case, it

may represent a TFCC injury (see b p. 512) treated by internal ﬁ xation.

References

1 M http://www.trauma.org/ortho/aoclass.html.

2 Frykman G (1967). Fracture of the distal radius including sequelae—shoulder–hand–ﬁ nger syn-

drome, disturbance in the distal radio ulna joint and impairment of nerve function. A clinical and

experimental study. Acta Orthop Scand Suppl 108, 3.

3 Salter RB, Harris WR (1963). Injuries involving the epiphyseal plate. J Bone Joint Surg Am 45,

587–632.

4 M http://www.eradius.com/

CHAPTER 15 Orthopaedic surgery

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Fractures of the radius and ulnar shaft

Mechanism

• Commonly a fall on to the outstretched hand or a direct blow injury.

• High energy may be involved, therefore look closely for neurovascular

status and compartment syndrome.

• As displaced or angulated fractures affect the proximal (Monteggia)

and distal (Galeazzi) radioulnar joints, it is essential to get orthogonal

X-rays of the wrist and elbow.

Fracture types

Children

• Usually transverse fractures of the radius and ulna.

• May be angulated only with one of the cortices still intact (‘greenstick

fracture’).

• Be aware of plastic deformation (no obvious fracture, but bowing of

one or both bones).

• May sustain a fracture dislocation as in adults.

Adults

• Usually either a transverse or oblique fracture of the radius and ulna.

• Isolated ulna shaft fractures (‘nightstick fractures’ named after

mechanism of defending direct blow from a policeman’s nightstick or

truncheon).

• Displacement and signiﬁ cant angulation are indications for ﬁ xation.

• Remember, the forearm is a ‘force parallelogram’ and that a fracture of

only one bone will usually result in a dislocation of the other bone at

the proximal or distal joints. These fracture dislocations are:

Monteggia fracture.• Proximal ulnar fracture with dislocation of the

proximal radial head.

Galeazzi fracture.• Distal radial fracture with dislocation of the DRUJ.

Treatment

Children

• Greenstick fractures. Closed reduction and cast immobilization from

wrist to above the elbow.

In-line traction is always the key to any initial reduction and often •

all that is required to realign, given patience.

Use minimal force. If the periosteal hinge is broken during •

reduction, the fracture may displace completely and become

unstable.

• Plastic deformation needs to be corrected.

• Displaced fractures are often unstable and can be treated by ORIF

with plates and screws, or ﬂ exible intramedullary nail ﬁ xation.

• Fracture dislocations (Monteggia and Galeazzi). Closed manipulation

and cast immobilization (failed reduction may require open reduction).

Adults

• Usually impossible to achieve or maintain a closed reduction for adult

forearm shaft fractures.

FRACTURES OF THE RADIUS AND ULNAR SHAFT

513

• Undisplaced fractures can be managed in an above elbow cast.

• Displaced fractures are treated with open reduction and compression

plate ﬁ xation.

• ‘Nightstick fractures’ of the ulna are splinted by the intact radius so if

undisplaced, then early protected motion with an elbow cast-brace is

indicated.

• If the fracture is displaced (>50% displacement or >10°), open

reduction and compression plate ﬁ xation should be used.

• Fracture dislocations. Treated with open reduction and internal

ﬁ xation to accurately reduce and hold the associated dislocations.

Complications

• Mal-union or non-union. Close follow-up of closed, manipulated

fractures. An X-ray at 1 and 2 weeks is mandatory to watch for slip of

position. Mal-union can present with functional problems with forearm

rotation.

• Non-union is normally treated by open reduction, debridement of the

non-union site, and compression plate ﬁ xation with or without bone

grafting.

• It is not usually necessary to remove metalwork from the radius and

ulna unless they cause signiﬁ cant problems after the fracture has

healed. Radial plate removal has been associated with a signiﬁ cant risk

of neurovascular complications.

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514

Fractures and dislocations around

the elbow in children

• Second commonest injury in children (8% of childhood fractures).

• Cause is usually a fall on to the outstretched hand. The result is

related to age:

<9y, supracondylar fracture of the humerus.•

>10y, dislocated elbow.•

>60y, shoulder injuries.•

• Salter–Harris injuries of the elbow occur through the lateral condyle

and radial neck.

Supracondylar fractures

Types

• Based on the mechanism of injury, extension type (approximately 95%)

and ﬂ exion type (5%).

• Classiﬁ ed using the modiﬁ ed Gartland system:

Type I. Undisplaced.•

Type II. Angulated/displaced, but posterior cortex is intact, acting •

as a hinge.

Type III. Complete displacement.•

Type IV. Completely displaced and unstable in ﬂ exion and •

extension.

Treatment

Displaced supracondylar fractures (types III/IV) are an orthopaedic

emergency, especially if complicated with an absent distal pulse. Do not

delay.

• Assess neurovascular status and document beforehand.

• Reduce under GA by straight arm traction (up to 5min may be

required).

• Then manipulate to correct rotation, varus/valgus tilt, and ﬁ nally any

extension deformity.

• Try to ﬂ ex the elbow up past 90° with the forearm pronated (may be

difﬁ cult due to anterior soft tissue swelling; the reduction technique

itself can cause loss of the pulse in the ﬂ exed position).

• Displaced (type III/IV) fractures should be reduced and stabilized with

K wires. Some advocate the same for type II injuries.

• Common conﬁ guration is two crossed condylar K wires, one medial

(beware of ulnar nerve), and one lateral used to ﬁ x the fracture.

• An above elbow cast is then used to supplement ﬁ xations and wires

are removed at 4 weeks.

• Long arm traction may be used as deﬁ nitive treatment, but involves a

long inpatient stay until the bone has united (usually 3 weeks).

Undisplaced fractures (type I) can be treated with a collar and cuff with or

without plaster backslab.

515

FRACTURES AND DISLOCATIONS AROUND THE ELBOW

Complications

Vascular

• Injury to the brachial artery is rare as the pulse usually returns after

fracture reduction.

• Examination is the key. An absent pulse with a well perfused hand

does not require any immediate vascular management; however, a

pulseless cold hand or a pulse that is lost post-reduction and pinning

does!

• True loss of the radial pulse may be due to:

Vascular spasm• . Typiﬁ ed by good capillary reﬁ ll after reduction,

but slow return of the pulse. Failure of pulse return may be due to

other injuries and requires a vascular surgical opinion. partial injury

(endothelial ﬂ ap) is treated by direct repair.

Complete transection or disruption• . May be treated by direct repair

or more often, interposition vein graft.

• Contracture. Untreated vascular injury will result in ﬁ brosis and

contracture of the forearm (‘Volkman’s ischaemic contracture’). This

is a devastating and debilitating condition and should be avoidable with

early (<12h) exploration and/or repair or vascular damage.

Neurological

• Neuropraxia is commonest with gradual recovery. May involve the:

Radial nerve.•

Anterior interosseous (branch of medial nerve).•

Median and rarely, ulnar nerves.•

Mal-union

• Incorrectly reduced fractures will not remodel and can lead to cubitus

valgus and a ‘gunstock deformity’. Much less common with K wire

ﬁ xation.

• Recurvatum common following cast management of type II/III;

remodels poorly.

Lateral condyle fractures

Types

Classiﬁ ed according to Milch, depending on how much of the intra-

articular surface is involved:

• Type I. Fracture through growth centre of capitellum (Salter–Harris

type IV).

• Type II. Fracture medial to growth centre and can involve trochlea

(Salter–Harris type II).

Treatment

• Displaced fracture. ORIF with either two cannulated screws or two K

wires.

• The fragment is always considerably larger than expected from the

X-ray due to the condyle being not fully ossiﬁ ed.

• If not reduced and ﬁ xed, the fragment will displace. This is due to the pull

of the wrist extensors, arising from the lateral epicondyle. This will lead

to a cubitus valgus deformity and can present in later life with an ulnar

nerve palsy as it has been chronically stretched (‘tardy’ ulnar nerve palsy).

CHAPTER 15 Orthopaedic surgery

516

Medial condyle fractures

• Not to be confused with epicondyle fractures.

• These fracture occur in a similar pattern to the lateral condyle (type I

and II).

• Treatment is essentially as described for lateral condyle fractures.

• The key is recognition of this injury as it is intra-articular and if missed,

can be associated with valgus instability of the elbow and subluxation.

Epicondyle fractures

Medial epicondyle fractures Avulsion type injuries of the apophysis. High

association with elbow dislocations. The fragment can remain undisplaced,

displaced, or become trapped in elbow joint. Treatment is usually con-

servative in a long arm cast. Surgery is indicated for trapped fragments.

Lateral epicondyle fractures Essentially the same as medial; treated with a

long arm cast unless fragment entrapped in joint.

Radial head and neck fractures

• Usually result from a valgus force to the elbow, associated with

dislocation or fractures (Monteggia).

• Fractures of the neck are often angulated, displaced, or both.

• Head fractures are of the Salter–Harris type.

• Fractures associated with dislocation happen at the time of injury or as

a result of reduction (radial head pushed into ulno-humeral joint).

Treatment

• <30°. Angulation acceptable; sling is provided and early mobilization.

• 30–60°. Reduction should be attempted, but ongoing debate.

• >60°. Reduction is required under GA, usually stable; once reduced,

do not require any further ﬁ xation.

• Occasionally open reduction is required.

• Intra-articular fractures that are displaced may require ﬁ xation with K

wires or screws.

Olecranon fractures

Can often be difﬁ cult to spot. The proximal epiphysis appears between 8

and 10y. Isolated fractures do occur, but are more commonly associated

with fracture dislocations of radial neck.

Treatment

• Undisplaced fractures require a cast in extension (removes pull of

triceps) for 4 weeks.

• Displaced fractures require ORIF with tension band wiring.

References

1 Wenger DR, Pring ME (2006). Rang’s Children’s Fractures, 3rd edn. Lippincott, Williams and

Wilkins, Philadelphia.

2 Wilkins KE (1997). Supracondylar fractures: what’s new? J Paediatr Orthop B 6(2): 110–16.

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CHAPTER 15 Orthopaedic surgery

518

Fractures of the humeral shaft and

elbow in adults

Humeral shaft fractures

Mechanism

• Usually as a result of a fall with direct blow or torsional forces.

• Can be low energy (osteoporotic) or high energy (younger age group).

• X-rays of joints (above and below) important to rule out intra-articular

extension. High energy injuries, especially to rule out ﬂ oating elbow or

shoulder.

• Remember to evaluate neurovascular status (radial nerve at risk).

Types

• Transverse, oblique, spiral, multifragmentary.

• Distal third fractures associated with radial nerve palsy, known as

Holstein–Lewis fracture.

Treatment

Conservative management Is the mainstay.

• Initial sugar tongue cast or hanging cast for 1–2 weeks, then convert

to functional brace until union (usually by 3 months); requires regular

clinic evaluation.

• Can accept 20° anterior/posterior angulation, 30° varus/valgus

angulation, 15° rotations, and 1–3cm of shortening.

• Remember to mobilize elbow and shoulder or will stiffen!

Surgical treatment Indicated if there is an open fracture, vascular injury,

associated intra-articular fracture, ﬂ oating joint (proximally or distally),

pathological fracture.

• Relative indications include multiple injuries, inability to maintain

reduction closed, segmental fractures, or transverse fractures in young

athletes.

• ORIF with plate and screws is commonly used. Locking plates can be

utilized if poor bone quality.

• Intramedullary nailing is an alternative, good for pathological or

segmental fractures, or medically labile patients due to small exposure.

It is associated with shoulder pain and rotator cuff dysfunction.

Humeral condylar fractures

Mechanism

Usually due to impaction injury (the olecranon driven into the humerus via

a direct fall and the condyle usually splits into a ‘T’- or ‘Y’-shaped pattern).

Pattern depends upon bone quality and angle of ﬂ exion at time of injury.

Careful neurovascular evaluation required.

Types

• Intercondylar fracture (most common). The fracture line extends from

the articular surface to the supracondylar region in a ‘T’- or ‘Y’-shaped

pattern.

• Supracondylar.

FRACTURES OF THE HUMERAL SHAFT AND ELBOW IN ADULTS

519

• Isolated medial or lateral condyle fracture.

• Isolated capitellum fracture.

Treatment

Intercondylar

• Intra-articular fractures. Thus principles are open anatomical reduction

with absolute stability, providing stability to allow early mobilization.

Posterior approach with either a triceps spilt or if more complex, a •

trans-olecranon osteotomy to visualize the articular surface.

Fixation by plate and screw constructs (reconstruction plates). •

Compression across the intra-articular segments may be required.

Newer pre-contoured distal humerus locking plates more

commonly used.

• Can be difﬁ cult to treat if heavily comminuted and the bone quality is

poor.

An option is conservative management in cast, but early •

mobilization to try to maintain as much function as possible (‘bag of

bones’ technique).

Non-union is not uncommon following these fractures and •

sometimes salvage surgery in the form of elbow replacement may

be considered.

In the elderly with a low fracture pattern, primary elbow •

replacement is sometimes used.

Supracondylar

• Conservative management in a cast if undisplaced or highly

comminuted in elderly. Mobilize at 2 weeks in hinged brace. Cast.

Discontinue when healed (6–8 weeks).

• ORIF if displaced. 90/90 plating was the classical method (medial and

posterolateral), but now utilize pre-contoured, bicolumnar locking

plates. Again stable ﬁ xation with early mobilization is the goal.

Transcondylar

• A very distal fracture and within the joint capsule.

• Management follows same principles as of supracondylar type.

Capitellum

• Radiographs. The capitellum aligns with radial head on AP and lateral

views. Classiﬁ cation dependent on size of fragment (best seen on

lateral).

Type I is a large osseous fragment, often involving the trochlea.•

Type II is a thin articular fragment with little osseous composition.•

Type III is multifragmentary.•

• Treatment. Type I requires ORIF. A common technique is headless

compression screws from a posterior to anterior direction. Type II

is usually not amenable to ﬁ xation and is excised, as are the loose

components of type II injuries.

• Kocher’s approach (interval between anconeus and extensor carpi

ulnaris) often used.

CHAPTER 15 Orthopaedic surgery

520

Olecranon fractures

Mechanism A fall on to the point of the elbow, but can occur as a fall on to

the outstretched hand where the triceps avulses the olecranon process.

Colton classiﬁ cation

• Type I. Undisplaced (<2mm separation, able to extend elbow against

gravity).

• Type II. Displaced (subtypes—IIA, avulsion; IIB, oblique/transverse; IIC,

comminuted; IID, fracture-dislocation).

Treatment

• Undisplaced. Place in a cast at 90°. At 4 weeks, begin mobilization.

• Displaced. ORIF with tension band wire technique.

• Comminuted. Plate and screw ± bone graft. Newer pre-contoured

locking plate available.

Radial head fractures

Mechanism Fall on to the outstretched hand, forearm in pronation.

Mason classiﬁ cation

• Type 1. Minimally displaced.

• Type 2. Displaced.

• Type 3. Comminuted and displaced.

Treatment

• Type 1 (<3mm displacement). Sling or half cast for 1–2 weeks, then

mobilization (aspiration of the joint haematoma acutely can give pain

relief and injection of local anaesthetic can rule out any mechanical

block).

• Type 2 (displaced, mechanical block to motion or part of more

complex injury pattern). ORIF with compression screw and/or mini-

plate.

• Type 3 (too comminuted to allow ORIF). Radial head replacement

indicated. Excision considered at a later stage and contraindicated if

other destabilizing ligamentous injuries.

Complications of elbow fractures

• Joint stiffness (rotational).

• Degenerative joint disease (osteoarthritis).

• Heterotopic ossiﬁ cation.

• Neurovascular injury and its sequelae.

References

1 M http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthelbowinjadult.htm.

2 Colton CL (1973). Fractures of the olecranon in adults: classiﬁ cation and management. Injury

5: 21–9.

3 Sarmiento A, Zagorski JB, Zuch GA, et al. (2000). Functional bracing for the treatment of frac-

tures of the humeral diaphysis. J Bone Joint Surg Am 82-A: 478–86.

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CHAPTER 15 Orthopaedic surgery

522

Dislocations and fracture dislocations

of the elbow

Mechanism

• Simple. No bony component.

• Complex. Associated bony injury.

• Posterior and posterolateral. Most common type; fall on to an

outstretched hand with the elbow in extension or slight ﬂ exion (with

supination and valgus forces).

• Anterior (rare). Fall on to a ﬂ exed elbow or as a direct blow from

behind (‘side swipe injury’).

• Divergent (rare). Radius and ulna separated proximally.

Associated fractures (complex injury)

• Elbow stability dependent on bony and ligamentous component

integrity—radial head, coronoid, olecranon, medial and lateral

collateral ligaments.

• Coronoid fractures. Occur as distal humerus is driven against it during

subluxation, dislocation, or instability. Any injury to coronoid suggests

an episode of instability.

• Regan and Morrey classiﬁ cation.

Type 1, tip fractured (consider anterior capsule injury).•

Type 2, <50% of the process.•

Type 3, >50% of the process.•

Treatment

• Aim to reduce under GA to allow thorough assessment of stability.

• In-line traction. Supinate forearm (clears coronoid); ﬂ ex elbow from an

extended position whilst pulling olecranon in an anterior direction.

• Check elbow stability once reduced and X-ray to conﬁ rm.

• If stable, collar and cuff at 90° for 7–10 days with early motion.

• If unstable (redislocates), place forearm in pronation if lateral collateral

ligament disrupted or supination if medial collateral ligament disrupted,

and immobilize in above elbow cast for 2–3 weeks.

• If there are associated injuries, then most fractures will require ORIF

to aid the stability and allow early mobilization. This may include radial

head prosthetic replacement.

The ‘terrible triad’

• Posterior elbow dislocation associated with radial head fracture,

coronoid process fracture, and lateral collateral ligament tear.

• The elbow will require surgical stabilization via ORIF of coronoid and

anterior capsular repair, ORIF or replacement of radial head, lateral

collateral ligament repair.

Complications

• Neurovascular injury.

• Compartment syndrome.

• Chronic elbow instability.

DISLOCATIONS AND FRACTURE DISLOCATIONS OF THE ELBOW

523

• Articular cartilage damage.

• Heterotopic calciﬁ cation.

• Stiffness (especially extension). Early motion at 1 week to try to

prevent this.

Further reading

Ring D, Jupiter JB (1998). Fracture-dislocation of the elbow. J Bone Joint Surg Am 80(4): 566–80.

[Current concepts review]

CHAPTER 15 Orthopaedic surgery

524

Fractures around the shoulder

Clavicle

Mechanism Fall or direct blow to lateral shoulder (5–10% of all fractures).

Types

• Occurs in the middle (75%), lateral (20%), or medial (5%) third.

• The pattern of lateral third fractures depends on relationship and

integrity of the coracoclavicular ligaments, and involvement of the

acromioclavicular joint.

• Medial third fractures are assessed with displacement and involvement

of sternoclavicular joint in mind.

Treatment

• Middle third. Virtually all can be treated conservatively with a broad

arm sling (not a collar and cuff). Indications for ORIF (plate and

screws) are open fractures, signiﬁ cant neurovascular injuries, skin

tenting, ﬂ oating shoulder. Fractures with >100% displacement and 2cm

of shortening have better outcomes with ORIF.

• Lateral third. Undisplaced can be treated non-surgically; however,

the presence of displacement suggestive of coracoclavicular ligament

disruption will require ﬁ xation with either plate and screw constructs,

hook plate, or ligament reconstruction (Weaver–Dunn procedure).

• Medial third. Most are undisplaced and treated conservatively in a

sling. Displacement, especially posterior, into the root of the neck may

warrant surgery.

Complications

• Metalwork. Failure or subcutaneous irritation.

• Non-union. Associated with displacement and shortening.

• Acute complications. Neurovascular injury (including brachial plexus

injury), neurovascular compression (costoclavicular syndrome),

pneumothorax from bony penetration of the pleura.

Scapula

Mechanism Direct trauma, usually a high velocity injury such as an RTA.

Always have a high clinical suspicion of other possible injuries such as rib

fracture, pulmonary contusion, and pneumo/haemothorax; 20–40% have

ipsilateral clavicle fractures.

Treatment

• Simple (no involvement of the glenoid (glenohumeral joint)). Adequate

analgesia (very painful injury; may require HDU admission) and early

mobilization.

• Complex (involving the glenoid and glenoid neck). May need ORIF

after further imaging such as CT/MRI scanning.

• Floating shoulder will require ORIF of clavicle.

FRACTURES AROUND THE SHOULDER

525

Proximal humerus

Mechanism Young—high energy injury; elderly—low energy falls. Full

neurovascular assessment (especially axillary nerve) is essential, alongside

pre-injury function (aids management decision).

The Neer classiﬁ cation

Based on Codman’s fracture lines along old physeal scars; four segments

or parts. A fracture part is considered when it is >1cm displaced or >45°

angulated. Thus deﬁ ned as 1-, 2-, 3-, or 4-part fractures.

Treatment

• Undisplaced or impacted. Collar and cuff with early pendular

mobilization.

• Displaced. Usually requires ORIF by ‘locking’ plate, proximal humeral

intramedullary nails or cannulated screws, and K wires with or without

tension band wiring.

• Severely comminuted fractures (4-part), especially including fracture

dislocations, have a high rate of avascular necrosis; usually treated with

hemiarthroplasty and soft tissue reconstruction of the rotator cuff to

the prosthesis.

Complications Non- and mal-union, avascular necrosis of the humeral

head, and osteoarthritis of the shoulder joint are the commonest. High

velocity injuries may also cause neurovascular injuries, particularly of the

brachial plexus.

Paediatric humeral fractures

• Usually occur at the surgical neck or through and around the proximal

humeral epiphysis.

• May be indicative of a non-accidental injury.

• Most require no treatment apart from collar and cuff with mobilization

as for adults. Remodelling potential is good in this area.

Reference

1 Neer CS (1970). Displaced proximal humeral fractures. I. Classiﬁ cation and evaluation. J Bone

Joint Surg Am 52-A: 1077–89.

CHAPTER 15 Orthopaedic surgery

526

Dislocations of the shoulder region

See Fig. 15.1.

Sternoclavicular joint

• Uncommon injury.

• Mechanism. Indirect force to lateral shoulder or direct impact on

medial end of clavicle.

• Types. Usually dislocates anteriorly; posterior dislocation is rare. The

deformity is at the medial clavicle.

• Complications. Tracheal and oesophageal compression may occur with

posterior dislocation. Careful assessment is required.

Treatment

• Anterior dislocation. Treated symptomatically with a sling, analgesia, and

early mobilization.

• Posterior dislocation with tracheal compression. Requires closed

reduction or open if this fails (with cardiothoracic surgical help).

Acromioclavicular joint (ACJ)

• Usually an injury of second to fourth decade, more common in males.

• Mechanism. Fall or direct impact on to the point of the shoulder.

• Rockwood classiﬁ cation.

Six types with increasing numbers relating to

increasing severity of ligamentous disruption (acromioclavicular and

coracoclavicular) and displacement.

Type I. Sprained acromioclavicular ligament (no displacement).•

Type II. Acromioclavicular ligaments disrupted, ACJ subluxed.•

Type III. Acromioclavicular and coracoclavicular ligaments disrupted •

(>100% displacement).

Type IV. Both ligaments disrupted with posterior displacement.•

Type V. All ligaments torn and massively displaced.•

Type VI. All ligaments torn and inferior displacement (very rare).•

Treatment

• Types I and II (and some III). Broad arm sling and early mobilization

when pain allows. Persistent pain or functional limitation is treated by

reconstruction of the coracoacromial ligament.

• Type III and above. Acute repair indicated. Soft tissue reconstruction

better than hook plate.

Anterior dislocation of the glenohumeral joint

2,3

Mechanism Traumatic event, leading to forced abduction and external

rotation (fall on to the outstretched arm).

Associated features

• Young. Ninety per cent have traumatic injury to bony and/or soft tissue

restraints in the shoulder—the Bankart lesion (anteroinferior glenoid

labrum tear, with or without a glenoid rim fracture), Hill–Sachs lesion

(impression fracture as the anterior glenoid impacts on humeral head).

• Rotator cuff tears. Approximately 30% of those >40y and 80% of those

>60y will have a tear.

• Greater tuberosity fractures. Common over the age of 50y.

DISLOCATIONS OF THE SHOULDER REGION

527

Clinical ﬁ ndings

• History of injury and whether had previous dislocations.

• The shoulder looks ‘square’ as the deltoid is ﬂ at and a sulcus can be

visible where the humeral head may be.

• The patient supports the arm which is abducted and very painful.

• Assess neurovascular status (axillary nerve).

• X-rays (AP and axillary or scapular ‘Y’ lateral views) show the humeral

head anterior and inferior to the glenoid. Used to exclude a fracture of

the humerus or glenoid.

Treatment

• Reduce as an emergency in A&E.

• Give IV morphine 5–10mg + inhaled N

O (IV midazolam 5mg is usually

unnecessary).

Simplest, extremely reliable method is gentle, continued straight •

line traction with the arm abducted about 10–20° from the trunk.

May take 10–15min, but patience is the key, not force.

Avoid rotation (such as in a ‘Kocher’s manoeuvre’) as this is •

dangerous and may cause fracture of the humerus.

Countertraction can be placed across the trunk with a broad sheet.•

• Alternative technique is patient prone on the trolley, arm hanging

freely down and weighted (e.g. 3L bag of saline) (‘Stimson’s

technique’).

• If there is an associated humeral neck fracture, then the reduction

should be done under GA.

• Place the arm in a collar and cuff sling under the clothes. Repeat the

X-ray to conﬁ rm reduction and that there has been no iatrogenic

fracture.

• Always document the neurological status (axillary nerve) before and

after reduction.

• Follow-up in clinic mandatory to assess for associated injuries.

Posterior dislocation of the glenohumeral joint

Mechanism Rare. Due to forced internal rotation or direct blow to the

anterior shoulder (e.g. after an epileptic ﬁ t or electric shock). Common

to be missed.

Features

• The arm is held internally rotated and no external rotation is possible.

• The humeral head should be palpable posteriorly.

• AP X-rays may show the humeral head as a ‘light bulb’ shape

(internally rotated), but this is not diagnostic of posterior dislocation.

• Lateral X-ray shows the dislocation.

Treatment

• In-line traction method (as above), but consider GA if difﬁ cult—avoid

excessive force.

• May be very unstable; occasionally the ‘broomstick’ plaster may be

used.

CHAPTER 15 Orthopaedic surgery

528

Recurrent dislocation of the shoulder

• Usually due to a Bankart lesion or capsular redundancy (stretched and

ﬂ oppy).

• Commonest in young age of ﬁ rst dislocation (90% recurrence if <20y,

60% if 20–40y, <10% if older than 40y).

Treatment—surgery

• Repair and ﬁ xation of the anterior ‘Bankart lesion’.

• May be done open or arthroscopically.

• Capsular laxity is treated by capsular shift, an overlapping ‘pants-over-

vest’ procedure to improve proprioceptive joint sensation.

References

1 Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P (Eds) (2009). Rockwood and Green’s

fractures in adults, 7th edn. Lippincott, Williams, and Wilkins, Philadelphia.

2 Robinson CM, Dobson RJ (2004). Anterior instability of the shoulder after trauma. J Bone Joint

Surg Br 86-B, 469. [review]

3 M http://www.wheelessonline.com/orthoo/43.htm.

N = normal position

D = dislocated

subglenoid

subcoracoid

(most common)

subclavicular

Fig. 15.1 Types of shoulder dislocation. Reproduced with permission from

Collier, J. et al. (2006). Oxford Handbook of Clinical Specialties, 7th edn. Oxford

University Press, Oxford.

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CHAPTER 15 Orthopaedic surgery

530

Fractures of the ribs and sternum

Mechanism

• Single rib fractures occur as a result of direct injury such as a fall.

• Fractures of the lower ribs can occur with coughing.

• Sternal fractures occur with direct injury, e.g. contact with steering

wheel or by restraint by a seat belt.

• High velocity (RTA) or large crush injuries can result in a ‘stove-in’

chest with a ﬂ ail segment, i.e. multiple rib fractures, each fractured at

two sites.

Treatment

• Single rib fracture. Symptomatic with analgesia.

• Multiple rib fracture. If t3 ribs involved, should admit for observation

overnight, but treatment symptomatic with analgesia and chest

physiotherapy.

• Sternal fracture. Symptomatic treatment, but observe for associated

injuries (see below).

• Flail chest or extensive multiple rib fractures. Potentially life-threatening

injury and may present with severe respiratory distress.

Flail segments move paradoxically, preventing adequate ventilation.•

Multiple fractures restrict respiratory effort, severely impairing •

ventilation.

Treat with high ﬂ ow O•

and analgesia. CPAP and even IPPV may be

required.

Complications

Incidence of complications rises dramatically if the injury involves:

• >3 ribs.

• First, second, or third ribs.

• Sternum.

• Scapula.

They are all indicators of high energy transfer injury.

Cardiac tamponade

• Bleeding into the pericardial cavity causes severe haemodynamic shock

and may be the cause of a cardiac arrest at presentation.

• Diagnosis is by high clinical suspicion, mufﬂ ed heart sounds, raised JVP,

and no signs of a tension pneumothorax.

• Treat by immediate pericardiocentesis with transfer to cardiothoracic

unit for repair of the defect.

Pneumothorax

• Usually due to direct pleural injury by bone fragments during injury.

• Often associated with haemothorax.

• Signs are respiratory distress, absent breath sounds, hyperresonant

percussion note (pneumothorax), or shock.

FRACTURES OF THE RIBS AND STERNUM

531

• Tension pneumothorax is life-threatening and requires immediate

decompression via a 16G needle placed into the second anterior

intercostal space, followed by deﬁ nitive chest drain placement.

• If in any doubt, always treat ﬁ rst on clinical grounds rather than wait

for investigations (X-rays, etc.).

Reference

1 American College of Surgeons (2008). Advanced trauma life support (ATLS) for doctors, student

manual, 8th edn. American College of Surgeons, Chicago.

CHAPTER 15 Orthopaedic surgery

532

Fractures of the pelvis

Mechanism

• Age <60y. High energy—RTA or falls at work (building sites) or sport

(horse riding).

• Age >60y. Low energy (insufﬁ ciency fracture)—fall from standing

height.

The force required to fracture the pelvis in the young is considerable and

as a result, the morbidity and mortality can be as high as 20%. It is the main

cause of death in multiple trauma patients.

Types

• The pelvis is a ring consisting of two innominate bones and the sacrum.

• Anteriorly are the ligaments of the symphysis pubis and posteriorly,

the ligaments to the sacrum (sacrospinous, sacrotuberous, and

sacroiliac).

• An isolated break at any part is generally stable (the ring will not

separate).

• Two breaks in the ring make it unstable (able to displace or open).

Remember this can be due to a fracture or ligament disruption!

• Young and Burgess classiﬁ cation (descriptive):

AP compression (impact from the front or rear).•

Lateral compression (impact from side).•

Vertical shear (usually a fall from height).•

Combined mechanical (mixture of all of the above).•

Assessment

• ATLS approach.

• Mechanism of injury important as gives insight into degree of injury.

• Assessment and documentation of other injuries is mandatory.

• Look for neurological, gastrointestinal, and genitourinal injury.

Treatment

Initial treatment of all pelvic fractures should include ATLS protocols.

Once stable, an AP pelvis X-ray supplemented with inlet and outlet views

are required.

A CT is helpful to assess the posterior pelvic structures that can be

obscured on a plain X-ray.

Single ring fracture (stable)

• Check for an occult sacroiliac ligament injury (local bruising and

tenderness with pain on stressing the joint); this suggests the injury

could be unstable.

• Fractures of both superior and inferior pubic rami on the same side

are a single break in terms of ring stability.

• Other stable patterns include ilium fractures into sciatic notch or

sacrum.

• Remember that if a signiﬁ cant single break in the ring is present, there

is a chance that concurrent ligamentous injury exists. Thus, a CT scan

is often required prior to mobilization to conﬁ rm stability.

FRACTURES OF THE PELVIS

533

• Isolated fractures of the ilium, ischium, or pubis are normally treated

with bed rest, analgesia, and early mobilization as soon as the pain

allows.

• Fractures that extend to the acetabulum (joint) require further

investigation to plan treatment, but are usually stable if isolated.

• Simple pubic rami fractures in the elderly (osteoporotic) can be

treated conservatively with bed rest and early rehabilitation.

Multiple ring fractures (unstable)

Unstable fractures are liable to massive haemorrhage within the soft

tissues of the pelvis. This is mostly because the pelvic ring is grossly

displaced during the injury and tearing of the extensive posterior pre-

sacral venous plexus occurs. A patient’s entire blood volume can be lost,

hence the high mortality rate.

Establish haemodynamic control

• Approach patient according to ATLS guidelines (ABCDE).

• Haemorrhage is leading cause of death with pelvic injuries.

• Tachycardia and hypotension suggest bleeding.

• Establish at least two large calibre IV infusions and commence

resuscitation with warm crystalloid 2000mL, and then reassess.

• Send blood for urgent cross-match of 4–6U. O –ve blood is given if no

response to initial ﬂ uid challenge.

• Continued bleeding must be controlled by reducing the pelvic volume.

This may be achieved by:

Pelvic binder or binding a bedsheet tightly around the pelvis •

and internally rotating the hips—very effective as an emergency

procedure.

Application of an external pelvic ﬁ xator is a more deﬁ nitive •

solution, but should be done in the trauma theatre.

• Laparotomy is contraindicated unless there are life-threatening

intra-abdominal injuries that must be treated since this effectively

‘decompresses’ the pelvis again superiorly.

• Urethral injury occurs, especially with anterior compression bony

injuries. If there is blood at the urethral meatus, perineal bruising,

haematuria, or a high riding prostate on rectal examination, then

catheterization should only be performed by an experienced urologist

(very often suprapubically). Investigation for injury is with a retrograde

urethrogram or IVU once the patient is stable.

Deﬁ nitive management

• Signiﬁ cant AP compression mechanism can result in an ‘open book’

pelvis. Severe subtypes of the lateral compression or vertical sheer

fractures are very unstable and associated with other injuries.

• Once ATLS stabilization is complete, CT scanning is required to deﬁ ne

the fracture and plan treatment.

• External ﬁ xation is excellent to temporarily control unstable fractures

and manage deﬁ nitively. It can help to control haemorrhage in a

haemodynamically unstable patient.

CHAPTER 15 Orthopaedic surgery

534

• Once stable, liaise with local pelvic ﬁ xation centres to arrange

deﬁ nitive ﬁ xation if required.

• ORIF with screws and plates for the symphysis pubis of ilium fractures.

Posterior pelvic instability involving the sacrum require screw ﬁ xation.

Complications

• Haemorrhage, shock, and death from exsanguination.

• Open fractures carry a 50% mortality and need to be treated

aggressively by both orthopaedic and general surgical teams.

• Urogenital injury.

• Thromboembolism (35–50% develop DVT and 10% PE).

• Neurological injury.

• Paralytic ileus.

• Mal-union may lead to difﬁ culty with pregnancy.

• Osteoarthritis.

Acetabular fractures

• Usually high energy injury in the young from RTA (dashboard impact)

or fall from a height. Associated with hip dislocation.

• Assess as per all pelvic fractures (i.e. ATLS).

• X-rays required include AP pelvic views plus Judet views (45° internal

and external views); CT is routine.

• Letournel–Judet classiﬁ cation. Fractures as posterior wall, posterior

column, anterior wall, anterior column, or transverse.

• Non-surgical management is reserved for fractures that are

undisplaced (except posterior wall as hip unstable) and do not involve

the ‘dome’, the superior acetabular roof (weight bearing area).

• Surgical management, ORIF, in displaced dome fractures, fractures

resulting in joint instability, or trapped intra-articular fragments.

Sacral fractures

• High energy injury in the young or low energy in the elderly.

• Assess as per all pelvic fractures (i.e. ATLS). Must assess for sacral

nerve root injury.

• X-rays include AP pelvic (inlet and outlet) views; CT is required as

difﬁ cult to fully appreciate on X-ray.

• Denis classiﬁ cation. Alar lateral to foramen, involving the foramen, or

central portion medial to foramen.

• Non-surgical management is reserved for fractures that are

undisplaced or impacted.

• Surgical management if displaced or loose fragments impinging on

nerve roots.

References

1 Burgess A, Young JWR et al. (1990). Pelvic ring disruptions: effective classiﬁ cation system and

treatment protocols. J Trauma 30(7), 848–56.

Further reading

Metaizeau JP (2004). Stable elastic intramedullary nailing for fractures of the femur in children.

J Bone Joint Surg Br 86-B: 954–7. [Operative technique]

Wolinsky P et al. (2001). Controversies in intramedullary nailing of femoral shaft fractures. J Bone

Joint Surg Am 83-A: 1404–15. [Instructional course lecture]

CHAPTER 15 Orthopaedic surgery

540

Fractures of the tibial shaft

Mechanism

• High energy injuries in young as a result of RTA, sporting injury, fall

from height.

• Direction of force dictates fracture pattern—torsional (spiral), direct

blow (transverse or short oblique). Higher energy patterns suggested

by multifragmentary fractures with or without bone loss.

• Soft tissue injuries common as tibia subcutaneous. Be aware of ‘OPEN’

fractures.

Assessment

• ATLS approach recommended.

• Inspect for angulation, deformity, and malrotation.

• Subcutaneous crepitation may be present or obvious open wound.

• Neurovascular status needs to be assessed and documented.

• Watch for ‘compartment syndrome’. Presents as pain, uncontrolled by

analgesia, and out of proportion to injury. Look for pallor, paraesthesia,

and pulselessness (late signs). Passive dorsiﬂ exion of joint distal to

injury stretching the muscles in the affected compartment is usually

diagnostic.

• Compartmental pressures can be measured; an absolute pressure

of >40mmHg or <30mmHg difference between compartment and

diastolic BP diagnostic.

• This is a clinical diagnosis and requires immediate management via

fasciotomies of affected compartments.

Classiﬁ cation

• AO system can be used, but is complex.

• Anatomical description is the simplest:

Position (mid-shaft, junction of distal third, etc.).•

Conﬁ guration (transverse, oblique, spiral, segmental, comminuted).•

Number of fragments.•

• Open injuries are normally classiﬁ ed additionally by the Gustillo–

Anderson system.

Treatment

2,3

There is no one method of treatment that is appropriate for all fractures.

There is a continual contentious debate about the pros and cons of differ-

ent modalities. The best rule is to judge each fracture and associated soft

tissue injury on an individual basis and treat appropriately.

Non-surgical (plaster of Paris)

• Used for undisplaced fractures and low energy displaced fractures in

children that can be closed reduced.

• Long leg cast, with the knee ﬂ exed 20* and the ankle in neutral.

• Mobilize non-weight bearing on crutches, with X-rays weekly for the

ﬁ rst 4 weeks to check alignment.

• Start weight bearing at 8 weeks in a weight bearing contact ‘Sarmiento’

cast.

FRACTURES OF THE TIBIAL SHAFT

541

• Union takes around 14–16 weeks.

• Advantages. Simple and avoids all operative risks.

• Disadvantages. Takes a long time; requires good follow-up and patient

compliance. Stiffness at the knee and ankle is common and unstable

injuries are very difﬁ cult to manipulate and control in plaster alone.

Cast bracing A variation of plaster where Sarmiento plaster is applied

from day 1.

Surgical

• Indicated if unable to maintain closed reduction, i.e. >50% displaced,

>10° angulated, >10° rotational deformity, >1cm shortening.

• Unstable fracture patterns. Multifragmentary and same level tibial

fractures.

• Open fractures.

Locking plate ﬁ xation

• Mostly used for fractures near the joint surface.

• Plates used in the shaft have a high rate of infection and non-union

caused by the large soft tissue exposure required.

• Advantages. Simple, quick, rapid mobilization, and avoids the need for

plaster.

• Disadvantages. Risk of infection, non-union, and implant failure.

Intramedullary nailing

• Currently the treatment of choice in most centres, but requires

increased operating time and experience.

• May be used in compound fractures, especially where soft tissue ﬂ aps

are required since it gives relatively unlimited access to the tibia ‘ﬁ x

and ﬂ ap’.

• Best for mid-shaft fractures and is poor at controlling fractures within

5–10cm of the knee and ankle joints.

• Advantages. Early mobilization, quicker rehabilitation than closed

methods, soft tissue undisturbed by technique, access for ﬂ aps easy.

• Disadvantages. Technically demanding, high rate of chronic anterior

knee pain (site of nail insertion—not recommended for kneeling

profession, e.g. carpet ﬁ tters).

External ﬁ xation

• Often used in compound fractures as it allows least disturbance of

soft tissue. Can be placed in an extremely rigid conﬁ guration to allow

stability. Rigidity can then be reduced sequentially in outpatients, if

required.

• Tensioned wire circlage frames pioneered in Russia (Ilizarov) can be

used for difﬁ cult fractures around the knee or ankle.

• Advantages. Technically simple (not Ilizarov); allows early mobilization,

avoids further soft tissue damage.

• Disadvantages. Pin site infections common, but usually easily treated.

Requires good nursing backup and patient compliance. Pin sites need

to be planned carefully with plastic team if ﬂ aps used so as not to

compromise soft tissue cover.

CHAPTER 15 Orthopaedic surgery

542

Open fractures

• Guided by the British Orthopaedic Association and British Association

of Plastic, Reconstructive, and Aesthetic Surgeons Guidelines.

• Recommend a multidisciplinary approach in a specialist centre, if

possible.

• High energy patterns of fracture with soft tissue injury (skin loss,

degloving, muscle damage or loss, arterial injuries) need to be acted

upon promptly.

• Initially ATLS approach.

• Assessment of affected limb. Neurovascular status essential and

repeated regularly.

• Give IV broad-spectrum antibiotics (within 3h of injury).

• Treat limb-threatening injuries immediately (vascular or compartment

syndrome).

• Remove gross contamination from open wounds, photograph, wrap in

saline-soaked gauze and ﬁ lm dressing. Immobilize the whole affected

limb in a splint. Tetanus status checked.

• Combined management approach to plan deﬁ nitive treatment of

fracture and soft tissues. Aim to do within 24h of injury if isolated open

fracture.

References

1 Gustilo RB, Anderson JT (1976). Prevention of infection in the treatment of one thousand and

twenty-ﬁ ve open fractures of long bones: retrospective and prospective analyses. J Bone Joint

Surg Am 58-A: 453–8.

2 Schmidt AH et al. (2003). Treatment of closed tibial fractures. J Bone Joint Surg Am 85-A, 352–68.

[Instructional course lecture]

3 Bhandari M et al. (2001). Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg B

83-B: 62–8. [Review]

4 Gopal S, Majumder S, Batchelor AG, et al. (2000). Fix and ﬂ ap: the radical orthopaedic and

plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 82-B: 959–66.

5 Standards for management of open fractures of the lower limb. (2009). BOA and BAPRAS.

M http://www.boa.ac.uk or M http://www.bapras.org.uk

6 Elliott KG, Johnstone AJ (2003). Diagnosing acute compartment syndrome. J Bone Joint Surg Br

85-B: 62–8. [Review]

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CHAPTER 15 Orthopaedic surgery

544

Fractures of the ankle

• Commonest fracture of the lower limb.

• Usually low energy rotational force, resulting in simple to complex

conﬁ gurations.

• The talus rotates in the mortise and produces different patterns

dependent on whether the foot is inverted or everted.

• Axial load causes fracture of the tibial plafond.

• The ankle should be thought of as a ring and stability is conferred by:

Bones.• Medial and lateral malleoli and the talus (form ‘mortise’).

Ligaments.• Laterally, the tibioﬁ bular ligamentous complex

(syndesmosis) and the lateral collateral ligaments (taloﬁ bula and

calcaneoﬁ bular); medially the deltoid ligament.

• Remember that a fracture of the proximal ﬁ bula (at the knee) is

associated with an ankle fracture or dislocation until proven otherwise.

Assessment

• Initially, ATLS approach.

• Inspect for bruising, swelling, obvious deformity, open wounds, skin

tenting, signs of neurovascular compromise.

• Depending on the degree of injury, some patients may walk in for

assessment.

• Remember to examine the whole ﬁ bula for proximal tenderness.

• Examine for medial tenderness. The medial injury may be ligamentous

only, but this is enough to destabilize the ankle and allow talar shift.

• X-rays are mortise AP (15° internal rotation) and lateral views.

Classiﬁ cation

• AO/Danis–Weber system (based on level of ﬁ bula fracture):

Type A. Below the syndesmosis.•

Type B. At the syndesmosis.•

Type C. Above the syndesmosis.•

• The Lauge–Hansen classiﬁ cation is more complex and based upon

mechanism of injury. Foot supinated and adducted or externally

rotated or foot pronated and abducted or externally rotated.

• A distal tibial fracture involving the joint is known as a pilon fracture.

Treatment

Displaced fracture/dislocation

• A displaced fracture dislocation is an orthopaedic emergency and is

always clinically obvious. Displacement is often more than expected

due to soft tissue swelling.

• Reduce the fracture immediately in A & E and apply a below-knee

backslab before sending the patient for an X-ray. An X-ray of a

dislocated ankle should never be seen!

• Check neurovascular status before and after reduction.

• Give plenty of analgesia ± sedation (usually done in resuscitation area).

FRACTURES OF THE ANKLE

545

Stable injuries

• Lateral malleolus only (Weber A or B) with no talar displacement

(shift) in the mortise.

• Ensure no medial tenderness exists.

• These can be managed in a well ﬁ tting below-knee cast with the foot

at 90° (neutral).

• Obtain a post-cast X-ray to ensure position acceptable.

• Regular follow-up and serial X-rays required to ensure reduction

remains.

• Total of 6 weeks cast.

• Weight-bearing is allowed.

• Some simple Weber A fractures require just a supportive elasticated

stocking.

Unstable injuries

• Minimal displacement (d2mm) is acceptable in the elderly and treated

by plaster as above.

• Weber B or C fractures with medial tenderness or talar shift.

• Initially placed into backslab for comfort, elevated, and iced (reduces

swelling).

• If too swollen, skin closure is compromised, thus aim to do within ﬁ rst

24–48h.

• Check for signiﬁ cant blisters around areas of incision.

• ORIF is used with the lateral fracture reduced and held with a ‘lag

screw’ and ‘neutralization’ plate and screw construct.

• The medial malleolus is ﬁ xed directly with two partially-threaded

cancellous screws (compression) or if a small fragment, a tension

band wire construct.

• A cast is applied following ﬁ xation and the patient remains in this

non-weight bearing for up to 6 weeks.

Pilon fractures

• Intra-articular fractures of the tibial plafond due to axial force (high

energy).

• Initial management is as for ankle fractures.

• Careful assessment for swelling, skin compromise, blisters, and

neurovascular status.

• Standard AP and lateral X-rays required; often a CT is needed to

deﬁ ne fracture pattern further and plan treatment.

• Non-surgical management only for undisplaced fractures.

• Surgical management is related to soft tissue status.

• External and internal ﬁ xation techniques are applicable.

Further reading

Vander Griend R, Michelson JD, Bone LB (1996). Fractures of the ankle and the distal part of the

tibia. J Bone Joint Surg Am 78-A: 1772–83. [Instructional course lecture]

M http://www.blackburnfeet.org.uk/hyperbook/trauma/ankle_fractures/ankle_fractures_intro.htm.

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Fractures of the tarsus and foot

Talus

Mechanism

• Usually a fall from height or an RTA (high energy).

• Foot forcibly dorsiﬂ exed against the tibia.

• Look for associated ankle fractures.

• Blood supply to the talus often compromised. Talus has limited soft

tissue attachments, thus relies on extraosseous vessels, which are

easily disrupted.

Assessment

• ATLS.

• Look for associated injuries.

• Look for compartment syndrome of foot.

• Neurovascular status.

• AP and lateral of ankle plus CT.

Classiﬁ cation

• By anatomical site, i.e. head, neck, body, or lateral process.

• ‘Hawkins’ classiﬁ cation for talar neck fractures (types I–IV, increasing

levels of displacement and subluxation with increasing grade).

Treatment

• Body fractures. Treated surgically with ORIF unless undisplaced.

• Neck fractures:

Undisplaced.• Strict non-weight bearing in below-knee plaster for 6

weeks.

Displaced.• ORIF is required. If dislocated, urgent management

required as soft tissue can be compromised.

Complications

• Avascular necrosis. Rate increases with displacement (10% in type I to

90% in type III).

• Osteoarthritis of tibiotalar and subtalar joints.

• Mal-union.

Calcaneum

Mechanism

Axial load. Fall from height or RTA.

Assessment

• ATLS.

• Assess for associated injuries. Spinal (thoracolumbar) fracture and

upper limb injuries.

• Swelling can be signiﬁ cant. Assess for compartment syndrome acutely.

• AP ankle and lateral plus axial Harris view.

• CT may be required.

FRACTURES OF THE TARSUS AND FOOT

547

Classiﬁ cation

• Extra- or intra-articular.

• Intra-articular fractures involve the subtalar joint and are classiﬁ ed by

their CT appearance by ‘Saunders’ system.

Treatment

• Extra-articular or undisplaced intra-articular fractures.

Conservative. Elevation, ice, bed rest, and observation of soft •

tissues overnight.

Mobilize non-weight bearing with a removable splint to stop •

equinus at the ankle. Early subtalar passive mobilization should be

initiated.

• Displaced intra-articular fractures. Operative treatment is still

controversial. ORIF is usually delayed 10–14 days for swelling to

resolve. Caution is exercised if patient a smoker, advanced age,

complex patterns, multiple trauma, compensation, bilateral fractures.

Complications

• Wound breakdown.

• Mal-union.

• Subtalar arthritis.

• Peroneal tendon pathology.

Tarsometatarsal (TMT) fracture-dislocations (Lisfranc)

Jacques Lisfranc de Saint-Martin described an amputation technique across

the ﬁ ve TMT joints as a solution to forefoot gangrene secondary to frost-

bite. This became known as the Lisfranc joint.

Mechanism and assessment

• Direct dorsal force (RTA) or indirect rotational injury to a plantar

ﬂ exed and ﬁ xed forefoot (foot caught in a riding stirrup and rotation

of body around it).

• The Lisfranc ligament runs from the base of the second metatarsal to

the medial cuneiform. It is the only link between the ﬁ rst ray and the

rest of the forefoot. The recessed base of the second metatarsal also

provides bony stability.

• Disruption of the Lisfranc ligament, with or without a bony

component, results in incongruity of the TMT joint.

• Neurovascular status and compartment syndrome must be assessed.

• AP, oblique, and lateral X-rays are required. Consider weight-bearing

views.

• The medial cortex of second metatarsal should align with medial

cuneiform. Look for ‘ﬂ eck’ sign, suggesting avulsion of Lisfranc

ligament.

• These injuries are commonly missed so a high index of suspicion is

required.

CHAPTER 15 Orthopaedic surgery

548

Treatment

• ORIF is required for all displaced injuries using screws, plates and

screws, and supplementary wires.

Complications

• Foot compartment syndrome in acute injuries.

• Metatarsalgia.

• Post-traumatic arthritis.

• Purely ligamentous injuries have the worse outcome.

Metatarsal and phalanges

Mechanism

• Crushing or twisting injuries (e.g. the foot being run over).

• Fifth metatarsal fracture occurs after an inversion injury and can be

mistaken for an ankle fracture if not examined correctly.

• Always be suspicious of compartment syndrome in severe crush

injuries.

Treatment

• Metatarsal fractures. If minimal displacement or angulations,

conservative treatment with mobilization as pain allows. Plaster only

if mobilization is too painful. Multiple fractures may require reduction

and ﬁ xation.

• Non-union of the ﬁ fth metatarsal sometimes requires ORIF with

grafting if problematic (rare).

• Phalangeal fractures. Neighbour strapping.

References

1 M http://www.orthoteers.co.uk/Nrujp~ij33lm/Orthfootfracfoot.htm.

2 Sanders R (2000). Displaced intra-articular fractures of the calcaneus. J Bone Joint Surg Am 82-A:

225–50. [Current concepts review]

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CHAPTER 15 Orthopaedic surgery

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Injuries and the spinal radiograph

If a patient complains of central pain in the spinal column after trauma,

always obtain radiographs. This should not delay resuscitation as a spi-

nal fracture can be immobilized and life-threatening problems corrected

ﬁ rst.

Spinal injuries can be associated with other injuries and the patient may

not be able to communicate this to you because they are:

• Unconscious.

• Intubated.

• Shocked.

• Intoxicated.

• Anaesthetized distal to a cord lesion.

Common injuries associated with spinal trauma are:

• Bilateral calcaneal fractures—thoracolumbar fractures.

• Facial fractures—cervical fracture/dislocation.

• Severe head injury—cervical injuries, especially C1/C2.

• Sternal dislocation—thoracic spine fracture.

• Ankylosing spondylitis—cervical and thoracic fractures.

• Cervical fracture—10% rate of fracture at another level.

An awake, alert, oriented patient who can demonstrate a normal painless

range of motion of the cervical spine does not need radiographic evaluation.

X-ray interpretation

• Develop a mental picture of the normal spinal radiograph. If you feel

that the X-ray ‘just doesn’t look right’, then it probably isn’t!

• Try to develop a system and use this for every fracture you see, even

when you know it will be normal. It gets you into the habit.

• A systematic approach has been shown to reduce the risk of missed

spine injuries.

C-spine

• AP, lateral, and open mouth views for C1/C2 are required.

• You must be able to see from C1 to T1; if not, request further views

(swimmer’s view).

• Look at the bones and their alignment.

• On the lateral ﬁ lm, a smooth line should run down the anterior aspect

of the vertebral body, the posterior aspect, the anterior aspect of the

spinous process (spinolaminar line), and the posterior aspect of the

spinous process.

• Look for any obvious steps between vertebral bodies (up to 25%

displacement may suggest unifacet dislocation, >25% suggests

complete facet joint instability) and angulation.

• Examine each vertebral body for integrity.

• Look at the facet joints for congruity (facet joint dislocations).

• Look at the distance between the spinous processes (increase suggests

injury).

• Assess the soft tissues. Disc spaced for narrowing or widening.

INJURIES AND THE SPINAL RADIOGRAPH

551

• Assess the soft tissues anterior to the spine. This should be no more

than 7mm at C3 and 3cm at C7. Any increase suggests swelling and

thus injury.

• Look at the odontoid peg and its relationship to C1. Look for fractures

and the gap in front of peg (usually <3mm).

• On the AP ﬁ lm, assess the vertebral body height and alignment.

• The interpedicular distances (increase may suggest fracture).

• Look for central alignment of the spinous processes. Beware the

empty vertebrae; this may imply damage to the spinous process.

• Check the transverse processes; they become displaced when

fractured.

Thoracolumbar spine

• AP and lateral views required.

• Thoracic spine is difﬁ cult to interpret; look for other clues such as

multiple rib fractures.

• On the AP, look at alignment.

Vertebral body height.•

Interpedicular distance. An absent or broken pedicular ring may •

suggest fracture of the posterior elements.

Central spinous process alignment.•

Integrity of the transverse processes.•

Disc height.•

• On the lateral X-ray, assess alignment and look for steps.

Look at the vertebral body and check for anterior wedging (>50% •

loss of body height suggests instability).

Any bony fragments displaced into the vertebral canal posteriorly.•

Check disc height.•

Overall angulation of the spine (kyphosis in lumbar spine or •

increased kyphosis of thoracic).

Further imaging

• If a fracture is found on the X-rays that is deemed unstable or the ﬁ lms

are difﬁ cult to interpret and there is a high suspicion of injury, a CT

should be requested.

• A CT scan will assess the bony spine.

• If a soft tissue or spinal cord injury is suspected, an MRI will be

required.

Signs that imply spinal instability

Denis divides the spine into three structural columns:

• Anterior. Anterior half of vertebral body and the anterior longitudinal

ligament.

• Middle. Posterior half of vertebral body and posterior longitudinal

ligament (PLL).

• Posterior. All structures posterior to the PLL (facet joints, pedicles,

ligamentum ﬂ avum, spinous processes, and their interspinous

ligaments).

With increasing column involvement, there is increasing instability, i.e.

one-column injury usually stable, three-column injury highly unstable.

CHAPTER 15 Orthopaedic surgery

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• Complete vertebral dislocation or translocation.

• Signiﬁ cant anterior wedging (>50%).

• Fractures in a previously fused spine, especially ankylosing spondylitis.

• Signs of movement. Malalignment, avulsion fractures, and evidence of

paravertebral swelling.

• Increased interspinous or interpedicular distance.

Further reading

Raby N, Berman L, de Lacy G (2005). Accident and emergency radiology: a survival guide, 2nd edn.

Saunders, London.

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CHAPTER 15 Orthopaedic surgery

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Spinal injuries

Any patient with major trauma arriving in A&E should be assumed to

have a cervical injury unless proven otherwise. Remember that the A in

the primary survey of ATLS resuscitation stands for airway with cervical

spine control, i.e. it is top priority.

• Cervical spine is the commonest area to have a major spinal injury.

• Other areas of concern are where mobile areas are at a junction with

a less mobile one, e.g. C7/T1, T12/L1, and L5/S1 junctions.

• The main reason for delay in diagnosis of spinal injuries is failure to

have a high clinical index of suspicion in all major trauma patients.

Principles of treatment

• Begin with ATLS approach and C-spine immobilization (rigid collar,

lateral head supports, and strapping).

• Particular attention needs to be paid to this as some studies have

suggested up to 25% of spinal cord injuries occur in the early

management phase, after the initial injury!

• All trauma patients should be assumed to have a spinal injury until

proven otherwise, especially in the presence of altered mental state or

blunt head injury.

• A thorough primary and secondary survey needs to be performed,

looking for mechanisms that would increase the risk of spine injury

(RTA, motorcyclist, seat belt marks) and signs suggestive of other

injuries (boggy swelling along the spine on log rolling).

• Until injuries of the spine have been deemed as stable, log rolling

should take place to prevent any spinal cord injury from occurring.

• A full neurological examination is mandatory (if patient conscious).

• Once resuscitation and stabilization have occurred, appropriate

radiological studies need to be undertaken.

• In the trauma setting, the ATLS manual now recommends CT scanning

of the C-spine rather than a lateral X-ray. However, you must still be

able to assess an X-ray if CT is unavailable!

Deﬁ nitive management

Cervical spine

• C1 (Jefferson fracture).

If stable, semi-rigid collar or halo ﬁ xator.•

If unstable, halo ﬁ xator or traction • ± surgical ﬁ xation.

• C2 (odontoid peg fracture).

Type 1 (tip). Treat with semi-rigid collar.•

Type 2 (waist). In elderly, consider cervical collar or C1/C2 fusion; •

in young patients, if undisplaced—halo ﬁ xator, if displaced—internal

ﬁ xation or C/C2 fusion.

Type 3 (base and extends into body of C2). Stable, treat with •

cervical collar.

• C3–C7.

SPINAL INJURIES

555

Anterior compression fractures treated in semi-rigid collar or halo •

(if >25% loss anterior height or kyphosis >11°, may need operative

fusion).

Burst fractures (from axial load). Associated with cord injury; •

treatment with decompression and fusion may be required.

• Facet joint dislocations. Both unilateral and bilateral dislocations

require reduction with progressive traction. Once reduced, unifacet

dislocations are stable and treated in a cervical collar; bilateral

dislocations require surgical stabilization.

Thoracolumbar injury

• Most common at T11–L2 as transitional segment (rigid to mobile).

• Up to 12% incidence of fracture at different spinal level.

• Denis classiﬁ ed into compression, burst, ﬂ exion-distraction, and

fracture-dislocations, based on 3-column theory.

• Stable fractures (<50% loss of vertebral body height, <25% kyphosis,

<50% spinal canal compromise) and neurologically intact are treated

conservatively with a thoracolumbar spine orthosis (TLSO) for 3

months.

• Unstable fractures or neurological deﬁ cit require stabilization via

fusion and decompression of spinal canal.

Sacral injury See Fractures of the pelvis, b p. 532.

Spinal cord injury (SCI)

• Assess acutely as previously described (ALTS and so forth).

• Full neurological evaluation.

• Establish level of SCI. C5 or above requires intubation.

• Complete or incomplete lesions. Find motor level, then establish

presence of sacral sensation (intact suggests incomplete).

• Look for other injuries and treat accordingly.

• Steroid use for SCI is controversial with a paucity of level 1 evidence.

• High dose methylprednisolone administered within 8h of injury and

continued for 48h has been shown to improve outcomes.

• Always adhere to local policy.

Neurogenic shock

• Neurological injury causing failure of descending sympathetic pathways

of cervical and upper thoracic cord. Affects vasomotor tone and

cardiac function.

• Results in vasodilatation and bradycardia (unopposed parasympathetic).

• Be careful of excessive ﬂ uid therapy to treat hypotension as may result

in ﬂ uid overload.

Spinal shock

• Loss of muscle tone (ﬂ accidity), loss of reﬂ exes (areﬂ exia), and

anaesthesia following SCI.

• Duration variable (usually 48h).

• End deﬁ ned by onset of spasticity below level of SCI.

• No recovery by 48h suggests complete cord injury and poor prognosis.

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‘Incomplete’ spinal cord syndromes

If there is preservation of some modalities of cord function distal to the

injury level, the cord lesion is referred to as ‘incomplete’. Several recog-

nized patterns exist.

Central cord syndrome

• Most common.

• Hyperextension injury to a spine with stenosis; usually age >50y.

• Weakness affects upper limbs > lower limbs. Deﬁ cits worst distal than

proximal. Variable sensory loss.

• Due to vascular compromise to cord (anterior spinal artery supplies

central cord).

• Recovery. Lower extremities, then bladder, then proximal upper limbs,

and then hands.

Anterior cord syndrome

• Flexion injury.

• Poorest prognosis (10–20% recovery).

• Dense motor (paraplegia/quadraplegia) and sensory loss below level of

injury. Affects spinothalamic and corticospinal tracts.

• Proprioception and vibration sense (posterior column) spared.

Brown–Sequard syndrome

• Penetrating trauma.

• Hemisection of the cord, giving ipsilateral motor (corticospinal),

vibration and proprioceptive loss (posterior columns), and

contralateral loss of pain and temperature (spinothalamic).

• Variable, but best chance of recovery.

Posterior cord syndrome

Proprioception and vibration sense lost, but intact motor power (rare).

References

1 American College of Surgeons (2008). Advanced trauma life support (ATLS) for doctors, student

manual. 8th Edition. American College of Surgeons, Chicago.

2 Bracken MB (2009). Steroids for acute spinal cord injury. The Cochrane Database of Systematic

Reviews Issue 1, Art. No.: CD001046.

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CHAPTER 15 Orthopaedic surgery

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Acute haematogenous osteomyelitis

This is a disease of growing bones. It is common in infants and children, but

rare in adults unless they are immunocompromised or diabetic.

Aetiology

• Infants (<1y). Staphylococcus (S.) aureus, group B streptococci, and

Escherichia coli.

• Children (1–16y). S. aureus, Streptococcus (S.) pyogenes, Haemophilus

(H.) inﬂ uenzae.

• Adults. S. aureus, Staphylococcus (S.) epidermidis.

• Sickle cell patients. Salmonella sp.

• Rare causes. Brucella, TB, spirochetes, and fungi.

Pathological features

The organisms settle near the metaphysis at the growing end of a long

bone. The following stages typically occur.

• Inﬂ ammation. Acute inﬂ ammation with venous congestion.

• Suppuration. After 2–3 days, pus forms in the medulla and forces its

way out to the periosteum.

• Necrosis. After 7 days, blood supply is compromised and infective

thrombosis leads to necrosis and formation of a pocket of dead tissue

(sequestrum).

• Repair. At around 10–14 days, new bone is formed from the

subperiosteal layer that was stripped with the swelling (involucrum).

• Discharge. Involucrum can develop defects (cloacae), allowing

discharge of pus and sequestrum to allow resolution. This can also be

achieved by surgical release and debridement.

Clinical features

• Usually a child with a preceding history of trauma or infection (skin or

respiratory).

• Fever, pain, and malaise develop after a few days.

• The child may be limping or refusing to weight bear.

• On examination, there may be localized swelling or redness of a long

bone.

• Infants may present with a failure to thrive, drowsiness, or irritability.

• Neonates may present with life-threatening septicaemia in which

obvious inﬂ ammation of a long bone develops or a more benign form

in which the symptoms are slow to develop, but bone changes are

extensive and often multiple.

Investigation

• Plain X-rays may be normal for the ﬁ rst 10 days. Do not be reassured!

•

Technetium bone scan is usually positive in the ﬁ rst 24–48h and is

effective in conﬁ rming diagnosis early.

•

Gallium bone scan and

111

indium-labelled white cell scans are more

speciﬁ c, but generally not available in most units.

• MRI is very sensitive, but not speciﬁ c and difﬁ cult for children.

• CT scanning can deﬁ ne extent of bone sequestration and cavitation.

ACUTE HAEMATOGENOUS OSTEOMYELITIS

559

X-ray features

• Soft tissue swelling is an early sign; look for displacement of fat planes.

• Patchy lucencies develop in the metaphysis at around 10 days.

• Periosteal new bone may be seen.

• Involucrum formation is only apparent at around 3 weeks.

• Sequestrum appears radiodense compared to the surrounding bone

which is osteopenic.

• Normal bone density occurs with healing.

Laboratory tests results

• FBC. i WCC, normally with a raised neutrophil count.

• i ESR.

• i CRP, but returns to normal quickly post-treatment.

• Blood cultures positive in 50% of cases (use to inform and adjust

antibiotic therapy).

• Perform U&E, LFTs, and glucose.

Treatment

• Pain relief by bed rest, splintage, and analgesics.

• Give IV antibiotics according to local guidelines (after blood cultures

and pus swab samples taken), e.g. ﬂ ucloxacillin IV, then PO qds for up

to 6 weeks, dose-adjusted according to age, clindamycin if penicillin-

allergic, vancomycin if MRSA, ampicillin for Haemophilus.

• Surgical drainage of mature subperiosteal abscess with debridement

of all necrotic tissue, obliteration of dead spaces, adequate soft tissue

coverage, and restoration of an effective blood supply.

Complications

• Disseminated systemic infection, e.g. septicaemia, cerebral abscess.

• Chronic osteomyelitis.

• Septic arthritis.

• Deformity due to epiphyseal involvement.

Further reading

Lazzarini L, Mader JT, Calhoun JH (2004). Osteomyelitis in long bones. J Bone Joint Surg Am 86-A:

2305–18. [Current concepts review]

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Chronic osteomyelitis

Causes

• Occasionally following acute haematogenous osteomyelitis.

• Most common following contaminated trauma and open fractures.

• After joint replacement surgery.

• Primary chronic infections of bone.

Secondary to acute osteomyelitis

Features

• Sinus formation due to sequestra or resistant bacteria.

• Prevented by adequate treatment of the initial acute attack.

Treatment

• Conservative (simple dressings) may be appropriate (elderly).

Recurrent attacks with spontaneous recovery may occur and surgery

should be reserved for cases where an abscess forms.

• Chronic abscess. May require drainage, debridement of all necrotic

tissue, and obliteration of dead spaces. May involve plastic surgery to

achieve soft tissue cover and restoration of an effective blood supply.

• Closed suction drainage/irrigation systems can be effective, especially

if irrigation ﬂ uid contains antibiotics. The disadvantage is that early

blockage of the system can occur.

• Antibiotic (gentamicin)-impregnated beads or sponges deliver high

local levels and may be beneﬁ cial in areas of poor blood supply, hence

systemic antibiotic penetration.

• Unresolving cases may require amputation.

Secondary to trauma (open fractures)

• Prevention by early aggressive approach to compound fractures with

debridement and lavage of contaminated tissue.

Excise all dead tissue widely and remove all devitalized bone •

fragments, i.e. with no soft tissue connections.

Copious lavage is necessary as • ‘the solution to pollution is dilution’

(t10L is common).

Skeletal stabilization is mandatory.•

IV antibiotics, e.g. IV cefuroxime • ± metronidazole if anaerobes may

be involved (soil).

• Treat established chronic infection as above with removal of internal

foreign bodies, e.g. metalwork, and possible application of external

ﬁ xation.

Secondary to joint replacement surgery

• Rare (d1%), but is often a disaster for the elective patient.

• Prevention is better than cure. Dedicated laminar ﬂ ow theatres, strict

theatre discipline, and prophylactic IV antibiotics are mandatory.

• Fifty per cent will require surgical intervention.

Initial joint irrigation, debridement, and tissue sampling can be •

attempted if the prosthesis is still solid and not ‘loose’.

CHRONIC OSTEOMYELITIS

561

If grossly infected, the prosthesis must be removed, the surfaces •

debrided, and an antibiotic cement spacer placed on the raw bone

ends to allow the soft tissue envelope to settle.

Once inﬂ ammatory markers have settled (CRP is the best) and •

the clinical infection has resolved, second stage replacement of the

spacer with a new prosthetic joint can go ahead. This may take 12

months and may not be possible.

Chronic osteomyelitis as an initial presentation

Brodie’s abscess

• An isolated well-contained chronic abscess.

• Treatment. Operative drainage with excision of the abscess wall and

antibiotics.

Tuberculosis

• Usually associated with other systemic features of the disease.

• May present acutely.

• Muscle atrophy develops and spontaneous discharge of a ‘cold’ abscess

may lead to sinus formation and destruction of bone.

• Spinal TB may cause vertebral collapse, leading to acute neurology

(‘Pott’s paraplegia’).

Syphilitic osteomyelitis

• Associated with advanced, tertiary disease in adults. Features diffuse

periostitis (with sabre tibia) or localized gummata with sequestra,

sinus formation, and pathological fractures. X-rays show periosteal

thickening with ‘punched out’ areas in sclerotic bone.

• Infants with congenital disease have epiphysitis and metaphysitis.

X-rays show areas of sclerosis near the growth plate separated by

areas of rareﬁ cation.

Mycotic osteomyelitis

• Typically occurs in immunocompromised patients.

• Bone granulomas, necrosis, and suppuration present without

worsening acute illness.

• Usually occurs as spread from primary lung infections such as

coccidiomycosis, cryptococcosis, blastomycosis, and histoplasmosis.

• Treatment. Amphotericin B and/or surgical excision.

Further reading

Lazzarini L, Mader JT, Calhoun JH (2004). Osteomyelitis in long bones. J Bone Joint Surg Am 86-A:

2305–18. [Current concepts review]

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Septic arthritis

A condition due to infection of a joint space and its synovium. It is com-

mon in infants and children, but rare in adults unless they are immunocom-

promised or diabetic.

Aetiology

The infective organisms are the same as for acute osteomyelitis.

Pathological features.

• Primary seeding of the synovial membrane.

• Secondary infection from adjacent metaphysis or directly from

epiphysis.

• In some joints, the metaphysis lies partly within the joint capsule

(shoulder, elbow, hip, and ankle); osteomyelitis can break through

metaphysis and into joint.

• Proteolytic enzymes are released from synovial cells and proteases

from chondrocytes, causing destruction of the articular cartilage:

By 5 days, proteoglycans are lost from cartilage.•

By 9 days, collagen is lost.•

Clinical features

• Usually a child with a preceding history of trauma or infection (skin or

respiratory).

• Acute onset with pyrexia and irritability.

• The child may be limping or refusing to weight bear.

• The affected joint is held still in position of maximal comfort (e.g. hip

ﬂ exed, abducted, and externally rotated gives largest joint volume).

• Look for an erythematous, hot, swollen joint with an effusion.

• A neonate may present with none of the above, just irritable, lethargic,

off feeds, and not moving affected limb.

• In the adult, the joint will be exquisitely painful, hot, red, and swollen,

and they will usually not allow passive motion.

Investigation

• Plain X-rays may show joint space widening, joint subluxation or

dislocation, and soft tissue swelling.

• Ultrasound scan can demonstrate effusion and guide aspiration.

• The mainstay of diagnosis is aspiration of the affected joint with

immediate Gram stain and microscopy, followed by cultures and

sensitivities.

• Always ask for the sample to be analysed for crystals and some septic-

looking joints in adults are actually due to crystalopathies (gout or

pseudogout).

Laboratory tests results

• FBC. i WCC, normally with a raised neutrophil count.

• i ESR.

• i CRP, but returns to normal quickly post-treatment.

SEPTIC ARTHRITIS

563

• Blood cultures positive in 50% of cases (use to inform and adjust

antibiotic therapy).

• Perform U&E, LFTs, and glucose.

Treatment

• Septic arthritis is a surgical emergency and as such, rapid diagnosis, and

management is required.

• Open (or arthroscopic) drainage of the affected joint with copious

irrigation.

• Resuscitation and antibiotics.

• Re-exploration should be considered for those not settling.

• IV antibiotics, broad-spectrum, then tailored once culture results are

available for 2 weeks, then oral for further 4 weeks.

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564

Peripheral nerve injuries

Common; approximately 9000 people a year are admitted to hospital with

an injury to a peripheral nerve.

• Causes include traction, trauma, inﬂ ammation, compression.

• The degree of injury depends on the mechanism (open or closed

injury, acute or chronic), health of nerve prior to injury.

Pathological features

Seddon classiﬁ cation.

Neuropraxia

• Stretching or compression of the nerve which remains anatomically

intact.

• Conduction block with normal conduction above and below.

• Focal demyelination occurs at the site of injury, which is repaired by

the Schwann cells.

• Recovery is usually complete, occurring in days or weeks. There is no

axonal degeneration.

Axontemesis

• The axon is divided, but the covering connective tissue component

remains intact, i.e. the nerve cylinder remains.

• Usually a traction or severe crush injury.

• Axonal (‘Wallerian’) degeneration occurs distal to the injury and is

followed by nerve regeneration (by sprouting from the severed nerve

end) after 10 days.

• Nerve growth occurs at a rate of 1mm per day.

• Prognosis is generally good as the cylinder is intact, but the more

proximal the lesion, the less the distal recovery.

• Sensation recovery is generally better than motor recovery, especially

if the lesion is proximal and muscle wasting occurs whilst it is

‘dennervated’.

Neurotemesis

• The nerve is completely divided or irreparably damaged with loss of

apposition of the severed nerve bundles and their respective distal

parts.

• Usually a high energy injury, penetrating trauma, severe traction,

ischaemia, or high pressure injection injury.

• Minimal recovery is possible without operative intervention to repair

or graft a new nerve to the injury.

• Surgical repair may allow axon regeneration to the correct end organ,

but recovery will not be complete as often ‘miswiring’ occurs.

Diagnosis

• What is the injury? Is there an open wound, fracture, recent surgery,

or prolonged immobility?

• Complete neurological examination. You must know the motor

and sensory supplies of peripheral nerves! Use a pin or your ﬁ nger

PERIPHERAL NERVE INJURIES

565

for sensory testing. Compare the area of normal and injured side

sequentially.

• Tips. Anaesthetic skin looks shiny and does not sweat. Dennervated

skin will not wrinkle in water.

• There are speciﬁ c features of different levels of injury in peripheral

nerves of the upper limb.

• Examination very soon after injury can be misleading as sensory loss

may take time to appear.

• Diagnosis of a peripheral nerve injury is clinical, but can be

supplemented with nerve conduction studies and electromyography

(EMG).

Treatment

Closed injury

• Injuries in continuity. Neuropraxia and axontemeses (vast majority)

can be expected to recover spontaneously, so exploration is not

indicated.

• Compression injuries should have compressive forces removed, e.g.

external such as plaster or internal such as carpal tunnel syndrome.

• Physiotherapy and splintage should be used whilst awaiting recovery;

this will maintain functionality and prevent contractures.

Open injuries

• Primary repair (suture). Within 24h is ideal, but an uncontaminated

operative ﬁ eld, adequate skin cover, and proper equipment (e.g.

microscopes) must be present.

• Delayed secondary repair. Can be done at any time after injury once

the soft tissues have healed (3–6 weeks acceptable). The nerve can be

mobilized to allow a no tension repair after resection of the cut nerve

stumps. Usually, however, a nerve graft has to be used to bridge the

defect (sural nerve as a donor the commonest).

Further reading

Soloman L, Warwick D, Nayagam S (Eds) (2010). Apley’s system of orthopaedics and fractures.

9th edn. Hodder Arnold, London.

CHAPTER 15 Orthopaedic surgery

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Brachial plexus injuries

The brachial plexus is formed from the ventral rami of C5 to T1. It is sub-

sequently divided into root, trunks, divisions, cords, and terminal branches.

The lesion can be at any of the above levels.

Terminal branches arising from the root level (phrenic nerve (C3–5),

dorsal scapular nerve (C5), and long thoracic nerve (C5–7)) are important

to recognize as if they are spared, it suggests the lesion is post-ganglionic.

Causes

• Child. Obstetric, i.e. difﬁ cult deliveries with traction on the plexus.

• Adult. Almost all traumatic.

Usually closed, e.g. motorcycle accidents, falls, and traction injuries •

with forced abduction of the arm.

May be open, e.g. stab or gunshot wounds.•

• Always look for associated injuries, e.g. head, neck, chest, abdominal,

and vascular.

Types

• Erb–Duchenne (upper). Involves C5 and C6; the arm classically hangs

at the side with the arm ﬂ accid, internally rotated, adducted, and the

wrist ﬂ exed (waiter’s tip position).

• Klumpke’s (lower). Involves C8 and T1; the hand is clawed due to

intrinsic muscle paralysis and if the sympathetic trunk is involved, there

is Horner’s syndrome.

Try to localize the lesion to preganglionic (intraspinal) or post-ganglionic

(extraspinal) by clinical means as described earlier. At the T1 level, look

for signs of Horner`s syndrome (ptosis, meiosis, ipsilateral anhydrosis),

suggesting a preganglionic lesion.

If histamine is injected into the skin of the supplied area, vasodilata-

tion, weal, and ﬂ are indicate a positive result and a preganglionic injury is

present. If there is no ﬂ are, the lesion is postganglionic.

Anatomic level of injury should be delineated.

Treatment

Physiotherapy to prevent joint contracture and stiffness. If no return of

function at 2 months, consider myelography or histamine tests to localize

the injury level.

• Open injuries should be explored acutely, but not if there are more

life-threatening injuries (which is usually the case). Primary repair may

be possible in this group.

• Delayed surgery (if required at all) is normal for most patients.

• Preganglionic injuries are irreparable and should not be explored.

• Post-ganglionic injuries may be explored for up to 6 months post-

injury. Secondary repair with nerve grafting can then be attempted if a

clear lesion is isolated.

Prognosis

• If there are no EMG abnormalities at 3–4 weeks, prognosis is good

with conservative treatment.

BRACHIAL PLEXUS INJURIES

567

• Causalgic pain, Horner’s syndrome, and the presence of root avulsion

on myelogram (hence intraspinal lesion) indicate a poor prognosis.

• Recovery is generally very slow and often unsatisfactory.

• Salvage surgery with tendon transfers or shoulder arthrodesis may

improve function and give better results than amputation.

Further reading

Birch R (1996). Brachial plexus injuries. J Bone Joint Surg Br 78-B: 986–92. [Review]

CHAPTER 15 Orthopaedic surgery

568

Osteoarthrosis (osteoarthritis)

This is degenerative joint disease; it is a disease of cartilage, not the joint.

• It is limited to the joint itself and there is no systemic effect.

• It may involve any synovial joint, but is most common in the hip, knee,

and hands.

• It is the most common form of arthritis with an estimated radiographic

incidence in moderate to severe changes in 5 million people in the

UK.

• Approximately 2 million people visit their GP with osteoarthritis per

year and it is predicted that there will be a 66% increase in the number

of people with osteoarthritis-related disability by 2020.

Types

Primary osteoarthritis (idiopathic)

Mainly affects the following joints: distal interphalangeal, ﬁ rst carpometa-

carpal, hips, knees, and apophyseal joints of the spine. Women are more

affected than men and there may be a hereditary component, but the

aetiology is unknown.

Secondary osteoarthritis

Affects previously damaged joints and is more common in weight-bearing

joints. Both sexes are equally affected. Local causes are fractures, acquired

or congenital deformities, joint injury (chondral lesions), diabetic neuropa-

thy (Charcot joints), and avascular necrosis.

Clinical features

• Characteristic pain, swelling, and deformity.

• Dull, aching pain with morning stiffness of the affected joint.

• Pain becomes steadily worse throughout the day and may disturb

sleep.

• Acute onset. Swollen, hot, and painful joint with raised inﬂ ammatory

markers.

• Look for Heberden’s nodes at the distal and Bouchard’s nodes at the

proximal interphalangeal joints.

• Physical symptoms may not correlate with the severity of the

radiographic changes so judge each patient on an individual basis.

X-ray changes

• Loss of joint space.

• Subchondral bone sclerosis.

• Cyst formation (especially at the hip).

• Osteophyte formation.

Treatment

Relieve pain, improve mobility, and correct deformity in that order.

Medical

• Pain relief with simple analgesics (paracetamol, codeine), in

combination with NSAIDs, helps control symptoms and increase

OSTEOARTHROSIS (OSTEOARTHRITIS)

569

mobility. Beware of GI bleeding, especially in the elderly, and of

worsening asthma.

• Radiant heat in the form of infrared light or a hot water bottle

frequently helps.

• Weight loss, physiotherapy, and aids to daily living such as walking

sticks, heel raises, raised chair, and household aids should all be in

place before contemplating surgery.

• Joint injections of steroid and local anaesthetic may help in up to 50%

patients.

Surgical treatment

This is indicated for pain relief, improved mobility, and correcting deform-

ity only when conservative measures have failed.

Options include:

• Osteotomy. Realignment of a joint to unload an arthritic area.

• Arthrodesis. Permanent stiffening of a joint by excision and fusion to

stop pain.

• Excision. Removal of the joint without fusion.

• Arthroplasty. Replacement of all or part of the joint surface by an

artiﬁ cial material.

Reference

1 M http://www.arc.org.uk/about_arth/astats.htm.

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Carpal tunnel syndrome

• Compression of the median nerve at the wrist.

• Boundaries of tunnel are: radially—scaphoid tubercle and trapezium,

ulnarly—hook of hamate and pisiform, transverse palmar ligament,

palmar aspect (roof).

• Contents—ﬂ exor tendons (ﬂ exor pollicis longus (FPL), ﬂ exor

digitorum superﬁ cialis (FDS), ﬂ exor digitorum profundus (FDP)) and

median nerve.

• Most common in middle age.

• Often bilateral, but when unilateral most commonly affects the

dominant hand.

Aetiology

Remember, the commonest is idiopathic.

Compression of the tunnel wall

• Trauma, e.g. distal radial fracture.

• Rheumatoid arthritis (thickening of the surrounding synovium and tissues).

• Subluxation or dislocation of the wrist.

• Acromegaly (soft tissue thickening and enlargement).

Compression within the tunnel

• Fluid retention, e.g. pregnancy.

• Myxoedema.

• Space-occupying lesion, e.g. benign tumour.

• Chronic proliferative synovitis.

Changes in the median nerve

• Diabetic mellitus.

• Peripheral neuropathies.

Clinical features

Symptoms

• Aching pain and paraesthesia (pins and needles) over radial three-and-

a-half ﬁ ngers and palm.

• Pain typically at night and can disturb sleep.

• Relieved by shaking the hand.

• May notice dropping items (weak pinch grip), clumsiness.

• Can be made worse by activity.

• Atypical symptoms can be common.

Signs

• Hand looks normal.

• Thenar muscle wasting if chronic and severe.

• Weakness of thumb abduction.

• Tinnel’s test. Tapping over the nerve at the wrist in neutral produces

symptoms.

• Phalen’s test. Rest elbows on the table and passively ﬂ ex the wrist. If

symptoms appear within 60s, test is positive.

• Median nerve compression test. Extend elbow, supinate forearm, ﬂ ex

wrist to 60°, press on carpal tunnel. Positive if symptoms within 30s.

CARPAL TUNNEL SYNDROME

571

Investigations Nerve conduction studies are gold standard, but still

show only 90% accuracy.

Treatment

Conservative

• Splintage.

• NSAIDs.

• Injection of corticosteroids.

• Avoidance of precipitating factors.

Surgical

• Surgical decompression.

• Use a tourniquet.

• Skin incision in line with ulnar border of the ring ﬁ nger. This is to avoid

the motor branch of the median nerve.

• Protect the nerve with a MacDonald’s dissector and visualize the nerve

directly throughout.

• Do not extend the skin incision beyond the wrist crease to protect the

palmar cutaneous branch of the median nerve.

Complications

• Complex regional pain syndrome.

• Tender, hypertrophic scar giving pillar pain (pain in the heel of the scar

on pressure).

• Neuroma of the palmar cutaneous branch.

• Recurrence.

• Bowstringing of ﬂ exor tendons.

Reference

1 Tetro AM, Evanoff BA, Hollstien SB, Gelberman RH (1998). A new provocative test for carpal

tunnel syndrome: assessment of wrist ﬂ exion and nerve compression. J Bone Joint Surg Br 80(3):

493–8.

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572

Ganglion

This is a degenerative mucinous cyst swelling that can arise from a tendon

sheath or joint. It contains clear, colourless, gelatinous ﬂ uid.

Common sites

• Dorsum of the wrist, arising from the scapholunate ligament or

midcarpal joint (70% of all cases).

• Radial aspect of the volar wrist normally from scaphotrapezial joint

(20% of all cases).

• Base or DIPJ of ﬁ nger.

• Dorsum of the foot.

• Around the knee.

Clinical features

• Slow growing, cystic lump commonly presenting as dorsal wrist pain.

• Increase and decrease in size.

• Firm, smooth, rubbery, and will usually transluminate.

• May be more obvious with wrist in palmar ﬂ exion.

Diagnosis

• Needle aspiration gives gelatinous ﬂ uid. If no ﬂ uid can be aspirated,

then investigate further since a soft tissue tumour (including sarcoma)

is possible.

• MRI scanning should be used if there is serious concern over a soft

tissue tumour.

• Occult ganglia (no palpable lump) can yield symptoms in the wrist or

foot. Ultrasound scan will conﬁ rm the diagnosis.

Treatment

• Fifty per cent will disappear spontaneously. Therefore, treat

conservatively unless pressed by the patient.

• Aspiration may be curative in 50% of cases.

• Deliberately induced traumatic rupture often leads to recurrence.

Surgery

• Excision is not guaranteed success (recurrence approximately 10%;

painful scar approximately 10%).

• Use a tourniquet.

• If not occult or excessively large, then local anaesthesia as day case

procedure appropriate.

• Excise thoroughly and transﬁ x the base to prevent recurrence.

• Volar wrist ganglia often surround or are very close to the radial

artery!

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CHAPTER 15 Orthopaedic surgery

574

Bone tumours

Diagnosis

The key to successful management of bone tumours is early detection and

treatment; always having a clinical suspicion is essential!

Presenting features

• Pain. Persistent, at night, response to analgesics?

• Mass or swelling (? getting bigger, rate of progression).

• If there is a fracture, is there a history of trauma?

• Neurological symptoms.

• Systemic symptoms.

• Previous tumours, radio- or chemotherapy.

• Any family history.

• Watch for the ‘red herring history’ of trivial injury.

Examination

• Extract features of the mass/swelling and palpate for lymphadenopathy.

• Is it around a joint, is it deep to the fascia? Size, relationship to

surrounding structures.

Radiological investigations

• A plain X-ray (AP and lateral) of affected area is mandatory.

• Where is lesion, what are effects on bone, is there a bone reaction

(new bone, periosteal reaction, Codman’s triangle, sunburst

spiculation), is there a matrix?

• Once a diagnosis has been considered/made, further imaging is

required; MRI scanning is usually gold standard.

• Accurately stage and assess local or systemic spread (CT, bony

architecture; MRI, soft tissue or bony extensions).

Blood tests

Rarely diagnostic and often non-speciﬁ c (e.g. i alkaline phosphatase,

i ESR, i Ca

Urgent referral

• Once a diagnosis is made, urgent referral (even before MRI is obtained

in highly suspicious lesion) to local tumour services is required.

• They will advise and guide further local management and arrange

deﬁ nitive treatment if required.

Other considerations

• Angiography. Helps plan radical surgery and possible limb salvage.

• Open biopsy. Best to achieve histological diagnosis and required for

treatment planning.

• Must be performed by the surgeon who is going to do the deﬁ nitive

surgery.

• The biopsy track must be excised as part of the deﬁ nitive excision and

placed to maximize the chance of limb salvage surgery.

BONE TUMOURS

575

Metastatic tumours

• Secondary metastases are the commonest tumours of bone (breast,

prostate, lung, thyroid, and kidney primaries).

• Bone pain—worse at night and with weight bearing.

• Systemic symptoms (fatigue, weight loss, no appetite).

• History of cancer (personal or family).

• Pathological fractures common.

• If a patient is admitted with a history of pathological fracture with

unknown primary, full examination should be performed to ﬁ nd source

(breast, rectal, prostate, etc.).

• Blood tests, including calcium, phosphate, tumour markers (PSA, CEA,

CA125).

• Bone scan, staging CT/MRI may be required.

• Treatment:

Treat electrolytes ﬁ rst if raised.•

Internal ﬁ xation (ideally prophylactic before fracture occurs) allows •

early weight bearing and hopefully early discharge from hospital.

Radiotherapy for pain.•

Manage in conjunction with oncologists.•

Benign tumours

Osteochondroma (‘exostosis’)

• Most common benign tumour.

• A cartilaginous capped outgrowth of bone from the cortex, normally

near an epiphysis. Lesion grows until skeletal maturity.

• Usually pain-free and present as lump. If painful, usually due to

inﬂ ammation of overlying bursa.

• Usually solitary. Multiple lesions require close follow-up (hereditary).

• Any sudden increase in size may indicate malignant transformation to

chondrosarcoma (<1%).

Chondroma

A non-calciﬁ ed cartilaginous growth in the medulla (enchondroma) or

cortex (ecchondroma) of tubular bones such as phalanges, metacarpals/

tarsals.

Osteoid osteoma

• Occurs in young patients (5–30y).

• Progressive pain (night) of long bone, referred to other joints,

classically relieved by NSAIDs.

• Commonly long bones (diaphysis), can be intra-articular, and a cause

of painful scoliosis.

• Radiology shows a ‘nidus’ which is a small osteolytic area surrounded

by a rim of dense sclerosis. Look for periosteal reaction.

Non-ossifying ﬁ broma

• Fibrous tissue tumour which usually appears radiologically as an oval

cortical defect with sclerotic rim. Common incidental ﬁ nding on

X-rays; usually needs no treatment.

CHAPTER 15 Orthopaedic surgery

576

• Treatment. Principles of treatment are simple local excision or

removal by curettage if symptomatic or likely to cause pathological

fracture (likely if >50% diameter of bone involved).

Cavities should be packed with bone graft or bone cement.•

Internal ﬁ xation may be used once large tumours have been •

removed.

Difﬁ cult tumours should be managed in a ‘bone tumour centre’.•

Primary malignant tumours (rare)

All primary malignant tumours require a ‘multidisciplinary team’ (ortho-

paedic surgeon, oncologist, musculoskeletal radiologist, histopathologist).

Osteosarcoma

• Commonest primary bone tumour.

• Long bones of young adults (peak incidence 10–20y) or as a

consequence of Paget’s disease in the elderly (see b p. 582).

• Presents with progressive pain (rest/night) refractory to analgesia.

• Swelling, reduced joint movement, limp.

• ? Trivial sporting injury—not related to tumour development!

• X-ray features. Bone destruction, soft tissue invasion, radiating spicules

of bone (‘sunray’ appearance), subperiosteal elevation with new bone

formation (‘Codman’s triangle’).

• MRI shows extent of tumour, skip lesions, soft tissue involvement.

• Metastasis via blood to the lungs and bone.

• Treatment:

Neoadjuvant chemotherapy followed by surgical resection and •

further chemotherapy.

Limb salvage surgery possible in about 90% (rare for pelvic •

tumours).

Local recurrence rate 5% (poor prognosis).•

Radiotherapy may be used as an alternative in the elderly.•

• 5y survival 60–70% (localized) or 25% (pelvic) with surgery; 20% if

present with metastases.

Chondrosarcoma

• Commonest in older patients (30–75y).

• Usually occurs in a ﬂ at bone, e.g. ilium of pelvis, ribs, scapula.

• Location of presentation gives clues to type (scapula malignant and

hand benign).

• May present de novo or arise from a pre-existing osteochondroma.

• Graded. Low to high (1, 2, 3, undifferentiated); 60% present grade 1.

• Metastasis is not common and is via blood.

• Local invasion is more usual, but is normally slow growing.

• High grade present with bone destruction and soft tissue mass.

• Treatment:

Low grade require wide resection. Local recurrence 20% at 10y.•

High grade require wide resection • ± amputation.

No real role for chemo- or radiotherapy unless undifferentiated or •

elderly).

5y survival dependent on grade. Grade 1, up to 90%; grade 2, •

60–70%; grade 3, 30–50%; undifferentiated, 10%.

BONE TUMOURS

577

Ewing’s sarcoma

• Children and young adults (<20y).

• Pain, associated hot/erythematous swelling with associated pyrexia so

that osteomyelitis may be suspected.

• Commonly pelvis, long bones, and scapula.

• i ESR and i WCC.

• X-rays show lytic bone destruction with periosteal reaction in multiple

layers (‘onion skin’ appearance).

• MRI scan shows soft tissue involvement, which would not usually be

the case in osteomyelitis.

• Metastasis to the lung is very fast and most people present with this.

• Treatment. Preoperative neoadjuvant chemotherapy (12 weeks) and

then re-evaluate and re-stage.

• Isolated lesions managed with wide excision or amputation.

• Radiation can be used if metastases present.

• Response to chemotherapy predicts prognosis.

• Prognosis is still poor. Isolated extremity Ewing`s approximately 65%

5y survival; metastatic disease at presentation <20% 5y survival.

Giant cell tumour (osteoclastoma)

• This is rare before the age of 20y.

• Usually benign, but may undergo malignant transformation (710%).

• Rarely metastasizes; usually to lungs, but may be locally invasive.

• Treatment. Local excision and defect ﬁ lled bone graft or cement.

• Recurrence is common (~20%), especially with malignancy.

Further reading

Excellent summaries of bone tumours can be found at: M http://www.bonetumor.org/

CHAPTER 15 Orthopaedic surgery

578

Low back pain

• Very common condition in the UK; 60–80% of adults will be affected

during their lifetime.

• Common cause of absence from work.

• In the majority of cases, it is a self-limiting condition requiring no

surgical intervention.

• Multifaceted condition with overlapping aetiology.

• Always consider neoplasia—metastasis, myeloma, osteoid osteoma.

Types of pain

Mechanical

• Pain (low back, buttock, and thigh), like ‘toothache’.

• Rarely radiates below knee.

• Worse over course of day and with activity.

• Cannot get comfortable and wakes from sleep when turn.

• Acute pain from trivial movement which settles with rest.

• Typically midline and made worse by lordotic postures, e.g. bending

and lifting (discogenic).

• Pain is from the annulus ﬁ brosis layer of the disc when it is being

stretched.

Nerve root entrapment

• Pain radiates down the leg from buttock to calf/foot.

• Commonly caused by a lumbar disc prolapse, compressing and

irritating the nerve root as it exits the spinal foramina.

• Pain from spinal stenosis is worsened with extension (walking down a

hill) and relieved with ﬂ exion (riding a bike).

• Radiation should match the sensory dermatome of the nerve root

involved.

• Other features are pain on sneezing, coughing, and straining.

Numbness or paraesthesia in the dermatome of the affected root may

also be present.

• The earliest and most persistent feature of nerve root compression is

loss of a tendon reﬂ ex, e.g. knee L3/4, ankle L5/S1.

Referred

May arise from retroperitoneal pathology (aortic aneurysm, pancreatic

and biliary tree pathology, rectal pathology, renal stones, lymphadenopa-

thy, and hip arthroses).

Psychosocial (yellow ﬂ ags)

• The commonest cause for chronicity.

• A diagnosis of exclusion, i.e. exclude all other pathology before

labelling people as ‘neurotic’.

• Typical features of non-organic pain are pain on axial compression

or pelvic rotation, non-dermatomal sensory loss, non-anatomical

tenderness, cogwheel (give way) weakness, and overreaction

(Waddell’s signs).

LOW BACK PAIN

579

Common pathological (organic) causes

• Mechanical (80–90%).

Unknown cause. Muscle strain or ligamentous injury.•

Degenerative disc or joint disease.•

Vertebral fracture.•

Congenital deformity (such as scoliosis, kyphosis, transitional •

vertebrae).

Spondylolysis.•

Instability (spondylolisthesis).•

• Neurogenic (5–15%).

Herniated disc.•

Spinal stenosis.•

Osteophytic nerve root composition.•

Failed back surgery syndrome (such as arachnoiditis, epidural •

adhesions, recurrent herniation). May cause mechanical back pain

as well.

Infection (such as herpes zoster).•

• Non-mechanical spinal conditions (1–2%).

Neoplastic (such as primary or metastatic).•

Infection (osteomyelitis, discitis, abscess—staphylococcal or TB).•

Inﬂ ammatory arthritis (such as rheumatoid arthritis and •

spondyloarthropathies, including ankylosing spondylitis, reactive

arthritis, enteropathic arthritis).

Paget’s disease.•

• Coccydynia. Pain in the coccyx may be due to lumbosacral disc disease.

Assessment

• History must distinguish between ‘simple’ back pain and that requiring

urgent care.

• ‘Red ﬂ ags’ of serious spinal pathology.

Retention of urine or incontinence.•

Onset over age 55 or under 20.•

Symptoms of systemic illness (weight loss, fever).•

Severe progressive pain (unrelenting).•

Trauma.•

A prior history of cancer.•

IV drug use.•

Prolonged immunosuppressant or steroid use.•

• Examination must cover:

Palpation, movements, straight leg raising, femoral stretch test, •

power, sensation, reﬂ exes.

• If signs of signiﬁ cant spinal pathology present (i.e. cauda equina),

perianal sensation and PR examination must be performed.

Investigations

• Spinal X-rays (AP and lateral of affected level).

• CT scan good for assessing bony structures.

CHAPTER 15 Orthopaedic surgery

580

• MRI scan good for soft tissue problems (discs, spinal cord, nerve root

involvement), but only relevant in planning, not in diagnosing treatment.

Should be left for treating surgeon as it is often not required.

Treatment

Non-operative

• Majority of patients require non-operative treatment.

• Initial rest (1–2 days only).

• Analgesia (paracetamol, NSAIDs, muscle relaxants, opioids).

• Early mobilization with strong encouragement.

• Physiotherapy (massage, acupuncture, hydrotherapy).

• Counselling and psychosocial support.

Surgery

• Only a minority requires surgery. Should be clearly focused on proven

pathology demonstrated by imaging where possible.

• Procedures used include:

Discectomy.•

Chemonucleosis/percutaneous disc removal.•

Nerve root decompression.•

Spinal decompression.•

Spinal fusion.•

Cauda equina

• Surgical emergency.

• Cauda equina (horse’s tail) is a collection of nerve roots (lower lumbar

and sacral) at distal end of cord.

• It can present acutely, chronically, or following longstanding lower

back problems.

• Causes include large central or paracentral disc herniation (L4/5 or

L5/S1), spinal injury neoplasms, tumours, infections (abscess or TB),

haematoma (iatrogenic).

• Key symptoms are dysfunction of bladder, bowel (and sexual function),

saddle or perianal anaesthesia.

• Other symptoms include low back pain, radiation down one or both

legs, sensory chances in lower limbs, weakness.

• Examination should be a thorough lower limb neurological assessment.

• Perianal sensation and anal sphincter tone (bulbocavernosus reﬂ ex) is

essential.

• Imaging is required urgently if convincing clinical evidence exists. MRI is

the modality of choice.

• Treatment once diagnosed is surgical decompression. Referral to an

appropriate spinal centre, if not on site, is required urgently.

• Timing of surgery is controversial. Better outcomes are seen if

performed <24h following onset.

• Outcomes are variable. If complete cauda equina (urinary retention or

incontinence), the prognosis for recovery is poor.

References

1 Cohen SP, Argoff CE, Carragee EJ (2009). Management of low back pain. BMJ 338: 100–6.

2 Lavy C, James A, Wilson-MacDonald J, Fairbank J (2009). Cauda equina syndrome. BMJ 338:

881–4.

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CHAPTER 15 Orthopaedic surgery

582

Paget’s disease (osteitis deformans)

Key facts

• Described by Sir James Paget (1876).

• Incidence increases with age (>50y).

• Any bone may be involved. Commonest sites are spine, skull, pelvis

and femur, tibia.

• Autosomal dominant.

Pathological features

• Increased osteoclastic bone resorbtion followed by compensatory

bone formation, i.e. there is an overall increase in bone turnover.

• Three phases. Lytic, mixed (lysis and formation), and sclerotic.

• The bone is softer, but thickened and is liable to pathological fracture.

Clinical features

• Most are asymptomatic.

• Diagnosed via an incidental ﬁ nding on X-ray or raised alkaline

phosphatase whilst investigating other pathologies.

• Increased thickness of bone may be the only symptom or sign.

• Subcutaneous bones may be deformed, classically the tibia when it

becomes ‘sabre’-shaped.

• Pain may be present, but is unusual. It may represent high turnover at

the time or more likely, a pathological fracture.

• In known Paget’s patients, increase in pain must be taken seriously as it

may be a marker of sarcomatous change in the bone.

Investigations

• Serum calcium and phosphorus are normal.

• Alkaline phosphatase is high (due to i osteoblast activity).

• Urinary excretion of hydroxyproline is high (i bone turnover).

• Isotope bone scan shows ‘hot spots’ in affected areas.

• X-ray shows both sclerosis and osteoporosis. The cortex is thickened

and the bones deformed. Pathological fracture is a feature and the

normal bone architecture is lost with coarse trabecular pattern.

Complications

• Pathological fractures.

• Osteosarcomatous change (<5%; prognosis very poor).

• High output cardiac failure may develop due to the increased

vascularity of Paget’s bone. Functionally, the bone is acting as an

arteriovenous ﬁ stula.

• Deafness. Bony deformation in the ear causes damage to cranial nerve.

• Osteoarthritis.

• Leontiasis ossea. Thickening of facial bones (rare).

• Paraplegia due to vertebral involvement (rare).

Treatment

• Most patients require no treatment.

PAGET’S DISEASE (OSTEITIS DEFORMANS)

583

• Fractures will heal normally, but bony deformity with a fracture can be

a difﬁ cult challenge!

• Drugs that reduce bone turnover such as calcitonin or

bisphosphonates are effective in relieving pain and may also relieve

neurological complications such as deafness.

Further reading

M http://www.paget.org/

CHAPTER 15 Orthopaedic surgery

584

The great toe

Hallux valgus (‘bunions’)

1,2

• Medial prominence of the ﬁ rst metatarsal head, with lateral deviation

of the great toe (hence valgus) due to the pull of the extensors.

• As time passes, a protective bursa develops over the metatarsal head

(the ‘bunion’) and the great toe begins to crowd, or even overlap, its

neighbours.

Causes

• Congenital. Often familial, related to metatarsus primus varus where

the ﬁ rst metatarsal is angled more medially, i.e. splayed, than usual and

is rotated.

• Acquired. The commonest form. Probably due to weak intrinsic

muscles due to age. It is not proven to be related to shoes, but there

is a higher incidence in shoe-wearing cultures.

Symptoms

• Commonly asymptomatic, even in cases of severe deformity.

• Pain typically at the site of the bunion due to pressure.

• Bursal inﬂ ammation.

• Nerve symptoms may be present (compression of digital nerve).

• As the disease advances, symptoms of joint pain may present due to

osteoarthritis and subluxation of the joint.

• Lesser toe deformities may be present (hammer toes, calluses).

Investigations

• Weight-bearing AP and lateral views of the foot.

• Measurements of the extent of deformity are made to guide

management.

• Commonly calculated are the hallux valgus angle (between long axis

of ﬁ rst metatarsal and corresponding proximal phalanx) and the ﬁ rst/

second intermetatarsal angle (between the long axis of ﬁ rst and

second metatarsals).

Treatment

Conservative

• Correct footwear with a wider toe box and padding to protect

bunion.

• This should always be tried and have failed before considering surgery.

Surgical

• Exostectomy. Removal of the bunion alone. This is simple, but does not

remove the underlying deformity and the problem will recur.

• Distal metatarsal osteotomy. The bunion is removed and the metatarsal

head or neck is cut. The distal fragment is then realigned anatomically

and the fracture held with a K wire. There are many types or shapes

of osteotomy described, but the commonest eponyms are Mitchell’s,

Wilson’s, and Chevron. This is only suitable for smaller deformities.

• Proximal metatarsal osteotomy. This is an osteotomy just proximal to

the base of the metatarsal and the metatarsocuneiform joint. Larger

THE GREAT TOE

585

bony deformities can be corrected this way. It may be combined with

a distal soft tissue release where the lateral constraints by the MTPJ

are also released through a small separate dorsal excision.

• Excision arthroplasty. Removal of the metatarsal head (Mayo) or base

of the proximal phalanx (Keller) can be attempted, but is fraught with

long-term complications and is only an operation for the elderly.

• Arthrodesis. This is suitable for severe deformity and degenerative

change and is tolerated well by males. Females may have a problem

with footwear (have to wear ﬂ at shoes after). It is normally reserved

for salvage surgery.

Hallux rigidus

Degenerate arthritis of the ﬁ rst MTPJ, leading to pain and functional limita-

tion of movement.

Causes

• Not fully determined.

• Congenital. Due to a shortened metatarsal.

• Acquired. Normally traumatic or idiopathic degeneration.

Symptoms

• Pain and swelling of the ﬁ rst MTPJ with profound stiffness (limited

dorsiﬂ exion).

• May irritate on shoes.

• Neurological symptoms due to pressure on the digital between

osteophyte and shoe.

Investigations

AP and lateral X-rays of the foot (demonstrate osteoarthritic changes).

Treatment

• Adolescents/young. Rocker sole to relieve pain.

• Adults.

MTPJ replacement (rare).•

Cheilectomy (excision of dorsal osteophyte and about 25% dorsal •

metatarsal head).

Arthrodesis.•

Excision arthroplasty (elderly only).•

References

1 M http://www.blackburnfeet.org.uk/hyperbook/conditions/conditions_index.htm#hallux.

2 Coughlin MJ (1996). Hallux valgus. J Bone Joint Surg Am 78-A, 932–66: [Instructional course

lecture]

CHAPTER 15 Orthopaedic surgery

586

Arthroplasty

• The surgical reconstruction or replacement of a malformed or

degenerate joint.

• The primary goal is to relieve pain.

• Increases in mobility and function are secondary aims.

Classiﬁ cation

• Excision, e.g. Keller’s or Mayo at the ﬁ rst MTPJ.

• Interposition. A joint is excised and then a piece of tissue is implanted in

the gap to cause a thick scar.

• Partial (hemi-) or total replacement. All or one-half of the articular

surface is removed and replaced with other material. This has been

made possible by the massive advances in both biomaterials and

bioengineering, which have produced inert, sterilizable materials of

acceptable strength to perform the joint functions.

Example: total hip replacement

1–3

Indications

• Osteo- and rheumatoid arthritis when pain affects sleep, quality of life,

and normal daily activities.

• Multiple joint involvement where hip is the worst.

• AVN of the head of the femur with secondary joint degeneration.

Prevention of infection

Deep infection is a potentially devastating complication of hip or any

arthroplasty and its incidence should be d1% in all units. This is achieved

by the following.

• Ultraclean air systems and exhaust body suits. The air in a conventional

theatre is ﬁ ltered so that there are >20 changes/h. By using a

unidirectional laminar ﬂ ow system, 300 or more changes/h with

ﬁ ltration can be achieved. The purpose is to make the number of

colony-forming units (CFUs) in the air the minimum possible. Body

suits, although cumbersome, provide the best physical barrier between

the patient and the surgical team.

• Prophylactic antibiotics. These are given IV on the induction of

anaesthesia; 10min is usually required for them to penetrate bone to

an acceptable level. Broad-spectrum antibiotics are usually used, e.g.

cefuroxime 1.5g, co-amoxiclav (Augmentin

) 1.2g, and gentamicin

80mg, being the most common. Two further doses at 6 and 12h post-

operatively are usually given.

• Strict theatre discipline.

Procedure

The surgical approach exposes both the femoral head and acetabulum.

The head of the femur is exposed, dislocated, and either reshaped (resur-

facing arthroplasty) or more commonly, removed at the neck. The acetab-

ulum is then deepened and reshaped to allow a cup to be placed (the new

‘socket’). A cavity is then created within the cut surface of the femur, going

downward to allow a stem to be placed (the new ‘ball’). The stem and cup

ARTHROPLASTY

587

are usually ‘grouted’ in place with polymethylmethacrylate bone cement

and the two components reduced and stability tested.

Sometimes the cup has a metal shell behind it and components can be

hammered in rather than cemented and this is known as an ‘uncemented

hip replacement’. This is more commonly used on the younger patient in

the UK, but is the implant of choice in the USA. The wound is then closed.

Patients are mobilized on day 1 post-operatively, fully weight bearing, and

discharged within 5–7 days usually.

Complications

Operative

• Sciatic nerve injury due to poor technique and overstretching of

tissues.

• Dislocation of the prosthesis if incorrectly aligned.

• Profound hypotension can be seen with absorption of the monomer in

the cement, causing cardiotoxicity.

Post-operative

• Mortality 1%. This is major surgery.

• Thromboembolic disease (DVT or PE).

• Deep infection (1%).

• Dislocation (4%). Usually due to patient non-compliance with

physiotherapy guidelines.

• Aseptic loosening (‘wearing out’). Most total hip replacements would

be expected to have t90% survival rates 10y after surgery.

References

1 M http://www.orthoteers.co.uk/Nrujp~ij33lm/Orththr1.htm.

2 M http://www.wheelessonline.com/o14/14.htm.

3 Huo MH, Muller MS (2004). What’s new in hip arthroplasty. J Bone Joint Surg Am 86-A:

2341–53.

CHAPTER 15 Orthopaedic surgery

588

Useful reading

Online orthopaedic hyperbooks

M http://www.orthoteers.co.uk (requires subscription)

M http://www.wheelessonline.com (free)

M http://www.blackburnfeet.org.uk (free)

M http://www.eatonhand.com (free)

M http://www.eradius.com (free)

Reference textbooks

Elective

Canale T, Beaty JH (Eds.) (2007). Campbell’s operative orthopaedics, 11th edn (4 vols). Mosby,

London.

Trauma

McRae R, Esser M (2008). Practical fracture treatment, 5th edn. Churchill Livingstone, Edinburgh.

Schatzker J, Tile M (2005). The rationale of operative fracture care, 3rd edn. Springer-Verlag Berlin

Heidelberg.

American College of Surgeons (2008). Advanced trauma life support (ATLS) for doctors, student

manual, 8th edn. American College of Surgeons, Chicago.

Wenger DR, Pring ME (2006). Rang’s children’s fractures, 3rd edn. Lippincott, Williams and Wilkins,

Philidelphia.

Bucholz RW, Court-Brown CM, Heckman JD, Tornetta P (Eds.) (2009). Rockwood and Green’s

fractures in adults. 7th edn. Lippincott, Williams, and Wilkins, Philadelphia.

Beaty JH, Kasser JR (Eds) (2009). Rockwood and Wilkin’s fractures in children, 7th edn. Lippincott,

Williams, and Wilkins, Philadelphia.

Review

Miller M (2008). Review of orthopaedics, 5th edn. Saunders, Philadelphia.

Soloman L, Warwick D, Nayagam S (Eds) (2010). Apley’s system of orthopaedics and fractures, 9th

edn. Hodder Arnold, London.

Ramachandran M (2007). Basic orthopaedic sciences: the Stanmore guide. Hodder Arnold, London.

Surgical exposures

Hoppenfeld S, De Boer P, Buckley R (2009). Surgical exposures in orthopaedics: the anatomic

approach, 3rd edn. Lippincott, Williams, and Wilkins, Philadelphia.

Clinical examination

Harris N, Stanley D (Eds) (2005). Advanced examination techniques in orthopaedics. Cambridge

University Press, Cambridge.

589

Plastic surgery

Suturing wounds 590

Skin grafts 594

Surgical ﬂ aps 596

Management of scars 598

Excision of simple cutaneous lesions 600

Skin cancer 602

Burns: assessment 604

Burns: management 606

Soft tissue hand injuries 610

Hand infections 612

Dupuytren’s disease 614

Breast reduction 616

Breast augmentation 617

Breast reconstruction 618

Chapter 16

CHAPTER 16 Plastic surgery

590

Suturing wounds

Principles of wound closure

A wound can be closed in the following ways:

• Direct apposition of skin edges by sutures, glue, or staples;

• Skin grafts (see b p. 594).

• Flaps (see b p. 596).

Key facts

A correctly orientated incision, adequate haemostasis, and minimal tissue

handling are prerequisites for an ideal scar. When closing wounds, bear in

mind the following:

• All wounds leave scars. You must warn your patient of this.

• Hypertrophic scars are more likely on the sternum and deltoid area.

• Speed of healing depends on site. The face heals more quickly than the

trunk and limbs.

• Children and young adults heal more quickly and achieve stronger

scars than the elderly, the chronically ill, and those on steroids.

• Stitch marks (‘tramline effect’) are caused by epithelial growth into

suture tracks and occur when sutures are left in longer than 7 days.

• Cross-hatching is more common when tight sutures cause ischaemia.

• If sutures are removed too early, the wound may dehisce, leaving a

worse scar.

Suture techniques

• Eliminate dead space with deep sutures or a drain, but avoid suturing

fat, which contributes no strength and may lead to fat necrosis.

• Consider buried, interrupted dermal sutures to reduce skin tension.

• Dermal sutures can be combined with a subcuticular running suture or

skin tapes to avoid suture marks.

• Use the ﬁ nest suture possible to maintain wound closure—5/0 or 6/0

for the face; 4/0 or 5/0 for the hand; 2/0 to 4/0 for the trunk.

• Evert the wound to reduce dead space and allow rapid healing.

• Approximate wound edges without strangulating the skin.

• Dressings can be used to splint a wound or immobilize a limb during

healing.

• Elevation will reduce post-operative swelling, bleeding, and pain.

• In a low tension wound closure, sutures may be removed at 5–7 days

on the face, 7–10 days on the arm and anterior trunk, and 14 days on

the back and lower limb.

• Most wounds beneﬁ t from being splinted with skin tape after removal

of sutures.

SUTURING WOUNDS

591

Interrupted skin suture (see Fig. 16.1(a))

• Use ﬁ ne-toothed Adson forceps or a skin hook to evert the skin.

• Pass the needle perpendicular to the skin through its full thickness.

• Either remove the needle through the wound or continue in one

sweep to the other side of the wound, using the forceps for

counter pressure so the needle passes perpendicular to the skin

on its way out.

• Tie the knot so the skin edges are just apposed, bearing in mind the

wound will swell post-operatively.

• Place the sutures evenly, approximately twice as far apart as they are

from the wound margins.

• The distance between the suture and the wound margin should be

similar to the thickness of the skin.

Mattress suture (see Fig. 16.1(b)) Pass the needle as above across

the wound, then turn it around and pass it back as if doing another

interrupted suture in the opposite direction. The second pass can be along

the wound from the ﬁ rst (a horizontal mattress) or nearer the wound

margin than the ﬁ rst pass (a vertical mattress suture).

Deep dermal suture (see Fig. 16.1(c)) Use the forceps or skin hook to

evert the skin and pass the needle from deep to superﬁ cial on the dermal

surface of the wound. Move to the other side of the wound and pass the

needle from superﬁ cial to deep within the dermis. Tie a knot which should

be buried deep in the wound.

Continuous suture (see Fig. 16.1(d)) A combination of repeated

interrupted-type sutures or interrupted, then mattress sutures.

Subcuticular suture (see Fig. 16.1(e)) The suture is passed continuously

within the dermis, usually near the dermo-epidermal junction, from one

end of the wound to the other, and pulled tight. It may be secured with

a knot buried deeply at either end or with skin tapes laid over the suture

ends and the wound surface.

CHAPTER 16 Plastic surgery

592

(a)

(b)

(c)

(d)

(e)

Fig. 16.1 Types of suture. (a) Interrupted suture. (b) Mattress suture.

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CHAPTER 16 Plastic surgery

594

Skin grafts

Deﬁ nition

A skin graft is a piece of dermis and epidermis that is completely

removed from its original bodily attachment (the donor site). It is ﬁ xed

to a recipient site and develops a new blood supply from the underlying

tissue.

• Autograft. Transfer from one part of a person’s body to another part.

• Isograft. Transfer between genetically identical individuals.

• Allograft. Transfer between individuals of the same species.

• Xenograft. Transfer between individuals of different species.

Full thickness skin grafts (Wolfe grafts) (see Table 16.1)

• Contain epidermis plus the entire thickness of dermis.

• Adnexal structures, e.g. hair, are included.

• Harvested by elliptical excision from sites of skin laxity, e.g.

post-auricular skin crease, supraclavicular, preauricular, groin, or

medial upper arm skin.

• Graft secured with a tie-over dressing, e.g. proﬂ avine-soaked cotton

wool, and inspected after a week.

• Donor site sutured closed.

Split thickness skin grafts (Thiersch grafts) (see Table 16.1)

• Consist of epidermis plus a variable thickness of dermis.

• Harvested by shaving off a layer of skin with a skin graft knife or

dermatome. Can be taken from any area of the body (thigh skin most

often used—plentiful and easy to access).

• Graft is often fenestrated (to stop blood or serous ﬂ uid collecting

under it) or meshed (to expand the graft and allow it to contour to

the wound bed).

• Graft secured with glue, sutures, or staples, then a non-adherent,

compressive dressing. Inspected after 5 days.

• Defect heals by re-epithelialization from skin appendages.

Graft healing

Stages of graft take

• Adherence (immediate). Fibrin bond between graft and recipient bed.

• Serum imbibition (days 2–4). Graft absorbs ﬂ uid and nutrients from

bed.

• Revascularization (after day 4). Blood enters the graft, either by

ﬂ owing directly into the graft vessels (inoculation) or by new vessel

ingrowth.

Reasons for graft failure

• Shearing. Revascularization cannot occur if the graft is mobile.

• Infection. Either of the bed or the graft tissue.

• Separation of graft from its bed. By haematoma or seroma.

• Inadequate bed, e.g. bare cortical bone; tendon without paratenon.

• Damage to the graft, e.g. poor surgical technique, excessive dressing

pressure.

SKIN GRAFTS

595

Table 16.1 Split thickness grafts versus full thickness grafts

Split skin graft Full thickness skin

graft

Cosmesis Thin, often hypertrophic

skin

Good cosmesis

Contracture Frequent Less frequent

Availability Plentiful; can re-harvest

after 14 days

Limited by skin laxity

Take Good—low metabolic

needs

Needs optimal bed

Donor scar Minimal—colour change

only

Linear scar

Contraindications Inadequate bed, e.g.

exposed bone, tendon,

cartilage (in which case

ﬂ ap needed)

Infected bed

Areas where cosmesis is

paramount

Large area to be

covered

Inadequate bed

Vacuum dressings

These are dressings that apply negative pressure via a sponge placed

in the wound cavity, covered with an airtight adhesive silicone sheet

and connected to a vacuum pump. They increase the initial rate of

granulation in a variety of wounds, including dehisced or infected

sternotomy and laparotomy wounds, pressure sores, chronic open

wounds, ﬂ aps, grafts, and burns. The dressing is changed every 48–72h.

Fluid from the wound bed is collected in a disposable canister. Chronic

wounds may heal by secondary intention (see b p. 146) or be closed

primarily.

CHAPTER 16 Plastic surgery

596

Surgical ﬂ aps

Deﬁ nition

A ﬂ ap is a unit of tissue that maintains its own blood supply while being

transferred from donor to recipient site.

Classiﬁ cation of ﬂ aps

Also see Fig. 16.2.

By blood supply

• Random pattern. Survive on blood vessels in dermal and subdermal

plexuses which have no speciﬁ c anatomical pattern. Length to breadth

ratio is therefore limited to 1:1 (or 3:1 on the face).

• Axial pattern. Have at least one speciﬁ c artery running longitudinally

within the ﬂ ap, so length to breadth ratio can be greatly increased.

All composite ﬂ aps and all free ﬂ aps have an axial blood supply.

By mode of transfer (for local ﬂ aps)

• Advancement. The base of the ﬂ ap advances in the direction of the ﬂ ap

axis, e.g. V-Y ﬂ ap of perianal skin into anal canal for anal stenosis.

• Pivot. Rotation or transposition. The ﬂ ap rotates around a single pivot

point, e.g. scalp rotation ﬂ ap to cover facial defect after tumour excision.

• Interpolation. The ﬂ ap pedicle passes over or under adjacent skin to

inset the ﬂ ap into a nearby defect, e.g. deltopectoral ﬂ ap for head and

neck reconstruction after radical tumour surgery.

Transfer of distant ﬂ aps

• Direct. Flap moved directly to non-adjacent area, e.g. cross ﬁ nger ﬂ ap.

• Tubed. Pedicle curled inwards to form a tube until base of ﬂ ap divided,

e.g. tubed ﬂ ap from upper arm for nose reconstruction.

• Free. Artery and vein to ﬂ ap are completely divided, then reattached

with microvascular anastomoses to a suitable artery and vein at the

recipient site, e.g. radial forearm ﬂ ap to release neck scar contracture.

By composition

• Cutaneous. Skin and subcutaneous tissue only, e.g. groin ﬂ ap.

• Fasciocutaneous. Includes deep fascia, making ﬂ ap vascularity more

reliable and allowing length to breadth ratio to be increased.

• Fascial or adipofascial. The fascia (and subcutaneous fat) is transferred,

but the skin, still attached, is replaced on the donor site, e.g.

temporalis fascial ﬂ ap. The transposed ﬂ ap can then be skin grafted.

• Muscle. Useful for infected or traumatic wounds. The ﬂ ap is skin

grafted, e.g. gastrocnemius ﬂ ap for exposed knee prostheses.

• Myocutaneous. Used in reconstructive surgery. The muscle carries the

blood supply to the skin, e.g. latissimus dorsi myocutaneous ﬂ ap.

• Perforator ﬂ aps. Modiﬁ ed myocutaneous ﬂ aps. A single artery and vein

are dissected from skin, through muscle, to the parent vessels. The

muscle remains in situ, so its function is retained, e.g. deep inferior

epigastric perforator (DIEP) ﬂ ap.

• Bone, osseocutaneous. Bone with or without skin, e.g. ﬁ bular ﬂ

ap for

reconstruction of mandible. Muscle may also be included.

SURGICAL FLAPS

597

(a)

Lesion

(b)

Lesion

Fig. 16.2 Types of surgical ﬂ aps. (a) V-Y ﬂ ap. (b) Rhomboid ﬂ ap.

CHAPTER 16 Plastic surgery

598

Management of scars

Deﬁ nition

A scar is an area of ﬁ brous connective tissue, produced by healing.

Clinical features

A normal scar is initially ﬂ at and pale, then becomes red, itchy, and raised.

Over months to years, it settles back to a ﬂ at, pale, slightly shiny patch.

Scarring is more pronounced if infection intervenes during healing or in

the presence of foreign bodies. Scars settle more slowly in children and

will improve over 2–3y, but resolve rapidly in the elderly.

There are several types of abnormal scar.

• Hypertrophic scars. Firm, red, itchy, and elevated above the skin

surface, but within the boundaries of the injury. More common over

presternal and deltoid regions. Regress with time.

• Keloid scars. Extend beyond wound boundaries. Do not regress

spontaneously. Painful and itchy. Common in dark skins and sites as

above.

• Stretched scars. Due to dehiscence of dermis under intact epidermis.

Common on the back.

• Scar contractures. Common over ﬂ exor surfaces of joint. Occur when

wounds heal by secondary intention, after split skin grafting, or when

incisions cross a joint perpendicular to the crease.

Treatment

Treatment aims to improve poor cosmesis, relieve local symptoms (pain,

itch, irritation), or reduce restriction of associated joint movement.

Medical/conservative treatment

• Observation. ‘Benign neglect’.

• Massage. Scar achieves ﬂ at, pale state more quickly. Relieves itch.

• Pressure. Pressure garments for large areas, e.g. skin-grafted burns.

Pressure devices, e.g. clip earrings for earlobe keloids. Worn

continuously till scars mature. Reduce hypertrophy and contracture.

• Silicone gel. Either a sheet of gel tape worn on the scar or a jelly

rubbed into it scar. Reduces hypertrophy and relieves itch.

• Lasers. Pulsed dye lasers used to reduce redness and hypertrophy.

Carbon dioxide laser resurfaces depressed scars.

• Intralesional injections. Steroids and cytotoxics (e.g. bleomycin, 5-FU)

reduce excess collagen formation; used to ﬂ atten hypertrophic and

keloid scars and reduce pain and itch. Usually need repeated injections

at 1–2-month intervals.

• Radiotherapy. Occasionally given immediately post-operatively to

wounds in patients known to be prone to hypertrophic or keloid

scarring.

MANAGEMENT OF SCARS

599

Surgical treatment

• Excision and closure. For stretched scar or scar with ‘tramlines’.

Usually restretch to some extent. Keloid or hypertrophic scars are

likely to recur if excised and may be much larger than the original scar.

Keloids should only be excised in combination with a post-operative

course of steroid injections.

• Z-plasty (see Fig. 16.3(a)). Lengthens scar. Can re-orientate scar into

lines of relaxed skin tension, or break up the line of the scar and make

it less noticeable.

• W-plasty (see Fig. 16.3(b)). Breaks up line of scar. Used on scalp to

avoid a hairless linear scar.

• Scar release and resurfacing. Used when Z-plasty inadequate for scar

release, either because there is insufﬁ cient laxity adjacent to the

contracture or if adjacent skin is of poor quality. Resurfacing may

include skin grafting, local ﬂ aps, or free tissue transfer.

(a)

(b)

Fig. 16.3 Surgical techniques for managing scars. (a) Z-plasty. (b) W-plasty.

CHAPTER 16 Plastic surgery

600

Excision of simple cutaneous lesions

Planning

• Under good light and before inﬁ ltration of anaesthesia, mark the

borders of the lesion. Mark the appropriate margin of excision: 2–5mm

for basal cell carcinoma (BCC), 4–6mm for squamous cell carcinoma

(SCC), 1–2mm for biopsy of a pigmented lesion.

• Incision biopsies should include a border of the lesion and normal skin.

• For direct closure, convert the excision to an ellipse, using lines of

relaxed skin tension as the long axis. Be guided by wrinkles and line of

hair growth (hair generally grows in the direction of relaxed skin

tension lines (RSTLs)).

• Wedge excisions are used on the borders of the ear, eyelid, and lip.

Circular excisions are used where there is little skin laxity, using ﬂ aps

or grafts to close the defect.

Anaesthesia

• Calculate the maximum safe dose for your patient (see b p. 218).

• Consider a mixture of bupivacaine 0.25% with lidocaine 1% to provide

longer acting anaesthesia. Adding sodium bicarbonate makes the

injection less painful.

• Using adrenaline with the inﬁ ltration reduces intraoperative bleeding,

but should not be used near anatomical ‘end’ arteries (e.g. the digital

arteries) due to the risk of distal ischaemic necrosis.

• In the face, nerve blocks (e.g. mental, infraorbital, supraorbital, and

supratrochlear) may reduce the pain of inﬁ ltration, the volume of

anaesthetic needed, and distortion of the tissues by the anaesthetic ﬂ uid.

• Check the anaesthetic is working before starting excision.

Shave excision For benign, non-pigmented naevi and seborrhoeic kera-

toses. Use a number 10 blade to cut horizontally across the lesion at

mid-dermal level.

Excision

• Be aware of underlying structures (e.g. the frontal branch of the

temporal nerve when excising lesions from the temple). Ask your

assistant to stretch the skin.

• Use a size 15 blade on the face; consider a larger size 10 blade on the

thicker skin of the back.

• Cut the margins of the lesion perpendicular to the skin; this will aid

closure.

• Cut away from the corners of the wound to avoid X-shaped overcuts.

Cut the lower edge before the upper one; blood trickling down may

obscure your view.

• Lift one corner of the lesion gently with a skin hook or ﬁ ne-toothed

(Adson’s) forceps and cut along the base of the lesion in horizontal

lines at the level of the subcutaneous fat. Avoid traumatic handling of

the lesion, which may compromise histological analysis.

• Perform accurate haemostasis.

• Close and dress the wound.

EXCISION OF SIMPLE CUTANEOUS LESIONS

601

Post-operative care

• All lesions should be sent for histological analysis, clearly labelled (if

necessary with a marking stitch for orientation).

• Elevate the wound.

• Keep the wound dry until the skin is healed.

• Paracetamol, ibuprofen, and codeine are suitable analgesics; aspirin is

best avoided due to risk of bleeding.

• Patients should not drive on the day of surgery.

CHAPTER 16 Plastic surgery

602

Skin cancer

Key facts

• BCC, a neoplasm of the basal cells of the epidermis affects 20–40%

Caucasians. It almost never metastasizes, but can invade deeply and

may therefore be fatal.

• SCC is a malignant neoplasm of the keratinizing cells of the epidermis

affecting 1 in 2000 Caucasians per year.

• Melanoma is a malignant neoplasm of melanocytes, with a lifetime risk

of about 1 in 70 for Caucasians. The incidence has doubled over the

past 20 y.

Clinical features

• Melanoma presents with a change in a pre-existing or new mole

(naevus). Remember Asymmetry; Border irregularity; Colour change

or variegated colour; Diameter >6mm; Elevation, itch, or bleeding. All

these features are suspicious of melanoma.

• The typical BCC is a skin ulcer with a pearly edge and telangectasia;

however, there may not be any of these features. A persistent, itchy;

scaly patch in a sun-exposed area may also be a BCC.

• SCC typically presents as an ulcer with a raised, rolled edge, but also

may take many forms from scaly patch to keratotic horn.

Risk factors

• Fair skin and blue eyes.

• Sun exposure, both adult and childhood, especially sunburn.

• Family history.

• Previous skin cancer.

• Immunosuppression, especially post-organ transplantation.

• Xeroderma pigmentosum.

• Pre-malignant lesions. Multiple atypical naevi and giant congenital naevi

for melanoma; sebaceous naevus of Jadassohn for BCC; Bowen’s

disease, solar keratosis, and chronic ulcers for SCC.

• Radiotherapy.

• A variety of chemicals, e.g. arsenic and coal, predisposes to SCC and

BCC.

Assessment

• History includes sun exposure, previous skin lesions, drug history, and

family history.

• Examine the entire skin and palpate draining lymph nodes.

• Dermatoscopy is used to improve accuracy of clinical diagnosis of

melanoma.

Management

Melanomas and SCCs are managed by skin cancer MDTs.

603

SKIN CANCER

Melanoma

• All suspicious pigmented lesions are biopsied with a 2mm margin to

include subcutaneous fat and sent for histological analysis.

• Surgery aims to cure melanoma. Radiotherapy and chemotherapy are

used for palliation only. Wide local excision margins depend on the

depth of invasion (Breslow thickness) of the tumour and are typically

1cm for lesions <1mm thick, 2cm for lesions 1–2cm thick, and 2–3cm

for lesions >2cm thick.

• Sentinel lymph node biopsy may be considered, with lymph node

dissection of the neck, axilla, or groin if positive.

• Prognosis depends on Breslow thickness, ulceration of the tumour,

and lymph node involvement.

SCC

• Lesions are excised with a 4–6mm margin depending on the site; 95%

of tumours are cured by this treatment.

• Moh’s micrographic surgery probably gives the highest cure rate.

• Radiotherapy is used as an adjuvant treatment for metastatic tumours

or as primary treatment if the tumour or the patient mean that surgery

is not possible.

• Palpable lymph nodes in the draining basin are investigated by FNA,

with lymphadenectomy if positive.

• Prognosis depends on diameter of lesion, depth of invasion, nerve or

vessel invasion on histology

BCC

• Margins of 3–4mm are suitable for well-deﬁ ned BCCs, but wider

margins are used when margins are unclear and in recurrent tumours.

• Moh’s micrographic surgery is also used, particularly when wide

excision would leave an unacceptable defect, e.g. around the eye.

• Other treatment modalities include curettage and cautery,

cryotherapy, radiotherapy, efudix, imiquimod.

• Ninety-ﬁ ve per cent of lesions are cured by complete excision, 99%

with Moh’s surgery. Radiotherapy cures 90%.

CHAPTER 16 Plastic surgery

604604

Burns: assessment

0 Assessment and management of burns go hand in hand and are

simultaneous in practice. They have been divided here only for ease of

reading.

Causes Most burns are due to ﬂ ame or contact with hot surfaces; scalds

are more common in children and the elderly. Chemical, electrical, irradi-

ation, and friction burns are rare.

History

• Find out the exact mechanism, including temperature of water,

duration of contact, concentration of chemical, voltage.

• Record factors suggesting inhalation injury, e.g. burns in a conﬁ ned

space, ﬂ ash burns.

• Enquire about other injuries.

• Document ﬁ rst aid given so far.

• Document timings of injury, ﬁ rst aid, and resuscitation.

Examination

Estimate area of burn Do not include areas of unblistered erythema.

• Rule of nines (see Fig. 16.4).

• Patient’s hand is approximately 1% total body surface area (TBSA).

• Lund and Browder chart (see Fig. 16.5) is the most accurate method.

• Subtract % unburned skin from 100% to check calculation.

• Draw a picture, ideally ﬁ lling in the Lund and Browder chart.

Estimating depth of burn

• Epidermal. Erythema only.

• Superﬁ cial dermal. Pink, wet or blistered, sensate, blanches and reﬁ lls.

• Deep dermal. Blotchy red, wet or blistered, no blanching, insensate.

• Full thickness. White or charred, leathery, no blanching, insensate.

Signs of inhalation injury

• Singed nasal hair.

• Burns to face or oropharynx. Look for blistered palate.

• Sooty sputum.

• Drowsiness or confusion due to carbon monoxide inhalation.

• Respiratory effort, breathlessness, stridor, or hoarseness are signs of

impending airway obstruction and require immediate intubation.

Features of non-accidental burns injury Refer to paediatric burns unit if sus-

pected in a child. Features include:

• Delayed presentation.

• History inconsistent or not compatible with injury.

• Other signs of trauma.

• Suspicious pattern of injury, e.g. cigarette burns, bilateral ‘shoes and

socks’ scalds.

BURNS: ASSESSMENT

605605

Post

Ant

Fig. 16.4 Rule of nines.

Total

REGION

Head

Neck

Ant trurk

Post trurk

L arm

R arm

Buttocks

R leg

Genitalia

L leg

AREA

A = of head

B = of one thigh

C = of one lower leg

43 3

0151015Adult

Fig. 16.5 Lund and Browder chart.

CHAPTER 16 Plastic surgery

606606

Burns: management

Immediate ﬁ rst aid

• Stop the burning process (do not endanger yourself ).

• Cool the wound. Running water at 2–15*C for 20min (beware risk of

hypothermia in infants, young children, and adults with >25% TBSA).

Resuscitation

• A. Airway maintenance with C-spine control. Intubate if suspected

inhalation injury; airway oedema can be rapidly fatal.

• B. Breathing and ventilation.

• C. Circulation with haemorrhage control.

• D. Disability and neurological status.

• E. Exposure and environmental control.

• F. Fluid resuscitation: child, >10% TBSA; adult, >15% TBSA burned.

• Two large peripheral IV lines, preferably through unburned skin.

• Send blood for FBC, U&E, clotting, amylase, carboxyhaemoglobin.

• Give 3–4mL Hartmann’s solution/kg/% TBSA burned. Half of this is

given over the ﬁ rst 8h following injury, half over the next 16h.

• Children need maintenance ﬂ uid in addition.

• Monitor resuscitation with urinary catheter (aim for urine output

0.5–1mL/kg/h in adults and 1–1.5mL/kg/h in children).

• Consider ECG, pulse, BP, respiratory rate, pulse oximetry, ABGs.

Perform secondary survey.

Referral to a burns unit (see Box 16.1) Intubate before transfer if

inhalation injury suspected. Give humidiﬁ ed 100% O

to all patients. Wash

the burn and cover with cling ﬁ lm. Give IV morphine analgesia. Discuss

NGT and catheter insertion with burns unit. Give tetanus prophylaxis if

required.

Box 16.1 Criteria for referral to a burns unit

>10% TBSA burn in adult; >5% TBSA in child.

Burns to face, hands, feet, perineum, genitalia, major joints.

Full thickness burns >5% TBSA.

Electrical or chemical burns.

Associated inhalation injury—always intubate before transfer.

Circumferential burns of limbs or chest.

Burns in very young or old, pregnant women, and patients with signiﬁ -

cant comorbidities.

Any burn associated with major trauma.

BURNS: MANAGEMENT

607607

Management of the burn wound

• Superﬁ cial dermal burns will heal without scarring within 2 weeks as

long as infection does not deepen the burn.

• For small burns, outpatient treatment with simple, non-adherent

dressings and twice weekly wound inspection is sufﬁ cient.

• Wash burns with normal saline or chlorhexidine.

• Debride large blisters. Elevate limbs to reduce pain and swelling.

• Dress hands in plastic bags to allow mobilization.

• Topical silver sulphadizine is used on deep burns to reduce risk of

infection (but should not be applied until the patient has been

reviewed by a burns unit as it makes depth difﬁ cult to assess).

Escharotomy Performed for circumferential full thickness burns to the

chest that limit ventilation or to the limbs that limit circulation. Loss of

pulses or sensation is a late sign. In the early stages, pain at rest or on

passive movements of distal joints indicates ischaemia. Patients may also

need fasciotomies.

Excision and skin grafting Performed for deep dermal or full thickness burns

that are too large to heal rapidly by secondary intention.

Electrical injuries

• Low voltage (<1000V). Domestic electrical supply. Causes local

contact wounds, but no deep injury. May cause cardiac arrest.

• High voltage (>1000V). High tension cables, power stations, lightning.

Causes cutaneous and deep tissue damage with entry and exit wounds.

• ECG on admission for all injuries. Continuous cardiac monitoring for

24h for signiﬁ cant injuries.

• In high voltage injury, muscle damage may require fasciotomy.

• Myoglobinuria can cause renal failure. Urine output >75–100mL/h.

Chemical burns

Treat with copious lavage for at least 30min until all chemical has been

removed and skin pH is normal.

• Acid. Causes coagulative necrosis; penetrates skin rapidly, but is easily

removed.

• Alkali (includes common household chemicals and cement). Causes

liquefactive necrosis so needs longer irrigation (>1h).

• Hydroﬂ uoric acid. Fluoride ions penetrate burned skin, causing

liquefactive necrosis and decalciﬁ cation; 2% TBSA burn can be fatal.

Irrigate with water.•

Trim ﬁ ngernails.•

Topical calcium gluconate gel, 10%.•

Local injection of 10% calcium gluconate.•

IV calcium gluconate.•

May need urgent excision of burn.•

• Elemental Na, K, Mg, Li. Do not irrigate initially; they ignite in water.

Brush off particles and direct high pressure jet of water to wound.

• Phosphorus. Irrigate with water, then debride particles which will

otherwise continue to burn. Apply copper sulphate which turns

particles black so they are easier to identify.

CHAPTER 16 Plastic surgery

608608

• Bitumen. Burns by heat; treat by cooling with water. Remove cold

bitumen with peanut or parafﬁ n oil.

• Tar. Burns by heat. Treat by cooling with water; no need to remove

tar as it gradually gets emulsiﬁ ed with topical ointments used for

treatment.

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CHAPTER 16 Plastic surgery

610

Soft tissue hand injuries

History

• Mechanism of injury.

• Dominant hand, occupation, hobbies.

• Medical and smoking history, previous hand injuries, social history.

Examination

Use local anaesthetic block if needed for pain (check sensation ﬁ rst).

Look Posture of hand and digits. Site of laceration(s) and tissue loss.

Feel Perfusion of hand and digits, pulses. Sensation in distribution of radial,

ulnar, median, and digital nerves. Pain over bones.

Move

• Long extensors extend MCPJs.

• EPL extends thumb dorsal to plane of hand (i.e. up off a table).

• FDP tendons ﬂ ex DIPJs.

• FDS tendons ﬂ ex PIPJs. Isolate FDS by holding all digits except the one

under examination extended.

• Testing wrist ﬂ exors and extensors is unreliable as ﬁ nger ﬂ exors and

extensors may mimic function, but pain on movement suggests injury.

• Examine intrinsics, hypothenar and thenar muscles, particularly

abductor pollicis brevis (supplied by median nerve) and Froment’s sign

(for adductor pollicis supplied by ulnar nerve).

• Check stability of joints. Pain or abnormal movement on lateral

deviation suggests collateral ligament damage.

Investigations X-ray for fractures of foreign bodies. Photographs.

Treatment

• Finger pulp injury. Debride under tourniquet. If there is no bone

exposed, it will heal by secondary intention. Exposed bone may need

surgery to shorten bone or cover it with a local ﬂ ap.

• Subungual haematoma. Painful bruise under nail. Trephine nail with

sterile needle to evacuate haematoma.

• Nailbed injury. Often with distal phalanx (DP) fracture. Remove nail

under tourniquet; irrigate wound; repair nail with absorbable 7/0

suture using loupe magniﬁ cation. Replace fenestrated nail as splint for

eponychial fold.

• Mallet ﬁ nger. Immobilize in stack splint for 6–8 weeks unless large

bony fragment present which may require surgical ﬁ xation.

• Foreign bodies. Remove organic matter and painful foreign bodies.

• Lacerations and puncture wounds.

Always explore with anaesthetic and tourniquet to determine •

underlying structural damage.

Irrigate wounds and debride as necessary.•

Tetanus prophylaxis (see • b p. 175).

Co-amoxiclav (500mg tds • PO) for bites.

SOFT TISSUE HAND INJURIES

611

Repair tendons, ideally primarily. Post-operative regimes typically •

involve splints for 6 weeks and 6 more weeks without heavy lifting.

Repair nerves under magniﬁ cation. Axonal regeneration progresses •

at 1mm/day after 1 month from repair.

Thoroughly irrigate open joints due to the risk of septic arthritis. •

Collateral ligaments may need to be repaired and are splinted for

around 4 weeks post-repair.

• Complications. Haematoma, infection, tendon or ligament rupture,

stiffness, painful scars, neuroma, complex regional pain syndrome,

scar contracture, cold sensitivity.

CHAPTER 16 Plastic surgery

612

Hand infections

Key facts

Usually follows a penetrating injury (which may seem insigniﬁ cant) or a

bite. Haematogenous spread of infection to the hand is rare.

• Infecting organisms. After penetrating injury, Staphylococcus aureus is

the most common, followed by streptococci. Human bites are often

also contaminated with Eikenella corrodens. Viruses (hepatitis B and C,

HIV) are rarely transmitted. Pasteurella spp. are common in infected

cat and dog bites.

• Paronychia. Infection of nailfold. Candida albicans causes chronic

paronychia and may require excision of crescent of epinychium and

topical antifungals. Herpes simplex causes whitlow with vesicles or

bullae around the nail, but no pus. Avoid surgery in these cases.

• Felon. Finger pulp infection.

• Palmar space infection. There are four fascial compartments in the palm

(web space, hypothenar, mid-palm, and thenar). They usually

conﬁ ne infection initially. Pain, swelling, and reduced movement are

features. Swelling is often more prominent on the dorsal surface of

hand.

• Flexor sheath infection. The cardinal signs are ﬂ exed posture of ﬁ nger,

pain on passive extension, fusiform swelling, pain along ﬂ exor sheath.

Often requires continuous saline irrigation for 24–48h post-drainage.

• Bites. High risk of infection so always irrigate, give antibiotic

prophylaxis (co-amoxiclav 500mg PO tds), and refer for surgical

exploration.

Treatment

Delay can be disastrous, resulting in stiffness, contracture, and pain. Early

cellulitis (24–48h after onset) may be treated by elevation, splints, and

antibiotics. Any collection of pus must be drained urgently.

Initial treatment

• Tetanus prophylaxis if indicated.

• Elevation and splintage.

• IV co-amoxiclav 1g tds (unless penicillin allergy) till sensitivities known.

• Plain X-ray may be useful to exclude associated fractures, foreign

bodies, underlying osteomyelitis, and evidence of gas-forming infection.

Surgical treatment

• Use a tourniquet, but elevate rather than exsanguinate the limb.

• Send pus swabs and tissue samples for culture.

• Debride and irrigate wounds; fully explore pockets of pus.

• Leave wound open for delayed primary closure.

Post-operative care

• Continue elevation.

• Daily saline soaks or irrigation of the wound.

• Splint for comfort with wrist extended, MCPJs ﬂ exed, and

interphalangeal joints (IPJs) extended. Mobilize with physiotherapists.

• Antibiotics until infection resolved.

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CHAPTER 16 Plastic surgery

614

Dupuytren’s disease

Key facts

A progressive thickening of the palmar and digital fascia that may lead

to contractures. Aetiology is unknown, but there is a higher incidence

among relatives of affected patients. Associated conditions include

diabetes and epilepsy. Alcoholism, TB, HIV, hand trauma, and tobacco

have all also been implicated. Incidence is 1–3% of northern Europeans,

but it is uncommon in Africa and Asia. It increases with age; ♂ > ♀,

approximately 7:1.

Pathogenesis

• Disease classiﬁ ed by Luck into three phases: proliferative, involutional,

and residual.

• In the proliferative phase, immature ﬁ broblasts, many of which are

myoﬁ broblasts, produce extracellular matrix containing type IV

collagen. Resembles a healing wound histologically.

• Mechanical tension appears to play a role in contractures.

Clinical features

• Thickened palmar and digital fascia forms nodules and cords.

• Progresses to contractures of the MCPJs and PIPJs of the affected rays.

• Tends to affect digits in order: ring, little, thumb, middle, index.

• Normal fascia is referred to as bands; diseased bands are called cords.

• A spiral cord may be a feature, wrapping around the neurovascular

bundle (NVB) and displacing it to the midline and superﬁ cially, putting

it at risk during surgery.

• The disease affects longitudinal fascial structures; the transverse palmar

fascia is never involved and provides a landmark for dissecting NVBs.

Extra-palmar manifestations

• Garrod’s pads. Thickening over dorsal aspect of PIPJs.

• Peyronie’s disease. Thickened plaques in the shaft of the penis.

• Ledderhose’s disease. Thickened plantar fascia.

Treatment

Indications for surgery

• Over 30* ﬁ xed ﬂ exion contracture at MCPJ or any PIPJ contracture.

Also any rapidly progressing contracture. Results are better for release

of MCPJs than PIPJs.

• Tabletop test. Surgery indicated when hand will not lie ﬂ at on table.

• Pain in nodules or Garrod’s patches. Injection with steroid or excision.

Many people with Dupuytren’s disease never require surgery.

DUPUYTREN’S DISEASE

615

Surgical considerations

Skin

Typical incisions include the following.

• Linear incisions with Z-plasties.

• Bruner incisions.

• Multiple V to Y incisions.

• Lazy ‘S’ incisions.

• Transverse palmar incision with longitudinal extensions.

• Multiple short curved incisions.

• Multiple Z-plasties.

Closure may be direct with skin grafts (split or full thickness) or palm left

open to heal by secondary intention.

Fascia

This may be incised (fasciotomy) or excised (fasciectomy).

• Radical fasciectomy removes the entire palmar fascia.

• Regional or limited fasciectomy removes only the diseased fascia.

• Segmental fasciectomy excises sections of the diseased cord.

• Fasciotomy via a percutaneous approach using a needle provides

temporary relief from contracture.

• Dermofasciectomy. Excision of fascia with overlying skin, used for

severe skin involvement and where risk of recurrence is high, e.g.

surgery for recurrent disease.

• Specimens are sent for histological analysis to rule out the rare

differential diagnosis of epithelioid sarcoma.

Joint contractures

Release of fascia usually resolves contracture at the MCPJ. Fixed ﬂ ex-

ion at the PIPJ is more difﬁ cult to release and contracture often recurs.

Consider releasing the check-rein and accessory collateral ligaments. DIPJs

are rarely involved except in recurrent disease.

Post-operative care The affected ﬁ ngers are splinted in extension and active

exercises begun in the ﬁ rst week, unless a skin graft has been used. Night

splints are used for at least 3 months.

Complications

• Early. Damage to neurovascular structures (1–3%), PIPJ

hyperextension, haemorrhage.

• Intermediate. Infection, skin ﬂ ap necrosis.

• Late. Complex regional pain syndrome; recurrence (25% of patients

treated surgically will need further surgery for Dupuytren’s disease).

Treatment of recurrence

Recurrence may be treated by repeat surgery although this tends to be

less successful and more extensive at each event. Amputation of a ﬁ xed

ﬂ exed digit is occasionally an option, particularly if the digit hampers work

or leisure activities.

CHAPTER 16 Plastic surgery

616

Breast reduction

To reduce the volume and weight of the hypertrophied breast while main-

taining a blood supply to the nipple and creating an aesthetically pleasing

breast.

Indications

• Neck, back, or shoulder pain.

• Indentation of shoulder skin by bra straps.

• Persistent infections or soreness in the inframammary crease.

• Restriction in activity, especially sport.

• Inability to ﬁ nd clothes that ﬁ t.

• Psychological. Embarrassment, low self-esteem, loss of sexual appeal.

Operative considerations

Blood supply to the nipple

In order to lift the nipple, skin around it is de-epithelialized or excised. The

base of the nipple is left attached to a mound of breast parenchyma (the

pedicle) through which its blood supply travels. Due to the rich vascular

anastamoses in the breast, numerous techniques are possible. Pedicles

can be based inferiorly, superiorly, supero-medially, laterally, or centrally.

Alternatively, the nipple can be removed before the breast is reduced and

replaced as a full thickness graft.

Skin excision and scars

An anchor shape (Wise pattern) excision leaves an inverted ‘T’-shaped

scar. It runs around the areola, vertically down to the inframammary fold

and horizontally along the fold. Other options include periareolar incision

only or periareolar incision with a vertical scar. These techniques limit the

amount of breast tissue that can be resected. L-shaped and horizontal scar

techniques are also possible, but more rarely used.

Post-operative care

The patient usually stays in hospital overnight or longer if drains are used.

She should wear a supportive bra and avoid heavy lifting for 4–6 weeks

post-operatively.

Complications

• Early. Haematoma, infection, altered nipple sensation, skin loss or

necrosis, fat necrosis, delayed wound healing, asymmetry.

• Late. Unsightly scar, inability to breastfeed, pseudoptosis (‘bottoming

out’), recurrence (if done before breast fully grown).

However, most patients are happy with the result, even if they do suffer

complications.

BREAST AUGMENTATION

617

Breast augmentation

To enhance breast size by placing an artiﬁ cial implant beneath the breast.

Indications

Performed for asymmetry, hypoplasia, and psychological reasons, e.g.

self-consciousness or problems with sexual relationships. Inadequate

breast volume may be due to hypoplasia or involution following childbirth

or menopause.

Operative considerations

Incision

• Inframammary fold. Good visualization of implant pocket; visible scar.

• Periareolar. Semicircular incision at the border of the areolus. Scar

fades well, but access is limited. More likely to alter nipple sensation.

• Transaxillary. Eliminates scars on breast. Limited access improved by

using endoscope. Better for subpectoral implants.

• Transumbilical. Only used for saline-ﬁ lled implants, inserted along a

tunnel created superﬁ cial to rectus sheath. Endoscope conﬁ rms

position of implant pocket. Implant inﬂ ated once in position.

Position of implant

• Submammary. Under the normal breast.

• Subpectoral. Under the pectoralis major (slightly less obvious upper

border in the thin; have lower rates of capsular contracture, but may

move when the pectoralis contracts).

Type of implant

• Size. Depends on patient’s choice.

• Shape. Round implants are low or high proﬁ le (depending on how

much they project forwards); anatomical implants are teardrop-shaped.

• Shell. Implants are made of a silicone shell that is smooth or textured.

Textured implants have lower rates of capsular contracture.

• Implant ﬁ lling. Saline-ﬁ lled implants allow for ﬁ ne adjustment of volume

and can be ﬁ lled or emptied post-operatively. Silicone gel-ﬁ lled

implants feel more like normal breast tissue. No current evidence to

support implication of silicone in causing autoimmune diseases.

Post-operative care

• Usually an overnight stay procedure (longer if drains are used).

• A supportive bra is worn and heavy lifting avoided for 4–6 weeks.

Complications

• Early. Haematoma, infection, nerve injury (altering sensation to the

nipple), incorrect position of implant.

• Late. Capsular contracture, rupture, or deﬂ ation; silicone gel bleed.

• Implants have a limited lifespan, up to about 20y. The likelihood is

that they will need to be removed or replaced at some time. Patients

can usually breastfeed after augmentation. Patients are warned that

mammography is technically more difﬁ cult, requiring different views.

CHAPTER 16 Plastic surgery

618

Breast reconstruction

Aims

To recreate a breast mound resembling the contralateral breast with

minimal donor deﬁ cit, using a technique appropriate for the patient. After

mastectomy, breast reconstruction is of psychological beneﬁ t. It is techni-

cally easier to perform it at the same time as mastectomy, rather than as

a delayed procedure as there is no scarring around the breast and original

landmarks are present. It also reduces the number of operations required.

However, there may be logistical difﬁ culties if a combined breast surgery/

plastic surgery team is needed. Also, some patients prefer to wait.

Surgical options

Tissue expander

Placed in the subpectoral position. Inﬂ ated with saline once the wounds

are healed (2–4 weeks post-operatively) via a subcutaneous port. The skin

is slowly stretched until a satisfactory size is reached. The implant can later

be changed for a silicone gel-ﬁ lled implant.

Latissimus dorsi myocutaneous ﬂ ap

A pedicled ﬂ ap based on the thoracodorsal vessels. The latissimus dorsi

muscle, with an ellipse of overlying skin and fat, is tunnelled under the

intervening skin bridge into the breast defect. Depending on the size of the

contralateral breast, an implant may be used under the ﬂ ap.

Abdominal ﬂ aps

The transverse rectus abdominis myocutaneous (TRAM) ﬂ ap consists

of a transverse ellipse of skin on the lower abdomen, plus one of the

two rectus abdominis muscles. This versatile ﬂ ap may be based on either

its upper (deep superior epigastric) or lower (deep inferior epigastric)

vascular pedicles. The upper pedicle is used as a pedicled ﬂ ap, tunnelled

under the abdominal skin into the breast. The lower pedicle is used as

a free tissue transfer. If a sizeable muscular perforator vessel is identiﬁ ed, a

DIEP ﬂ ap can be used, leaving the muscle behind. This ﬂ ap is usually large

enough not to need an implant.

Nipple reconstruction At a later stage, the reconstructed breast can be

tattooed with a picture of a nipple or a nipple formed with a combination

of local ﬂ aps, skin graft, and grafts from the contralateral nipple.

Surgery to the contralateral breast The opposite breast may be reduced,

augmented, or lifted to improve symmetry.

619

Cardiothoracic surgery

Basics 620

Principles of cardiac surgery 622

Coronary artery disease 626

Valvular heart disease 628

Cardiothoracic ICU 630

Lung cancer 632

Pleural effusion 634

Pneumothorax 636

Mediastinal disease 638

Chapter 17

CHAPTER 17 Cardiothoracic surgery

620

Basics

Common cardiac emergencies

Atrial ﬁ brillation (see b p. 55)

• Give 10–20mmol K

via central line to get serum K

4.5–5.0mmol/L.

• Give empirical 20mmol Mg

via central line if none given post-op.

• Give of 300mg amiodarone IV over 1h in patients with good left

ventricle, followed by 900mg amiodarone IV over 23h.

• In patient with poor left ventricular function, give digoxin in 125mcg

increments IV every 20min until rate control is obtained, up to a

maximum of 1500mcg in 24h.

• Synchronized DC cardioversion for unstable patients (b p. 189).

Bleeding (see b p. 180)

• Get immediate help if bleeding is >400mL in 30min.

• Give gelofusine to get CVP 10–14 and systolic BP 80–100mmHg.

• Order further 4U of blood, 2U FFP, and 2 pools platelets.

• Send clotting and FBC, request a CXR.

• Transfuse to achieve Hb >8.0g/dL, platelets >100 x 10

/L, APTT <40.

• Give empirical protamine 25mg IV.

• Emergency re-exploration is indicated for excessive bleeding.

Profound hypotension

• Get immediate help.

• Quickly assess pulse, rhythm, rate, CVP, O

sats, and bleeding.

• Deﬁ brillate VF or pulseless VT, treat AF as above.

• Treat bradycardia with atropine 0.3mg IV or pace.

• Give gelofusine to raise CVP to 12–16mmHg, place bed head down.

• If suspect cardiac tamponade (b p. 480), prepare for re-sternotomy.

• If patient warm and vasodilated, draw up 10micrograms of

metaraminol into 10mL of saline and give 1mL through a central line,

and ﬂ ush.

• If patient still profoundly hypotensive, give 1mL 1:10 000 adrenaline IV.

Poor gases (see b p. 108)

• If O

sats <85% and falling, get immediate help.

• Increase the FiO

to 100% temporarily, check the pulse oximeter.

• Look at expansion, auscultate the chest, check PaO

• If you suspect tension pneumothorax, treat immediately (b p. 480).

• Suction the ET tube, check that the patient is not biting on it.

• Check that the drain tubing is patent and drains are on suction.

• Treat bronchospasm with salbutamol 5mg nebulizer.

• Disconnect from the ventilator and hand-ventilate the patient.

• Get a CXR: look for pneumothorax, haemothorax, atelectasis, ET

tube position, and lobar collapse, and treat (see b p. 108).

Poor urine output (see b p. 112)

• Check that the Foley catheter is patent.

• If the patient is hypotensive, treat this ﬁ rst.

• Give a ﬂ uid challenge of gelofusine to raise the CVP to 14mmHg.

• If not hypotensive and CVP >14mmHg, give 20mg furosemide IV.

BASICS

621

Key revision points: coronary artery anatomy (see Fig. 17.1)

• The left main stem (LMS) arises from the ostium of the left sinus of

Valsalva, travels between the pulmonary trunk anteriorly and the left

atrial (LA) appendage to the left atrioventricular (AV) groove, dividing

after 1–2cm into left anterior descending (LAD) artery, circumﬂ ex

(Cx), and occasionally a third artery (the intermediate). As it provides

almost the entire blood supply to the left ventricle (LV), occlusion

can be fatal; severe left main disease is known as ‘the widow maker’.

• The LAD runs down the anterior interventricular groove to the

apex of the heart, usually extending round the apex to the posterior

interventricular groove. A variable number of diagonals are given

off over the anterior surface of the LV, small branches supply the

anterior surface of the right ventricle (RV), and superior septals are

given off perpendicularly to supply the anterior two-thirds of the

interventricular septum. Occlusions of the LAD result in anterior MI.

• The circumﬂ ex originates at 90* from the LMS and runs medially to the

LA appendage for 2–3cm, continuing in the posterior left AV groove to

the crux of the heart. Occlusions of the Cx result in posterior infarcts.

In left dominant hearts (5–10%), the Cx turns 90*

into the posterior

interventricular groove to form the posterior descending artery (PDA).

In 85–90% of hearts, the PDA arises from the right coronary artery

(RCA) (right dominant). About 5% of hearts are co-dominant.

• A variable number of obtuse marginals (OMs) arise from the Cx to

supply the posterior LV. The ﬁ rst branch of the Cx is the AV nodal

artery in which 45% course round the LA near the AV groove.

• The RCA arises from an ostium in the right sinus of Valsalva, gives

off an infundibular branch and then a branch to the sinoatrial (SA)

node, and runs immediately into the deep right AV groove where

it gives off RV branches to the anterior RV wall. Occlusions of the

RCA result in inferior infarcts and bradycardia. The acute marginal

is a large branch which crosses the acute margin of the heart. In

right dominant hearts, the RCA reaches the crux of the hearts

where it turns 90* to form the PDA, which runs in the posterior

interventricular groove. Inferior septals, which supply the inferior

third of the interventricular septum, arise at 90* from the PDA. The

AV node artery is given off by the RCA in 55% at the crux.

Branch to sinus

node

Right coronary

artery

Branch to

AV node

Aotra marginal

Posterior descending

Left ventricular branch

Diagonal 2nd

Obtuse marginal

Circumflex

Diagonal 1st

Left anterior descending

Left main stem

Fig. 17.1 Coronary artery anatomy.

CHAPTER 17 Cardiothoracic surgery

622

Principles of cardiac surgery

Key facts

• The majority of procedures are coronary artery bypass graft (CABG)

operations, followed by aortic valve replacements, and mitral valve

(MV) repair and replacements.

• Many patients are elderly with multiple comorbidities, but 90% should

be out of ICU within a day or two, and ready to go home in a week.

Preoperative preparation

Careful preoperative work-up is essential. All investigations must be

checked; small abnormalities which would not cause a problem in other

specialties can have catastrophic results in cardiac surgery.

• Full history. Quantify symptoms, previous MI or stroke. Comorbidities

(especially COPD, renal failure, peripheral vascular disease), MI <90

days (which increases mortality), drugs (aspirin, clopidogrel, and

warfarin normally stopped 5 days preop to reduce bleeding), allergies,

recent chest infection. Valve patients must have been cleared by

dentist. Ask about previous heart surgery, varicose vein surgery.

• Full examination. Look for signs of heart failure. Active infection, e.g.

abscess is a relative contraindication to valve replacement. Look at

conduit: any evidence of varicose veins?

• All patients should have FBC, U&E, LFTs, clotting screen.

• Cross-match 2U of blood.

• ECG and CXR.

• All patients undergoing coronary artery surgery and patients >35y

undergoing valve surgery should have coronary angiogram less than

1y-old.

• Patients undergoing valve surgery must have had an echo.

• Carotid duplex in any patient with history of stroke, TIA, or carotid

bruits; some centres perform these routinely in patients >70y old.

• Consent by registrar or consultant.

• Sliding scale for diabetic patients (see b p. 52).

Cardiopulmonary bypass (CBP)

Any operation that involves stopping or opening the heart (valve surgery,

surgery on septal defects) or great vessels (ascending and arch aortic

dissection and aneurysm surgery, resection of some tumours invading

great vessels, e.g. renal cell) requires CPB to maintain blood ﬂ ow. This

involves:

• Heparinizing the patient so that blood does not clot in the CPB circuit.

• Securing a 24F aortic cannula in the ascending aorta.

• Securing a 32F venous cannula in the RA or in the superior vena cava

(SVC) and inferior vena cava (IVC).

• Connecting both cannulae to the bypass circuit.

• The venous return from the body is siphoned into the bypass circuit.

• The venous blood is oxygenated, ﬁ ltered, and can be cooled or

warmed, and is pumped back to the patient via the aortic cannula.

• At the end of bypass, heparin is reversed with protamine.

PRINCIPLES OF CARDIAC SURGERY

623

• Complications of CPB include stroke (atheromatous emboli,

hypoperfusion, air, microemboli), SIRS, renal and pulmonary

dysfunction (see b p. 622).

Pathophysiology of CPB

CPB is unavoidable for many operations. It has a major impact on nearly

every organ system and problems associated with bypass include:

• Activation of coagulation and complement cascades.

• Consumption of platelets and clotting factors, causing coagulopathy.

• Microemboli and atherosclerotic emboli from aortic cannulation which

can cause stroke and peripheral limb and end-organ ischaemia.

• Increased capillary permeability.

• Renal, pulmonary, hepatic, and pancreatic dysfunction.

Cardioplegia

CPB does not stop the heart; it just bypasses the beating heart. If the

surgeon wants to operate on a still heart, CPB gives the surgeon three

options: ﬁ brillate the heart, cool the patient, or use cardioplegia.

Cardioplegic arrest is by far the commonest technique.

• Cardioplegia is a potassium rich solution.

• It can be based on blood or crystalloid (blood delivers O

better).

• It can be warm or cold (cold may reduce ischaemic injury more).

• It is delivered into the coronary arteries, either anterogradely by

inserting a cannula into the aortic root which is clamped distal to the

cardioplegia cannula or retrogradely via the coronary sinus vein.

• It can be given continuously or intermittently, every 20min or so.

• Cardioplegia arrests the heart and prevents myocardial ischaemia.

Post-operative management

Management of ﬁ ve common post-operative emergencies is outlined on

b p. 620. Most patients are well enough to be extubated within 6h, leave

ITU within 24h, and go home within 5 days. Stable patients should have

bloods, CXRs, and ECGs on days 1, 2, 4, and 6.

First 6 hours

• Myocardial function deteriorates due to ischaemia-reperfusion injury.

• Inotropic support and pacing may be required.

• Patient should be ﬁ t for extubation by 6h post-op.

• Patients should have diuresis >1mL/kg/h.

• Mediastinal bleeding should steadily decrease.

• Insulin requirements usually increase.

Days 1–2

• Inotropes and pacing weaned, invasive monitoring lines removed.

• Chest drains removed after 2h of zero drainage.

• Catheter and any epidural removed, patient mobilized.

• PCA morphine reduced to oral analgesia.

• Patient should be on aspirin, low molecular weight heparin,

furosemide.

• Patient normally eating and drinking.

CHAPTER 17 Cardiothoracic surgery

624

Days 3–5

• Temporary pacing removed if ECG satisfactory.

• Valve repair patients should undergo echocardiography.

• Physiotherapists assess exercise tolerance.

• Back to baseline weight, medications stabilized, ready for discharge.

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CHAPTER 17 Cardiothoracic surgery

626

Coronary artery disease

Deﬁ nition

Narrowing of the coronary arteries caused by atherosclerosis (see b p.

152).

Incidence

Five in 1000 males over 40y have symptomatic ischaemic heart disease

(IHD), 5 in 1000 heart attacks per year, 6000 coronary artery operations

per year in the UK.

Aetiology

Age, male sex, smoking, i BP, diabetes, hyperlipidaemia, obesity, family

history, stress.

Pathology

See b p. 152 for description of atherosclerotic disease. Stenoses tend

progress in severity and distribution. Rate of progression is variable and

regression of lesions has been observed.

• Narrowings of 50% of cross-sectional area limit coronary ﬂ ow reserve

(the increase in blood ﬂ ow that occurs to meet increased O

demand).

• Coronary blood ﬂ ow at rest is reduced by narrowings of 90%.

• LV function may be abnormal. In normal people, global LV systolic

function improves with exercise, but in patients with coronary artery

disease (CAD), it gets worse in the area supplied by the stenotic

arteries.

• Acute MI is caused by acute total or subtotal vessel thrombotic

occlusion. Patients with proximal LAD lesions are particularly at risk

(see b p. 54 for description of anatomic territories).

Clinical features

• Angina and/or dyspnoea. Severity is classiﬁ ed using the New York Heart

Association (NYHA) score. Dyspnoea implies congestive heart failure

(CCF).

• Class I. Symptoms only with prolonged or strenuous exertion.

• Class II. Symptoms causing slight limitation of ordinary activity.

• Class III. Symptoms with marked limitation of ordinary activity.

• Class IV. Angina occurring even with mild activity or at rest.

Diagnosis

• History and examination.

• ECG may show evidence of old infarcts.

• Exercise treadmill has 97% speciﬁ city for exertional angina.

• Coronary angiography is diagnostic and obligatory for planning surgery.

• Myocardial perfusion studies such as thallium scans are also useful.

• CT coronary angiography is increasingly used to screen lower risk

patients, but is not helpful in evaluating lesions in high risk patients.

CORONARY ARTERY DISEASE

627

Indications for surgery

The options are medical and percutaneous coronary intervention (angi-

oplasty or stent). Many large trials have been carried out to decide which

groups of patients beneﬁ t most from surgery. This is currently:

• Patients with >70% LMS stenosis.

• Symptomatic patients with >70% proximal LAD stenosis.

• Symptomatic patients with >70% disease in all three vessels (three-

vessel disease).

• Patients with less signiﬁ cant coronary disease having cardiac surgery

for other reasons, e.g. valve replacement.

Coronary artery bypass surgery

Median sternotomy. A piece of conduit (saphenous vein, left internal tho-

racic artery (LITA), radial artery) is anastomosed to the coronary artery

beyond the lesion and then to the ascending aorta. The LITA is usually

anastomosed to the LAD because this combination remains patent for

decades and the LAD is the most important stenosis to treat. The LITA

is a branch of the left subclavian artery and runs down the inside of the

rib cage 2cm lateral to the sternum. The origin from the subclavian is left

intact; it does not need to be anastomosed to the aorta.

• Coronary artery bypass is mostly performed on-pump (with the use of

a CPB machine) on the still heart.

• Performing on the beating heart off-pump (without CPB) is more

difﬁ cult, but gives some advantages (see b p. 622).

Complications

Complications (see b p. 620) are more likely with advanced age,

poor LV function, renal failure, COPD. Risk of mortality is scored, e.g.

EUROscore.

• Death, 0–1% in low risk patients.

• Stroke, 1–2% in low risk patients.

• Re-sternotomy for bleeding or tamponade 5%.

• Chest infection, AF, wound infection, renal failure.

Prognosis

• In untreated patients with symptoms severe enough to warrant

coronary angiography, 10% have an acute MI within 1y and 30% have

an acute MI within 5y. Hospital mortality of MI is 7–10%.

• In three-vessel disease, the 5y survival is 50%, lower if LV function is

impaired.

• LMS disease has a 2y survival of 50%.

CHAPTER 17 Cardiothoracic surgery

628

Valvular heart disease

Mitral regurgitation (MR)

• Incidence Commonest valvular lesion. Prevalence 2–6%.

• Aetiology MV prolapse (congenital or rupture of chordae/papillary

muscles), rheumatic disease, endocarditis, connective tissue disorders.

• Clinical features Acute MR presents with signs of CCF. Chronic MR

causes exertional dyspnoea, orthopnoea. Displaced apex beat, soft S1,

pansystolic murmur—loudest at apex, radiating to axilla. AF in 80%.

• Diagnosis CXR shows cardiomegaly. Transthoracic echocardiogram

(TTE) diagnostic.

• Indications for surgery Acute MR, severe chronic MR.

• Prognosis Mortality of untreated severe MR is 5% per year. Operative

mortality is 2–3% for low risk cases.

Mitral stenosis

• Incidence Prevalence <1% in west, commoner in Asia and Africa.

• Aetiology Rheumatic heart disease.

• Clinical features Dyspnoea, bronchitis, haemoptysis, AF, left parasternal

heave, tapping apex beat, loud S1, rumbling mid-diastolic murmur at

apex.

• Diagnosis CXR shows splaying of carina (enlarged LA). Echo diagnostic.

• Indications for surgery MV area <1.0cm

(normal valve 3–4cm

• Prognosis Poor once symptoms of heart failure present.

Aortic stenosis

• Incidence Prevalence 1–2% in age over 65.

• Aetiology Calciﬁ c degeneration, bicuspid valve, rheumatic disease.

• Clinical features Triad of angina, syncope, dyspnoea. Sudden death.

Slow rising and low volume pulse, heaving apex beat, reversed

splitting S2, ejection systolic murmur loudest in aortic area radiating to

carotids.

• Diagnosis ECG shows LV hypertrophy, TTE diagnostic.

• Indications for surgery Symptomatic aortic stenosis.

• Prognosis Without surgery, 50% of patients with angina are dead in 5y,

50% with syncope are dead in 3y, and 50% with dyspnoea are dead in

2y. UK perioperative mortality is 3–5%.

Aortic regurgitation (AR)

• Incidence Less than 1% prevalence.

• Aetiology Rheumatoid, endocarditis, aortic dissection, Marfan’s and

other connective tissue disorders, calciﬁ c degeneration, trauma.

• Clinical features Acute AR (endocarditis) presents with signs of left

ventricular failure (LVF). Chronic AR often asymptomatic. Later,

orthopnoea, fatigue, dyspnoea. Signs of wide pulse pressure, collapsing

water hammer pulse, Quinke’s sign (nail bed pulsation), Corrigan’s sign

(visible neck pulsation), De Musset’s sign (head nodding), Durozier’

sign (femoral diastolic murmur), hyperdynamic displaced apex beat,

early diastolic murmur, Austin Flint mid-diastolic murmur due to

regurgitant stream hitting anterior MV cusp.

• Diagnosis CXR shows cardiomegaly. TTE diagnostic.

VALVULAR HEART DISEASE

629

• Indications for surgery Acute AR is a surgical emergency. Chronic AR is

operated on before the ejection fraction <55% or LV dilates >5.5cm.

• Prognosis Acute AR has poor prognosis. Chronic AR has good

outcome until failure occurs (50% 2y mortality). UK operative

mortality is 3–5%.

Options for valve surgery

MV repair (annuloplasty and valvuloplasty)

Results of repair of the aortic valve are unpredictable so it is usually

replaced. The MV is often repaired with good results.

Mechanical valves, e.g. St Jude mechanical, Carbomedics

These are made of ceramic. They can be mono- or bileaﬂ et. Ball-and-cage

like the Starr Edwards is no longer used.

• Advantages. Last forever so patient will not need future surgery.

• Disadvantages. Thromboembolic so patient must be warfarinized; patients

with bleeding diatheses, women of childbearing age, professional sports

players may not be suitable for long-term warfarinization.

Tissue valves (xenografts), e.g. Mosaic, Perimount

These are made of pig valves or cow or horse pericardium, usually sus-

pended on a metal frame covered by a cloth sewing ring.

• Advantages. Patient does not need to be warfarinized.

• Disadvantages. Tissue valves last for 10–15y in the aortic position and

6–10y in the mitral position, depending on the age of the patient;

younger patients (<65–70y) will often need a second operation.

Principles of valve surgery

Median sternotomy incision. MV may be approached via R thoracotomy.

Valve surgery must be carried out with CPB (see b p. 626).

Complications

Complications (see b p. 620) are more likely with advanced age, poor LV

function, renal failure, COPD, pulmonary hypertension, additional CABG.

• Death, 0–3% in low risk patients.

• Stroke, 5–10% (debris from removing calciﬁ ed valve, cannulating aorta).

• Re-sternotomy for bleeding or tamponade, 5%.

• Chest infection, AF, complete heart block requiring permanent

pacemaker insertion, wound infection, renal failure.

• Prosthetic endocarditis, failure, thrombosis, paravalvular leak.

Key revision points—anatomy of heart valves

• Aortic valve. Tricuspid valve, sitting within bulb of aortic root. Three

dilatations called sinuses of Valsalva. Left coronary sinus gives rise to

LMS, right gives rise to right coronary artery. Third known as non-

coronary sinus. AV node lies between right and non-coronary cusp.

Annulus (where leaﬂ ets attach to aorta) is coronal-shaped.

• MV. Bileaﬂ et valve, lying between LA and LV. Anterior leaﬂ et smaller

than posterior leaﬂ et. Leaﬂ ets held in place by chordae which attach

to two papillary muscles of LV. Annulus is oval-shaped.

CHAPTER 17 Cardiothoracic surgery

630

Cardiothoracic ICU

Commonly used terminology (see Table 17.1)

• Instead of referring to systolic and diastolic blood pressure, arterial

pressure is usually described using single ﬁ gure: the mean arterial

pressure (MAP) which is calculated by adding a third of the difference

between diastolic and systolic pressures to the diastolic pressure, e.g.

the MAP of a patient with a BP 120/60mmHg is 80mmHg.

• The MAP on its own does not adequately describe cardiac function; a

number of other parameters are frequently used.

• Cardiac output. The volume of blood ejected by the heart per minute.

• Stroke volume. The volume of blood ejected by the heart per beat.

• Cardiac output equals heart rate x stroke volume.

• Cardiac index. Is simply the cardiac output adjusted to take into account

the size of the patient and is a more accurate reﬂ ection of cardiac function.

Low cardiac ouput

Much of the initial care after cardiac surgery is aimed at preventing, recog-

nizing, and treating low cardiac output states, as these can lead to organ

failure, contribute to sepsis, and cause death, even in ‘straightforward’

patients. Low cardiac output can be deﬁ ned as a cardiac index <2.2mL/

min or evidence of end-organ hypoperfusion (e.g. lactic acidosis, oliguria,

low mixed venous O

saturations).

• Common causes of low cardiac output include:

Bleeding (occasionally other causes of hypovolaemia, e.g. polyuria).•

Tamponade.•

Arrhythmias.•

Acidosis, hypoxia.•

Preoperative cardiomyopathy.•

Ischaemia and stunning (myocardial recovery from surgery).•

• Hypotension can due to low cardiac output, but even a patient with a

high cardiac output could be hypotensive if they were very vasodilated

(most commonly due to SIRS (see b p. 138) or sepsis).

• Sometimes a number of problems may be going on at once and it is

easy to miss important problems so a systematic approach to assessing

post-operative cardiac surgery patients is vital.

General assessment of cardiac surgery patients

• Except in emergencies, usually you have time to evaluate every system.

• Review the history. What was the ventricular function preop? What

other comorbidities? What operation was done—any problems?

• Cardiovascular.

Look at the heart rate and rhythm and check the ECG for evidence •

of ischaemia (ST segment changes), comparing with preop.

Look at the MAP and CVP. A high CVP is always concerning, •

suggesting tamponade, ventricular failure, or respiratory problems.

Look at the cardiac output, lactate, mixed venous, and feel the •

patient’s extremities; a warm patient with good peripheral pulses

cannot have a low cardiac output. What is the SVR?

What inotropes, vasoconstrictors, and antihypertensives are on?•

CARDIOTHORACIC ICU

631

• Respiratory. Is the patient breathing spontaneously or ventilated?

Look at the O

saturations and a recent blood gas to check the PaO

PaCO

, and pH. What does the CXR look like?

• Renal. How much urine is the patient making (ideally >1mL/kg/h)?

What is the patient’s ﬂ uid balance (if it is negative or low, the patient

may be hypovolaemic; if it is very high, ﬂ uid overload is a concern).

Check electrolytes; abnormalities can cause arrhythmias.

• Bleeding. Should be less than 100cm

/h in the chest tubes, with steady

fall in the rate. Look at wound sites (remember groin + leg). Is the

haematocrit dropping? Check coagulation.

• Assess mental status and focal neurology, analgesia.

Table 17.1 Key haemodynamic formulae and normal values

Cardiac output = SV x HR

Cardiac index = CO/BSA

Stroke volume index = SV/BSA

Mean arterial pressure = DP + (SP – DP)/3

Systemic vascular resistance = ((MAP – CVP)/CO) x 80

Systemic vascular resistance index = SVR/BSA

Pulmonary vascular resistance = ((PAP – PAWP)/CO) x 80

Pulmonary vascular resistance index = PVR/BSA

Normal value

Cardiac output (CO) 4.5–8L/min

Stroke volume (SV) 60–100mL

Body surface area (BSA) 2–2.2m

Cardiac index (CI) 2.0–4.0L/min/m

Stroke volume index (SVI) 33–47mL/beat/m

Mean arterial pressure (MAP) 70–100mmHg

Diastolic pressure (DP) 60–80mmHg

Systolic pressure (SP) 110–150mmHg

Systemic vascular resistance (SVR) 800–1200dyne-s/cm

Central venous pressure (CVP) 6–12mmHg

Systemic vascular resistance index (SVRI) 400–600dyne-s/cm

Pulmonary vascular resistance (PVR) 50–250dyne-s/cm

Pulmonary artery pressure (PAP) 20–30mmHg

Pulmonary artery wedge pressure (PAWP) 8–14mmHg

Pulmonary vascular resistance index (PVRI) 20–125dyne-s/cm

CHAPTER 17 Cardiothoracic surgery

632

Lung cancer

Key facts

• Commonest cause of death from cancer in the UK.

• i Incidence in females (25% of cancer-related deaths in women).

Risk factors

• Cigarette smoking. Strongly positive association with cigarette smoking

(polycyclic aromatic hydrocarbons plus nicotine-related carcinogens).

• Radon exposure.

• Occupational factors. Asbestos, polycyclic aromatic hydrocarbons,

arsenic, nickel, silica, coal tar, aluminium production, coal gassiﬁ cation,

exposure to paints, chromium compounds, bischloromethal ether.

• Genetic predisposition and male sex.

Pathology

Bronchial carcinoma is classiﬁ ed as non-small cell or small cell.

Non-small cell lung cancer

Squamous cell carcinoma

• Twenty to thirty per cent of all lung cancers.

• Most common histological type in Europe.

• Often arising in large airways as an endobronchial mass (two-thirds).

• Slow-growing, late to metastasize.

Adenocarcinomas

• Thirty to ﬁ fty per cent of lung cancers. Incidence increasing.

• Usually peripheral tumours (approximately three-quarters).

• Moderate growth with early metastasis.

Large cell undifferentiated carcinoma:

• Fifteen per cent of all lung cancers.

• Peripheral location more common than central.

• Two subtypes. Clear cell carcinoma and giant cell carcinoma. Giant cell

tumours are uncommon, <1% of lung cancers. Very poor prognosis.

Histological subtypes

• Bronchioloalveolar tumours. Highly differentiated adenocarcinoma; 2.5%

all lung cancers.

• Adenosquamous carcinomas.

Small cell lung cancer

Neuroendocrine tumours

Approximately 20% of lung cancers. Aggressive tumours, not usually ame-

nable to surgical resection. Three subtypes—pure small cell (90%), mixed

small and large cell, combined small cell with areas of squamous or glan-

dular differentiation.

Clinical features

• Proximal tumours tend to produce symptoms of major airway

obstruction and irritation (haemoptysis, dyspnoea, cough, wheezing,

LUNG CANCER

633

stridor, hoarseness, Horner’s syndrome, SVC obstruction, post-

obstructive pneumonia, pleural effusion, Pancoast’s syndrome).

• Peripheral tumours are often asymptomatic or present with signs and

symptoms of pleural or chest wall invasion or pleural effusion (pleuritic

chest wall pain, progressive dyspnoea).

• May present with symptoms and signs of metastatic spread.

Neurological—headache, blurred vision, nausea, diplopia, decreased

consciousness, ataxia; bony pain and pathological fracture; liver and

abdominal pain, anorexia, jaundice, ascites, liver failure, hepatomegaly;

adrenal glands—symptoms of Addison’s disease.

• Paraneoplastic syndromes.

History and examination

• Ask about: history of tobacco smoking (pack years), asbestos exposure,

employment history, weight loss of greater than 5% body weight,

recent onset of joint pains, change in voice, chest wall pain, back pain.

• Look for: lymphadenopathy, evidence of signiﬁ cant weight loss, pleural

effusion, localized chest wall pain, clubbing, cutaneous lesions.

Principles of management

Non-small cell lung cancer is relatively resistant to chemotherapy. Curative

resection allows best chance of long-term survival. Surgery is normally

offered to all patients with stage I and stage II disease, along with speciﬁ c

patients with stage III disease (after chemoradiotherapy). Surgical princi-

ples of resection are:

• No spillage of cells from primary tumour during resection.

• Entire tumour must be resected by lobectomy or pneumonectomy

along with intrapulmonary lymph nodes; lesser resections proven to

have worse outcome, only considered in high risk patients.

• All accessible mediastinal lymph nodes should be excised or biopsied

to allow complete staging and plan for any adjuvant therapy.

• Frozen section analysis of resection margins to conﬁ rm appropriate

surgical resection and complete excision of primary tumour.

Survival

• Stage I, 5y survival 75%; stage II, 5y survival 40%; stage III, 5y survival

<30%.

• Post-operative mortality rate. Lobectomy, 2%; pneumonectomy, 6%.

Chemotherapy

To date, no proven beneﬁ t from adjuvant therapy in patients with surgi-

cally resectable and potentially curative disease.

Radiotherapy

• Radical. Used in patients unﬁ t or unwilling to undergo surgery. Also

used in those with bulky stage IV disease. Survival beneﬁ t in non-

surgical patients when combined with concomitant chemotherapy.

• Adjuvant. Also used as an adjunct to surgery or as palliation.

CHAPTER 17 Cardiothoracic surgery

634

Pleural effusion

Key facts

Abnormal amount of ﬂ uid within the pleural space. Pleural effusions may

be divided into transudate and exudates, according to Light’s criteria (see

Box 17.1, but the divide is not always clear.

Box 17.1 Light’s criteria

An exudates is characterized by:

• Pleural ﬂ uid:serum protein >0.5.

• Pleural ﬂ uid:serum LDH >0.6.

• Pleural ﬂ uid LDH >200IU.

Causes of transudates

• Cirrhosis of the liver.

• Nephrotic syndrome.

• Glomerulonephritis.

• CCF.

• Myxoedema.

• Sarcoidosis.

• Multiple PE.

Causes of exudates

• Neoplasms. Mesothelioma, metastatic disease, primary lung cancer.

• PE.

• Chylothorax.

• Haemothorax.

• Infectious diseases. Viral and bacterial infections, fungal and parasitic

infections, TB.

• Gastrointestinal disease. Pancreatitis, subphrenic abscess, intrahepatic

abscess, perforated oesophagus.

• Collagen vascular disease. Systemic lupus erythematosus, Wegener’s

granulomatosis, Sjogren’s syndrome.

• Drug-induced pleural disease.

• Mediterranean fever.

• Rheumatoid disease, sarcoidosis, yellow nail syndrome.

• Asbestos exposure, electrical burns, radiation therapy.

• Trapped lung, post-pericardiectomy.

• Uraemia, urinary tract obstruction.

• Post-myocardial syndrome, Meigs’ syndrome.

Clinical presentation

• Small effusions are often asymptomatic. Larger effusions cause cough,

chest pain, dyspnoea.

• Decreased ipsilateral chest expansion, dullness to percussion,

decreased breath sounds over the effusion on auscultation,

crepitations may be heard.

PLEURAL EFFUSION

635

Investigations

• Chest radiograph. Small effusions are demonstrated by blunting of the

costodiaphragmatic angles; larger effusions produce a ﬂ uid level with a

meniscus.

• Ultrasound scan. Useful for loculated effusions, helps to localize optimal

site for chest drainage.

• CT. Useful when looking at underlying lung and pleural lesions.

• Pleural aspiration cytology. May obtain diagnostic information, helpful

when planning treatment.

Management

If possible, treat the underlying cause. Simple pleural effusions due to ﬂ uid

overload may resolve with diuresis.

• Tube thoracostomy (see b p. 200).

• Chemical pleurodesis (tetracycline, blood, talc).

• Surgical abrasion pleurodesis.

• Surgical pleurectomy (open or thoracoscopic).

• Pleuroperitoneal shunt.

Complications

• Infection and empyema.

• Treatment failure with recurrence of pleural effusion.

• Damage to underlying lung parenchyma, leading to prolonged air leak

and bronchoalveolar air leak.

Empyema

This is an infected pleural ﬂ uid collection, commonly after pneumonia.

• Stage I. Acute exudative phase.

Typically occurs 2–5 days after a pneumonia.•

Accumulation of ﬂ uid with low cellular content and viscosity.•

Characterized by low WCC, LDH, and glucose, and a normal pH.•

Can be successfully treated with antibiotics only.•

• Stage II. Fibrinopurulent phase.

Typically occurs 5–14 days after a pneumonia.•

Turbid or purulent ﬂ uid with heavy ﬁ brin deposits.•

Appearance of simple loculations and septations.•

May have bacterial invasions and high numbers of PMNs and •

lymphocytes.

Characterized by low pH and glucose and increased LDH.•

Antibiotics and chest tube drainage is required, may need video-•

assisted thoracoscopic surgery (VATS) decortication.

• Stage III. Chronic organizing phase.

Lung trapping by collagen visceral and parietal pleural peel with •

ingrowth of ﬁ broblast and capillaries.

Antibiotics and aggressive decortications, generally by thoracotomy.•

Bacteriology.•

CHAPTER 17 Cardiothoracic surgery

636

Pneumothorax

Key facts

The presence of air in the pleural space with secondary lung collapse.

Aetiology

• Primary spontaneous pneumothorax.

• Secondary spontaneous pneumothorax.

• Post-traumatic and iatrogenic.

Primary spontaneous pneumothorax

Commonly seen in young tall male smokers. More common on the right

side. Less than 10% of cases are bilateral. Usually caused by rupture of

small subpleural blebs (collections of air <2cm). Usually found at the apex

of the upper lobe or the apical segment of the lower lobe. The rest of the

lung parenchyma is normal. May also be caused by rupture of bullae (large

air-ﬁ lled spaces).

Presentation

• Dyspnoea, chest pain, cough, tachypnoea.

• Ipsilateral decreased chest wall movement, hyperresonant hemithorax

to percussion, absent breath sounds on auscultation, pleural rub,

tachycardia.

Investigations

• PA chest radiograph usually diagnostic.

• CT scan gives an accurate estimate of size of pneumothorax and is

useful for assessment of remaining lung parenchyma and contralateral

lung.

Complications

• Tension pneumothorax.

• Pneumomediastinum.

• Haemopneumothorax.

• Recurrent pneumothorax.

Conservative management

• Observation (small, <20% pneumothorax).

• Needle aspiration.

• Tube thoracostomy 9 chemical pleurodesis.

Surgery

• Surgery is indicated in the following cases.

• First episode. Prolonged air leak, tension pneumothorax, haemothorax,

bilateral pneumothoraces, residual collapse of lung despite non-surgical

treatment, 100% pneumothorax, occupational hazard, pneumothorax

secondary to giant bulla, previous contralateral pneumonectomy.

• Recurrence of pneumothorax.

The aim is to resect the blebs or bullae and obliterate the pleural space

with adhesions, either using chemical or abrasion pleurodesis or parietal

PNEUMOTHORAX

637

pleurectomy (apical or full). It may be performed through a mini-thoracot-

omy, axillary incision, or thoracoscopically

Recurrence rate

• Less than 2% following surgical pleurectomy via mini-thoracotomy.

• Five per cent following thoracoscopic procedures.

• Five to ten per cent following chemical pleurodesis.

Secondary spontaneous pneumothorax

Causes

• Cystic ﬁ brosis, chronic obstructive airways disease (COAD) and other

bullous disease, asthma.

• Interstitial lung disease.

• Infections, including AIDS, mycobacterial, Pneumocystis carinii, bacterial,

parasitic, mycotic.

• Malignancy. Bronchogenic carcinoma, metastatic lung cancer (sarcoma

and lymphoma).

• Collagen diseases, catamenial, Ehlers–Danlos syndrome, histiocytosis

X, scleroderma, lymphangioleiomyomatosis, Marfan’s syndrome.

• Rupture of the oesophagus.

Cystic ﬁ brosis Pneumothorax found in 10% of patients. Remember these

patients are possible candidates for future lung transplantation when con-

sidering management options. Full parietal pleurectomy is a contraindica-

tion to lung transplantation.

COAD The most common cause of secondary pneumothorax. Age usually

>50y. Patients often have very little pulmonary reserve. They may not tol-

erate surgical management and single lung ventilation. Treatment options

are therefore tube thoracoscopy and chemical pleurodesis or long-term

tube thoracoscopy.

Infection Cavitating pulmonary lesions rupture into pleural space.

AIDS Usually secondary to Pneumocystis carinii and pneumonia. May be

presenting feature of AIDS. Most effective treatment is surgical.

Catamenial Age 20–30y. Incidence 3–6% of women. Occurs 2–3 days fol-

lowing onset of menstruation. Right side more commonly affected. Usually

small, presenting with dyspnoea and chest pain. Pathogenesis unclear.

Primary spontaneous pneumomediastinum

Uncommon. Males affected more frequently than females. Occurs follow-

ing exertion or increased intra-abdominal pressure. Commonly associated

with cocaine, marijuana, and crack cocaine usage. It is caused by rupture

of alveolar sacs with air tracking along the peribronchial and perivascular

spaces into the neck.

Presentation

• Sudden onset of chest pain, dyspnoea, dysphagia, cough.

• Subcutaneous emphysema over neck and chest wall, Hamman’s sign.

• Chest radiograph conﬁ rms diagnosis.

Management Non-operative, treat expectantly. Emergency surgical decom-

pression very rare.

CHAPTER 17 Cardiothoracic surgery

638

Mediastinal disease

Pericardial effusion and cardiac tamponade

Key facts

• Pericardial effusion is abnormal ﬂ uid in the pericardial space; there is

normally about 20mL of plasma ultraﬁ ltrate.

Pericardial effusion may be acute or chronic.•

Acute accumulation of ﬂ uid can cause cardiac tamponade which is a •

surgical emergency (see Box 17.2).

Effusions commonly results from pericarditis, CCF, metastatic •

spread to pericardium commonly from lung or breast malignancy,

lymphoma or leukaemia, autoimmune disorders, chronic hepatic

and renal failure, infections—speciﬁ cally HIV.

Clinical features

• Very dependent on the time course. Acute accumulation of a small

amount of ﬂ uid can cause life-threatening cardiac tamponade, whereas

slow accumulations of large volumes of ﬂ uid may be well tolerated.

• Chronic pericardial effusion may present with decreased exercise

tolerance, atypical chest pain, orthopnoea, and associated signs of

CCF, as well as features of cardiac tamponade.

Box 17.2 Cardiac tamponade

Suspect cardiac tamponade if the patient has a history of chest trauma.

• d BP, i JVP, (Beck’s triad is d BP, i JVP + mufﬂ ed heart sounds).

• Pulsus paradoxus (exaggeration of the normal d BP with

inspiration).

• Progressive tachycardia and dysrythmias, including SVT, VF, and

EMD.

• d Urine output.

• Excessive widening of the mediastinum on CXR.

• Echo may show clot in pericardium and collapse of RV in diastole.

• Equilibration of cardiac ﬁ lling pressures (at cardiac catheterization).

Management

• Emergency pericardiocentesis (b p. 204).

• Emergency thoracotomy or sternotomy.

• Aggressive ﬂ uid resuscitation is a temporizing measure.

Management

• Medical management includes diuretics and pericardiocentesis.

• Creating a hole in the pericardium or pericardial window so that ﬂ uid

can drain directly into the pleura via:

Thoracotomy or subxiphoid approach.•

Left VATS approach.•

MEDIASTINAL DISEASE

639

Thymoma

Key facts

• The thymus is a bilobar structure located in the anterior mediastinum

which contains lymphoid tissue. It is the location for maturation of

T-cells in early life.

• Thymoma may be benign or malignant.

• Thymectomy is the deﬁ nitive treatment for myasthenia gravis.

Clinical features

• Thymoma is usually asymptomatic in adults, whereas children often

present with thoracic outlet obstruction or upper airway compromise.

• Clinical features of myasthenia gravis are described on b p. 63.

• Thymoma appears as a smooth mass in the upper half of the CXR.

• CT shows enlarged thymus as well as lymph node involvement.

Treatment

• Thymectomy via a median sternotomy.

Key revision points—mediastinal anatomy

• Mediastinum is the space between the pleural sacs, below the

thoracic inlet and above the diaphragm.

• Superior mediastinum.

From thoracic inlet to the line from sternal angle to T4–5 space.•

Contains great vessels, trachea, oesophagus, phrenic nerves, •

vagus nerves, thoracic duct.

• Anterior mediastinum.

Anterior to pericardium.•

Contains sternopericardial ligaments, thymus, lymph nodes.•

• Middle mediastinum.

Contains pericardial cavity, heart, great vessels, phrenic nerves.•

• Posterior mediastinum.

Posterior to pericardium.•

Contains oesphagus, descending aorta, azygous veins, thoracic •

duct, lymph nodes.

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641

Peripheral vascular

disease

Acute limb ischaemia 642

Chronic upper limb ischaemia 644

Chronic lower limb ischaemia 647

Intermittent claudication 648

Critical limb ischaemia 650

Aneurysms 652

Ruptured abdominal aortic aneurysm 654

Vascular developmental abnormalities 656

Carotid disease 658

The diabetic foot 660

Amputations 662

Vasospastic disorders 664

Varicose veins 666

Deep venous thrombosis 668

Thrombolysis 670

Complications in vascular surgery 672

Chapter 18

CHAPTER 18 Peripheral vascular disease

642

Acute limb ischaemia

Deﬁ nition Any sudden decrease in limb perfusion that causes a \

potential threat to viability.

Prevalence One in 6000 of the population.

Causes and features

Acute thrombosis in a vessel with pre-existing atherosclerosis

(60% of cases)

• Predisposing factors are: dehydration, hypotension, malignancy,

polycythaemia, or inherited prothrombotic states.

• Features suggestive of thrombosis are:

Previous history of intermittent claudication.•

No obvious source of emboli (see below).•

Reduced or absent pulses in the contralateral limb.•

Emboli (30% of cases)

• Eighty per cent have a cardiac cause (AF, MI, ventricular aneurysm).

• Arterial aneurysms account for 10% of distal emboli and may be from

the aorto-iliac, femoral, popliteal, or subclavian arteries.

• Rarely, acute thrombosis in pre-existing atherosclerosis (see above)

will embolize.

• Commonest sites of impaction are the brachial, common femoral,

popliteal, and aortic bifurcation (‘saddle embolus’).

• Features suggestive of embolism are:

No previous history of claudication.•

Presence of AF or recent MI.•

Rare causes

• Aortic dissection, trauma, iatrogenic injury, peripheral aneurysm

(particularly popliteal), and intra-arterial drug use.

Symptoms and signs (any cause)

Six Ps:

• Pain, pallor, pulselessness, paraesthesia, paralysis, perishingly cold.

Complications

• Death (20%).

• Limb loss (40%). Severe ischaemia leads to irreversible tissue damage

within 6h.

Emergency management

Remember, patients will usually have coexisting coronary, cerebral, or

renal disease.

Resuscitation

• Give 100% O

• Get IV access and consider crystalloid ﬂ uid up to 1000mL if

dehydrated.

• Take blood for FBC, U&E, troponin, clotting, glucose, group and save.

• Request CXR and ECG (look for dysrhythmias).

ACUTE LIMB ISCHAEMIA

643

• Give opiate analgesia (5–10mg morphine IM).

• Call for senior help.

Establish degree of urgency

• Limb viability assessment. Involve senior help early.

Irreversible• . Fixed mottling of skin, petechial haemorrhages in skin,

woody hard muscles.

Immediate treatment needed• . Muscles tender to palpation/swollen,

loss of power, loss of sensation.

Prompt treatment after investigation• . Pulseless, pale, cold, reduced

capillary reﬁ ll.

Treatment of all patients

Give heparin (5000IU unfractionated heparin IV bolus and start an infu-

sion of 1000IU/h) if there are no contraindications (e.g. aortic dissection,

multiple trauma, head injury).

• Recheck APTT in 4–6h.

• Aim for a target time of 2–2.5 x the normal range.

Deﬁ nitive management

Depends on the severity of ischaemia (as above) and there are three

broad categories.

• Irreversible (non-salvageable limb). Amputation is inevitable and urgent

(but not emergency).

• Immediate treatment needed (to prevent the systemic complications

of muscle necrosis—hyperkalaemia, acidosis, acute renal failure, and

cardiac arrest). Consider amputation if ischaemic changes advanced

and life-threatening. Surgery to revascularize limb and perform

fasciotomies (to prevent or treat compartment syndrome).

• Prompt treatment after investigation. Continue heparinization.

Angiogram (stop heparin 4h before) or duplex/CT angio to determine

cause/location of disease. Thrombolysis, angioplasty, arterial surgery,

or combination. Limb may remain viable and functional after period of

heparinization alone.

Principles of embolectomy (see b p. 746)

CHAPTER 18 Peripheral vascular disease

644

Chronic upper limb ischaemia

Key facts

Upper limb ischaemia occurs less frequently than in the lower limb.

Causes

• Previous trauma or axillary irradiation, leading to arterial stenosis.

• Atherosclerosis. As in the lower limb.

• Buerger’s disease. Affects small vessels of the hands and feet, principally

in smokers, associated with Raynaud’s phenomenon, mostly young

men, but women may be affected, presents with digital gangrene/

ischaemia and may present with acute limb ischaemia in young people.

• Subclavian steal syndrome. Stenosis of subclavian artery proximal to

vertebral artery origin; arm claudication causes reversed ﬂ ow in the

vertebral artery/diminished hindbrain perfusion (dizziness/syncope).

• Takayasu’s arteritis. Uncommon in Europe; major arch/upper limb

vessels affected.

• Thoracic outlet syndrome (see Fig. 18.1).

Term used to cover a spectrum of symptoms resulting from the •

compression of the neurovascular bundle (NVB) as it leaves the

chest to enter the upper limb, in an area enclosed by the ﬁ rst rib,

clavicle, and the scalenus anterior muscle.

Presents as a variable combination of neural, arterial, and venous •

symptoms exarcebated by elevation of the limb, with shoulder,

arm, or head pain, and parasthesiae, weakness, or arm claudication.

Ninety-ﬁ ve per cent are neurogenic and 5% are arterial or venous

manifestations (arm engorgement, swelling with subclavian vein

stenosis or thrombosis—Paget–Schroetter syndrome).

Clinical features

• Weakness, cramp or exercise-related pain, and digital ischaemia/

gangrene.

• Examine bilateral upper limb pulses, BP in both arms (elevated/at

sides), wrist Doppler pressures.

• Roos test. Arm abducted to 90*, hands up with elbows braced

backward, chin elevated, hands serially clenched/opened for 1–2min,

positive if pain or weakness in hand or forearm.

• Adson’s test. Pulse diminishes or absent on elevation/abduction of arm

with head turned to contralateral side. Reliability improved by using in

conjunction with arterial duplex.

• Allen’s test. Assesses integrity of the palmar arch and dominant vessel

(radial or ulnar).

• Tinel’s test. For carpal tunnel syndrome.

Diagnosis and investigation

• Cervical spine and thoracic outlet X-rays, wrist Doppler pressures.

• CT/MRI to look for ﬁ brous bands/ribs and stenoses/occlusions.

• Arterial duplex or angiography to diagnose proximal arterial lesions.

• Duplex or venography for subclavian vein stenosis or occlusion.

CHRONIC UPPER LIMB ISCHAEMIA

645

Treatment

Thoracic outlet syndrome

• Mild neurogenic problem. Simple analgesia, physiotherapy, and advice

on risk factors.

• Surgery (supraclavicular or axillary approach) has good results for

those with arterial or venous symptoms/complications.

• Excision of the ﬁ rst rib/band will improve symptoms in over 90%.

• Careful evaluation is needed prior to surgery for pure neurological

symptoms, e.g. nerve conduction studies.

Cervical sympathectomy in upper limb disease

Indications

• Palmar hyperhidrosis (less effective and infrequently used for axillary).

• Buerger’s disease/small vessel disease with digital ischaemia.

Approach

• Aim is to de-innervate the second and third thoracic ganglia.

• Approach is almost universally thoracoscopic and open approaches

have been largely abandoned.

Complications

• Horner’s syndrome.

• Pneumothorax.

• Haemorrhage.

• Compensatory truncal hyperhidrosis.

• Frey’s syndrome (gustatory sweating).

Axillary hyperhidrosis Treatment of choice is now subcutaneous botulinum

toxin A injections to the axillary sweat glands, repeated as necessary, often

6-monthly.

Key revision points—anatomy of thoracic outlet

Several structures can compress the neurovascular structures.

• Cervical rib. Articulates with C7.

• Scaleneus anterior. Aberrant anatomy or scarring/swelling from

trauma.

• Costoclavicular ligament.

CHAPTER 18 Peripheral vascular disease

646

Scalenus medius

Groove for plexus

and subclavian artery

Groove for

subclavian vein

Tubercle for

scalenus anterior

Clavicle

Brachial plexus

Fig. 18.1 Structures involved in thoracic outlet syndrome.

CHRONIC LOWER LIMB ISCHAEMIA

647

Chronic lower limb ischaemia

• Atherosclerosis is a generalized disease and has a predilection for the

coronary, cerebral, and peripheral circulations (see b p. 152).

• In the lower limb, it may affect the aorto-iliac, femoral or popliteal, and

calf vessel levels singly or in combinations (see Fig. 18.2).

• Single-level disease usually results in intermittent claudication (IC) and

two-level disease in critical limb ischaemia (CLI).

The Fontaine classiﬁ cation of lower limb ischaemia

• I. Asymptomatic.

• II. Intermittent claudication.

• III. Rest pain.

• IV. Ulcers/gangrene.

Grades III and IV = critical limb ischaemia.

inguinal ligament

common femoral

superficial femoral

profunda femoris

popliteal

anterior tibial

posterior tibial

peroneal

dorsalis pedis

Fig. 18.2 The arterial supply to the leg. Reproduced with permission from

Longmore, M. et al. (2007). Oxford Handbook of Clinical Medicine, 7th edn.

Oxford University Press, Oxford.

CHAPTER 18 Peripheral vascular disease

648

Intermittent claudication

Key facts

• Affects 4% of people over 55y, mostly men.

• One-third of patients improve, one-third remain stable, and one-third

deteriorate.

• Four per cent require an intervention and 2% result in amputation.

• Risk factors and association. See Table 18.1.

Clinical features

• Muscular pain on exercise of the affected limb, worsened with

increasing level of exercise, relieved by rest; most commonly, calf.

• Differential diagnosis.

Spinal stenosis. Neurogenic pain caused by drop in distal cauda •

equina blood ﬂ ow due to exercise, leading to neurogenic pain.

Osteoarthritis, especially hip joint.•

Nerve root entrapment, e.g. sciatica.•

Popliteal artery entrapment (rare). Due to compression of popliteal •

artery over medial head of gastrocnemius during exercise. Distal

pulses reduced/absent on plantar ﬂ exion alone. Treated by surgical

release after MRI deﬁ nes anatomy.

Diagnosis and investigation

• Diagnosis is mostly clinical and not based on imaging.

• Post-exercise fall in ankle–brachial pressure index (ABPI) can be diagnostic.

• Measure BP, serum glucose, cholesterol, FBC.

• Imaging only if treatment by intervention planned. Angiography

(usually digital subtraction (DSA), may be CT angiogram, or magnetic

resonance angiogram (MRA).

• Abdominal ultrasound if aneurysm disease suspected.

Treatment

Risk factor modiﬁ cation

• Forty per cent of peripheral vascular disease (PVD) patients have

signiﬁ cant coronary or cerebral arterial disease; the mainstay of

treatment is aggressive risk factor modiﬁ cation. Stop smoking, oral

statin treatment, increased exercise, control of BP and serum glucose,

antiplatelet therapy.

Table 18.1 Intermittent claudication—risk factors and associations

Risk factors Associations

Hypertension Obesity

Hyperipidaemia Diet

Diabetes mellitus Sedentary lifestyle

Tobacco smoking Gender

Positive family history Occupation

INTERMITTENT CLAUDICATION

649

Endovascular treatment

• Angioplasty ± stent. Excellent results in the aorto-iliac segment (>90%

success) and good results in the superﬁ cial femoral segment (90%

success and 60–80% patency at 2y).

• Usually performed under LA percutaneously as a day case.

• Rarely performed for claudication in the popliteal and tibial segments

due to high risk of occlusion.

• Most useful in short stenoses/occlusions.

Surgery

• Used for short distance claudication, severe lifestyle limitation, and

failure/unsuitability of endovascular treatment in the aorto-iliac

segments.

• Procedures available are:

Aortobifemoral graft• . 5y patency of >90%, but carries 5–8% mortality

and a risk of impotence. Used for younger patients.

Femorofemoral cross-over bypass graft• . Used for isolated unilateral

iliac disease; 90% 1y patency.

Common femoral endarterectomy• . Used for isolated common

femoral disease; good results and a low complication rate.

Femoro-above knee popliteal bypass• . 80% 2y patency with vein or

prosthetic graft.

Femoro-below knee popliteal bypass• . 70% 2y patency with vein graft.

Femoro-distal (below knee) bypass• . 5y patency <35%; usually

reserved only for critical ischaemia.

• Most commonly used for long stenoses/occlusions and combined with

endovascular treatment.

CHAPTER 18 Peripheral vascular disease

650

Critical limb ischaemia

Key facts

• Often progresses to limb loss or progressive tissue loss if it remains

untreated.

• High risk condition, often occuring in high risk patients with multiple

comorbidities.

Clinical features

• European consensus statement deﬁ nes critical ischaemia if there is:

Rest pain for >2 weeks not relieved by simple analgesia; or•

Doppler ankle pressure <50mmHg (toe pressures <30mmHg if •

diabetic).

Tissue necrosis (i.e the presence of gangrene or ulceration).•

• Rest pain typically worsens at night and during elevation of the limb

and is relieved by hanging the limb dependent.

• Arterial ulceration cannot reliably be distinguished from other causes.

Diagnosis and investigation

Diagnosis is clinical. Investigation should aim to:

• Identify and treat risk factors. Treat BP, stop smoking, optimize

diabetes control, reduce cholesterol (statins by choice), use

antiplatelet agent (aspirin/clopidogrel by choice).

• Identify location and severity of all arterial stenoses involved. May

include:

Colour duplex Doppler ultrasound. Zero risk, non-interventional, •

best for proximal vessels (iliac, common femoral).

Angiography (usually DSA). Interventional, carries risk of arterial •

injury and renal toxicity of contrast, good for popliteal and distal

vessel assessment.

MRA. Low risk.•

CT angiography. Low risk (radiation and contrast).•

Treatment

• All efforts should be made to revascularize if possible (providing the

general condition of the patient allows it).

• General principle is to deal with most proximal disease ﬁ rst and

progress to distal disease only if critical ischaemia still present.

Medical care

• Nursing care.

• Analgesia. Opiates (e.g. Oramorph

, MST Continus

Endovascular treatments

Angioplasty 9 stent proximal disease (aorto-iliac, common femoral, super-

ﬁ cial femoral). Less successful in popliteal disease and distal disease.

Surgery

• Femoro-distal (e.g. to popliteal, tibioperoneal trunk, or anterior or

posterior tibial arteries).

CRITICAL LIMB ISCHAEMIA

651

• Aorto-iliac bypass (‘anatomical’) or axillo-femoral or femoro-femoral

(‘extra-anatomical’) bypass.

• Amputation.

Usually below knee or above knee in smoking-related •

atherosclerosis.

Distal amputations (toe, forefoot, ankle) may be appropriate in •

diabetic disease.

• There is little evidence of beneﬁ t from treatment with prostacyclin or

sympathectomy (surgical or chemical).

CHAPTER 18 Peripheral vascular disease

652

Aneurysms

Key facts

• An aneurysm is an abnormal localized dilatation of a blood vessel.

• It may be associated with structural abnormalities of collagen and

elastin in the vessel wall.

• Prevalence of abdominal aortic aneurysm, 4% of men aged 65,

increasing with age.

• ♂:♀, 9:1.

• Associated with hypertension, tobacco smoking, and family history (all

associated with atherosclerosis).

Pathological features

Types

• True aneurysms. Contain all three layers of artery wall. May be fusiform

(symmetrical dilatation) or saccular. Underlying cause is usually

atherosclerosis-related, but may be associated with infective causes

(‘mycotic aneurysm’), Marfan’s and Ehlers–Danlos syndromes (collagen

and elastin abnormalities).

• False aneurysms. Do not contain all three layers of vessel wall and

often only lined by surrounding connective tissue or adventitia. Usually

secondary to penetrating trauma, including iatrogenic injury (e.g.

femoral cannulation, surgery).

Sites

Thoracic, abdominal, and peripheral (iliac, femoral, popliteal, visceral,

carotid or subclavian), cerebral ‘berry’ aneurysms.

Clinical features

Thoraco-abdominal

• Crawford classiﬁ cation types I–IV (dependent on involvement of

descending thoracic/abdominal aorta); managed in specialist centres.

• Often asymptomatic.

• Different clinical features to thoracic aortic dissection (acute chest pain

(angina/MI), back pain, acute aortic regurgitation, or cardiac failure).

• Diagnosed by widened mediastinum on CXR or on CT/MRI.

• Rupture has high mortality and rare without prior symptoms.

• Elective surgery has up to 20% mortality and risk of paraplegia; 10%

require dialysis after surgery.

• Endovascular stenting is a potential future treatment of choice due to

high surgical risks.

Abdominal aortic

• Ninety-ﬁ ve per cent start below the origin of the renal arteries

(‘infrarenal’).

• Fifteen per cent extend down to involve the origins of the common

iliac arteries.

• Associated with other peripheral aneurysm (e.g. popliteal).

• Five to ten per cent are ‘inﬂ ammatory’ (have gross connective tissue

changes around the aortic wall in the retroperitoneum).

ANEURYSMS

653

• Most are asymptomatic; 40% are detected incidentally (clinical

examination, ultrasound, AXR, IVU).

• A national ultrasound screening programme exists.

• Six-monthly scans for surveillance if size 4–5.4cm (1% per year risk of

rupture).

• Mycotic aneurysms are rare, but have a high rupture rate.

• Risk of rupture and mortality increases with increasing aneurysm

diameter.

• Surgical intervention is indicated for:

AP diameter >5.5cm in ﬁ t individuals.•

Rapid increase in diameter on serial surveillance scans, e.g. >0.5cm •

in 6 months.

Peripheral aneurysms

• Iliac. Two per cent of patients >70y. Mostly common iliac and

asymptomatic. Rarely palpable and rupture may be missed as acute

abdomen or renal colic.

• Femoral. Mostly asymptomatic pulsatile groin swelling or pain. May

present with lower limb ischaemia.

• Popliteal. Many asymptomatic and over half are bilateral. May present

with acute limb ischaemia. Aneurysm thrombosis is associated

with high risk of limb loss. Prophylactic bypass probably best for

symptomatic, embolizing aneurysms.

• Carotid. Rare and may be bilateral. May present with neurological or

pressure symptoms. May present simply as a pulsatile neck swelling.

Rarely presents with rupture. Diagnosis with duplex scan.

• Visceral. Account for 1% of all aneurysms. Generally small and

asymptomatic until rupture. Splenic artery most common followed by

hepatic and renal arteries.

Treatment of abdominal aortic aneurysm (AAA)

Aim is to prevent death as 80% of patients with ruptured AAA will die.

Elective surgery

• Open repair by inlay synthetic graft. May be ‘straight’ if aneurysm

conﬁ ned to aorta or ‘bifurcated/trouser’ if there are common iliac

aneurysms as well; 3–7% operative mortality.

• Laparoscopic repair may offer earlier return to normal function and

reduced hospital stay.

Endovascular repairs

• Endovascular aneurysm repair (EVAR) with a stent graft. Percutaneous

insertion of covered stent to exclude the aneurysmal segment from

arterial pressure.

• Advantages. Percutaneous technique, reduced early mortality.

• Disadvantages. High early re-intervention rate, requires lifelong

surveillance, no long-term survival beneﬁ ts over open repair shown to

date.

CHAPTER 18 Peripheral vascular disease

654

Ruptured abdominal aortic aneurysm

Causes and features

• Associated with hypertension (especially uncontrolled), smoking, family

history, and atherosclerosis.

• Rare in patients aged <55.

• Risk of rupture relates to maximum AP diameter.

Less than 0.5% per year, <4.0cm diameter.•

One per cent per year, 4–5.5cm.•

Over 3% per year, >5.5cm.•

• Patients with a ‘contained leak’ with initial haemodynamic stability

proceed rapidly to rupture.

• Less than 50% of patients with a ruptured AAA reach hospital alive and

the overall mortality of the condition may be as high as 75–95%.

• Outcome is best in the hands of an experienced vascular team

(vascular surgeon, vascular anaesthetist, theatre nursing team,

two assistants, and ITU) and a rapid transfer from the emergency

department to theatre.

Symptoms

• Severe/sudden onset epigastric and/or back/loin pain.

• History of sudden ‘collapse’, often with transient hypotension.

• May have history of AAA under surveillance.

Signs

• Cardinal signs are unexplained rapid onset hypotension, pain, and

sweating.

• A pulsatile abdominal mass is not always easy to feel (due to pain and

abdominal wall rigidity).

Emergency management

Resuscitation

• If the diagnosis is seriously considered, call for senior surgical

assistance immediately. Transfer to theatre may be required even as

resuscitation continues.

• ‘Permissive hypotension’. Do not ‘chase’ a ‘normal’ systolic BP to

reduce the risk of worsening the rupture.

• If the patient is critically hypotensive, consider calling a peri-arrest

cardiac emergency.

• IV access via two large bore cannulae, catheterize, cross-match blood

(10U), order FFP and platelets.

• High ﬂ ow O

via non-rebreathing mask.

• Give modest doses of analgesia (morphine 5–10mg).

• Alert anaesthetist, theatres, ITU.

• Witnessed verbal consent for surgery may be the only practical way

and is acceptable here.

Establish a diagnosis

• If patient stable and diagnosis uncertain, request contrast CT.

• If going to CT, ensure blood is sent for cross-match and IV access has

been established before going.

RUPTURED ABDOMINAL AORTIC ANEURYSM

655

Early management

Ruptures fall into three groups:

• Considered not a candidate for surgery. For analgesia and palliative

care. Mortality approximates to 100%. The decision is based on age,

physiological status, comorbidities, expressed patient preference,

family wishes.

• Free rupture with collapse and critical condition. All candidates for

surgery require emergency transfer to theatre.

• Contained leak. May be stable after initial presentation, but likely to

progress to free or complicated rupture unless urgently surgically

treated.

Principles of surgery for rupture

• Go straight to the operating table, not anaesthetic room.

• If unstable, muscle relaxation/anaesthesia is not started until patient is

prepared/draped and surgical team ready to go.

• If haemodynamically stable, central line and arterial line sited while

waiting for blood to arrive and surgical team in theatre.

• Give antibiotic prophylaxis.

• Proximal neck is controlled rapidly with aortic cross-clamping. Full

ﬂ uid expansion with blood can now safely begin.

• Distal outﬂ ow of aneurysm is controlled.

• The sac is opened and lumbar vessels and inferior mesenteric artery

are oversewn to control back bleeding.

• Dacron/Gore-Tex

graft is sewn to proximal neck and tested.

• Distal anastomosis performed next and tested.

• Sequential reperfusion is undertaken accompanied with volume

expansion to minimize post-declamping shock. Ideally the systolic BP

should be maintained over 85mmHg.

• Blood products at this stage may be required to correct coagulopathy

(e.g. platelets and FFP).

• The sac is closed over the graft to reduce the risk of aortoenteric

ﬁ stula.

Post-operative care

• Transfer to ITU.

• Normalize core temperature.

• Correct clotting and maintain Hb >10g/dL.

• Adequate analgesia and accurate ﬂ uid balance.

• Attention to cardiac/renal/pulmonary dysfunction.

Complications

• Death (overall up to 50% of operated cases).

• MI.

• Renal failure.

• Lower limb embolism.

• Gut ischaemia/infarction.

• Abdominal compartment syndrome.

CHAPTER 18 Peripheral vascular disease

656

Vascular developmental abnormalities

Key facts

Classiﬁ ed broadly into two principal groups.

Vascular tumours (e.g. haemangiomas)

• All congenital or idiopathic.

• Mostly sporadic, but may rarely be part of a familial syndrome (e.g. von

Hippel–Lindau).

• Pulmonary haemangiomas, commonly seen in hereditary haemorrhagic

telangiectasia, are linked to a deﬁ ciency in endoglin (endothelial

growth factor).

Vascular malformations

• Vascular malformations are histologically categorized as capillary,

venous, lymphatic, arteriovenous malformations (AVM), or mixed-in

type, depending on the predominant vessel type affected and

subdivided into low or high ﬂ ow (AVMs) varieties.

• AVMs have three main causes.

Congenital.• Origin/cause unknown.

Traumatic.• May follow relatively minor trauma.

Iatrogenic.• Following a variety of surgical/interventional procedures.

Clinical features

• Congenital AVMs are usually evident at birth and the superﬁ cial lesion

may only represent a part of the overall abnormality.

• Symptoms are dependent on the size, site, and type of vessel affected,

and whether the AVMs are high or low ﬂ ow.

Low ﬂ ow

• May result in considerable cosmetic deformity if large (e.g. Klippel–

Trenaunay—port wine stain + ipsilateral hypertrophy, usually limb).

• Pain may be a feature due to spontaneous thrombosis of some/all of

the venous elements.

• Typically, the symptoms are worse after exercise when blood ﬂ ow is

maximized.

High ﬂ ow

• These are largely asymptomatic, but there may be a detectable venous

hum or bruit.

• They may result in local hyperhidrosis, heat, ulceration, or present

with profuse bleeding.

• May lead to high output cardiac failure if large and untreated.

Diagnosis and investigation

• Colour duplex. Diagnoses lesion, can estimate ﬂ ow rate, and is useful

for follow-up monitoring.

• MRI has replaced CT as the best imaging modality and gives both the

extent and related anatomy for complex lesions.

• Angiography is reserved for high ﬂ ow lesions when suitability for

embolization or surgery is being assessed.

VASCULAR DEVELOPMENTAL ABNORMALITIES

657

Treatment

• Largely conservative.

Congenital AVMs frequently reduce in size with growth of the child •

and treatment is rarely easy with recurrence common.

Adult AVMs only require treatment for complications or •

occasionally cosmesis.

Interventional radiology

• Percutaneous or intravascular embolization using wire coils or

sclerosant under radiological guidance.

• Risks include:

Those of percutaneous puncture (infection, false aneurysm •

formation, inadvertent embolization of adjacent vessels).

Tissue necrosis after successful lesion embolization.•

Post-embolization syndrome• may occur with pain at the site of

embolization, accompanied by malaise, fever and leucocytosis,

hyperkalaemia. This usually settles with symptomatic treatment in

24–48h. Due to tissue necrosis and cytokine release.

Surgery

• Small lesions may be excised completely.

• Obliteration of small superﬁ cial venous malformations can be

undertaken by direct puncture and injecting a sclerosant such as STD

(sodium tetradecyl sulphate).

• Open surgery is mostly conﬁ ned to high ﬂ ow lesions after

preoperative embolization.

CHAPTER 18 Peripheral vascular disease

658

Carotid disease

Key facts

• A cerebrovascular accident (CVA) or ‘stroke’ is ‘a rapidly developing

neurological deﬁ cit lasting >24h’.

• A transient ischaemic attack (TIA) is ‘an acute episode of focal

(cerebral or visual) neurological deﬁ cit which resolves within 24h’.

• CVA is the third most common cause of death in UK after coronary

heart disease and cancer.

• Incidence—stroke 200 per 100 000, TIA 35 per 100 000.

• Approximately 150 000 CVAs occur in the UK per year and

approximately 15% of these are due to atherosclerotic disease of the

carotid arteries.

Pathological features

CVA or TIA arises from disease at the origin of the internal carotid artery

(ICA) and may be due to platelet or atheromatous embolization from the

surface of the plaque (usually after an acute rupture or opening of the

plaque surface).

Clinical features

• Several clinical variants of a classic CVA are recognized.

Stroke in evolution.• Progressive neurological deﬁ cit occurring over

hours/days.

Completed stroke.• The stable end result of an acute stroke lasting

over 24h.

Crescendo TIA.• Rapidly recurring TIA with increasing frequency,

suggesting an unstable plaque with ongoing platelet aggregation and

small emboli.

• Carotid bruits are detectable in over 10% of patients aged >60, poor

correlation with the degree of stenosis/risk of CVA, and may not arise

from the ICA.

• Patients with a signiﬁ cant stenosis may have no audible bruit.

Neurological features

Depend on the territory supplied by the vessel affected by the embolism,

the degree of collateral circulation to that territory, and the size/resolu-

tion of the embolism.

• Amaurosis fugax. Transient monocular visual loss (described as a

curtain coming down across the eye), lasting for a few seconds

or minutes—central retinal artery (occlusion can lead to permanent

blindness).

• Internal capsular stroke. Dense hemiplegia, usually including the

face—striate branches of the middle cerebral artery.

• Hemianopia. Loss of vision in one half of the visual ﬁ eld.

Prognosis of patients with TIA

Eighty per cent of TIAs are in the carotid territory. The risk of stroke fol-

lowing a TIA is around 18% in the ﬁ rst year, 10% in the ﬁ rst 90 days, and

4% in the ﬁ rst 24h.

CAROTID DISEASE

659

Diagnosis and investigation

• Colour duplex scan. All patients with TIA/CVA within last 6 months.

• MRA or CT angiography (CTA). Used when duplex is inconclusive or

difﬁ cult due to calciﬁ ed vessels.

Treatment

Medical management

• Best medical therapy is an antiplatelet agent (e.g. aspirin,

dipyridamole), smoking cessation, optimization of BP and diabetes

control, and a statin (e.g. simvastatin 40mg daily) for cholesterol

lowering, irrespective of baseline cholesterol.

• Acute thrombolysis in CT-proven ischaemia indicated in specialized

units if detected early.

Surgery

Carotid endarterectomy (CEA)

• Offered to patients with symptomatic >70% stenosis of the ICA or

>50% stenosis if recent TIA/CVA and high ABCD2 risk score (age, BP,

clinical, duration, diabetes).

• Urgent CEA within 2 weeks now considered for all patients presenting

of acute TIA/CVA.

ECST (Europe) and NASCET (North America) trials demonstrated •

d CVA in the ﬁ rst year following CEA from 18% with best medical

therapy to 3–5% with surgery and best medical therapy. No

signiﬁ cant beneﬁ t to symptomatic patients with <70% stenoses.

ACST (UK) and ACAS (North American) trials have shown some •

beneﬁ t of CEA to asymptomatic patients with >70% stenosis, but

the numbers needed to prevent one stroke are 22 patients treated.

• Technical details.

Increasingly undertaken under local (LA) block.•

Incision anterior to sternomastoid.•

Carotid vessels controlled after dissection.•

IV heparin prior to trial clamp (if patient awake).•

Cerebral circulation protected in 10% of awake patients with a •

shunt (Pruitt/Javed) (without an intact circle of Willis, there is not

enough collateral blood ﬂ ow from the contralateral carotid).

Shunt in GA patients, depending on surgeon preference and •

cerebral monitoring (stump pressure of 50mmHg or transcranial

Doppler monitoring of middle cerebral artery blood ﬂ ow).

Patch closure of the arteriotomy common. Eversion •

endarterectomy technique may avoid the need for a patch.

Post-operatively, close monitoring of BP and neurological state.•

• Complications.

Death or major disabling stroke, 1–2%.•

Minor stroke with recovery, 3–6%.•

MI.•

Wound haematoma.•

Damage to hypoglossal nerve (weak tongue, moves to side of •

damaged nerve), glossopharyngeal nerve (difﬁ culty swallowing),

facial numbness.

CHAPTER 18 Peripheral vascular disease

660

The diabetic foot

Key facts

Foot ulceration is the commonest endpoint of diabetic vascular complica-

tions. Diabetics are 15 times more likely to undergo major lower limb

amputation than non-diabetics.

Causes and features

• Key features of the diabetic foot are:

Ulceration.•

Infection.•

Sensory neuropathy.•

Failure to heal trivial injuries.•

Ulceration

• Risk factors for ulceration include:

Previous ulceration.•

Neuropathy (stocking distribution loss and ‘Charcot’s joints’).•

Peripheral arterial disease (more commonly affects the below-knee •

calf vessels (trifurcation) which are frequently highly calciﬁ ed, giving

rise to falsely elevated ABPI readings or incompressible vessels).

Altered foot shape.•

Callus, indicating high foot pressures.•

Visual impairment.•

Living alone.•

Renal impairment.•

• Secondary to either large vessel or small vessel arterial occlusive

disease or neuropathy or a combination of both.

• Forty-ﬁ ve per cent of diabetic foot ulceration are purely neuropathic

in origin, 10% are purely ischaemic, 45% are of mixed neuro-ischaemic

origin.

Diagnosis and investigation

Pure neuropathic ulceration

• Warm foot with palpable pulses.

• Evidence of sensory loss, leading to unrecognized repeated local

trauma.

• Normal or high duplex ﬂ ows.

Ischaemic/neuro-ischaemic ulceration

• Foot may be cool.

• Absent pulses.

• Ulcers commonly on toes, heel, or metatarsal head.

• Secondary infection may be present with minimal pus and mild

surrounding cellulitis.

• ABPIs may be misleadingly high.

• Duplex ultrasound assessment.

• Angiography for suspected critical ischaemia.

THE DIABETIC FOOT

661

Treatment

Prophylactic management

• Best undertaken in a specialist diabetes foot clinic with multidisciplinary

input.

• Regular foot inspection for evidence of pressure/ulceration.

• Always use appropriate wide-ﬁ tting footwear.

• Attention to nail care with regular chiropody.

• Chiropodist debridement of pressure sites/callus.

• Keep away from heat and do not walk barefoot.

Established ischaemic ulceration

• Treat local or systemic infection.

Broad-spectrum antibiotics (local guidelines).•

Debride obviously dead tissue, including digital amputation.•

Drain collections of pus.•

Take plain X-ray for signs of underlying osteomyelitis.•

• Consider revascularization if appropriate.

Angioplasty.•

Femoro-distal bypass grafts.•

• Consider amputation for failed medical or surgical treatment.

Often possible to do limited distal amputations (e.g. •

transmetatarsal).

May be progressive if disease spreads.•

The diabetic surgical patient

• Renal disease requires close monitoring of hydration, BP, and renal

function.

• Metformin needs to be stopped for 48h before angiography to avoid

lactic acidosis.

• Insulin-dependent diabetics starved for any reason require a sliding

scale.

• Avoid pressure sores if immobile for any long period with foam leg

troughs, heel elevation, and prompt attention to any skin breaks.

CHAPTER 18 Peripheral vascular disease

662

Amputations

Key facts

• Ninety per cent for arterial disease, 10% for trauma, and rarely for

venous ulceration, tumour, or deformity.

• Amputation may be a very beneﬁ cial treatment for pain, to restore

mobility or occasionally, to save a life in trauma or acute limb

ischaemia.

• Amputation for arterial disease carries a signiﬁ cant mortality and a

major morbidity.

• The surgical aim is to achieve a healthy stump for a suitable prosthesis

and successful rehabilitation.

• Amputees are at the centre of a large team, including surgeons, nurses,

physiotherapists, prosthetists, occupational therapists, pain team,

counsellors, and the family.

Causes and features

• ‘Dangerous’: life-saving.

Spreading gangrene, e.g. necrotizing fasciitis, gas gangrene.•

Extensive tissue necrosis following burns or trauma.•

Uncontrolled sepsis (diabetic foot) with systemic infection.•

Primary malignant limb tumours not suitable for local excision.•

• ‘Dead’: vascular events.

Critical limb ischaemia with unreconstructable disease.•

Extensive tissue necrosis.•

• ‘Damn nuisance’: neuropathic or deformed. Failed, complicated

orthopedic surgery with severely impaired gait.

Level

• The level is chosen according to:

Lowest level where tissue is viable for healing.•

Include as many working major joints as possible to improve •

function.

Ideally sited between large joints to allow prosthesis ﬁ tting.•

• Above knee. Most will heal, but only young and ﬁ t achieve walking with

a prosthesis.

• Through knee. Fewer heal and some achieve walking.

• Below knee. About two-thirds heal and more achieve walking than with

above-knee amputations.

Types

• Hip disarticulation. Rarely needed, but indicated for trauma or tissue

necrosis above high thigh.

• Above knee amputation (AKA). Bone transected at junction of upper

two-thirds and lower third of femur (12–15cm above knee joint),

common in end-stage vascular disease.

• Gritti–Stokes (supracondylar AKA). Increasingly popular for bilateral

amputees as creates a long stump; especially good for wheelchair-

dependent patients.

AMPUTATIONS

663

• Through-knee amputation (TKA). Produces a wide stump, which is

difﬁ cult for prosthesis ﬁ t.

• Below-knee amputation (BKA). Weight bearing on patellar tendon with

good prosthetic ﬁ t; good knee function essential.

Skew ﬂ ap is arguably best technique as it produces a better stump •

for prosthetic ﬁ tting.

Alternative is a posterior ﬂ ap, which is bulkier and leads to longer •

time to mobilization.

The tibia is transected 8–10cm distal to the tibial tuberosity and the •

ﬁ bula 2cm more proximally.

Post-operative mobilization is early and temporary limb aids can be •

used when the wound is sound.

• Symes (ankle). Few indications for this in vascular patients and best

avoided other than in trauma or diabetics. Prosthetic ﬁ tting is difﬁ cult

and a good BKA is better for walking.

• Transmetatarsal. Useful in diabetics or when several toes are

gangrenous.

• Ray. Used when digital gangrene extends to forefoot, especially useful

for diabetics when infection tracks up tendon sheath.

• Digital. Usually only for diabetic disease or local trauma.

Treatment

Preoperative care

• Restore Hb levels and correct ﬂ uid and electrolyte balance.

• Ensure good diabetes control.

• Cross-match 2U of blood.

• Adequate analgesia (epidural may reduce phantom pain).

• ECG and CXR.

• Optimize cardiac function.

• Prophylactic antibiotics to include gentamicin.

• Counselling if available.

Post-operative care

• Pain control with epidural 9 PCA.

• Regular physiotherapy to prevent muscle atrophy or contractures as

well as upper limb exercises.

• Early rehabilitation on temporary limb aid.

• Own wheelchair to aid early mobilization.

Complications

• Infection.

• Non-healing of stump.

• Progression of underlying disease and higher level amputation.

• Phantom limb pain. Due to hypersensitivity in divided nerves, can be

helped with gabapentin, amitryptyline, or carbamazepine.

• Failed mobilization. Early regular analgesia and physiotherapy are

important.

• Perioperative cardiovascular events in arteriopathic patient.

CHAPTER 18 Peripheral vascular disease

664

Vasospastic disorders

Key facts

Many systemic disorders have vasospasm as part of their presentation.

Causes

Rheumatological disease

Often associated with autoimmune disease.

• Systemic sclerosis.

• Systemic lupus erythematosus (SLE).

• Rheumatoid arthritis.

• Sjögren’s syndrome.

• Dermatomyositis.

• Polymyositis.

Neurological disease

• Reﬂ ex sympathetic dystrophy.

• Post-traumatic vasospasm.

• Vibration white ﬁ nger (due to exposure to handheld vibrating tools in

miners, ﬁ tters, builders, platers).

Drug induced

A-agonist treatment (ergotamine).

Idiopathic

Raynaud’s disease.

• ♂:♀, 9:1.

• Affects 20–30% of young women, with a possible familial

predisposition.

• Possibly due to deﬁ ciency of a potent vasodilator (a calcitonin gene-

related peptide) in the digital nerves, allowing action of unopposed

cold stress-induced release of the vasoconstrictor, endothelin.

Features

Vasospasm of any cause results in ‘Raynaud’s phenomenon’.

• Intermittent attacks.

• Initiated with pallor (‘white’). Due to local tissue oligaemia.

• Proceeding to cyanosis (‘blue’). Due to venous stasis and

deoxygenation.

• Followed by rubor (‘red’). Due to reactive hyperaemia as blood ﬂ ow is

restored.

Diagnosis and investigations

• Stop all vasoactive treatment 24h prior to assessment.

• After local cooling to 15*C, ﬁ nger Doppler pressures change (fall

>30mmHg signiﬁ cant).

• Screen. FBC, U&E, urinalysis, thyroid function tests, plasma viscosity,

rheumatoid factor, autoantibody screen.

VASOSPASTIC DISORDERS

665

Treatment

Medical

• Avoidance of precipitating factors (e.g. outdoor work, smoking).

• Electrically heated gloves/socks.

• Drug therapy used if symptoms are severe enough to interfere with

work/lifestyle.

Calcium channel blockers (e.g. nifedipine 10mg/day increasing to •

20mg/day tds) may help, but side effects (headache) may limit use.

Iloprost•

(prostacyclin) infusion. Weight-related doses given

IV over 48–72h, as tolerated by side effects, for severe pain or

impending/actual tissue loss.

Surgical

Sympathectomy. Reserved for patients with failure to respond to medical

therapy or secondary complications (e.g. digital ulceration).

• Lumbar. Open/laparoscopic/chemical for foot symptoms; effects are

mostly short-lived.

• Cervical. Mostly now thoracoscopic technique; effects are poor

response rate and high relapse rate.

CHAPTER 18 Peripheral vascular disease

666

Varicose veins

Key facts

• The venous system of the leg comprises of three groups.

Superﬁ cial.• Long (great) and short (lesser) saphenous systems and

tributaries.

Deep.• Between the muscle compartments of the legs following the

major arteries.

Perforators.• Connecting the superﬁ cial and deep systems.

• Blood passes from the superﬁ cial to deep systems via perforators

in the calf, and also at the saphenofemoral junction (SFJ),

saphenopopliteal junction (SPJ), and mid-thigh perforators (MTP)

which contain one-way valves.

• Varicose veins are tortuous and dilated segments of veins, associated

with valvular incompetence.

• Affect 35% of the population.

• Males and females almost equal prevalence.

Causes and features

Classiﬁ cation

• Thread veins. Intradermal dilated veins, also called ‘ﬂ are’, ‘starburst’, or

‘broken’ veins.

• Reticular veins. Subdermal 1–2mm diameter veins.

• Truncal veins. The long or short saphenous systems.

• Varicose veins. Usually arising from the truncal veins.

• Venous malformations. For example, congenital (Klippel–Trenaunay

syndrome).

Causes

• Congenital.

• Primary idiopathic (the majority).

• Acquired.

Pelvic masses (e.g. pregnancy, uterine ﬁ broids, ovarian mass, pelvic •

tumour).

Pelvic venous abnormalities (e.g. after pelvic surgery or irradiation, •

previous iliofemoral DVT).

Clinical features

• Symptoms. Pain, aching, itching, heaviness, swelling, oedema, worse at

end of day/hot weather/premenstruation, cosmetic concerns.

• Complications. Eczema, phlebitis, lipodermatosclerosis, ulceration, or

bleeding.

Diagnosis and investigations

• General history and examination. Oedema, eczema, ulcers (usually

medial calf), lipodermatosclerosis, atrophie blanche, healed ulceration.

• Visible standing. Cough impulse, thrill, or saphenovarix at SFJ.

• Tap test. Tap downwards over vein from SFJ, impulse should be felt

lower down if valves are incompetent (outdated and unhelpful).

VARICOSE VEINS

667

• Trendelenberg test. For competence of SFJ, MTP, and SPJ (rarely used

now Doppler/duplex available).

With the patient supine, elevate the leg, empty veins, apply •

tourniquet high in the thigh, and ask patient to stand.

Look for venous ﬁ lling and then release the tourniquet, observing •

ﬁ lling of the veins.

If controlled by the tourniquet and then rapidly ﬁ ll on release, the •

incompetent valve is above the level of the tourniquet, i.e SFJ.

Then repeat twice with tourniquet just above knee and below knee •

to test the MTP and SPJ, respectively.

• Handheld Doppler (HHD). Listen over SFJ and SPJ and apply calf

compression with other hand and listen for reﬂ ux lasting 1–2s. Most

accurate outpatient method of diagnosis and localization of primary

venous reﬂ ux disease.

• Colour duplex. Gold standard investigation in deﬁ ning anatomy and

incompetence. Can be used for all or selectively for recurrent varicose

veins, suspected short saphenous vein reﬂ ux, known or suspected

previous DVT, mismatch between clinical examination and HHD.

Treatment options

Medical

• Microsclerotherapy, laser sclerotherapy for thread and reticular veins.

• Foam sclerotherapy for truncal and varicose veins.

• Compression stockings.

Surgical

• Local ‘stab’ avulsions. Deals with varicosities.

• Saphenofemoral or saphenopopliteal disconnection.

• Long saphenous vein stripping (effectively avulses all incompetent

thigh perforators). Not usually done below the knee due to risk of

saphenous nerve injury.

• Endovenous laser therapy (EVLT).

• Radiofrequency ablation (endoluminal heating).

• Subfascial endoscopic perforator ligation (SEPL). For calf perforators.

Indications for treatment

• Cosmetic.

• For symptoms.

• To prevent complications.

• To reduce risk of recurrent complications.

Complications of surgery

• Bruising (virtually universal).

• Recurrence (50% cases at 10y).

• Haemorrhage (minor or, rarely, major from damaged femoral vein).

• Wound infection (commonest in groin).

• Saphenous or sural nerve damage with paraesthesia (20% numbness,

1% dysaesthesia).

• Damage to major arteries, e.g. femoral (rare).

CHAPTER 18 Peripheral vascular disease

668

Deep venous thrombosis

Causes and features

• Occurs due to abnormalities of the vein wall, blood ﬂ ow, or

constituents of blood (Virchow’s triad).

• May be due to vein compression or stasis (immobility, trauma, mass,

surgery, paralysis, long distance travel, including airline travel).

• May be due to inherited hypercoagulability (factor V Leiden, protein C,

protein S, or antithrombin insufﬁ ciency).

• May be due to acquired hypercoagulability (surgery, malignancy,

polycythaemia, smoking, hormone replacement therapy, oral

contraceptive pill (OCP), dehydration).

• Severity may vary from isolated asymptomatic tibial/calf thrombosis to

severe iliofemoral segment thrombosis with phlegmasia caerulea dolens

(venous gangrene).

Clinical features

• Clinical manifestations may be absent.

• Local features of venous engorgement and stasis.

Limb swelling.•

Pain.•

Erythema and warmth to the touch.•

Mild fever and tachycardia result from release of inﬂ ammatory •

mediators.

Homan’s sign. Calf pain on dorsiﬂ exion of the foot is very •

unreliable and should NOT be performed.

• Complications.

PE.•

Venous gangrene (• phlegmasia caerulea dolens).

Diagnosis and investigations

Aim to conﬁ rm presence and extent of thrombosis (to decide on neces-

sity and type of treatment, risk of embolization).

• Ascending venography. Rarely used now.

• Duplex scan. Investigation of choice; visualizes anatomy, gives extent

of thrombosis, and relies on ﬂ ow of blood and compressibility of vein.

Operator-dependent and has lower sensitivity for calf DVT.

• VQ scan. If suspicion of PE.

• CT pulmonary angiography (CTPA). Most sensitive and speciﬁ c

investigation for suspected PE.

Treatment

• Effective prophylaxis is better than treatment (see b p. 72).

• Conservative measures. Elevation and good hydration.

• Uncomplicated DVT. Low molecular weight heparin (LMWH),

initially in hospital, may be as an outpatient via a dedicated DVT clinic.

Subsequent treatment is with oral anticoagulation with warfarin for

3–6 months.

• Complicated DVT. Initially with IV unfractionated heparin (UFH) or

LMWH whilst converting to oral anticoagulation with warfarin.

DEEP VENOUS THROMBOSIS

669

• Thrombolysis or surgical thrombectomy are reserved for severe

thrombosis with venous gangrene.

• Vena caval ﬁ lter. Percutaneously inserted via jugular or femoral vein

into infrarenal IVC to catch thromboemboli and prevent PE.

Used for patients with recurrent PE despite treatment, at risk of •

major central PE and anticoagulation contraindicated, requiring

urgent or major surgery (so cannot be anticoagulated), major DVT

with concomitant CNS injury or major fractures.

Risks include air embolism, arrhythmias, pneumo/haemothorax, IVC •

obstruction, renal vein thrombosis, retained, misplaced, migrating,

eroding, embolizing or broken catheters/sheaths, complications of

insertion (e.g. bleeding).

Chronic venous insufﬁ ciency Severe forms are often secondary to

extensive or recurrent lower limb DVT (post-phlebitic limb).

Clinical features

• Leg/ankle oedema.

• Varicose/eczema, pigmentation, lipodermatosclerosis.

• Venous ulceration (medial more common than lateral).

• Venous claudication (rare).

Assessment

• Many (80%) venous disease alone, others mixed with arterial disease.

• History of proven/suspected DVT is common.

• Ulcers present in many patients and 70% are recurrent.

Investigations

• Handheld Doppler pressures (e.g. arterial disease ABPI <0.85).

• Venous duplex to detect DVT or deep venous incompetence and to

look for superﬁ cial venous disease.

Treatment

• Elevation, bed rest, and elevation of foot of bed.

• Four layer bandaging (Charing Cross) if ulceration present and ABPI

>0.85. Up to 75% ulcer healing at 12 weeks.

• Graduated compression hosiery (when ulcers healed).

Class I• . Ankle pressure <25mmHg, prophylaxis.

Class II• . Ankle pressure 25–35mmHg, marked varicose veins and

chronic venous insufﬁ ciency.

Class III• . Ankle pressure 35–45mmHg, chronic venous insufﬁ ciency.

Class IV• . Ankle pressure 45–60mmHg, lymphoedema.

Surgery

• Skin grafts (split skin and pinch skin grafts).

• Ulcer bed clearance of slough/infection (physical, chemical, larval—

maggots, vacuum debridement).

• Surgery for superﬁ cial venous disease only (as for varicose veins

surgery).

• Role in mixed superﬁ cial and deep venous disease is controversial.

• May need arterial revascularization.

CHAPTER 18 Peripheral vascular disease

670

Thrombolysis

Key facts

• Introduced over 30y ago.

• Use diminishing over last 5y due to up to 5% risk of major

haemorrhage or stroke.

• Usually administered as a low dose intra-arterial infusion or as an

adjunct to surgery intraoperatively.

Agents

• Urokinase. Expensive, rarely used in UK other than for dialysis

catheters.

• Streptokinase. Cheap, but has systemic effects and 27min half-life. Has

side effects of anaphylaxis, fever, and antibody resistance, limiting

repeated use. Widely used for treatment of MI.

• Recombinant tissue plasminogen activator (tPA). Powerful clot afﬁ nity,

lower systemic effects and bleeding complications, and half-life <6min.

Indications

• Treatment of acute limb ischaemia with viable limb due to in situ

thrombosis or embolism not suitable for surgery or extensive distal

(calf) thrombosis.

• Treatment of acute surgical graft complications, e.g. prosthetic graft

occlusion <2 weeks duration.

• Treatment of residual thromboembolic disease during reconstructive

surgery (intraoperatively).

• Thrombosed popliteal artery aneurysm (allows clearance of distal calf

vessels).

• Venous thrombosis (axillary/femoral) may be treatable by venous or

arterial lysis, but need to balance risk of haemorrhage and stroke.

Regimen

• Administered via arterial catheter and simultaneous heparin via

catheter sheath.

• Regular clinical assessment and coagulation checks are needed with

clear protocols. Half-hourly temperature, pulse rate, and BP as well as

foot observations.

• Regular review with repeat angiography.

• Increased complication rate after 24–36h of infusion.

Contraindications

• Increased risk of bleeding (haemorrhagic disorders, current peptic

ulcer, recent haemorrhagic stroke, recent major surgery, or multiple

puncture sites).

• Evidence of muscle necrosis as may result in reperfusion syndrome and

multi-organ failure.

• Urgent cases because threatened limb viability if lysis takes too long to

work.

THROMBOLYSIS

671

Complications

• Minor. Allergic, catheter problems (leak, occlusion), bruising, 15% risk

of minor haemorrhage.

• Major. Five per cent risk of major haemorrhage or stroke.

CHAPTER 18 Peripheral vascular disease

672

Complications in vascular surgery

Complications may occur in the perioperative, early, or late post-operative

periods. In general, vascular patients are older and have increased cardiac,

cerebral, pulmonary, and renal comorbidities. This is due to the associated

risk factors of hypertension, diabetes mellitus, hypercholesterolaemia, and

smoking.

General

Cardiac (see b p. 106)

• Atherosclerosis is a systemic disease with a predilection for the

cerebral, coronary, peripheral arterial, and renal circulations.

• Forty per cent of patients with PVD have at least two other

circulations affected.

• Twenty per cent of patients undergoing non-cardiac vascular surgery

have evidence of silent myocardial ischaemia.

• Seventy per cent of the mortality associated with aortic surgery is

attributable to perioperative cardiac dysfunction.

Pulmonary (see b p. 108)

• Worsened by pre-existing pulmonary disease, smoking, and obesity.

• Ensure adequate analgesia with PCA or epidural and good

physiotherapy and early mobilization.

Haemorrhage (see b p. 102)

• Perioperative. Bleeding from uncontrolled blood vessels.

• Post-operative. May be due to breakdown of vascular anastomoses.

Recognized by acute hypotension, shock, abdominal swelling, and pain.

Return to the operating theatre.

Renal failure

• Many vascular patients have pre-existing renal impairment due to

renovascular disease, drug treatments, or surgery.

• Acute perioperative risks include dehydration, use of IV contrast, use

of NSAIDs, or nephrotoxic antibiotics.

Infection

• Wound infections reduced by prophylactic antibiotics.

• MRSA easy to prevent (hand hygiene), but difﬁ cult and expensive to

treat.

• Clostridium difﬁ cile enteritis (hand washing prevents) associated with

antibiotic mis/overuse in inpatients.

Speciﬁ c

Post-declamp shock (reperfusion syndrome)

• Ischaemic extremities during surgery reperfused into circulation.

• Features of acute haemodynamic instability due to release of toxins

(potassium, myoglobin).

• Prevented by controlled gradual reperfusion with ﬂ uid resuscitation

and vasopressor treatment to maintain a good perfusion pressure to

the coronary, cerebral, and renal circulations.

• Mannitol often used as a free radical scavenger.

COMPLICATIONS IN VASCULAR SURGERY

673

Trash foot

• Embolization of debris to the skin of feet or buttocks after aorto-iliac

surgery.

• Avoided by careful surgical technique and distal vessel clamping ﬁ rst.

Swollen limb

• Most are due to reperfusion injury of previously ischaemic limbs.

• Consider investigations for DVT.

Lymphocoele

• Occurs mostly after groin surgery.

• Presents as a ﬂ uctuant, non-tender swelling.

• Most will settle spontaneously, although larger collections may be

aspirated under STRICT aseptic conditions.

• Rarely require further surgery to oversew the lymphatics.

Gut ischaemia

• May follow aortic surgery (ischaemic colitis); 2.5% after ruptured AAA

surgery and <1% of elective aortic aneurysm surgery due to loss of gut

blood supply.

• May present as vague abdominal pain or bloodstained diarrhoea.

• Sigmoidoscopy usually conﬁ rms the diagnosis.

• If there is no evidence of peritonitis, then ﬂ uids to rehydrate and close

observation are required.

• If there is evidence of peritonitis, then an urgent laparotomy is needed

with resection of the ischaemic bowel.

Impaired sexual function

Due to damage to the peri-aortic or hypogastric plexus and underlying

vascular disease of the blood supply to the pelvis.

Late complications

Graft occlusion

• Early failure (<30 days). Technical cause; recognized by acute

deterioration in symptoms or acute limb ischaemia.

• Late failure. Usually due to intimal hyperplasia, continued smoking, or

disease progression; recognized by progressively worsening symptoms,

falling ABPI, or duplex scanning showing graft stenosis.

False aneurysm

Usually secondary to infection or occasionally, fatigue of graft material

(long-term). Further surgery is usually required.

Graft infection

• Mostly gut bacteria or coagulase-negative staphylococci; MRSA an

increasing problem.

• Can be minimized by prophylactic antibiotics, meticulous technique,

and infection control policies on vascular wards.

• Once infected, the graft usually has to be removed and alternative

reconstruction required.

• Recognized by signs of low grade or chronic sepsis (i CRP, d Hb,

fever).

CHAPTER 18 Peripheral vascular disease

674

Aortoenteric ﬁ stula

• Rare, usually fatal if not treated.

• Usually follows aortic grafting. Can be years later.

• Presents with small, often overlooked, GI bleeds or anaemia.

• Diagnosis difﬁ cult. CT can be helpful; often all other causes of bleeding

are negative.

• Treatment by open surgery or endovascular exclusion and antibiotics.

675

Transplantation

Basic transplant immunology 676

Immunosuppression and rejection 678

Transplant recipients 682

Transplant donors 684

Heart and lung transplantation 690

Kidney transplantation 692

Pancreas and islet transplantation 694

Liver transplantation 696

Small bowel transplantation 698

Chapter 19

CHAPTER 19 Transplantation

676

Basic transplant immunology

Allorecognition

Allorecognition is the identiﬁ cation of antigen as ‘non-self ’. It is a func-

tion mainly of the adaptive immune response, but is dependent on prim-

ing by an inﬂ ammatory response from the innate immune system; such a

response occurs in transplantation, both from the inﬂ ammatory response

to surgery and ischaemia-reperfusion injury in the graft.

Allorecognition depends on two main processes. First, alloantigen must

be taken up and complexed with surface major histocompatibility complex

(MHC) molecules on antigen-presenting cells (APCs) that include den-

dritic cells and macrophages. Direct recognition occurs when donor APCs

within the allograft perform this function whereas indirect recognition is the

term used when host APCs do this. Secondly, antigen-speciﬁ c host T-cell

receptors must bind to the peptide fragments of alloantigen complexed

with the MHC molecules on APCs. This T-cell binding only activates a

response if there is also co-stimulatory signal from the APC.

B- and T-cell diversity

Lymphocytes are able to identify non-self by the presence of both T-cell

receptors (TCR) and B-cell receptors (BCRs) speciﬁ c for each alloantigen.

The production of a huge number of receptors (approximately 2.5 x 10

each speciﬁ c to a particular peptide fragment, is possible because of the

millions of potential combinations of the thousands of TCR and BCR gene

segments. The TCR gene segments are located in chromosomes 14 and 7;

the BCR gene fragments are on chromosome 14.

T-cell activation

When the TCR binds to antigen complexed with MHC molecules, a chain

of reactions between intracellular signalling molecules leads to cell apop-

tosis unless a co-stimulatory signal from the APC also occurs. Binding of

the TCR as well as CD and co-stimulatory molecules with the MHC leads

to T-cell activation, differentiation, and clonal expansion. This results in

the rapid production of large numbers of cells able to coordinate and

effect destruction of tissues bearing the speciﬁ c alloantigen; this manifests

clinically as rejection.

Rejection

There are several types of rejection:

• Hyperacute rejection is mediated by preformed antibodies that bind to

antigens of ABO blood groups, non-self HLA, causing immediate tissue

oedema, haemorrhage, and thrombosis, which can produce a severe

systemic reaction like an ABO-incompatible blood transfusion.

• Acute rejection is mediated either by T-cells (‘cellular rejection’) or

newly formed antibodies (‘humoral rejection’) and results in tissue

destruction over days to many months after transplant.

• Chronic rejection is a poorly understood vasculopathy associated with

ﬁ brosis of small blood vessels that occurs over years. It is a chronic

inﬂ ammatory condition which probably has an alloreactive component.

BASIC TRANSPLANT IMMUNOLOGY

677

A basic glossary of terms in transplant immunology

• Adaptive immunity. Learned response to speciﬁ c non-self antigens.

• Allo-. Tissue from genetically different member of same species.

Alloantigen. Antigen from genetically different member of same

species. Allogenicity. Ability of tissue to provoke an immune response

when transplanted into genetically different member of same species.

Allorecognition. Recognition of alloantigen as non-self.

• Antigen. Cell surface glycoproteins.

• Antibody. Speciﬁ c proteins produced by B-cells in response to

non-self antigen, consisting of two light and two heavy chain proteins

composing a constant and a variable region. The variable chain

region binds with the antigen that triggered the response and the

constant region coordinates the cellular response.

• APC (antigen-presenting cells). These cells ingest and process

antigen, then present it bound to surface MHC to T-cells. APCs are

most commonly dendritic cells or macrophages, but other cells can

act as APCs.

• B-cells. These cells mature in bone marrow. They produce antibodies,

but can also present antigen. In response to antigen, they undergo

clonal expansion, triggered and coordinated by T helper cells.

• Cellular immunity. Adaptive immunity mediated by lymphocytes.

• CD. Cellular differentiation molecule (followed by a number, e.g.

CD4).

• Clonal expansion. Production of large numbers of identical cells.

• Co-stimulatory molecules. Molecule receptors that must be

activated, in addition to a main receptor, for a process to happen.

• Direct recognition. Donor APCs present alloantigen to host T-cells.

• HLA (human leucocyte antigen). Human MHC.

• Humoral immunity. Immunity mediated by non-cellular components

of the immune system such as antibodies or complement.

• Indirect recognition. Host APCs present alloantigen to host T-cells.

• Innate immunity. Rapid inbuilt response to certain non-self proteins.

• MHC (major histocompatibility complex). Glycoproteins

expressed on the surface of all cells, coded for by the MHC

genes on chromosome 6. Alloantigen must be bound to MHC

for T-cells to recognize it. There are two classes of MHC. Class

I (HLA molecules A, B, and C) is present on all cell membranes.

Class II (HLA molecules DP, DQ, and DR), also known as minor

histocompatibility complex, is present on only certain cell types.

Class II is less allogeneic.

• Rejection. Injury to tissue by host immune response.

• T-cells. These cells mature in the thymus. T-cells that bind to thymic

tissue (self) are destroyed. T helper cells that are CD4 +ve coordinate

and T cytotoxic cells (CD8 +ve) effect the response. Regulatory

T-cells are also CD4 +ve and reduce the alloreactive response.

• Tolerance. A condition of lack of immune response to alloantigen

where such a response is expected or has occurred previously.

• Xenograft. Tissue transplanted between species.

CHAPTER 19 Transplantation

678

Immunosuppression and rejection

The goal of immunosuppression is to inhibit the immune response to

alloantigen, while preserving the immune response to infection and malig-

nancy. Immunosuppression consists of a short, intense induction phase

followed by a maintenance phase in which immunosuppression dosage is

tapered. A careful balance is maintained between therapeutic and toxic

doses of immunosuppression; this is generally achieved by combining

drugs with different mechanisms of action (see Box 19.1).

Acute rejection

Diagnosis

Clinical features depend on the organ transplanted and are generally mani-

fested by clinical and biochemical evidence of impaired organ function

or organ injury (such as elevated transaminase levels in liver transplanta-

tion). Systemic immune symptoms are less common and include low grade

fever, malaise, and tenderness over the graft. Blood tests may reveal a

lymphocytosis. Diagnosis is made by biopsy, which will also determine

whether rejection is T-cell mediated or humoral, and can identify other

causes of graft dysfunction.

The immunosuppression may mask symptoms until rejection is quite

advanced, so routine surveillance may be undertaken, especially for those

organs where loss of function would be catastrophic. When required,

optimal surveillance is by ‘protocol biopsies’ taken at predetermined time

points such as at 7–10 days after transplantation, with repeat biopsies

taken at intervals. Percutaneous imaging-guided biopsy is typically used

in liver and renal transplantation, endoscopic biopsy in small bowel and

lung transplantation, and transjugular biopsy in heart transplants or liver

transplants with uncorrectable coagulopathy.

Management

• Asymptomatic mild rejection may be monitored in some organs, but is

always treated in renal transplants as kidneys are very immunogenic.

• The main form of treatment is increased immunosuppression.

• Up to 3 days IV methylprednisolone 500–1000mg/day is typically given

as initial treatment for acute rejection.

• Repeat biopsy is performed if no improvement, followed by repeat

steroid course if ongoing rejection, or give rescue therapy if severe.

• Rescue protocols include administration of anti-T-cell antibodies.

• Plasmapheresis to remove antibody may be required in humoral

rejection, diagnosed by positive CD4 staining.

• Retransplantation is occasionally performed after graft loss due to

refractory rejection, but is not performed for certain organs, such as

the heart and lung, as results are extremely poor.

Chronic rejection

Chronic rejection is a chronic inﬂ ammatory process associated with

intimal hyperplasia with dependent ischaemia and ﬁ brosis. The cause is

unknown, but appears related to the severity of acute inﬂ ammatory proc-

IMMUNOSUPPRESSION AND REJECTION

679

esses at the time of transplantation, such as ischaemia-reperfusion injury

and acute rejection.

The intimal hyperplasia and dependent ischaemia affect the organs in dif-

ferent ways, such as coronary artery disease in heart, glomerulosclerosis in

kidneys, and vanishing bile ducts in livers.

The term ‘chronic rejection’ is not widely used at present, with a variety

of different names used according to the affected organ such as cardiac

allograft vasculopathy (heart), bronchiolitis obliterans (lung), and chronic

allograft nephropathy (kidney).

There is no speciﬁ c treatment available for chronic rejection at the

present time, with retransplantation as the only effective option.

Side effects of immunosuppression

Opportunistic infection

Cytomegalovirus (CMV) can cause life-threatening infection in transplant

recipients and is especially common in the ﬁ rst 6 months. Examples are

CMV pneumonitis and CMV colitis. Diagnosis is by quantitative polymer-

ase chain reaction (PCR) and treatment by oral valganciclovir or IV gan-

ciclovir for severe infections. Recipients felt to be at risk based on donor

and recipient serology are given prophylactic valganciclovir for 100–200

days.

Pneumocystis jiroveci (P. carinii) infection can lead to a severe atypical

pneumonia in immunosuppressed patients. It is generally prevented by

prophylactic co-trimoxazole for the ﬁ rst 3 months.

BK virus infection is generally asymptomatic, but is a possible cause of

failure of renal transplants.

Malignancy

Immunosuppression reduces immune surveillance of tumours, so some

are more common in transplant recipients and others can be more aggres-

sive than would otherwise be the case. Virally-mediated tumours and

squamous cell carcinoma of the skin are especially common.

Post-transplant lymphoproliferative disorder (PTLD) is a condition of

B-cell proliferation which may extend to B-cell lymphoma and is due to

inhibition by immunosuppressant drugs of the IL2-dependent mechanism

by which T-cells regulate the B-cell proliferation occurring in Epstein–Barr

virus infection.

Although not a complication of immunosuppression per se, malignancy

can also be transmitted from transplant donors to recipients and so must

be excluded as far as possible with potential donors.

CHAPTER 19 Transplantation

680

Box 19.1 Immunosuppressive agents

Corticosteroids

Corticosteroids inhibit the immune response at many levels. They

decrease production of G-interferon and interleukins that would nor-

mally cause up-regulation of the lymphocyte response and reduce mac-

rophage function.

Calcineurin inhibitors (CNI)

Ciclosporin and tacrolimus are calcineurin inhibitors: they inhibit the

production of IL-2 by T helper cells, selectively reducing the cytotoxic

T-cell response. Nephrotoxicity is a major side effect, but they also

impair glucose tolerance and affect lipid metabolism.

Mammalian target of rapamycin (mTOR) inhibitors

Sirolimus (rapamycin) and everolimus both inhibit the production of IL-2

by T-cells and thus stops their clonal expansion in a manner similar to

the calcineurin inhibitors. mTOR inhibitors are not themselves nephro-

toxic, but they appear to potentiate the nephrotoxicity of CNIs if given

together.

Mycophenolic acid

Mycophenolic acid inhibits purine synthesis in lymphocytes, reducing

clonal expansion and lymphocyte counts. It can cause severe GI side

effects which are reduced by administration as enteric-coated tablets or

as the pro-drug, mycophenolate mofetil (MMF).

Azathioprine

Azathrioprine reduces lymphocyte production by suppression of purine

synthesis. Allopurinol inhibits the metabolism of azathioprine. Bone mar-

row suppression and pancreatitis are common adverse reactions.

Basiliximab

Monoclonal antibody that binds to the IL-2 receptor of T-cells and thus

prevent clonal expansion of T-cells. Usually given as induction agent.

Anti-thymocyte globulin (ATG)

Derived from rabbits or horses immunized with T-cells; primarily

directed against the T-cell receptor. Systemic inﬂ ammatory reactions

occur due to cytokine release from T-cells when the receptor bound.

Alemtuzumab (Campath)

Monoclonal antibody binding to CD52 receptor, leading to depletion

of T-cells, B-cells, natural killer cells, lymphocyte precursors, dendritic

cells, and macrophages. It thus reduces all the cells involved in antigen

presentation, cellular rejection, and humoral rejection. Usually used as

an induction agent. Side effects include bleeding and sepsis.

Belatacept

A new drug which blocks co-stimulation of T-cells by antigen presenting

cells. Not nephrotoxic or diabetogenic. Long-term effect unknown.

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CHAPTER 19 Transplantation

682

Transplant recipients

Indications for transplantation

Cardiac transplantation

• End-stage heart disease with a life expectancy of 12–18 months.

• NYHA class III or IV heart failure, refractory to medical or surgical

therapy.

• Cardiomyopathy and congenital heart disease.

Lung transplantation End-stage lung disease where conventional therapy

is not likely to provide acceptable beneﬁ ts or satisfactorily improve life

expectancy.

Renal transplantation All patients with end-stage renal failure should be con-

sidered for renal transplant unless there are speciﬁ c contraindications.

Liver transplantation

• Unacceptable quality of life because of liver disease.

• Anticipated 1y mortality >9% without transplant.

Pancreas transplantation

• Usually with or after kidney transplantation for diabetic nephropathy.

• Can be done alone for hypoglycaemic unawareness (consider islets).

Small bowel transplantation (often part of multivisceral)

• Congenital extensive atresia.

• Life-threatening complications of TPN in patients with intestinal failure.

• Loss of central venous access sites in patients with intestinal failure.

Absolute contraindications to transplantation

• Predicted life expectancy <5y due to comorbidity.

• Inability to comply with immunosuppression.

• Chronic current systemic infection.

• Continued abuse of alcohol or other drugs.

• Irreversible secondary organ failure not appropriate for combined

transplant.

• Severe cerebrovascular disease.

• Active malignancy.

• Other life-threatening medical condition.

Relative contraindications to transplantation

• HIV (controversial), hepatitis B/C (except in liver transplants).

• COPD with FEV

<50%, PVR >4 Wood units in heart transplants.

• Chronic renal impairment with GFR >50mL/min, unless candidate for

renal transplant, including combined transplants with kidney.

• Diabetes with target organ damage (heart).

• Lipid disorders refractory to diet or therapy (heart).

• Severe osteoporosis.

• Amyloidosis.

• Continued smoking (heart or lung).

TRANSPLANT RECIPIENTS

683

Routine investigations in transplant assessment

• A full history and clinical examination.

• CXR, ECG.

• Functional cardiopulmonary assessment if indicated, e.g. CPEX.

• Cardiac catheterization and coronary angiography if indicated.

• Lung function tests.

• MSU, urinalysis, nose swab, and MRSA screen.

• Blood group antibody screen.

• FBC and coagulation proﬁ le.

• U&E, calcium, phosphate, LFTs, fasting blood glucose, and lipids.

• Serology for hepatitis B/C, HIV, syphilis, rubella, EBV, herpes varicella

and zoster, CMV, toxoplasma.

• HLA typing, lymphotoxic antibody screen.

• Assessment of compliance; may include interview with social worker.

• Further organ-speciﬁ c tests as indicated.

Accepting a patient on to the transplant list

Accepting a patient for transplantation is a multidisciplinary process which

varies from organ to organ. Potential kidney and/or pancreas transplant

recipients are typically initially assessed by their nephrologist and then

referred to a transplant surgeon. Potential recipients of liver, small bowel,

heart, or lung transplants are usually discussed in a multidisciplinary meet-

ing of transplant surgeons, anaesthetists, physicians, transplant coordina-

tors, and specialist nurses. The patient is informed of the decision and

receives:

• A detailed explanation of the waiting list procedures (including their

responsibility to be within contact and available for potential transplant

at all times and duty to inform the transplant team of any changes

in their health; planned holidays can be permitted by temporary

suspension from the list).

• A booklet describing this in more detail and explaining what to do

when called for surgery, the operation, post-operative care, and

follow-up arrangements.

CHAPTER 19 Transplantation

684

Transplant donors

Availability of organs for transplantation

The increasing success of organ transplantation as a modality of treatment

for end-stage organ disease has increased demand, a problem further

exacerbated by widening the criteria for which patients can be consid-

ered suitable candidates for transplantation. This has lead to an increasing

national shortage of organs despite efforts to increase donation.

A national Organ Donation Task Force was set up in the UK in 2006 and

issued fourteen recommendations in 2008 for increasing organ availability.

The ﬁ nal phase of their implementation commenced in 2010.

Deceased donation

Deceased donors form the majority of organ donors in the UK.

Traditionally, the majority have been heart-beating donors after brainstem

death (DBD), but increasingly non-heart-beating donors after circulatory

death (DCD) are being used. Potential donors undergo a review of their

history and clinical examination, ECG, CXR, ABGs, ABO typing, testing

for HIV, hepatitis C/B, and CMV, and tests of organ function (e.g. U&E,

LFTs, echo).

Criteria for cadaveric organ donation

• Signed donor card, registration as organ donor, or agreement by next

of kin.

• Haemodynamic stability without high dose inotropic support.

• Absence of septicaemia, extracerebral malignancy, HIV, hepatitis B/C,

viral encephalitis, use of human growth hormone, and new variant

CJD.

• Brainstem death testing performed twice by two senior doctors after

essential preconditions met and apnoea test performed (for DBD

donors) (see Box 19.2).

• Organ-speciﬁ c criteria include the following.

Kidney• . Age 1–90y with acceptable renal function.

Heart• . Age 1 month–60y with no known cardiac disease.

Heart–lung• . As above; no pulmonary disease or trauma; PO

, PCO

levels acceptable on less than 50% inspired oxygen.

Liver• . Age 1 month–70y. No known liver disease, drug addiction, or

hepatitis B.

Pancreas• . Age 10–60y with no diabetes.

TRANSPLANT DONORS

685

Box 19.2 Brainstem death testing (UK code)

Essential preconditions

The patient must be in an apnoeic coma, i.e. unresponsive and depend-

ent on a mandatory ventilation mode, following irreversible structural

brain damage due to a ‘disorder which may cause brain death’.

Drug intoxication, hypothermia, and metabolic or endocrine distur-

bances must be excluded before brainstem death testing as these may

mimic brainstem death clinically.

Apnoea test

Conﬁ rmation of apnoeic coma is performed by ventilator disconnec-

tion, with lack of spontaneous respiratory effort despite rising arterial

carbon dioxide tension. Care must be taken to avoid hypoxia which

could potentially cause further brain injury in a patient who might not

yet be brainstem dead.

• Ensure systolic BP >90mmHg and adequate intravascular volume.

• Preoxygenate with 100% O

for 10min.

• Check PaCO

is at least 5.3kPa (40mmHg). If not, give 95% O

/5%

until PaCO

>5.3kPa.

• Disconnect ventilator and insufﬂ ate 100% O

at 6L/min via an

intratracheal catheter passed to the level of the carina.

• Continue disconnection until PaCO

>6.65kPa (50mmHg), which

should occur within 8min.

Apnoea testing should be abandoned if there are cardiac arrhythmias,

hypotension, or arterial desaturation. In the UK, apnoea testing must be

attempted again before brainstem death is diagnosed.

Clinical tests

The brainstem reﬂ exes should be tested by two experienced doctors,

one of whom must be a consultant and neither of whom is a member of

the transplant team. They may perform the tests together or independ-

ently and must repeat all the tests after a period of at least 2h.

• No pupillary response to light (both direct and indirect reﬂ exes).

• No corneal reﬂ ex.

• No vestibulo-ocular reﬂ ex. No eye movement on irrigation of

tympanic membrane with 20–50mL ice-cold water.

• No cranial nerve motor responses, e.g. grimacing to pain.

• No gag or cough reﬂ ex on deep bronchial suctioning.

• No oculocephalic reﬂ ex (‘doll’s eyes test’).

2 Further information on brainstem death testing is located at: http://

www.aomrc.org.uk/publications/reports-guidance/doc_download/42-a-

code-of-practice-for-the-diagnosis-and-conﬁ rmation-of-death.html

Management of brainstem-dead organ donors (DBD)

Resuscitation of organ donors requires early recognition and assiduous

support. Brain death is associated with a variety of sequelae, which include

haemodynamic instability, hypothermia, coagulopathy, fall in T

and T

myocardial depression, and diabetes insipidus.

CHAPTER 19 Transplantation

686

Therapeutic intervention must be continued up to and throughout

the donation procedure. Unnecessary delays should be avoided and the

retrieved organs must be in optimal condition.

Monitoring

• ECG.

• Radial artery line (MAP 60–70mmHg).

• Urine output (>100mL/h).

• CVP (greater than or equal to 12cmH

O).

• Temperature (over 35.5°C).

Cardiovascular support

Noradrenaline (norepinephrine) is used for refractory hypotension.

Dopamine may exacerbate any polyuria and cause vasoconstriction with

end-organ damage. Dobutamine may exacerbate hypotension.

Hormone replacement therapy

• T

. Bolus of 4 micrograms, then infusion of 3 micrograms/h.

• Diabetes insipidus. Replace urine loss with 5% dextrose and water via

NGT. Vasopressin may exacerbate vasoconstriction, so its analogue,

desmopressin (DDAVP), is generally used instead. The aim is to

achieve 1.5–3mL urine/kg/h output.

Respiratory support Respiratory support requires meticulous asepsis.

Oxygen delivery is optimized to achieve a normal PaCO

. High PEEP

should be avoided to minimize lung injury.

Haematological support Coagulopathies are treated with FFP and platelets,

guided by the local laboratory.

Management of donors after circulatory death (DCD)

Most DCD are controlled donors, where life-prolonging treatment is

withdrawn after a decision that the overall prognosis means that such

treatment is felt to be futile. As such donors are living patients until the

time of cardiac arrest and generally lack capacity to consent due to being

unconscious, they can only be treated in line with their best interests

under common law, restricting the interventions possible to optimize the

condition of the transplanted organs.

Uncontrolled DCD following failed resuscitation for cardiac arrest can-

not, by deﬁ nition, be optimized prior to cardiac arrest, but basic measures

to improve organ viability after death but prior to consent for donation

are allowed under the Human Tissue Act and can include femoral cannula-

tion to start aortic perfusion and peritoneal cooling.

Principles of cadaveric organ retrieval

The aim is to minimize ischaemic times of all organs. Retrieval of multiple

organs is common, so a coordinated approach is needed. Inotropic, vol-

ume, and respiratory support is continued until the retrieval teams are

ready to start cold perfusion.

• A midline incision from sternal notch to pubis is made.

• IV heparin 200U/kg is given.

• A diagnostic laparotomy is performed to assess for any undiagnosed

disease, especially malignancy.

TRANSPLANT DONORS

687

• Organs are carefully examined for evidence of trauma and disease. The

aim is to retain adequate vascular and visceral cuffs to facilitate later

anastomosis. Variant vascular anatomy to the liver is common and can

affect retrieval of liver and pancreas, so this must be carefully assessed.

• As soon as both the abdominal and thoracic teams have completed

their assessment and are ready for cold perfusion, the supracoeliac

aorta is cross-clamped, ventilator stopped, cold perfusion established

through aortic cannulae, and ice slush poured into the abdomen and

the thorax. The organs are then dissected out and removed once cold.

Retrieval of organs from donors after circulatory death is different as

cardiac arrest has already occurred, so the ﬁ rst priority is to start cold

perfusion, with assessment of anatomy and disease done in the cold phase

prior to organ retrieval.

Organ preservation

The key to minimizing ischaemic injury remains minimizing ischaemic

time, but use of appropriate perfusion solutions reduces the severity of

ischaemic injury. A variety of storage solutions are used at temperatures of

4–10°C. Two categories exist: extracellular solutions characterized by high

and low K

such as Bretschneider (HTK) and intracellular solutions

characterized by high K

and low Na

such as University of Wisconsin

solution (UW) or St Thomas’s cardioplegia solution.

Machine perfusion

Organs are usually stored in ice slush once perfused, but are sometimes

stored in a machine providing continuous perfusion of the organ. This is

especially common for DCD kidneys using a cold perfusion circuit, which

can also allow assessment of viability by measurement of pressure-ﬂ ow

characteristics and biochemical markers of ischaemic injury.

Warm perfusion using oxygenated perfusion solutions to assess and

treat ischaemic injury prior to implantation has been used experimentally

and may enter clinical practice in the near future.

Living donors

These are generally relatives or from genetically unrelated, but emotion-

ally connected individuals (mostly commonly spouses), though undirected

living donation to complete strangers is also allowed (‘altruistic dona-

tion’). Living donation requires meticulous preparation to minimize risk

to the donor and exclude coercion or ﬁ nancial reward; potential altruistic

donors must also be psychologically assessed.

Kidneys are the most common transplants from living donors. Donation

of a liver lobe is also possible due to the large functional reserve of the

liver and its ability to regenerate by hypertrophy; left lobe liver donation

from adults to children is especially common.

Living donation of lung lobes is also possible, but requires two donors

for each recipient. Living pancreas donation using a distal pancreatectomy

has been described, but is not widely used due to the potential risks to the

donor of diabetes or pancreatic duct leakage.

• All donors undergo blood grouping, tissue typing, and assessment of

viral status for hepatitis B/C, HIV, and CMV.

CHAPTER 19 Transplantation

688

• Tests of organ function, such as isotope split GFR for kidneys, are

needed to ensure adequate post-operative function for both donor

and recipient.

• General tests of donor ﬁ tness are also essential to minimize risk.

ABO-incompatible living donors (see Tables 19.1 and 19.2)

Although ABO incompatibility is normally an absolute contraindication

to transplantation as the preformed antibodies will lead to hyperacute

rejection, it is possible to desensitize the potential recipient by a preop-

erative course of plasma exchanges or immunoadsorption to remove the

antibody preceded by an infusion of the anti-B-cell antibody, rituximab, to

prevent antibody regeneration. This treatment is only feasible for living

donor transplants as these are planned operations.

Similar treatment can also be given to desensitize patients with pre-

formed antibodies directed against the HLA type of their potential donor

(such antibodies can be formed after sensitizing events, such as previous

transplants or blood transfusions).

To prevent resensitization, care must be taken to avoid accidentally

transfusing anti-ABO antibodies when administering blood products after

the transplant. Red cell and platelets transfusions should use washed cells

of recipient blood group. FFP and cryoprecipitate transfusions must be

donor-type if the transplant is donor group A or B to recipient group O or

type AB if the transplant is between A and B; alternatively, recipient-type

blood products can be used if screened for low antibody activity.

Where recipient desensitization is not possible, paired exchange may be

an alternative where the donor from each pair donates to the recipient of

the other pair. Paired exchange requires a large pool of donor-recipient

pairs to be successful and is only feasible for kidney transplants.

Table 19.1 ABO compatibility for transplants

Recipient blood

group

Donor blood group

A B AB O

A Yes No No Yes

B No Yes No Yes

AB Yes Yes Yes Yes

O No No No Yes

Table 19.2 Paired exchange to avoid ABO incompatibility

Donor Mr Smith

( group A)

donates a transplant to Recipient Mr Jones

(group A)

Recipient Mrs Smith

(group B)

receives a transplant from

Donor Mrs Jones

(group B)

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CHAPTER 19 Transplantation

690

Heart and lung transplantation

Cardiac transplantation

Matching donor to recipient

• ABO compatibility. Donor and recipient must be ABO-compatible;

hyperacute rejection occurs in ABO-incompatible patients. Children

under 1y can be transplanted despite ABO incompatibility.

• HLA typing. Although heart is amongst the least allogeneic organs and

a HLA mismatch is not a contraindication to transplantation, HLA-A

or -A

mismatch has been associated with chronic rejection and some

centres choose to avoid this.

• Size match. Important; up to 30% undersize acceptable if normal PVR,

oversize if high PVR.

Technique of transplantation

Orthotopic heart transplantation involves transplanting the donor organ

into the space vacated by the recipient heart. There are several techniques

of orthotopic heart transplantation.

• The most commonly used is the bicaval anastomosis technique. The

donor cavae are attached directly to the recipient cavae. This results in

less tricuspid regurgitation and better haemodynamic performance.

• In the original technique, right and left atria of donor and recipient are

preserved; anastomosing atria to atria is technically less demanding

than bicaval anastomosis.

• In the total anastomotic technique, each pulmonary vein is individually

anastomosed.

• In heterotopic transplantation, used in 2.5% of heart transplants, the

donor heart is retained and the transplanted heart is anastomosed

so that it acts to bypass the left heart. The technique is reserved for

severe pulmonary hypertension.

Post-operative care Monitoring for rejection is done via transvenous

endomyocardial biopsy.

Complications

• Infections (nosocomial, opportunistic, or acquired).

Bacterial (common nosocomial (see • b pp. 104, 174) and

opportunistic infections include Pneumocystis carinii, Mycobacterium

spp.).

Viral (CMV, HBV, HIV may be transmitted from graft).•

Fungal (• Candida albicans, Aspergillus).

• Rejection (b pp. 676, 678) and graft ischaemic heart disease.

• Hyperlipidaemia and diabetes secondary to immunosuppression.

• Renal failure (similar risk factors to heart failure, perioperative

hypoperfusion, nephrotoxic immunosuppression regimes).

• Hypertension. Aetiology poorly understood.

• Malignancy. Decrease in the T-cell response to EBV as a result of

immunosuppression.

HEART AND LUNG TRANSPLANTATION

691

Results of cardiac transplantation

• UK 30-day mortality is 4%.

• 1y survival is 82%; 5y survival is 65%; 10y is 50%.

Lung and heart–lung transplantation

Matching donor to recipient

• ABO compatibility. Donor and recipient must be ABO-compatible;

hyperacute rejection occurs in ABO-incompatible patients.

• HLA typing. Although a HLA mismatch is not a contraindication to

transplantation, improved graft survival is associated with matching

HLA-B, HLA-A, and HLA-DR loci.

• Size match. Important.

Technique of transplantation

• Single lung transplant is performed where the remaining native lung

will not compromise graft function or present a hazard; emphysema,

asthma, and sarcoid require single lung transplants.

• Double lung transplants are performed via a clam-shell incision for

cystic ﬁ brosis and bronchiectasis.

• Because of donor organ shortages, heart–lung transplants are

performed less often with an increase in the use of lung transplants.

• Domino heart–lung transplants, where a heart–lung transplant was

performed for septic lung disease and the healthy explanted heart then

transplanted into a second recipient, is now rarely performed.

Post-operative care

Early post-operative management centres around maintaining a balance

between adequate perfusion and gas exchange, while minimizing ﬂ uid load,

cardiac work, and barotrauma. Cardiovascular management and complica-

tions are very similar to those outlined on b p. 622. Monitoring for rejec-

tion is done by transbronchial biopsy and bronchoalveolar lavage.

Complications

• Infections (nosocomial, opportunistic, or acquired).

Bacterial (common nosocomial (see • b p. 174) and opportunistic

infections include Pneumocystis carinii, Mycobacterium sp.).

Viral (CMV, HBV, HIV may be transmitted from graft).•

Fungal (• Candida albicans, Aspergillus sp.).

• Vascular stenoses. Arterial stenosis results in pulmonary oligaemia and

venous stenosis in pulmonary oedema.

• Tracheal stenoses.

• Tracheal ischaemia may result in leak and mediastinitis.

• Infection with Pseudomonas sp. is common in cystic ﬁ brosis patients.

CMV infection is dangerous.

Results of lung transplantation

• 1y survival is 61%.

• 5y survival is 40%.

CHAPTER 19 Transplantation

692

Kidney transplantation

Kidney transplantation is the commonest form of organ transplant. A total

of 2739 were performed in the UK in 2009–10, of which 1038 were kid-

neys from living donors.

Matching donor to recipient

• ABO compatibility. Donor and recipient must normally be ABO-

compatible; hyperacute rejection occurs in ABO-incompatible patients

unless desensitization treatment has been performed preoperatively.

• HLA typing. Graft survival is better if there is no more than one

mismatch for HLA-A and/or HLA-B and no mismatches for HLA-DR.

• Children. Given priority; even small children can take adult kidneys.

Technique of transplantation

The kidney is normally placed extraperitoneally into the iliac fossa. Both

the left and right kidneys can be placed into either iliac fossa, but the right

is easier as the external iliac vein is more accessible.

• The renal vessels are anastomosed to the external iliac vessels. The

common or internal iliac artery can be used if the external is diseased.

• The ureter is anastomosed to the bladder, usually over a stent.

• Preoperative native nephrectomy is only occasionally needed for

continued/recurrent urinary infection, TB of the kidney, or massive

polycystic kidney disease.

Post-operative care

Early post-operative management centres around maintaining a balance

between adequate renal perfusion and BP control.

• Graft function is monitored by serial creatinine measurements (this is

especially useful if these are plotted on an inverse creatinine chart).

• Early graft failure is usually due to lack of perfusion following an

arterial or venous thrombosis, so graft perfusion should be assessed

by DTPA scan or Doppler ultrasound if there is not immediate graft

function.

• Delayed graft function with oliguria or anuria is common early after

transplantation, especially if there has been ischaemic injury prior to

organ retrieval or a prolonged cold ischaemic time.

• Intermittent haemodialysis may be needed if there is delayed function.

• Polyuria is common once the kidney starts to function until renal

tubular function recovers; ﬂ uid needs to be replaced to prevent pre-

renal failure of the graft.

• Biopsy to conﬁ rm suspected rejection is done percutaneously under

ultrasound guidance.

Complications

• Infection.

• Rejection (see b p. 678).

• Renal vein or artery thrombosis may result in loss of the kidney.

• Ureteric stenosis. Treated by ureteroplasty and a stent or surgery.

• Urinary leak often can be managed by urinary catheterization for 6

weeks followed by cystogram to conﬁ rm healing.

KIDNEY TRANSPLANTATION

693

• Lymphocoele is managed by percutaneous drainage or by laparoscopic

or open marsupialization into the peritoneum.

Results of kidney transplantation

• For cadaveric kidney transplantation. 1y survival is 88%; 2y survival is

81%; 5y survival is 71%.

• For living donor kidney transplantation. 1y survival is 94%; 2y survival is

93%; 5y survival is 84%.

CHAPTER 19 Transplantation

694

Pancreas and islet transplantation

Pancreatic transplantation is performed for insulin-dependent diabetes. It

is either performed alone (rare) or in conjunction with kidney transplanta-

tion for diabetics in end-stage renal failure. A total of 160 combined kidney

and pancreas transplants were performed in the UK in 2009–10.

Pancreas transplantation

The transplant operation

The pancreas is usually retrieved as the whole organ with the duode-

num attached. It is transplanted either intraperitoneally or extraperito-

neally into the right iliac fossa using similar techniques to those of renal

transplantation.

The dual arterial supply of the pancreas, based on the splenic artery

and superior mesenteric artery branches, is provided by forming an arte-

rial Y graft from a length of common, internal, and external iliac arteries

retrieved from the donor. The venous drainage is from the portal vein

attached to the pancreas, which is generally anastomosed to the recipi-

ent’s external iliac vein or vena cava; some centres anastomose the vein

to a portal vein tributary, but this is technically challenging and requires a

vein extension graft formed from donor iliac vein.

The drainage of exocrine function is by anastomosis of the attached

duodenum either to the bladder or to a loop of small intestine. Most

complications arise from the unwanted exocrine function of the graft.

Bladder-drained exocrine secretions can cause chemical cystitis, requiring

later conversion to enteric drainage in up to 25%. Exocrine anastomotic

leakage may occur, giving rise to local inﬂ ammation, peritonitis, or pseu-

doaneurysm of the iliac artery.

Post-operative management

Immunosuppression is as for kidney transplantation although higher levels

of immunosuppression, including use of induction antibody therapy such

as alemtuzumab or ATG, is common.

Bladder-drained graft function may be monitored by assay of urinary

amylase; this should be sampled from a 24h urine collection as there is

diurnal variation in amylase secretion. Bicarbonate supplementation is

required for bladder-drained pancreas transplants.

Enteric-drained pancreas transplants may be monitored by serial serum

amylase and lipase levels. Immunological damage to the pancreas is

advanced before changes in blood sugar are recognized.

When the pancreas is transplanted with a kidney, the kidney may be

biopsied if rejection is suspected as it usually affects both organs or the

kidney alone if only one organ is rejected.

Thrombosis of the venous drainage of the pancreas is common, so some

centres routinely anticoagulate pancreas transplant recipients.

Fungal infections are a major problem, so antifungal prophylaxis with

oral ﬂ uconazole is administered for the ﬁ rst week to 10 days or until the

drains have been removed.

PANCREAS AND ISLET TRANSPLANTATION

695

Islet cell transplantation

To avoid the complications associated with the exocrine secretions of

the pancreas, transplantation of the pancreatic islets alone is an attractive

option. The islets are isolated from the retrieved pancreas and prepared

as an infusion to be embolized into the liver via a portal venous catheter

inserted by an interventional radiologist.

Islet cell retrieval is especially feasible from donors with high BMI as the

steatotic pancreas often has a large number of functioning islets, but the

pancreas is inﬁ ltrated with fat and tolerates ischaemia poorly, leading to

severe pancreatitis after reperfusion.

Islet cell transplantation only leads to insulin independence in a minority

of patients, but it usually does improve glycaemic control and hypogly-

caemia is rare. It is therefore an especially good option for diabetics with

hypoglycaemic unawareness.

Complications of islet cell transplantation include portal vein thrombo-

sis and bleeding. Transient elevation of liver enzymes is commonly seen.

Acute rejection does occur, but is impossible to diagnose. Recurrent infec-

tions can increase levels of antibodies, reducing success rates.

CHAPTER 19 Transplantation

696

Liver transplantation

Approximately 700 liver transplants are performed each year in the UK,

but around 14% of patients listed die before being transplanted. The liver

can be split into right and left lobes for transplantation into an adult and

child simultaneously or to allow living donor liver transplants.

Diseases suitable for transplantation

• Hepatitis C cirrhosis.

• Alcoholic liver disease (6 months abstinence before consideration).

• Primary biliary cirrhosis.

• Primary sclerosing cholangitis (excluding cholangiocarcinoma).

• Hepatocellular carcinoma (HCC) in a cirrhotic liver (selected cases).

• Fulminant hepatic failure (e.g. acute viral hepatitis, drug reactions, or

paracetamol overdose).

Clinical indications (also see Table 19.3)

• Acute fulminant liver failure (see Table 19.4).

• Category 1. Expected 1y mortality >9% without liver transplant.

• Category 2. HCC within ‘Milan criteria’ (see Box 19.3).

• Category 3. Variant syndromes affecting quality of life.

Persistent and intractable pruritus.•

Diuretic-resistant ascites.•

Hepatorenal syndrome.•

Hepatopulmonary syndrome.•

Chronic hepatic encephalopathy.•

The transplant procedure

The liver is transplanted on an urgent basis, ideally within 12h of retrieval.

The recipient undergoes removal of the native liver, may be placed on

veno-venous bypass, and then the new liver is implanted in an orthotopic

position, restoring the normal vascular anatomy with the biliary drainage

via an end-to-end choledocho-choledochostomy or a Roux-en-Y hepa-

tico-jejunostomy if the recipient bile duct is diseased.

If the recipient has accessory hepatic arteries, the common hepatic

artery may be insufﬁ cient to perfuse the liver and so arterial conduits can

be fashioned from the donor iliac arteries retrieved with the liver.

Post-operative management

Most commonly, immunosuppression is achieved using combination of

tacrolimus, azathioprine, and steroids. The liver is less prone to acute

rejection than other organs, so immunosuppression can be fairly rapidly

tapered after the immediate post-operative phase.

Hepatic artery thrombosis (HAT) is a common complication, usually

requiring immediate retransplantation, and usually presents as metabolic

acidosis with rising serum lactate levels. Doppler ultrasound scanning is

done as soon as possible after the operation to detect HAT at an early

stage. Administration of platelet transfusions increases the risk of HAT.

Graft survival is 80% at 1y and 60% at 5y.

LIVER TRANSPLANTATION

697

Table 19.3 Monitoring disease progression using a Child–Pugh score.

Patients in class C should be referred for transplantation

• Child–Pugh class B, 5–6 points.

• Child–Pugh class B, 7–9 points.

• Child–Pugh class C, 10–15 points.

1 point 2 points 3 points

Bilirubin (μmol/L) <34 34–51 >51

Albumin (g/L) >35 28–35 <28

Prothrombin time (seconds

prolonged)

1–3 4–6 >6

Ascites None Slight Moderate

Encephalopathy grade None 1–2 3–4

Table 19.4 King’s College criteria for transplantation for acute liver

failure

Paracetamol overdose Other causes

Arterial pH <7.3; OR PT >100s; OR

All three of:

PT >100s;

Creatinine >300μmol/L;

Grade III/IV encephalopathy.

Any three of:

Bilirubin >300μmol/L;

Encephalopathy within 7 days;

PT >50s;

Age <10 or >40;

Drug toxicity.

Box 19.3 The Milan criteria for transplantation for

hepatocellular carcinoma (HCC)

• Child’s class B or C cirrhosis; and

• Single tumour <5cm or up to three tumours <3cm; and

• Absence of macrovascular portal vein invasion.

CHAPTER 19 Transplantation

698

Small bowel transplantation

Small bowel transplantation is rarely performed compared with other

organs, with around 10 per year in the UK. Small bowel may be performed

alone, in combination with a liver transplant, or as part of a multivisceral

transplant.

The results of small bowel transplantation were previously very poor,

but have improved dramatically in recent years. Graft survival at 1y

increased from 52% to 75% between 1997 and 2005, with 1y patient sur-

vival increasing from 57% to 80% over the same time period.

Indications

The main indication is short bowel syndrome with permanent requirement

for parental nutrition; long-term TPN is often associated with liver failure,

so many small bowel transplants are combined with a liver transplant.

Indications for small bowel transplantation are chronic intestinal failure

(most commonly due to Crohn’s in adults) with one or more of:

• Loss of two or more central venous access sites.

• Loss of single venous access site from infection after appropriate

attempts to salvage with aggressive line-conserving treatment.

• Early cholestatic liver disease or portal hypertension.

Successful small bowel transplantation is dependent on adequate central

venous access being available, so potential candidates need to be referred

before loss of all access sites.

Small bowel transplantation may also be considered in patients with

chronic intestinal failure due to disease conditions where survival on

long-term TPN is expected to be poor such as for chronic obstruction,

extremely short bowel (<50cm), and end-jejunostomy without colon.

Combined liver and small bowel transplantation is appropriate for

patients who would be candidates for small bowel transplantation, but

also have advanced liver disease.

Small bowel transplantation is cost-effective, with lower maintenance

costs compared with home TPN and additionally, recipients can normally

resume full normal activities with potential return to employment. Quality

of life is also better than home TPN.

Post-operative management

• Feeding tube inserted to introduce early enteral nutrition.

• Serial video zoom endoscopy to assess mucosa. Villous atrophy is early

sign of acute rejection.

• Endoscopic protocol biopsies to exclude early acute rejection.

• Diarrhoea is main presenting symptom of graft dysfunction, whether

due to rejection, infection, or ischaemia and is investigated by

endoscopy and biopsy.

Acute rejection remains a major concern. It is common as there is a high

population of immune cells in the gut compared with other organs. It is

problematic as acute rejection reduces gut wall barrier function, leading to

sepsis, especially in the context of augmented immunosuppression to treat

SMALL BOWEL TRANSPLANTATION

699

rejection. Rejection is still associated with high risks, both of graft loss and

death, so early diagnosis is the key.

In the long term, most foods can be tolerated although foods high in

simple carbohydrates and soluble ﬁ bre may cause dumping syndrome

symptoms.

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701

Surgery in tropical

diseases

Medicine in the tropics 702

Typhoid 704

Amoebiasis and amoebic liver abscess 706

Anaemias in the tropics 708

Malaria 710

Schistosomiasis (bilharziasis) 712

Filariasis 714

Hydatid disease 716

Ascariasis 718

Leishmaniasis 719

Trypanosomiasis 720

Tuberculosis in the tropics 722

Leprosy (‘Hansen’s disease’) 724

Guinea worm infestation 726

Threadworms 727

Mycetoma (madura foot) 728

Chapter 20

CHAPTER 20 Surgery in tropical diseases

702

Medicine in the tropics

Key facts

Although the principles of surgical care are the same in the tropics as

in developed countries, there are important differences as resources are

limited in the tropics.

• There are major transport problems.

• Treatment is often complicated by underlying disease such as anaemia

and malnutrition.

• There are differences in cultural attitudes to disease, for example:

Stomas are often considered an intolerable burden in some •

societies for religious or cultural reasons.

Sexually-transmitted diseases may carry greater a stigma than in •

the UK.

Treatment

Surgery on tropical diseases requires ﬂ exibility in both clinical manage-

ment and surgical techniques. Doctors, irrespective of where they work,

should be knowledgeable about common tropical diseases and be aware

of the possibility of seeing an imported disease in a patient, with the con-

comitant risks to the patient and the community.

MEDICINE IN THE TROPICS

703

Spending time in tropical medicine

• Find out about where you are going to, the conditions you will work

under, and the local diseases. Be prepared for these conditions.

Visit an occupational service before you go to plan antimalarials

and vaccinations. Discuss with them options for post-exposure HIV

prophylaxis.

• When you arrive, listen to local health care workers. They always

know more than you do.

• Your elective is the perfect time to develop a research mind—look

and ask why things are being done. Develop a relationship with a

more senior doctor and ﬁ nd questions relevant to his/her practice.

However, do not expect to get an awful lot done or make any major

breakthroughs in just a few weeks.

• Beware ‘getting in a bit of practice’. An elective is not designed to

allow you to get in a bit of practice doing things to ‘the natives’ that

you are not allowed to do at home. This is a real risk when Western

medical students go to under-resourced tropical hospitals. By all

means, expand your horizons and use your skills to their limit, but

know your limits and always work within them wherever you are.

• You will always be advised to eat only cooked or peeled food. This

is clearly impossible. However, when the diarrhoea starts, do not sit

on it as you might in more temperate climes. We have twice had to

put up drips on medical students who arrived to spend time working

with us, having had diarrhoea for several days.

• In regions where dengue or malaria occurs, a fever lasting more than

a day requires a visit to a doctor for a blood ﬁ lm and FBC, despite

apparently focal signs such as diarrhoea. Again, don’t sit out a fever

in the tropics. ICUs are not the best places to spend electives.

• The most dangerous time during your time in the tropics is likely

to be time spent travelling. Think before you get on bus, boat, or

plane. Ask yourself: is this a safe form of transport? Can I minimize

the risk in any way? Do not feel ashamed for stopping your journey

and getting out of the vehicle if you realize the risk is signiﬁ cant. You

might meet someone fascinating . . .

• Lastly, show respect for the local culture. It is often difﬁ cult to

appreciate some things and easy to hark back to good things at

home. Careless expression of such thoughts can cause great distress

to people proud of what they have accomplished.

CHAPTER 20 Surgery in tropical diseases

704

Typhoid

Key facts

• Caused by Salmonella (S.) typhi or S. paratyphi (Gram –ve bacilli),

ingested via contaminated food or water (faecal-oral or urine-oral

routes from infected patients or chronic carriers).

• Approximately 33 million cases per year.

• Endemic in whole regions due to inadequate sewage disposal and

contaminated water supplies.

• There are two clinical forms, typhoid and paratyphoid fever,

collectively known as enteric fever.

Clinicopathological features

• Following ingestion, the bacilli penetrate the intestinal mucosa and

multiply within the mesenteric lymph nodes.

• Re-entry into the bloodstream after about 10–14 days causes a bout of

‘typhoid fever’.

• Systemic complications ensue due to haematogenous spread.

• Re-infection of the gut occurs through bile or bacteraemic spread and

the bacilli localize in Peyer’s patches in the lower ileum which become

swollen and red.

• Infection of the bone marrow may cause neutropenia.

Complications of typhoid fever

• Paralytic ileus.

• Intestinal haemorrhage.

• Cholecystitis with perforation. Bacilli in the bile can produce a carrier

state which can cause isolated outbreaks of typhoid fever (‘typhoid

Mary’ was the cook who infected food wherever she worked).

• Infected aortic aneurysm.

• Phlebitis, especially of the left common iliac vein.

• Intestinal perforation along the anti-mesenteric border of the ileum at

the site of Peyer’s patches in the long axis of the gut.

• Genitourinary typhoid.

• Bone and joint infection.

• Myositis and myalgia.

• Parotitis.

• Laryngitis.

• Sinus bradycardia.

Clinical features

• Disease affects older children and young adults with an incubation

period of about 10–14 days.

• Onset is gradual with high fever, headache, abdominal discomfort,

cough, malaise, and anorexia.

• Characteristic stepwise increase in fever occurs over several days and

pea-soup diarrhoea is a feature.

• In severe cases, mental changes can occur with change in conscious

level and psychiatric features. Meningism is also a feature, but

meningitis is rare.

TYPHOID

705

• Maculopapular (‘rose spot’) rash may appear during the second or the

third week, usually on the upper abdominal and lower chest. It fades

within 2–3 days.

Diagnosis

• Widal test (serology).

• Stool culture with selective enrichment media (e.g. McConkey or DCA

agar).

Treatment

• Chloramphenicol is extremely effective, cheap, and readily available

in the tropics, but complications are not uncommon. Works by

destroying the organisms responsible for the production of vitamin B

complex.

• Alternative antibiotics are amoxicillin, trimethoprim, ciproﬂ oxacin (less

available in the tropics and more expensive).

• Treatment of intestinal perforation is surgical, with lavage and closure

of the perforation and IV chloramphenicol.

Prevention Immunization—intradermal or intramuscular doses of killed/

attenuated organism. Often given with parathyphoid immunization. Finite

period of protection may require re-inoculation every 2y.

CHAPTER 20 Surgery in tropical diseases

706

Amoebiasis and amoebic liver abscess

Key facts Amoebic liver abscess is a complication of amoebic hepatitis

secondary to amoebic dysentery.

Pathological features

• Caused by Entamoeba histolytica protozoal infection.

• Cysts ingested from infected water or food.

• Amoebae enter ileal and colonic wall, especially in the ascending

colon, multiply, and enter the portal venous circulation.

• Amoebae that traverse the liver enter the general circulation and

systemic effects may occur.

• Amoebae in the liver destroy liver tissue directly with little or no

tissue reaction (no abscess ‘rim’). Secondary infection may occur.

The central ‘pus’ is characteristically chocolate-coloured due to liver

cell liquefaction and usually also contains staphylococci, streptococci,

Escherichia coli, and Entamoeba histolytica.

Complications

• Infected individuals may be asymptomatic and act as ‘carriers’.

• Intestinal amoebiasis producing dysentery and dysenteric colitis and/or

amoebic appendicitis. Complications include:

Perforation and generalized peritonitis.•

Haemorrhage, bloody diarrhoea, chronic anaemia of blood loss.•

Intussusception.•

• Hepatic amoebiasis and liver ‘abscess’. Complications include:

Intraperitoneal rupture with peritonitis.•

Intrapleural rupture with amoebic empyema.•

Rupture into an attached loop of bowel.•

Rupture into the pericardium.•

• Extraintestinal amoebiasis may be hepatic or cutaneous.

Clinical features

Intestinal amoebiasis

• Fever, anorexia, weight loss.

• Acute or acute-on-chronic diarrhoea (may be bloody).

Hepatic amoebiasis

• Additional night sweats, rigors.

• Fever, anorexia, weight loss.

• Right upper quadrant and lower chest rigidity and tenderness.

• Right shoulder tip pain and right-sided basal changes, including a

pleural rub may also occur.

• Hepatomegaly.

Diagnosis and investigations

• Microscopy and culture of fresh hot stool for amoebae.

• Liver ultrasound to assess number, size, and distribution of abscesses

and allow aspiration of pus.

AMOEBIASIS AND AMOEBIC LIVER ABSCESS

707

Treatment

Medical

• Emetine 40mg IM for 7 days and metronidazole 800mg tds for 7–10

days.

• Repeated abscess aspirations.

Surgical

• Open drainage of abscess that fails to respond.

• Excision of perforated viscera or for uncontrollable haemorrhage.

CHAPTER 20 Surgery in tropical diseases

708

Anaemias in the tropics

Key facts

• The main causes of anaemias are iron deﬁ ciency or secondary to

infections and infestations.

• Others causes include:

Glucose-6-phosphate dehydrogenase deﬁ ciency.•

Thalassaemias.•

Sickle cell anaemia.•

Sickle cell anaemia

Pathological features

• Substitution of valine for glutamic acid at sixth position of the

haemoglobin gamma chain. Leads to sickle cell anaemia if both genes

are affected (homozygotes) or sickle cell trait in single gene carriers

(heterozygotes).

• Sickle cell S-haemoglobin forms crescent-shaped rods when in the

reduced state (deoxygenated).

• High incidence in Africa is because heterozygous carriers are more

resistant than normal to Plasmodium falciparum malaria during early

childhood and hence have a degree of ‘natural selection’ for survival

and passing on their genes.

Clinical features

• Vaso-occlusive episodes precipitated by low O

tension in tissues.

• The abnormally shaped red cells cannot pass through arterioles and

capillaries. Infarction, pulmonary emboli, recurrent infections, and

arthralgia are common. These episodes of vaso-occlusion may also

result from GA.

• Patients with a sickle cell trait have no clinical disabilities, but may

suffer from sickling episodes when at altitude or ﬂ ying in unpressurized

aircraft. Sickling tendency may lead to splenic infarction.

Complications

Susceptibility to infection, in particular, pneumococcal infection, meningi-

tis, and salmonella. Several types of crisis can occur:

• Painful crisis. Typically affects extremities, bones, and joints.

• Organ infarction, e.g. spleen, renal, brain.

• Sequestration crisis. When sickled erythrocytes are sequestrated in the

liver and the spleen, leading to a massive drop in blood volume.

• Aplastic crisis. Loss of red cell production.

Diagnosis and investigations

At-risk patients must be identiﬁ ed before surgical procedures to ensure

adequate oxygenation during GA and to prevent dehydration.

• Carry out a ‘sickling test’ on suspected patients. Add a reducing agent,

e.g. carbon dioxide (CO

), to an unstained drop of blood. Homozygote

blood sickles in a few hours. Heterozygote blood takes up to 24h.

• If the sickling test is positive, ensure adequate oxygenation during GA

and prevent dehydration.

ANAEMIAS IN THE TROPICS

709

Treatment

• During a crisis, the main objective is to keep tissue oxygen tension high

and preventing slow ﬂ ow in vessels, which promotes sickling. This is

achieved by:

Providing analgesia.•

Keeping the patient fully hydrated.•

Keeping the patient warm (especially the peripheries).•

Giving supplemental O•

(high ﬂ ow or even hyperbaric) if possible.

Giving antibiotics to prevent secondary infection.•

• Following a crisis, give the patient folic acid (5mg per day) to ensure

red cell production is not inhibited by inadequate levels.

CHAPTER 20 Surgery in tropical diseases

710

Malaria

Key facts

• Endemic in Africa, South East Asia, and South America.

• Attempts to eradicate it have been unsuccessful because of economic

factors and the development of resistance to drugs.

Malaria can present as an acute abdomen with pain, pyrexia, and vomiting.

Consider it when other causes of abdominal pain have been excluded,

especially in patients who have recently returned from the tropics who

have not taken antimalarial prophylaxis.

Pathological features

• The causal organisms are:

Plasmodium (P.) falciparum• . Malignant tertian malaria.

P. vivax• . Benign tertian malaria.

P. ovale• . Benign tertian malaria.

P. malariae• . Quartan malaria.

• Transmission is by the anopheline mosquito, the female alone of

which bites. The mouthpiece (full of organisms) inoculates the skin by

repeated bites.

• Parasites enter into red blood cells and divide.

• The incubation period is 10–14 days before multiplying organisms

enter the bloodstream and cause clinical disease.

• Organisms may be cleared from the circulation by the immune system,

but eradication of those within the red cells is rarely possible without

drug treatment and repeated episodes of systemic infection are

characteristic of all forms of malaria (e.g. every 3 days = ‘tertian’; every

4 days = ‘quartan’).

• Chronic carriage of organisms may occur with repeated episodes of

illness, eventually causing immunosuppression and debility.

• Infected red cells may be removed from circulation by the spleen and

liver, which may carry a particularly heavy load of organisms.

Clinical features

The fever of malaria is characteristically:

• Intermittent.

• Associated with sweating, chills, and rigors.

• Followed by an afebrile period.

Complications

Complications are more likely with more virulent species, especially P.

falciparum.

• Increased blood viscosity during attacks/’crises’ may lead to

microvascular infarction of organs such as:

Brain (cerebral malaria).•

Kidney (renal failure with haemoglobinuria—‘blackwater fever’).•

Liver (jaundice and even acute hepatic failure).•

• Increased haemolysis of infected red cells leading to:

Haemolytic anaemia.•

Haemoglobinuria.•

MALARIA

711

Diagnosis and investigations

This is based on a history of exposure (e.g. tourists) and the clinical fea-

tures with microscopy of bloodstained smear which increases the chance

of ﬁ nding parasites.

• Microscopy and culture of fresh hot stool for amoebae.

• Liver ultrasound to assess number, size, and distribution of abscesses

and allow aspiration of pus.

Treatment

Medical

Prophylaxis

All visitors to areas of endemic disease must be advised to take full prop-

hylaxis. The recommended regimen depends on the predominant species

and the presence of resistant strains.

Uncomplicated malaria

A 3-day course of the antimalarial drug, chloroquine 600mg PO, imme-

diately followed by 300mg PO qds for 3 days, then 300mg PO daily for

2 days.

Complicated malaria

• Should always be managed in a hospital with experience and

appropriate facilities, if possible.

• Begin active rehydration immediately (IV crystalloid).

• Quinine hydrochloride 600mg IV over 10min every 8h for 7–10 days.

• Blood transfusion for anaemia.

• IV steroids for cerebral malaria.

• Monitor renal function.

Prognosis Untreated vivax malaria subsides in 10–30 days, but may recur

intermittently. Intercurrent infection worsens the prognosis. Untreated

falciparum malaria is frequently fatal.

CHAPTER 20 Surgery in tropical diseases

712

Schistosomiasis (bilharziasis)

Key facts Endemic in many parts of north Africa, the Middle East, and

South East Asia.

Pathological features

• Caused by the helminths, Schistosoma (S.) haematobium, S. mansoni

(Africa), or S. japonicum (Asia).

• Infestation occurs from standing in infected water. The intermediate

host is a snail (bullinus contortus) that inhabits slow running water.

• Multiplication of the larvae occurs in the snail; they then become free

swimming and enter the human victim. After shedding their tails, they

are swept by the bloodstream to all parts of the body. The worms

have a particular preference for some sites according to their species.

• S. haematobium has an afﬁ nity for the vesical plexus, i.e. are mostly

found in the urinary bladder and ureter. S. mansoni and S. japonicum

have an afﬁ nity for the mesenteric veins and biliary tree, i.e. cause

intestinal disease.

• Those that reach the liver develop into male and female worms, living

in erythrocytes and when they mature, they leave the liver via the

bloodstream to reach the vesical venous plexuses. The worms mate

and the ova pass into the urine and faeces where they pass out and

infect new water (especially stagnant). After hatching, the larvae enter

the snail within 24h.

Clinical features and complications

• Intestinal worms cause:

Intestinal ulcers with bleeding, leading to abdominal pain and •

distension (due to ascites).

Perforation with peritonitis.•

Pseudopolyps and inﬂ ammation, leading to bloody diarrhoea;•

Chronic malabsorption and malnutrition.•

Liver ﬁ brosis (periportal), leading to portal hypertension.•

• Systemic infection may affect:

Brain, causing malaise and fever.•

Lungs, causing dyspnoea.•

Spinal cord, causing paralysis.•

• Bladder worms produce:

Inﬂ ammation of mucosa and slough (dysuria, frequency, •

haematuria).

Obstruction of the urinary tract (hydronephrosis).•

Squamous carcinoma of the bladder is associated with long-term •

carriage.

Diagnosis and investigations

• Microscopic examination of an early morning urine or faecal specimen

can demonstrate the presence of living eggs.

• Histological examination of a biopsy from the bladder or rectal

mucosa can also provide conﬁ rmation of infection.

SCHISTOSOMIASIS (BILHARZIASIS)

713

Treatment

Medical

Antimony preparations may be used in the early stages. Metrifonate and

praziquantel are the most effective. It can take many months before the

dead worms are expelled.

Surgical

Surgical intervention is necessary when complications such as portal

hypertension, urethral stricture, or peritonitis after perforation develop.

CHAPTER 20 Surgery in tropical diseases

714

Filariasis

Key facts

• Caused by a range of nematode worms, including Wuchereria bancrofti,

Onchocercia volvulus, and Brugia malayi.

• Widespread in tropical and subtropical areas (India, Africa, China, the

West Indies, and Australia).

Clinicopathological features

• Transmitted to humans by the bite of many genera of mosquitoes.

• Wuchererial worms enter the lymphatic system and cause:

Acute lymphangitis. Acute, swollen, painful lymphatics and nodes.•

Chronic lymphadenitis and lymphatic obstruction. Especially of the •

lower limbs and genitalia—‘elephantiasis’.

• Onchocercial worms may reach the eye (especially in African disease)

and cause disruption of the intraocular tissues—‘river blindness’.

Diagnosis Is usually clinical.

Treatment

Acute lymphadenitis

• Rest the affected part.

• Antibiotics (ampicillin 500mg by IM injection bd for 10 days) are used

to treat secondary infection caused by beta-haemolytic streptococcus

and Staphylococcus aureus.

• Speciﬁ c antiﬁ larial drugs, diethylcarbamazine citrate (Hetrazan

Banocide

), start at 1mg/kg orally tds for 3 weeks.

• Surgical drainage of abscesses when they occur.

Chronic lymphoedema (‘elephantiasis’)

There is no satisfactory operation. Abnormal subcutaneous tissue can be

excised and the affected part covered with a split skin graft. One variation

is to excise the skin of the leg in long strips and then excise the subcutane-

ous tissue and apply skin to the denuded tissue. Apply a plaster of Paris

dressing. The results are satisfactory, but certainly not cosmetic.

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CHAPTER 20 Surgery in tropical diseases

716

Hydatid disease

Key facts Occurs in sheep- and cattle-raising areas of the world, e.g.

rural Wales, New Zealand, and not just the tropics.

Clinicopathological features

Pathological features

• Caused by the larval forms of the cestode worms, Echinococcus

granulosus and Echinococcus multinodularis.

• Dogs are usually the primary host, eating infected sheep or cow offal,

and the echinococcus parasite, about 1cm long, develops in the dog’s

intestine.

• It consists of a head and three segments, the last of which contains

hundreds of ova. These are passed on to grass, for example, by

defecation.

• Sheep and cattle ingest the ova to complete the normal life cycle.

Humans are an incidental ‘dead end’ host, but the ova penetrate the

small intestine and enter the portal circulation.

• Eighty per cent of the ova thrive in the liver with the development of

hydatid cysts.

• They may also enter the general circulation, forming cysts elsewhere

(e.g. kidneys, lungs, brain).

Clinical features/complications

• Infection is usually contracted in childhood, but produces symptoms

and signs in adult life.

• Commonest presentation is of a liver cyst (either found as a palpable

mass, incidentally on CT scanning, or during abdominal surgery).

• Compression of the intrahepatic bile ducts may produce jaundice.

• Rupture of a cyst into the peritoneal cavity causes peritonitis and

shock. Cyst ﬂ uid also causes a severe allergic reaction with urticaria

and eosinophilia if it enters the circulation (either by spontaneous

rupture or surgical intervention).

• The prognosis is poor.

Diagnosis

• Casoni’s test (serum antigen) is positive in 80%, but gives many false

positives.

• Indirect haemagglutination tests are most accurate.

• Ultrasound and CT scanning may be used to localize cysts.

• ERCP may demonstrate connections with or compression of the bile

ducts.

Treatment

Medical

Mebendazole 400mg tds for 30 days.

Intraperitoneal rupture

• Treat shock.

• Carry out peritoneal toilet.

• Give hydrocortisone before, during, and after surgery.

HYDATID DISEASE

717

Surgical

Excision or aspiration of the cyst(s).

• Extreme caution must be taken to prevent peritoneal contamination.

Black packs soaked in hypochlorite are placed around the liver to

show up any daughter cysts or scolices.

• The cyst is partially aspirated and partially reﬁ lled with hypertonic

saline which is scolicidal. It is then carefully separated from the liver

and the cavity closed or drained.

• Give mebendazole post-operatively.

Prevention Community hygiene projects to reduce the risk of humans

being exposed to infected dog faeces in areas of endemic disease.

CHAPTER 20 Surgery in tropical diseases

718

Ascariasis

Key facts

• Caused by the nematode roundworm, Ascaris lumbricoides.

• Common in eastern and south eastern Africa, Sri Lanka, southern and

south eastern India, and Bangladesh.

• The incidence of the condition is related to the state of development

of the sewage systems.

Clinicopathological features

• Oral infection may occur in children or adults.

• Worms cross the intestinal wall and remain in the GI tract.

• Entry into the circulation may lead to systemic spread to other organs,

e.g. liver, lungs, upper aerodigestive tract, blood.

• Intestinal infection causes:

Abdominal colicky pain and indigestion.•

Diarrhoea.•

Obstructive appendicitis.•

Intestinal obstruction due to inﬂ ammation and impaction of a •

‘worm mass’ or intussusception that may present as a mobile

abdominal mass.

Protein-losing enteropathy with hypoproteinaemia and bleeding, •

leading to anaemia.

• Lung infestation may cause severe pneumonitis.

• Bile duct or pancreatic infestation may cause:

Bile duct strictures.•

Liver abscess.•

Cholangitis and empyema of the gall bladder.•

Diagnosis

• Ova are demonstrated by examination of hot fresh stools.

• A plain AXR or barium meal may demonstrate radiolucent lines within

a dense shadow, which represent individual worms.

Treatment

Medical

• Piperazine, one dual dose sachet repeated after 14 days (adults), one-

third sachet (age 3–12 months), two-thirds sachet (age 1–6y), 1 sachet

(age >6y). Causes ﬂ accid paralysis of roundworms and threadworms

and permits their expulsion by peristalsis.

• Mebendazole, 100mg bd for 3 days (adults and children >2y).

Immobilizes the worms by disrupting their transport systems.

Surgical

• Abdominal surgery is only indicated for obstruction or peritonitis.

• If intestines are not inﬂ amed, the worm load is squeezed into the

caecum and colon where it will be removed by peristalsis. Alternatively,

remove it via an enterostomy. Any non-viable gut is resected.

• Biliary infestation may be treated by antispasmodics to allow the

sphincter to relax and then kill the worm load with antihelminthics or

removal by ERCP or laparotomy.

LEISHMANIASIS

719

Leishmaniasis

Key facts A spectrum of diseases caused either by the direct effects of

infestation by protozoans of the Leishmania group or the type IV delayed

hypersensitivity to the presence of the organisms.

Clinicopathological features

• The common route of infection is by bites from infected sand ﬂ ies.

• The organisms spend their life cycle in the cytoplasm of circulating

macrophages.

• Causative organisms include:

Leishmania (L.) donovani.• Visceral leishmaniasis (‘kala-azar’, Indian

subcontinent).

L. tropicana, braziliensis, mexicana. • Cutaneous leishmaniasis.

L. brasiliensis brasiliensis, tropica Ethiopia. • Mucocutaneous

leishmaniasis (‘espundia’, South America and Africa).

Cutaneous leishmaniasis

• May be a simple sore at the site of ﬂ y bite with primary healing.

• May become a systemic infection if immune response poor.

• Severe type IV hypersensitivity reaction causes multiple skin ulcers

(‘recidiva’).

Visceral leishmaniasis (kala-azar)

• An infection of the reticuloendothelial system with enlargement of the

liver, spleen, and lymph nodes.

• May cause splenomegaly and pancytopenia if there is marrow infection.

• Secondary dermoid leishmaniasis occurs in failing immunity and is

highly infectious.

Mucocutaneous leishmaniasis

• Affects the skin and subsequently the mucous membranes of the

mouth and nose, causing nodules and ulceration.

• Large ulcers on the skin of the face and destruction of skin and

cartilage are referred to as ‘Chiclero’s ear’.

Diagnosis

• Bone marrow aspiration.

• FNA of the spleen or liver.

• Complement ﬁ xation test.

• Leishmania skin test (Montenegro).

Treatment

• Cutaneous leishmaniasis often heals spontaneously, but when skin

lesions are extensive, treat with sodium stibogluconate, an antimony

compound in a dose of 20mg/kg/day by IM or IV injection for 20 days.

• Treat skin lesions for 10 days.

• Use amphotericin in unresponsive cases (AmBisome

1–3mg/kg daily

for 10–21 days). Cautions include hepatic impairment and pregnancy.

CHAPTER 20 Surgery in tropical diseases

720

Trypanosomiasis

Key facts

• Caused by infection with ﬂ agellate protozoa of the Trypanosoma group.

• Two main sites of infection are South America and Africa.

Clinicopathological features

• Causative organisms are:

Trypanosoma (T.) brucei rhodensiense• (east African). ‘Sleeping

sickness’.

T. brucei gambiense• (west African). ‘Sleeping sickness’.

T. cruzi• (South American). ‘Chagas’ disease’.

• Transmission is by bites of infected tsetse ﬂ ies in sleeping sickness or

from infected faeces from small ‘bedbugs’ entering the mouth or eye in

Chagas’ disease.

Sleeping sickness

• Bite site develops primary chancre/ulcer.

• Parasitaemia results in acute lymphadenitis (often cervical—

‘Winterbottom’s sign’).

• Progressive waves of parasitaemia cause successively less effective

immune responses with IgM and eventual failure of the immune

response with widespread systemic parasite infestation.

• CNS infection leads to:

Spasm and tremor.•

Discoordination.•

Spastic and ﬂ accid paralysis.•

Unrousable sleep, progressing to coma and eventually death.•

Chagas’ disease

• Acute ﬂ u-like illness following infection. Lymphadenopathy and

splenomegaly may occur.

• Eventual systemic parasite infection has a predilection for autonomic

and neural crest derived nervous tissue, for example:

Enteric nervous system destruction leads to ‘megaoesophagus’ and •

‘megacolon’.

Myocardial infection causes myocarditis.•

Cardiac conducting system destruction leads to ventricular •

aneurysm formation, dysrhythmias, and sudden death syndrome.

Diagnosis

• Wet blood ﬁ lm showing viable parasites.

• FNAC of lymph nodes and/or lumbar puncture may reveal organisms.

Treatment

Medical

• Suramin 0.1–0.2g initially. If there is no renal impairment, 1g every 5–7

days to a maximum of 10g.

• Pentamidine 3–4mg/kg daily for 10 days.

Surgical Rarely required for complications of Chagas’ disease (e.g. cardiac

or intestinal surgery).

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CHAPTER 20 Surgery in tropical diseases

722

Tuberculosis in the tropics

Key facts

• Caused by Mycobacterium tuberculosis.

• In the tropics, chronic malnutrition and associated immunosuppression

lead to more acute illness, more rapid advancement of disease, and

presentation at a much more advanced stage.

• Intestinal TB is much more common in tropical presentations.

Clinicopathological features

Infection routes include:

• Infection from food contaminated with the bacilli.

• Swallowed sputum containing bacilli.

• Bacteraemic phase of primary lung infection.

Features of intestinal disease

• May affect the terminal ileum, mesenteric lymph nodes, omentum,

peritoneum, and solid organs related to the GI tract.

• Low grade fever with night sweats, malaise, anorexia, and weight loss.

• Dull abdominal pain and abdominal distension.

• Ascites.

• Rectal examination may reveal ﬁ stulas or ﬁ ssures.

Pathological types

• Ulcerative. Deep, transversely placed ulcers in the direction of the

lymphatics that may cause perforation and peritonitis.

• Hyperplastic. Fibroplastic reaction, resulting in thickening of the bowel

wall along the mesentery and affecting the lymph nodes and the

omentum, which may lead to malabsorption.

• Sclerotic. Associated with strictures in the small intestine, leading to

intestinal obstruction.

Diagnosis

• FBC. i WCC (lymphocytosis).

• Barium meal and follow-through may show intestinal strictures or

ulcers that may be indistinguishable from those of Crohn’s disease as

seen in temperate climates.

• Ultrasound and CT scanning may suggest inﬂ ammatory masses

(typically in the right iliac fossa).

• Intestinal tissue biopsies may demonstrate caseating granulomas.

Treatment

Medical

Antituberculous therapy:

• Streptomycin, 15–20mg/kg IM daily (unlicensed in UK).

• Isoniazid, 7–10mg/kg daily for 12 months.

• Rifampicin, 10mg/kg for 6 months.

Surgical Laparotomy for peritonitis due to perforation, obstruction, or

unresolving inﬂ ammatory masses.

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CHAPTER 20 Surgery in tropical diseases

724

Leprosy (‘Hansen’s disease’)

Key facts

• Endemic in much of Africa, Southern Asia, the Far East, and South

America.

• Affects about 15 million people.

Clinicopathological features

• Caused by the acid-alcohol fast bacillus, Mycobacterium leprae.

• Commonly contracted in late childhood or adolescence, the likely

source of infection being nasal discharge from infected patients (rather

than open skin lesions).

• Inﬁ ltration of nasal membranes leads to very slow systemic spread

(incubation period of 3–5y).

• Bacilli eventually inﬁ ltrate areas of the body at lower than normal

temperatures (especially dermis, upper respiratory tract, and

peripheral nerves), although central organs (e.g. liver, bone marrow,

kidneys, and spleen) may be involved, especially later in the disease.

• Patterns of disease depend on the degree of host cell-mediated

immune (CMI) reaction:

Poor CMI.• Lepromatous leprosy (LL). Highly infectious; open

ulcerating lesions contain macrophages loaded with bacilli.

Modest CMI.• Dimorphous/indeterminate leprosy (BB). Features

of both types (loss of CMI leads to LL, but treatment produces

TT-type disease).

Good CMI.• Tuberculoid leprosy (TT). Pronounced lymphocytic

inﬁ ltration of lesions causing scarring; nerve damage is prominent

feature.

Clinical features

Consider the diagnosis of leprosy in any patient who presents with a com-

bination of neural and dermatological disorders.

• Lepromatous leprosy.

Dermal changes. Typically widespread hypopigmented and •

erythematous rash affecting the face, limbs, and trunk.

Generalized malaise, fever, and arthralgia.•

Neural lesions. Often widespread neuritis followed by nerve •

thickening and progressive neuropathic tissue injury and ulceration

due to anaesthesia.

Associated iritis is common.•

Systemic amyloidosis may occur.•

• Tuberculoid leprosy.

Dermal changes. Typically focal destruction of melanocytes •

(hypopigmentation), hair follicles, sweat and sebaceous glands (dry,

hairless, anaesthetic plaques of tissue).

Neural lesions. Isolated, thickening of nerves (e.g. ulnar, peroneal), •

with late and relatively limited deformity.

LEPROSY (‘HANSEN’S DISEASE’)

725

Diagnosis

Diagnosis is based on:

• A history of contact.

• The clinical ﬁ ndings.

• Histological conﬁ rmation of Mycobacterium leprae.

In practical terms, infected tissue is usually obtained by taking a smear with

a scalpel blade inserted into the pinched skin of an affected eyebrow or

earlobe. The tissue ﬂ uid obtained is stained with a modiﬁ ed Ziehl–Nielsen

stain.

Treatment

Medical

• Dapsone (diaminodiphenysulphone) 50–100mg daily.

• Combination chemotherapy is often used to reduce the incidence of

dapsone resistance, for example:

Rifampicin 600mg once per month.•

Dapsone 100mg daily.•

Clofazimine 50mg daily + 300mg once per month.•

• Continue treatment for at least 2y and often required for life.

• Contacts receive BCG vaccination or prophylactic dapsone.

Surgical

Surgical treatment is indicated to correct deformities which may be:

• Primary. Caused directly by the disease, e.g. thickening of the skin,

paralysis of the eyelids, paralysis of the hands and feet.

• Secondary. Due to neuropathic injury. Education of the patient in

avoidance of injury and self-care is vital to prevent progressive injury

since damaged nerves may be permanently anaesthetic.

Severely damaged limbs may require amputation.

CHAPTER 20 Surgery in tropical diseases

726

Guinea worm infestation

Key facts This freshwater-borne disease is common in the Middle East,

South East Asia, certain parts of Africa, and India.

Clinicopathological features

• Contracted from drinking fresh water contaminated by the arthropod,

Cyclops, which contains the larva of the guinea worm (Dracunculus

mediensis).

• Stomach and upper small bowel lining is infected with the larvae.

• Direct spread occurs to the connective tissue of the abdominal wall

where larvae mature and mate.

• Females then migrate to the areas of the body likely to be submerged

in water, such as the lower leg, where the eggs are laid.

• The worm produces a proteolytic toxin, which leads to blister

formation. When the blister bursts, the worm physically extrudes to

allow the cycle of water re-infection to complete.

Clinical features Usually present as blistering rash on the legs with visible

worm in the base.

Complications

• The subcutaneous worms may cause cellulitis, abscess, and sinus

formation.

• Systemic infection can result in allergic conjunctivitis, osteomyelitis, or

arthritis.

Diagnosis When the worms die, they may be visible as calciﬁ ed areas

in the subcutaneous tissue of the soles of the feet, legs, groin, scrotum,

and back.

Treatment

The worms must be removed from their subcutaneous cavities slowly.

A sudden pull will break the worm and leave the remaining part needing

surgical removal.

Slow, progressive winding of the exposed worm around a small stick

over several days is usually successful.

THREADWORMS

727

Threadworms

Key facts Endemic in tropical and temperate climates.

Clinicopathological features

• Caused by infestation by the round nematode, Enterobius vermicularis.

• Caught by ingestion of food or water infected by worm ova.

• Typically spreads throughout a family, especially one with young

children.

• Worms live in the lumen of the lower colon and rectum and often

migrate to the anal margin at night.

Clinical features

• There is chronic, and sometimes severe, anal irritation with associated

excoriation of the perianal skin. It may be confused with other perianal

disease and should be considered, particularly in children.

• Vaginitis and urethritis are associated complications.

Diagnosis

• Proctoscopy and sigmoidoscopy often reveal the worms in the colonic

mucosa.

• A mucosal smear can be taken, but is usually unnecessary once the

worms have been visualized. This is done using a wooden spatula to

the end of which adhesive tape has been applied, adhesive surface

outwards. The skin or mucosa is touched with the tape and smeared

on to a slide, thus enabling the diagnosis to be made.

Treatment

Treat the whole family.

• Piperazine, one dual dose sachet repeated after 14 days orally for

adults, one-third sachet (3 months–1y), two-thirds sachet (1–6y), one

sachet (>6y); or

• Mebendazole 100mg orally repeated after 2–3 weeks (>2y).

CHAPTER 20 Surgery in tropical diseases

728

Mycetoma (madura foot)

Key facts

• Caused by a subcutaneous fungal infection.

• May be caused by different species with different colours of spores,

but the clinical picture is remarkably uniform.

Clinicopathological features

• The ﬁ rst sign is a painless swelling in the foot that gradually develops

multiple sinuses and sometimes discharges purulent material containing

the grains of the fungus.

• Local spread may occur if the primary infection is not treated, leading

to deep tissue infection, e.g. fungal osteomyelitis.

• Systemic fungal infection is rare.

Diagnosis Microscopy of the discharge shows fungal hyphae.

Treatment

Medical treatment Dapsone, co-trimoxazole, streptomycin, and rifampicin

are used either alone or in combination.

Surgical treatment

• All the affected area, including all sinuses, must be excised once

treatment has begun.

• Amputation is occasionally necessary if deep osteomyelitis has

occurred.

729

Common operations

Diagnostic laparoscopy 730

Principles of laparotomy 732

Cholecystectomy 734

Appendicectomy 736

Inguinal hernia repair 738

Perforated peptic ulcer repair 740

Haemorrhoid surgery 742

Pilonidal sinus excision (Bascom II) 744

Femoral embolectomy 746

Right hemicolectomy 748

Stoma formation 750

Wide local excision—breast 752

Below knee amputation 754

Chapter 21

CHAPTER 21 Common operations

730

Diagnostic laparoscopy

Indications (typical)

Acute/emergency

• Lower abdominal pain with suspected acute appendicitis (see b

p. 298) or ruptured ovarian cyst.

• Upper abdominal pain with suspected perforated peptic ulcer (see b

p. 284).

Elective

• Investigation of subfertility.

• Investigation of chronic abdominal pain.

• To perform biopsy (e.g. omental or lymph node) in suspected

malignancy.

Pre-theatre preparation

• Always GA, therefore NBM 2h and ﬂ uids only 4h preop.

• Group and save required.

• Ensure consent is obtained for proceeding to other procedures if they

are anticipated.

Positioning and theatre set-up

• Urethral catheterization. Usual, especially if lower abdominal pathology/

assessment likely, to ensure the bladder is decompressed.

• NGT. NOT required unless the patient is vomiting or gastric

distension/surgery is likely.

• Table positioning. Supine. It is always best to have the patient in

leg extensions. They allow the perineum to be accessed if vaginal

manipulation or lower GI endoscopy is needed and they help to

secure the patient on the table if head downtilt or lateral role is

required.

• Monitor/stack position. Depends on the expected pathology.

Steps of surgery

• Incision. Periumbilical; usually curved infra-umbilical although supra-

umbilical is also used. Vertical infra-umbilical can be used, especially

where conversion to a midline laparotomy is anticipated.

• Exposure of the linea alba. By sharp dissection.

• Incision of linea alba. Elevate with forceps and incision with scalpel

(no. 11 or 15).

• Open trochar insertion. Elevate linea alba with forceps, blunt scissor

opening of pre-umbilical fat pad and peritoneum and placement of

trochar (blunt) or:

• Blunt trochar insertion. Elevate linea alba with forceps without a small

initial incision, insert trochar (blunt or with visual assistance using

laparoscope inside the port) or:

• Verres needle insertion. Elevate linea alba with forceps, insert Verres

needle using only thumb and ﬁ nger pressure until ‘clink’ felt, test for

intraperitoneal placement with saline ‘drop’ test.

DIAGNOSTIC LAPAROSCOPY

731

• Insufﬂ ation. CO

typical pressure between 12–15mmHg; use slow ﬂ ow

initially, check for low pressure ﬂ ow before increasing ﬂ ow rate.

• Assessment. Inspect area beneath insertion port for signs of visceral

injury or bleeding, assess anterior abdominal wall for availability of

further port sites, inspect viscera sequentially.

Closure

Port sites 10mm and above require musculofascial closure, 5mm ports

do not.

Post-operative care and instructions

• Remove catheter unless required for post-operative ﬂ uid balance

observation.

• Antibiotics. Only required for pathology found.

• Oral diet. Normal as soon as tolerated.

Complications (speciﬁ c to the procedure)

• Port site infection, <5%.

• Port site herniation, <2% if closed.

• Visceral injury during port insertion/basic laparoscopy and assessment,

<1%.

CHAPTER 21 Common operations

732

Principles of laparotomy

Laparotomy is the term for any open access to the peritoneal cavity and

includes midline incisions as well as paramedian and oblique approaches. It

is the traditional method of access for most visceral surgery. It is still the

approach of choice for some trauma, many emergency presentations, and

some extensive surgery.

Pre-theatre preparation

• All, but smaller lower abdominal incisions which may be performed

under regional or ﬁ eld block LA, require GA.

• Group and save or cross-match, depending on procedure.

• Ensure consent is obtained for other procedures if anticipated.

Positioning and theatre set-up

• Urethral catheterization. Usual, especially if lower abdominal

pathology/assessment likely, to ensure the bladder is decompressed.

• NGT. Usual for upper intestinal obstruction (to reduce risk of

aspiration at induction).

• Table positioning. Several are possible (see b p. 76).

Supine.• Most common for open visceral surgery (e.g. small and large

bowel, gastric and major arterial).

Lloyd Davis• (supine with hips slightly ﬂ exed and abducted). Used

where access is required to the peritoneal cavity and the perineum/

anorectum.

Lateral.• For combined approaches to the retroperitoneal structures.

Steps of surgery

• Skin incision. Scalpel or cutting diathermy with needle point electrode.

• Fat incision. Blend diathermy to reduce risk of bleeding.

Midline access (see b p. 82)

• Midline fascia (linea alba) incision. At or above the umbilicus (pre-

peritoneal fat reduces the risk of underlying bowel injury). The midline

can be identiﬁ ed by the presence of oblique crossing/interleaved fascial

ﬁ bres. Expose fascia, elevated with clips to generate negative intra-

abdominal pressure and sharply incised.

• Access extension. With blend diathermy in the midline.

Paramedian access

• Rectus sheath fascia incision. Vertical with blend diathermy.

• Rectus muscle. Fibres separated with minimum muscle division.

• Peritoneal incision. Elevated between clips and sharply incised.

• Access extension. With blend diathermy vertically.

Oblique access (e.g. gridiron, subcostal)

• Rectus sheath fascia incision. Oblique with blend diathermy.

• Muscle. For small incisions, ﬁ bre separation may achieve adequate

access; this may be multiple layers (e.g. gridiron) or single (e.g.

mini-subcostal). For larger incisions, muscle division with coagulation

diathermy is required (e.g. full subcostal).

PRINCIPLES OF LAPAROTOMY

733

Basic procedures

• Assessment of ‘non-target’ viscera. Traditionally performed, but less

important with preoperative imaging (especially CT scanning). Done

in logical progression, e.g. central (small bowel, omentum, transverse

colon), left upper quadrant (LUQ) (spleen, stomach), right upper

quadrant (RUQ) (liver, gall bladder), right ﬂ ank (right colon, right

kidney), pelvis (bladder, uterus, ovaries, rectum), left ﬂ ank (left colon/

kidney).

• Assessment of ‘target’ organ(s). Depends on pathology expected, but

consider these issues—‘resectability’ (tethering/involvement of vital,

non-resectable structures), extent of resection (length or additional

organs/structures to remove), mobility (adequate approximation of

structures to be joined).

Specimens

• Ascites (free ﬂ uid). Send for M,C,&S; send for cytology if suspected

malignancy.

• Pus. Send for M,C,&S (as liquid specimen if possible) or swab.

• Peritoneal tissue. Excise or biopsy peritoneal tissue nodules (parietal or

visceral).

Key principles of emergency laparotomy

• Bleeding. Control by pressure (packs) initially rather than direct closure

(clips or sutures); remove packs, starting with those least likely to

cover bleeding sites; allow anaesthetic ‘catch up time’.

• Multiple visceral injuries. ‘Close and control’ rather than ‘restore and

join’. Preventing contamination and visceral leakage are required, but

restoration of anatomy/physiology can be deferred to subsequent

procedures.

• Contamination. Seek out and treat all areas of pus/contamination.

Frequently overlooked areas are subphrenic, subhepatic, interloop

ileal, pelvic. Wash should be warm, copious, and repeated sequential

dilutions rather than a single large washout. Large calibre drains for

heavily soiled areas (likely to recollect), consider repeat (‘re-look’)

surgery in 24–48h.

Closure

• Peritoneum. Should be approximated where possible (reduces risk

of adhesions to exposed muscle) with absorbable suture; may be

included with musculo-fascial closure (e.g. mass closure).

• Muscle ﬁ bres. Where parted—will usually re-approximate without

sutured closure; where slit—may require absorbable sutures.

• Fascia. Always closed, usually heavy absorbable sutures, but may be

non-absorbable.

• Skin. Sutures (subcuticular or interrupted) or clips.

Complications (speciﬁ c to the procedure)

• Wound infection, 2–30%, depending on pathology.

• Incisional hernia, up to 30%; affected by sepsis, malnutrition, age.

CHAPTER 21 Common operations

734

Cholecystectomy

Simple cholecystectomy (removal of gall bladder and proximal cystic duct)

is restricted to benign disease.

Open approach (elective) is usually only indicated for common bile duct

exploration where laparoscopic exploration is not possible.

Indications (typical)

• Symptomatic proven gallstones.

• Symptomatic congenital abnormalities of the gall bladder.

• Previous acalculous cholecystitis.

• Very rarely indicated for prophylaxis in individuals at risk of

cholecystitis (congenital heart disease, immunosuppressed).

Pre-theatre preparation

• Always GA, therefore NBM 2 h and ﬂ uids only 4h preop.

• Group and save required.

• Ensure consent is obtained for proceeding to other procedures if they

are anticipated (e.g. common bile duct exploration).

• Check LFTs and any previous ERCP/MRCP imaging has been reviewed.

Positioning and theatre set-up

• Urethral catheterization; NGT NOT required.

• Table positioning. Supine. Some surgeons prefer to stand between the

legs for the dissection (requires the patient in leg extensions).

• Monitor/stack position. LUQ.

• Patient may be placed slightly head up and left side down to improve

RUQ exposure.

Steps of surgery

• Establish laparoscopy (see b p. 730) if appropriate.

• Incision for open surgery. Right subcostal (‘Kocher’s’) with (partial)

division of upper right rectus muscle.

• Expose gall bladder neck, cystic duct and common bile duct (‘Calot’s

triangle)—fundal traction. Tip: if exposure is poor, try adding further

5mm ports for retraction and ask for another assistant.

• Identify cystic duct origin from gall bladder neck by blunt dissection.

• Identify cystic artery by blunt dissection.

• Clip (or tie if open) cystic duct (2 distal, 1 or 2 proximal on gall

bladder neck) and divided. Repeat for cystic artery.

• Dissect gall bladder from liver ‘bed’ by retrograde dissection (i.e. from

neck to fundus). Dissection is carried out close to the gall bladder wall.

• Gall bladder retrieved (usually in a waterproof bag if laparoscopic via

epigastric port).

• Check haemostasis.

Closure

• Port sites (see Fig. 21.1). See laparoscopy (see b p. 730).

• Open. Usually closed in layers (peritoneum, (musculo)fascial, and skin).

CHOLECYSTECTOMY

735

Post-operative care and instructions

• Remove catheter unless required for post-operative ﬂ uid balance

observation.

• Antibiotics. Only required for pathology found (e.g. cholecystitis).

• Oral diet. Normal as soon as tolerated.

Complications (speciﬁ c to the procedure)

• Port site infection, <5%.

• Bleeding, 2%.

• Conversion to open surgery (if laparoscopic), 2% (depends on gender,

age, sex, previous inﬂ ammatory episodes, previous abdominal surgery).

• Visceral injury during port insertion/basic laparoscopy and assessment, 1%.

• Common bile duct injury, 1 in 300.

CBD

CHD

(a)

(b)

Fig. 21.1 (a) Ports sites for laparoscopic cholecystectomy. (b) View of Calot’s

triangle after dissection prior to structure division. (Borders: LS, liver surface; CHD,

common hepatic duct; CD cystic duct. Other structures: GB, gall bladder; CBD,

common bile duct; CA, cystic artery.)

CHAPTER 21 Common operations

736

Appendicectomy

Most surgeons prefer the laparoscopic approach for suspected or proven

appendiceal pathology. Open right iliac fossa (RIF) incisions offer less

exposure with greater tissue trauma. Consider a lower midline laparot-

omy if there is a large appendix mass, the patient is elderly, and other

pathology is suspected.

Indications (typical)

• Acute appendicitis (see b p. 298).

• Acute abdominal pain where diagnostic laparoscopy has revealed no

other cause (not always performed).

• Previous resolved appendicitis (‘interval appendicectomy’).

• Appendix mass or mucocele (usually discovered on CT imaging).

Pre-theatre preparation

• Always GA, therefore NBM 2h and ﬂ uids only 4h preop.

• Group and save normal.

• Check the CT imaging if one has been performed.

Positioning and theatre set-up

• Urethral catheterization. Aids port placement safety, especially in

females, by ensuring the bladder is decompressed.

• Table positioning. Supine; it is always best to have the patient in leg

extensions (see b p. 76).

• Monitor/stack position. Right caudal.

Steps of surgery

• Establish laparoscopy (see b p. 730) if appropriate.

• Incision for open surgery, RIF oblique (‘gridiron’). Incision of skin, open

external oblique, internal oblique, and transversus abdominis, splitting

the ﬁ bres in the direction of their travel without cutting them. Open

the peritoneum between clips.

• Identify appendix from the base attachment to the caecum (the base

lies reliably on the inferomedial pole of the caecum at the conﬂ uence

of the taenia coli, the tip is variable in position).

• Mobilize the appendix from all surrounding structures, if necessary, by

blunt dissection.

• Open the appendix mesentery from tip towards the caecum by

diathermy (hook if laparoscopic).

• Identify appendiceal artery by blunt dissection and clip (or tie if open)

(2 proximal, 1 distal on appendix side) and divide.

• Complete mesenteric division to appendiceal-caecal angle.

• Doubly ligate appendix stump close to caecum (with Endoloop

laparoscopic) and divide between.

• Appendix retrieved (usually in a waterproof bag if laparoscopic via

umbilical port to reduce wound infection risk).

• The appendix stump is now rarely buried with a purse-string suture

at open appendicectomy; there is no evidence that it reduces stump

complications.

APPENDICECTOMY

737

Closure

• Port sites (see Fig. 21.2). See laparoscopy (see b p. 730).

• Open. Usually closed in layers (peritoneum, (musculo)fascial for each

layer of the oblique muscles, and skin).

Post-operative care and instructions

• Antibiotics. Five-day course if acute appendicitis with perforation.

• Oral diet. Normal as soon as tolerated.

Complications (speciﬁ c to the procedure)

Wound/port site infection, <5% (greater if open and perforated).

App

Cae

AMF

ApArt

(a)

(b)

Fig. 21.2 (a) Port sites for laparoscopic appendicectomy—main ports sites in

black; alternative layout for 2 x 5mm port sites in white. Monitor usually right side,

caudal. (b) View of appendix and mesentery prior to dissection/division. (App,

appendix; AM, appendix mesentery; AppArt, appendiceal artery; Cae, caecum;

AMF, antemesenteric fat of terminal ileum; TI, terminal ileum.)

CHAPTER 21 Common operations

738

Inguinal hernia repair

Open approach is still very popular, especially for LA/regional anaesthet-

ics, but laparoscopic approaches (transabdominal pre-peritoneal surgery

(TAPS) or totally extra-peritoneal surgery (TEPS) are also widely used,

especially for bilateral hernias (see b p. 338).

Indications (typical)

• Symptomatic inguinal hernia.

• Asymptomatic inguinal hernia with high risk of complications or patient

at high risk if complications develop.

Pre-theatre preparation

May be GA, LA (± sedation), or regional block (e.g. spinal).

Positioning and theatre set-up

• Urethral catheterization. NOT usually required for open unless the

patient is at high risk of acute retention, but used for TEPS/TAPS.

• Table positioning. Supine.

• Monitor/stack position (TAPS/TEPS). Caudal end, same side as hernia.

Steps of surgery

Open

• Identify external oblique aponeurosis and cord at the superﬁ cial ring.

• Open aponeurosis, identify cord and deep ring.

• Direct hernia. Separate cord from sac, reduce sac, and plicate

transversalis fascia to hold sac reduced.

• Indirect hernia. Open cord, separate sac from cord structures, sac may

be reduced and the deep ring plicated or sac ligated and excised at the

deep ring.

• Polypropylene mesh placed to cover from pubic tubercle to lateral to

the deep ring; usually sutured in place.

Laparoscopic TAPS

• Establish laparoscopy (see b p. 730).

• Open parietal peritoneum above hernia (e.g. hook diathermy) and

dissect to groin structures.

• Identify testicular vessels and vas deferens.

• Reduce sac intraperitoneally where possible (part reduce and excise

apex where necessary).

• Polypropylene mesh placed to cover from pubic tubercle to lateral to

the deep ring; usually secured with laparoscopic tacking device.

Laparoscopic TEPS

• Open cut down to pre-peritoneal space via umbilical port access;

opening the peritoneum is avoided.

• Open the pre-peritoneal space from umbilicus to groin (usually with

assistance from a balloon dissecting device), then as for TAPS step 3.

Closure

• Port sites 10mm and above require musculo-fascial closure.

• Open, layers with absorbable sutures.

INGUINAL HERNIA REPAIR

739

Post-operative care and instructions

Remove catheter (once fully mobile if open op with risk of ARU).

Complications (speciﬁ c to the procedure)

• Groin wound infection, <5%.

• Recurrence, 3% lifetime.

• Groin haematoma, 2%.

• Painful scar/chronic groin pain, 1–2%.

• Injury to testicular vessels (causing ischaemia), <1%.

CHAPTER 21 Common operations

740

Perforated peptic ulcer repair

Traditionally by an open approach, but now frequently done by laparos-

copy since this offers complete abdominal assessment prior to proceed-

ing and may allow a targeted long or lower midline laparotomy if other

pathology is found.

Indications (typical)

Suspected perforated peptic ulcer from history ± CT imaging ﬁ ndings (see

b p. 284).

Pre-theatre preparation

• Always GA, therefore NBM 2h and ﬂ uids only 4h preop.

• Group and save required.

• Ensure consent is obtained for proceeding to other procedures (e.g.

bowel resection since other pathologies may be found).

Positioning and theatre set-up

• Urethral catheterization. Fluid balance chart required post-operatively.

• NGT. Not indicated.

• Table positioning. Supine, but well secured to allow for head uptilt.

• Monitor/stack position. Right cranial.

Steps of surgery

• Open incision. Mini-vertical supra-umbilical laparotomy (may be

extended).

• Laparosopic. Establish laparoscopy (see b p. 730).

• Conﬁ rm diagnosis and identify site of perforation (duodenal, prepyloric

or gastric).

• Assess pathology. If suspicion of underlying malignancy in perforated

gastric ulcer, consider if excision or partial gastrectomy may be

required (senior help).

Repair is by patch closure of the ulcer wherever possible using omental

tissue and not by sutured apposition closure of the defect (see Fig. 21.3).

• Dissect a broad ‘tongue’ of omentum using diathermy (at least 5cm

wide x 10cm long).

• Three sutures placed through each edge of the ulcer, but not tied.

• Omental strip laid under and secured in place by sutures (snug, but

not tight).

• Copious intra-abdominal lavage (all quadrants); drainage rarely

required.

Closure

• Port sites. See laparoscopy (see b p. 730 and Fig. 21.1a).

• Incision. See laparotomy (see b p. 732).

Post-operative care and instructions

• Antibiotics. Not required for simple peptic ulcer perforation.

• Oral diet. Start liquid diet as soon as tolerated .

PERFORATED PEPTIC ULCER REPAIR

741

Complications (speciﬁ c to the procedure)

Leakage at closure site, 5% (worst in immunosuppressed or advanced

malignancy).

(a)

(b)

Fig. 21.3 (a) Sutures placed in ulcer edges. (b) Omental patch in place.

CHAPTER 21 Common operations

742

Haemorrhoid surgery

Surgical treatment is usually reserved for failed outpatient treatment (see

b p. 412) although the choice to go to surgery depends on symptoms,

patient preference, and anatomy of the haemorrhoids.

Haemorrhoid de-arterialization procedures (blind or ultrasound-guided)

are becoming more popular.

Indications (typical)

• ‘Conventional’ haemorrhoidectomy. Intero-external haemorrhoids (one

or more).

• ‘Stapled haemorrhoidectomy’. Circumferential, prolapsing haemorrhoids,

or extensive internal haemorrhoids resistant to outpatient treatment.

Pre-theatre preparation

May be GA or regional anaesthesia (e.g. low spinal or caudal).

Positioning and theatre set-up

Table positioning. Lithotomy.

Steps of surgery

Conventional haemorrhoidectomy (see Fig. 21.4)

• Assess pedicle(s) to be excised and clarify which mucocutaneous

bridges will be left at the end of the procedure.

• Incise the external (skin) margin (caution to not over-excise; the skin

defects enlarge easily!).

• Develop subcutaneous/submucosal plane (superﬁ cial to internal

sphincter); may be assisted with weak adrenaline solution injection.

• ‘Cone’ mucosal excision to apex of the pedicle.

• Ligate or seal with energy source the pedicle origin and vascular supply.

Stapled haemorhhoidectomy

• Determine anorectal mucosal ‘ring’ to be excised.

• Anal dilatation with circular dilator and rotating ‘windowed’ retractor.

• Circumferential running purse-string suture into mucosa and

submucosa, avoiding circular smooth muscle (internal sphincter).

• Placement of staple-gun anvil ‘head’ above the purse-string level and

tightening-tying of purse-string.

• Stapling device closed onto plicated mucosal ring, avoiding inclusion of

anal canal lining by gentle eversion during closure.

• Excision of anorectal mucosal plicated ring by stapling device and

check of homeostasis.

Closure

• No closure required.

• Anal pack not usually required.

• LA to conventional haemorrhoidectomy wounds.

Post-operative care and instructions

• Laxatives. If prone to constipation.

• Antibiotics. No proven beneﬁ t in reducing post-operative pain.

HAEMORRHOID SURGERY

743

Complications (speciﬁ c to the procedure)

• Bleeding (requiring intervention), <5%.

• Painful anal wound, 2%.

• Anorectal leakage, 2–3%.

• Anal stenosis, 1% (worse in conventional haemorrhoidectomy).

(a)

(b)

Prolapsed mucous membrane

drawn into the casing

Fig. 21.4 (a) Extent of conventional haemorrhoidectomy. (b) Correct positioning

of anorectal mucosal plication and stapling device.

CHAPTER 21 Common operations

744

Pilonidal sinus excision (Bascom II)

Different options exist for excision and primary closure of a non-acutely

infected pilonidal sinus (see b p. 408)—Bascom I, Bascom II, Karayadakis,

rhomboid ﬂ ap, rotational ﬂ ap. Principles of all primary closure procedures

are:

• Excision/extirpation of sinus disease.

• Obliteration (elevation) of natal cleft.

• Asymmetric closure of natal cleft (scar off the midline).

Indications (typical)

Symptomatic pilonidal sinus disease with unilateral or limited bilateral sec-

ondary cutaneous openings.

Pre-theatre preparation

• Usually under GA, therefore NBM 2h and ﬂ uids only 4h preop.

• Single dose antibiotics on induction.

Positioning and theatre set-up

• Usually prone, sometimes with slight prone ﬂ exion at the hip. Buttocks

may initially be taped laterally to aid retraction (should be released for

ﬁ nal mobilization and closure).

• May be performed in left or right lateral jackknife position, but

symmetrical buttock position is hampered.

Steps of surgery (Bascom II) (see Fig. 21.5)

• Asymmetrical, semi-elliptical excision of sinus pit origins.

Choice of lateral extent usually determined by the site of any •

lateral tracks.

‘Rat’s tail’ extension of cutaneous incision on the ‘short side’ to •

prevent ﬁ nal dig ear closure.

• Excision of skin and pits only with preservation of subcutaneous fat.

• Curettage, excision, and diathermy obliteration of all sinus tracks and

lateral tracks.

• Mobilization of cutaneous skin ﬂ ap of ‘long side’ of the incision.

• Mobilization of edge of skin ﬂ ap of ‘short side’ of the incision.

• Scrupulous haemostasis and wound wash-out.

• Sutured closure apposition of natal cleft fat.

Closure

• Closure of skin ﬂ aps (interrupted mattress sutures—removable

monoﬁ lament or dissolvable subcuticular suture).

• Small calibre low pressure suction drain occasionally used for larger

ﬂ aps.

Post-operative care and instructions

• Remove catheter unless required for post-operative ﬂ uid balance

observation.

• Antibiotics. Only required for pathology found.

• Oral diet. Normal as soon as tolerated unless indicated by further

procedure performed.

PILONIDAL SINUS EXCISION (BASCOM II)

745

Complications (speciﬁ c to the procedure)

• Wound infection, 5%.

• ‘Recurrent’ sinus formation (wound sinus formation or wound non-

healing), 3–5%.

• Painful scar, 2%.

(a)

(b)

Fig. 21.5 (a) Typical incision for midline pits (shown in dark grey) with extent of

skin removal (shown in light grey). (b) Fat and ﬂ ap closure to achieve natal cleft

obliteration and para-midline scar.

CHAPTER 21 Common operations

746

Femoral embolectomy

Femoral embolectomy should only be undertaken where there are facili-

ties for further vascular surgical exploration or procedures since underly-

ing occlusive vascular disease and alternative diagnoses are common

Indications (typical)

Strongly suspected or proven acute embolic occlusion of the distal super-

ﬁ cial femoral artery (SFA) or popliteal artery with acute critical limb

ischaemia (see b p. 642).

Pre-theatre preparation

• May be GA or, more commonly, under LA.

• Group and save and clotting required.

• Ensure consent is obtained for proceeding to other procedures if they

are anticipated.

• Single dose antibiotics on induction.

Positioning and theatre set-up

• Operating table should be X-ray compatible.

• NGT. NOT required unless the patient is vomiting or gastric

distension/surgery is likely.

Steps of surgery (see Fig. 21.6)

• Incision. Oblique groin over the common femoral artery.

• Expose and control all inﬂ ow and outﬂ ow vessels (common femoral,

superﬁ cial femoral, and profunda femoris).

• 3 or 4 FG Fogarty catheter is passed proximally and distally, and

embolus retrieved.

• If good inﬂ ow and good backﬂ ow achieved, then close with

interrupted 6/0 prolene sutures and conﬁ rm return of distal pulses or

reperfused limb.

• Completion angiography may be undertaken on table (senior help).

• On table, thrombolysis may be required if there is residual thrombus

(senior help).

• Surgical reconstruction or bypass may be necessary if there is in

situ thrombosis on an underlying critical stenosis instead of simply

embolism (senior help).

• Consider fasciotomies (up to four compartments) if there is suspicion

of a post-operative compartment syndrome (muscles are tense or

tender or prolonged ischaemia >6h).

Closure

Subcuticular suture.

Post-operative care and instructions

• Monitor pulse, BP, distal limb perfusion, pain, and pulses closely post-

operatively.

• IV heparin infusion—24 000IU over 24h by pump and check APTT

at 4–6h and daily after. Also repeat APTT 4h after every change in

dosage, keeping APTT at 2–2.5 times the normal range.

• Start warfarinization at 48h.

FEMORAL EMBOLECTOMY

747

Complications (speciﬁ c to the procedure)

• Haematoma formation, 5%.

• False aneurysm formation, <1%.

• Distal limb compartment syndrome.

(A)

Femoral

Popliteal

(B)

(C)

Fig. 21.6 Vessel exposure and control. (A) Incisions for femoral and popliteal

artery exposure. (B) Control of femoral artery and its branches. (C) Femoral

embolectomy and closure without and with a vein prosthetic patch.

CHAPTER 21 Common operations

748

Right hemicolectomy

Usually performed by laparoscopy although open access may be indicated

for large or locally extensive tumours, previous abdominal surgery, inabil-

ity to tolerate pneumoperitoneum. Laparoscopy may be multi- or single

port.

Indications (typical)

• Right colonic (caecal, ascending colonic, or hepatic ﬂ exure)

adenocarcinoma (see b p. 404).

• Right colonic adenomas too extensive for endoscopic excision.

• Right colonic stricture (symptomatic).

• Right colonic Crohn’s disease (symptomatic) (see b p. 394).

Pre-theatre preparation

• GA (NBM 2h and ﬂ uids only 4h preop).

• Group and save required.

• No bowel preparation usual for right hemicolectomy.

• Single dose antibiotics on induction.

Positioning and theatre set-up

• Urethral catheterization.

• Table positioning. Supine, well secured to allow for head up/down tilt

and lateral role.

• Monitor/stack and ports positions. Right side (see Fig. 21.7).

Steps of surgery (laparoscopic)

Dissection of right colon and ileum may be done from medial to lateral

(starting at the ileocolic mesentry) or from lateral to medial (starting

with the peritoneal attachments off the colon—one method is described

below).

• Establish pneumoperitoneum, assess access and peritoneal cavity.

• (Head up and left down roll) Open and divide right gastrocolic

omentum and divide peritoneum above the hepatic ﬂ exure.

• Divide right paracolic peritoneum and reﬂ ect right colon medially.

• (Head down and left down roll) Divide attachment of ileal and caecal

mesentery to pelvic brim/iliac fossa peritoneum and reﬂ ect caecum

superiorly.

• Mobilize right colon mesentery from anterior pararenal fascia,

anterolateral duodenum, and head of pancreas.

• Isolate and divide ileocolic vessels and right colic vessels at mesenteric

root.

• Divide transverse colic and terminal ileal mesenteries.

• Divide terminal ileum and proximal transverse colon (linear stapler).

• Deliver specimen via (peri)umbilical incision and form ileocolic

anastomosis (extracorporeal).

Closure

• Mass closure to (peri)umbilical wound.

• Port sites. See laparoscopy (see b p. 730) (see Fig. 21.7).

RIGHT HEMICOLECTOMY

749

Post-operative care and instructions

Enhanced recovery programme usual. Oral ﬂ uids day 1, light diet day 2.

Complications (speciﬁ c to the procedure)

• Conversion to open procedure, (up to) 20%.

• Anastomotic leak, 2–5% (see b p. 420).

• Temporary stoma formation, 2% (see b p. 750).

• Intra-abdominal bleeding, 5%.

• Port site infection, <5%.

Fig. 21.7 Typical port sites and monitor position and extent of resection.

CHAPTER 21 Common operations

750

Stoma formation

Indications (typical) (see b p. 84).

Pre-theatre preparation

• GA if done as part of other procedures or if laparoscopically formed;

may be LA/regional if isolated loop stoma formation.

• Group and save required.

• Ideal sites for proposed stomas should be marked by stoma specialist

preoperatively unless emergency surgery.

• Single dose antibiotics.

Positioning and theatre set-up

Table positioning. Supine unless required by related operation.

Steps of surgery

Ideally, any stoma should traverse the musculo-fascial layers of the abdom-

inal wall (commonly the rectus abdominis); incisions in the fascia placed

vertically with muscle ﬁ bres splayed apart (but not divided unless where

necessary) to allow the stoma adequate space without ‘pinching’, but

reduce the longer-term risk of herniation (a major problem especially in

long-term stomas).

Loop ileostomy formation

• Ensuring proximal and distal limbs are identiﬁ ed and orientated (if

done as an isolated procedure via a trephine incision, this is difﬁ cult;

the only reliable indicator is the antemesenteric fat ‘stripe’ leading onto

the surface of the caecum; much more reliably done laparoscopically

for direct visualization of each limb). Done before creating defect if

laparoscopic procedure.

• Opening of the antemesenteric wall of the loop (slightly oblique

towards the distal limb).

• Placement of sutures (untied) to ‘spout’ the proximal limb (see Fig.

21.8).

• Placement and tying of sutures across the posterior wall of the loop

and around the distal limb.

• Tying the proximal limb sutures and spouting the proximal limb.

A bridge is almost never necessary.

Closure

Port sites. As per laparoscopy.

Post-operative care and instructions

Oral diet. Normal as soon as tolerated unless indicated by further proce-

dure performed.

Complications (speciﬁ c to the stoma formation)

• Stomal oedema, ~30% (common and usually requires no treatment).

• Stomal ischaemia, <5% (serious and requires prompt treatment).

• Intestinal obstruction (due to tight musculo-fascial opening), 5%.

STOMA FORMATION

751

• Stoma retraction (usually due to inadequate mobilization), <5%.

• Stoma prolapse, <5%.

• Stomal/parastomal hernias (rare acutely), up to 50% long term.

Fig. 21.8 Suture placement for spouting of proximal limb of loop ileostomy.

CHAPTER 21 Common operations

752

Wide local excision—breast

Indications (typical)

Carcinoma of the breast. Preferred to mastectomy for all, but large,

tumours in small breasts, multifocal carcinomas, or those with multifocal

DCIS and central tumours.

Pre-theatre preparation

• Always GA, therefore NBM 2h and ﬂ uids only 4h preop.

• Group and save required.

• Consent may be required for additional procedures (such as axillary

node surgery), especially if sentinel node detection is being used.

Positioning and theatre set-up

• Radiography. Ensure mammograms or other radiographs are available.

• Table positioning. Supine with arm extension to allow access to the

axilla.

Steps of surgery

• Skin incision according to breast folds and skin lines. Skin excision only

required for superﬁ cial tumours with skin changes.

• Dissection carried out in a column or wide sphere of normal breast

tissue margin down to fascia of pectoralis major.

• Haemostasis. Scrupulous care required.

Closure

Dissolvable sutures to fascia and skin.

Post-operative care and instructions

• The specimen requires orientation with marking (by sutures or clips)

to mark three out of the six ‘surfaces’: anterior, inferior, and medial

surfaces—‘AIM’.

• Drains not usually required but if so, remove once output.

Complications (speciﬁ c to the procedure)

Breast haematoma, 5%.

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CHAPTER 21 Common operations

754

Below knee amputation

Indications (typical)

• Unreconstructible peripheral vascular disease of distal limb with critical

ischaemia (involving vessels below the popliteal artery).

• Acute unsalvageable distal limb ischaemia (involving vessels below the

popliteal artery).

• Unreconstructible trauma below the mid-tibia.

• Tumours of the soft tissue or bone of the distal limb (some).

• Unreconstructible congenital deformities of the foot with

complications.

Pre-theatre preparation

• May be GA; spinal or regional common in vascular disease.

• Group and save required, may need cross-match for 2U.

Positioning and theatre set-up

• Table positioning. Supine.

• Ensure angiograms/limb CT scans available if appropriate.

Steps of surgery (see Fig. 21.9)

Two approaches are commonly used—‘long posterior ﬂ ap’ and ‘skewed

symmetrical ﬂ aps’. ‘Long posterior’ ﬂ ap is more common, especially in

ischaemia.

Long posterior ﬂ ap

• Mark ﬂ aps. Anterior ﬂ ap slightly convex 10cm (in adults) below tibial

tuberosity, just over hemicircumference of the calf skin. Posterior ﬂ ap

at least twice the length of the anterior ﬂ ap. Opening of skin to fascia.

• Opening and division of fascia, then muscles of anterior and lateral

compartments with diathermy.

• Identify anterior tibial neurovascular bundle; separate vessels and

ligate; divide nerve under tension (promotes nerve retraction). Same

for peroneal bundle.

• Fibular, then tibial divisions (ﬂ exible, wire, or powered saw); division of

ﬁ bula high; bevel front of tibia at 45°.

• Striping of posterior compartment muscles off tibia and interosseous

septum below level of the division to the extent of the posterior ﬂ ap.

• Identify posterior tibial neurovascular bundle; separate vessels and

ligate; divide nerve under tension (promotes nerve retraction).

• Trimming soleus and gastrocnemius to reduce bulk of posterior ﬂ ap to

allow comfortable coverage of bony stump.

• Suturing of muscle/fascia to tibial peritosteum.

Closure

• Skin and fascia. interruptible sutures.

• Drain usually placed deep to myocutaneous ﬂ ap.

Post-operative care and instructions

Early physiotherapy to knee joint to promote range of movements.

BELOW KNEE AMPUTATION

755

Complications (speciﬁ c to the procedure)

• Flap necrosis, <5%.

• Haematoma.

Skew flap

10–15cm

2cm

1/4 circumference

1/3 circumference

2/3 circumference

Burgess flap ‘Rule of thirds’

10–12cm

Fig. 21.9 Flaps used of below knee amputation. (a) Long posterior ﬂ ap.

(b) Skewed symmetrical ﬂ aps.

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757

Eponymous terms and

rarities

Chapter 22

CHAPTER 22 Eponymous terms and rarities

758

Acanthosis nigricans Pigmentation of the axillary skin associated with

breast or gastric cancer.

Achondroplasia Familial dwarﬁ sm in which growth of the long bones

and skull is defective.

Adenomyomatosis, gall bladder Thickening of the gall bladder wall

with occasional intramural sinuses that may partially occlude the gall blad-

der lumen.

Adiposa dolorosa Multiple lipomas, usually on the arms and trunks,

that are occasionally painful.

Adrenogenital syndrome A condition, usually autosomal recessive

inheritance, affecting 1 in 5000 to 1 in 15 000 births, characterized by

cortisol and/or aldosterone deﬁ ciency due to an enzymatic defect in cor-

tisol synthesis, which results in secondary adrenal hyperplasia through loss

of feedback on the pituitary gland. Diversion of precursors into the syn-

thesis of other steroids, particularly androgens, results in virilization and

ambiguous genitalia (through clitoral hypertrophy) of the female fetus and

pseudoprecocious puberty in the male. Early closure of the epiphyseal

plates leads to short stature. Impaired aldosterone secretion can cause a

salt-losing state that requires replacement therapy.

Aerocele The collection of air in one or more tissue layers of the cra-

nium due to injured or inﬂ amed cranial air sinuses.

Albers–Schönberg disease See osteopetrosis.

Albright’s hereditary osteodystrophy An X-linked form of pseu-

dohypoparathyroidism characterized by mental retardation, low serum

calcium, cataracts, and tetany. Patients tend to be of short stature and

have short ﬁ rst, fourth, and ﬁ fth metacarpals. Metastatic calciﬁ cation of

the basal ganglia is a feature.

Albright’s syndrome/polyostotic ﬁ brous dysplasia A condition

thought to be due to disordered bony development, featuring ﬁ brodys-

plastic bony changes, patchy skin pigmentation, and precocious puberty

in girls. Affected bones become soft and deformed from childhood

onwards.

Allen’s test This assesses the adequacy of the collateral circulation to

the hand. Digital pressure is applied to both the radial and ulnar arteries

at the wrist and the patient repeatedly clenches a ﬁ st. Adequate collateral

supply exists if there is complete palmar ﬂ ushing with 15s of release of

each vessel in turn.

Amastia Absence of both breast and nipple. Ninety per cent of patients

with unilateral amastia have absent or hypoplastic pectoral muscles.

Amaurosis fugax Episodes of transient blindness due to central

retinal artery embolization from carotid vessel disease/proximal vessel

atherosclerosis.

Amazia Congenital absence of breast tissue, but not the nipple. It is now

known as hypoplasia of the breast, to differentiate it from amastia.

EPONYMOUS TERMS AND RARITIES

759

Angiodysplasia Vascular lesions of unknown aetiology, most frequ-

ently found in the right colon, occasionally associated with cutaneous and

oral lesions. They occur with increasing age and present with bleeding that

may be torrential, but more often as a series of small bleeds.

Angiomyoneuroma (glomus tumour) A small, painful, benign

tumour of blood vessels, rarely larger than a few mm in size, mainly found

in the extremities. Half arise in the digits, predominantly subungally. They

are exquisitely painful and tender and appear blue-purple in colour. Treat

by excision with a wide margin.

Angiosarcoma A soft tissue tumour of young men and women, pro-

ducing a hot, bulky tumour with a tendency to bleed and metastasize to

the lungs.

Ankyloglossia Also known as tongue-tie, it is due to a short lingual

frenulum. It rarely affects speech, but frenectomy is recommended when

food control and oral hygiene are a problem.

Antibioma A hard, oedematous swelling containing sterile pus following

the treatment of an abscess with long-term antibiotics, rather than incision

and drainage.

Aortoenteric ﬁ stula A connection between the aorta and small intes-

tine, resulting in haemorrhage that becomes increasingly frequent and may

culminate with exsanguinations; most commonly due to infection of a

prosthetic graft rather than primary spontaneous ﬁ stula.

Apert’s syndrome Occurs in 1 in 160 000 births. Thirty per cent of

cases are autosomal dominant. Skull is ‘tower-shaped’ (oxycephaly) with

premature fusion of all the sutures. Mild face aplasia and syndactyly of

the middle three ﬁ ngers occur. Other associations include oesophageal

atresia, renal and congenital heart anomalies.

Aphthous ulcers The most common disorder affecting the oral

mucosal membranes. Of unknown aetiology. They are painful, recurrent,

and occur most commonly in childhood, rarely in the edentulous. Large

ulcers, present for 3 months or more, may mimic carcinomas and should

be biopsied if doubt exists.

Arnold–Chiari malformation A hindbrain abnormality where the

cerebellum and medulla are found to lie below the level of the foramen

magnum. Compression of the foramen of Magendie results in obstructive

hydrocephalus in 80–90% of cases. Syringomyelia and spina biﬁ da are com-

monly associated.

Askanazy cell tumour/Hurtle cell adenoma, thyroid A tumour

consisting of featureless granular cells of varying size distributed in the

ﬁ brous stroma of the thyroid. They are difﬁ cult to differentiate from malig-

nant tumours, but are regarded as benign.

Asplenia Absence of the spleen, associated with cardiac anomalies,

including situs inversus.

Athelia Absence of the nipple. It is exceedingly rare.

CHAPTER 22 Eponymous terms and rarities

760

Baker’s cyst A central swelling of the popliteal fossa, most evident

when the patient stands. It represents a synovial membrane diverticulum,

almost always associated with knee joint pathology such as arthritis or

torn meniscus.

Balanitis xerotica obliterans A disease of unknown aetiology char-

acterized by keratotic lesions with inﬂ ammatory changes, leading to phi-

mosis and occasional meatal stenosis. It has the appearance of a white

stenotic band at the end of the foreskin and minor trauma often results

in haemorrhage.

Ballance’s sign Fixed dullness in the left ﬂ ank with shifting dullness best

appreciated in the right ﬂ ank, resulting from intraperitoneal and extraperi-

toneal bleeding following splenic rupture.

Barrett’s oesophagus The presence of columnar lined mucosa in the

anatomical oesophagus; may be due to acid or biliary reﬂ ux. It is found in

10% of patients undergoing endoscopy for reﬂ ux symptoms. Strictures,

ulceration, bleeding, dysplasia, and malignant transformation may occur.

Battle’s sign Bruising over the mastoid process following a base of skull

fracture that involves the petrous temporal bone.

Bazin’s disease See erytrocyanosis frigida.

Beckwith–Wiedemann syndrome A congenital defect of the ante-

rior abdominal wall associated with macroglossia, gigantism, and transient

hypoglycaemia episodes.

Bezoars Masses of ingested human hairs (trichlobezoars) or indigest-

ible vegetable matter and ﬁ bre (bezoars) that form in the stomach and

interfere with digestion or may migrate into the small bowel and cause

intestinal obstruction.

Bier spots The presence of white patches amongst the mottled blue–

purple appearance of an acutely ischaemic limb that has been in a warm

environment for several hours.

Blind loop syndrome Malabsorption due to colonization of a blind-

ending segment of bowel by abnormal bacteria that prevent the digestion

and absorption of food. Causes include congenital abnormalities (e.g. small

bowel diverticula), strictures, or, more commonly, surgical construction of

small bowel anastomoses and loops.

Blue naevus Results when embryonic melanocyte migration from the

neural crest is arrested in the dermis.

Bochdalek hernia A posterior diaphragmatic hernia where the septum

transversum fails to unite with the intercostal part of the diaphragm. It

occurs in infants and is characterized by gross herniation of abdominal

contents and associated lung hypoplasia.

Boehaave’s syndrome Spontaneous oesophageal rupture following an

episode of intense vomiting or retching, characterized by severe upper

abdominal and chest pain, tachycardia, tachypnoea, and subcutaneous

emphysema.

EPONYMOUS TERMS AND RARITIES

761

Bornholm disease (epidemic pleurodynia) Coxsackie B4 virus

infection of pleura and peritoneum characterized by severe upper abdo-

minal and chest pain (worse on movement and respiration) associated

with dyspnoea, pleuritic pain, headache, and sore throat.

Bowen’s disease An irregular, reddish brown cutaneous plaque, occa-

sionally ulcerated and commonly found on the trunk. It is an intra-epider-

mal carcinoma in situ and may develop into squamous cell carcinoma.

Branham’s test When a pneumatic tourniquet is inﬂ ated around the

root of a limb with a suspected arteriovenous malformation, a signiﬁ cant

fall in the pulse rate suggests a signiﬁ cant arteriovenous shunt.

Budd–Chiari syndrome Post-hepatic venous obstruction that may

result from spontaneous thrombosis, extrinsic compression by tumour,

or a web in the vena cava.

Buschle–Lowenstein tumour A rare benign penile ‘tumour’ caused

by human papilloma virus infection with giant tumour growth, but only

local tissue destruction; may result in urethral ﬁ stula formation.

Cloquet’s (Callisen’s) hernia A deep femoral hernia that cannot pro-

trude from the saphenous opening as it lies deep to the femoral vessels.

Calot’s triangle An essential landmark in laparoscopic cholecystectomy

surgery. Its boundaries are the common hepatic duct, cystic duct, and

inferior border of the liver.

Campbell de Morgan spots Small, red spots that commonly occur on

the trunk in middle age and do not blanch. They are of no signiﬁ cance.

Cancer en cuirasse Multiple malignant nodules on the chest wall in

breast cancer that mimic the breast plate on a suit of armour.

Caput medusa Engorged veins radiating from the periumbilical

region, resulting from extrahepatic portosystemic shunting from portal

hypertension.

Carbuncle Multiple, adjacent follicular infections with Staphylococcus

aureus, commonly seen in diabetics. Treat with ﬂ ucloxacillin and surgical

drainage as required.

Cardiac myxoma A rare primary cardiac tumour, commonly arising in

the left atrium, which can present either with obstruction mimicking mitral

stenosis or tumour emboli.

Carnett’s test Determines whether an abdominal lump lies intraperi-

toneally or within the abdominal wall. The patient lies ﬂ at and raises his

extended legs off the couch. An intraperitoneal lump disappears whereas

one in the abdominal wall persists.

Caroli’s disease An anatomical abnormality characterized by intra-

hepatic cystic changes with an increased risk of bile duct cancer.

Carr’s concretions Microscopic calculi within the papilla of the kid-

ney thought to be involved in the pathogenesis and propagation of renal

calculi.

CHAPTER 22 Eponymous terms and rarities

762

Charcot’s triad Fever, rigors, and jaundice characteristic of acute

cholangitis. Right hypochondrial pain is often an additional feature. This is

a serious and potentially fatal condition, caused by ascending infection of

the biliary tree associated with partial biliary obstruction.

Chemodectoma A carotid body tumour extending from the carotid

bifurcation that presents with a solitary or bilateral lump(s) anterior and

deep to sternocleidomastoid. Characteristically, they can be displaced lat-

erally, but not vertically, and are associated with bruits and thrills in 20%

of cases. The risk of malignancy increases with size.

Chopart’s amputation An amputation made through the tarsal

bones.

Churg–Strauss syndrome Affects young and middle-aged adults,

often with a history of atopy, asthma, and allergic rhinitis, in which there

is a marked eosinophilia. Clinical manifestations include peripheral neu-

ropathy, cardiac involvement (heart failure and myocardial infarction), and

vascular involvement that affects the stomach, small bowel, kidneys, and

CNS due to aneurysm formation, thrombosis, and infarction.

Chvostek’s sign Hyperexcitability of the facial nerve to local percussion

over the parotid gland in patients with a reduced serum calcium concen-

tration. It can also occur in 10% of normal people.

Chylothorax The accumulation of lymphatic ﬂ uid (which can have the

appearance of pus) within the pleural cavity following thoracic duct trauma

(blunt and penetrating injuries or surgical procedures), obstruction by

malignant disease (particularly lymphomas and carcinomas of the lung and

breast), and congenital defects (usually also associated with ascites).

Codman’s triangle Radiographic evidence of periosteal elevation

found with osteosarcomas.

Contrecoup injury Injury to the brain on the opposite side of the initial

injury, due to the transmitted movements of the cerebral tissue within

the skull.

Cooper’s hernia A rare multilocular deep femoral hernia that enters

the thigh via deep investing fascia.

Corrigan’s pulse A collapsing pulse found in the presence of an arte-

riovenous ﬁ stula.

Courvoisier’s law A palpable distended gall bladder in a jaundiced

patient is more likely to be due to malignant disease obstructing the bile

ducts than gall stones (where the gall bladder tends to be ﬁ brotic and

contracted).

Craniocleidodysostosis An autosomal dominant disease character-

ized by partial or complete clavicular aplasia, vertebral and digital deformi-

ties, and patent fontanelles.

Craniofacial dysostosis/Crouzon’s syndrome A condition charac-

terized by stenotic cranial sutures, maxillary hypoplasia and prognathism,

beaked nose, exophthalmos, and mental retardation.

EPONYMOUS TERMS AND RARITIES

763

Crigler–Najjar syndrome Pre-hepatic jaundice due to an inability to

conjugate bilirubin within the liver. There are two types, autosomal reces-

sive (type I) and autosomal dominant (type II).

Cronkhite–Canada syndrome A triad of GI polyps, alopecia, and

ﬁ ngernail atrophy. The changes are not neoplastic, but due to an unidenti-

ﬁ ed deﬁ ciency state.

Crueveilhier’s sign (saphena varix) It is positive if an impulse is felt

at the saphenofemoral junction when the patient stands and coughs.

Cullen’s sign Periumbilical bruising seen in acute severe necrotizing pan-

creatitis or other form of severe intraperitoneal bleed, i.e. ectopic preg-

nancy, abdominal trauma.

Curling’s ulcer Acute gastroduodenal ulceration associated with severe

burns.

Curtis–Fitz–Hugh syndrome Severe right hypochondrial pain due to

perihepatitis due to Chlamydia trachomatis infection.

Cushing’s ulcer Acute gastroduodenal ulceration associated with

stress, such as severe haemorrhage, myocardial infarct, multiple trauma,

and in critically ill patients.

Dandy–Walker syndrome Congenital absence of the foramen of

Magendie, resulting in marked ventricular dilatation. The lateral sinuses

appear higher than normal on X-ray because of cerebellar hemisphere

widening and the higher attachment of the tentorium cerebelli.

DeQuervain’s disease Inﬂ ammation around the extensor pollicis

brevis and abductor pollicis longus tendons, often associated with thicken-

ing of the extensor retinaculum. This results in pain on movement of the

thumb and tenderness where the tendons cross the radial styloid.

DeQuervain’s thyroiditis Self-limiting viral inﬂ ammation of the thy-

roid gland, which usually follows a recent upper respiratory tract infection,

characterized by giant cell inﬁ ltration.

Dermatomyositis A condition of insidious onset characterized by

proximal muscular weakness, pain, and tenderness. There is a charac-

teristic purple skin rash that affects the cheeks and light-exposed areas.

Association with occult malignancies of the colon, lung, breast, and geni-

tourinary tract.

Desmoid tumour A locally expanding tumour of mesenchymal tissue

often found in the infra-umbilical abdominal wall muscles or intra-abdom-

inal mesenchymal tissue. It commonly affects middle-aged females and

requires wide excision. Associated with familial adenomatous polyposis.

Dietl’s crisis The passage of large volumes of urine following acute

intermittent hydronephrosis. Classically, there is ureteric colic and a pal-

pable, distended kidney. Both resolve after the passage of urine.

Dysplastic naevus (famm) syndrome Dysplastic naevi are consi-

dered precursors of malignant melanoma when there is a family history.

CHAPTER 22 Eponymous terms and rarities

764

Solitary lesions in the absence of a family history are not. All patients

should avoid excessive sunlight.

Ectopia vesicae (bladder exstrophy) Occurs in 1 in 30 000 live

births, more commonly in males. There is an open bladder and defective

anterior abdominal wall associated with separated pubic bones and penile

epispadias or biﬁ d clitoris. Associated with glandular metaplasia and the

risk of squamous carcinoma of the bladder remnant.

Ehlers–Danlos syndrome A rare collagen disorder characterized by

the development of saccular or dissecting aneurysms.

Emphysematous cholecystitis A rapidly progressive infection of the

gall bladder due to anaerobic organisms, characterized by air in the wall of

the gall bladder and a high risk of perforation.

Empyema—gall bladder A pus-ﬁ lled gall bladder, resulting from

impaction of a gallstone in the neck of the gall bladder.

Encephalocele The protrusion of cranial meninges, cerebrospinal ﬂ uid,

and brain tissue through an opening in the skull.

Epidermal naevus syndrome The presence of extensive light

brown warty lesions in association with skeletal and CNS developmental

abnormalities.

Epiplocele A hernial sac containing omentum.

Epispadias A rare condition characterized by failure of development

of the anterior wall of the lower urogenital tract, affecting the glans and

penis alone (1 in 120 000) or the whole urinary tract when it is commonly

associated with bladder exstrophy (1 in 30 000). It most commonly affects

males and is characterized by the urethra exiting from the dorsal penile

surface at varying sites.

Epithelioma of Malherbe Another term for a pilomatrixoma, a red/

white subepidermal nodule, frequently calciﬁ ed and found on the upper

body.

Erythrocyanosis frigida Also known as Bazin’s disease. It affects

healthy females with fat and often hairless legs. Capillary dilatation along-

side arteriolar constriction results in dusky red/purple blotches that blanch

on pressure and rapidly reﬁ ll. They can be painful. Ulceration and persist-

ent oedema may occur in severe cases.

Erythromelalgia A condition characterized by erythema and pain in the

dependent extremities, relieved by elevation. The inappropriate release of

local vasodilators has been implicated..

Erythroplasia of Queryat A reddish brown, irregular lesion found on

the glans penis, which may ulcerate and crust. It is regarded as a carcinoma

in situ and nearly always occurs in uncircumcised patients.

Exophthalmos Proptosis (sticking out of the globe of the eye), lid

retraction, conjunctival oedema, and, in severe cases, ophthalmoplegia or

optic nerve damage. Affects 2–3% of patients with Graves’s disease.

EPONYMOUS TERMS AND RARITIES

765

Extradural haematoma The formation of a haematoma in the extra-

dural space, most commonly following a fracture of the parietal or tem-

poral bones with rupture of the middle meningeal artery or its branches

that traverses them.

FAP (familial adenomatous polyposis) Autosomal dominant syn-

drome characterized by multiple colorectal and intestinal polyps as well as

other intestinal and mesenchymal lesions.

Fallot’s tetralogy Congenital cyanotic heart disease with four features:

(1) ventriculoseptal defect, (2) pulmonary stenosis, (3) overriding aorta,

(4) right ventricular hypertrophy. The infant becomes cyanosed on exer-

tion and adopts a classical squatting position which raises their systemic

vascular resistance, thereby increasing pulmonary blood ﬂ ow.

Felty’s syndrome An association between rheumatoid arthritis,

splenomegaly, and granulocytopenia, which may be complicated by leg

ulcers and recurrent infections.

Finkelstein’s test Used to identify cases of stenosing tenosynovitis. The

patient places his thumb in his palm and clenches a ﬁ st. The examiner

pushes the hand into ulnar deviation and, if positive, pain is felt at the radial

styloid, radiating down the forearm.

Foster Kennedy syndrome Optic atrophy of one eye and papil-

loedema in the other, which is due to a frontal tumour blocking the sub-

arachnoid space on the ipsilateral side, but causing papilloedema on the

other side because of raised intracranial pressure.

Fournier’s gangrene A form of necrotizing fasciitis involving the peri-

neal or scrotal skin, leading to subcutaneous necrosis. Synergy appears to

occur between normal non-pathogenic organisms, leading to local vascular

thrombosis and necrosis. Associated with uncontrolled diabetes mellitus.

Frey syndrome Gustatory sweating of the cheek following accidental

or surgical trauma of the parotid region. It results from cross-regeneration

of the transected sympathetic and parasympathetic ﬁ bres and develops

over about 12 months.

Froment’s sign Weakness of the adductor pollicis, following a high

ulnar nerve palsy, leads to compensatory overaction of the ﬂ exor pollicis

longus (innervated by the median nerve) when the patient is asked to

squeeze a sheet of paper between thumb and index ﬁ nger.

Galactocele A cystic lesion containing breast milk, occurring in women

who suddenly stop breastfeeding.

Gamekeeper’s thumb A sprain of the metacarpophalangeal joint of

the thumb, leading to rupture of the ulnar collateral ligament. Non-healing

leads to chronic instability and weakened pinch grip.

Gardner’s syndrome Variant of FAP, involving an association between

multiple epidermal cysts, intestinal polyposis, desmoid tumours, and

osteomas.

CHAPTER 22 Eponymous terms and rarities

766

Garrod’s pad Subcutaneous tissue thickening over the proximal

interphalangeal joints that are histologically similar to those found in

Dupuytren’s disease.

Gaucher’s disease A genetic abnormality leading to active storage of

abnormal glucocerebrosides in the spleen, resulting in massive childhood

splenomegaly.

Gilbert’s syndrome Congenitally acquired mild jaundice due to a fail-

ure of transport of bilirubin to the liver, which can be precipitated by

episodes of starvation. There is an absence of urinary bilirubin although

faecal and urinary urobilinogen levels are increased. It is of little clinical

signiﬁ cance.

Glomus tumour See angiomyoneuroma.

Glucagonoma A tumour of the pancreatic islet cells characterized by

mid-maturity onset diabetes, an erythematous rash that tends to blister

and crust, glossitis, and raised glucagon levels.

Gluteal hernia A very rare type of hernia where visceral contents

pass through the greater sciatic notch. It is often only discovered during

laparotomy for the relief of intestinal obstruction of no obvious cause.

Rarely, swelling around the buttock and pain referred along the sciatic

nerve occur.

Grawitz tumour Adenocarcinoma of the kidney.

Grey–Turner sign Bruising in the ﬂ anks resulting from retroperitoneal

haemorrhage (e.g. haemorrhagic pancreatitis).

Gynaecomastia The benign growth of breast tissue in males. The

breast is uniformly enlarged and soft. May be physiological (e.g. maternal

oestrogens, oestrogen-androgen imbalance of puberty), hypogonadism

(pituitary disorders, androgen blockade), neoplasms (adrenal/gonado-

trophic tumours, bronchogenic, renal cell, etc.), systemic disease (hepatic

failure, renal dialysis, hypothyroidism), and drug-induced (androgen block-

ers, oestrogens, cimetidine, spironolactone, ketoconazole, methyldopa,

metoclopramide, etc.).

Hamartoma Overgrowths of one (or more) cell type(s) normally found

within the organ from which they arise, e.g. neuroﬁ bromas.

Hammer toe Hyperextension of the metatarsophalangeal joint and dis-

tal interphalangeal joint with ﬂ exion of the proximal interphalangeal joint.

This can lead to the development of bursae and calluses. Frequently asso-

ciated with hallux valgus, overcrowded toes, and diabetic neuropathy.

Hand–Schüller–Christian disease Multiple visceral and lytic skeletal

lesions, characteristically also involving the skull, that are associated with

diabetes insipidus and exophthalmos.

Hangman’s fracture Traumatic disruption of the pars interarticularis

of the atlas (C2) following a hyperextension injury.

Hashimoto’s disease A diffusely enlarged, painless thyroid gland

due to lymphocyte inﬁ ltration. Rubbery in nature and often mimicking a

EPONYMOUS TERMS AND RARITIES

767

multinodular goitre. If enlargement is asymmetrical, other causes must be

excluded. Clinically, the patient is euthyroid or mildly hyperthyroid.

Henle–Coenen sign If an arteriovenous ﬁ stula is occluded and the dis-

tal vessels still pulsate, this indicates that the ﬁ stula can be safely treated

by ligation.

Hereditary osteodystrophy An X-linked form of pseudohypopar-

athyroidism characterized by hypoparathyroidism, low serum calcium,

mental retardation, cataracts, and tetany. Metastatic calciﬁ cation of the

basal ganglion is also a feature.

Hesselbach’s hernia A rare form of external femoral hernia that enters

the thigh lateral to the deep epigastric and main femoral vessels.

Hibernoma A lipoma consisting of brown fat cells.

Hidradenitis suppurativa A chronic recurrent deep-seated skin infec-

tion of the axilla or perineum.

Housemaid’s knee Chronic bursitis of the prepatellar bursa from the

trauma of repeated kneeling (as in scrubbing ﬂ oors).

Howship–Romberg sign Pain referred to the inner aspect of the knee

via the genicular branch of the obturator nerve, which may arise from an

obturator hernia that strangulates.

Hunner’s ulcer Stellate white ulcers within the bladder, resulting from

chronic inﬂ ammation, that open up on distension and bleed on decom-

pression. Aetiology is unknown and women are more frequently affected.

Bladder capacity is reduced and symptoms include urinary frequency and

pain on distension, relieved by micturition.

Hydatid of Morgagni Also known as the appendix testis. Remnant of

the Müllerian duct found at the upper pole of the testis, situated in the

groove between the testis and epididymis; may undergo torsion.

Hyperhidrosis Excessive sweating of the axilla, palms, and feet, which

can be socially embarrassing and distressing.

Hyperostosis frontalis interna (Morgagni’s hyperostosis)

Increased density and projection of the frontal bones, affecting the inner

table only. Aetiology is unknown. Patients are often asymptomatic.

Hypersplenism A combination of splenomegaly, anaemia, leucopenia,

and/or thrombocytopenia with bone marrow hyperplasia. Splenectomy

may be required.

Inspissated bile syndrome Inspissation of bile in the common bile

duct during early infancy (usually from haemolysis), resulting in proximal

bile duct and gall bladder dilatation.

Insulinoma A rare tumour of pancreatic islet beta-cells, characterized by

hypoglycaemic attacks that are both unpredictable and worsen in severity

with time. Diagnosis is based on Whipple’s triad.

CHAPTER 22 Eponymous terms and rarities

768

Intraperitoneal rupture of bladder Usually traumatic in origin, from

surgical instrumentation or abdominal trauma in the presence of a full

bladder.

Jansen’s disease An inherited autosomal dominant form of metaphy-

seal dysostosis, characterized by deafness and extreme dwarﬁ sm.

Jefferson’s (burst) fracture Disruption of the ring of atlas (C2) fol-

lowing traumatic injury to the neck. Spinal column damage is uncommon

as the fragments tend to open outwards.

Kalokerino’s sign A ﬁ lling defect of the fundus of the stomach that

mimics a neoplasm. It arises when part of the fundus to the left of the

cardio-oesophageal junction is about to herniate through it.

Kanavel’s sign Is due to an infected ulnar bursa. Greatest tenderness is

elicited in the transverse palmar crease on the ulnar side.

Kantor’s string sign Is indicative of Crohn’s disease. Involvement of

the terminal ileum leads to structuring of the lumen. This gives the radio-

logical appearance of a thread-like structure on barium follow-through.

Kaposi’s sarcoma Painless red-brown macules on the limbs and anal

and oral mucosa. Occasionally, they may ulcerate. They can be found in

the elderly, endemically (e.g. in Africa), and in immunosuppressed patients

(e.g. transplant patients, HIV).

Kartagener’s syndrome Bronchiectasis and sterility resulting from

abnormal ciliary action.

Kehr’s sign Left shoulder pain referred from splenic injury and rupture.

Kenaway’s sign A venous hum that is louder on inspiration (on auscul-

tation with the bell of the stethoscope below the xiphisternum), associ-

ated with splenomegaly in patients with bilharzial cirrhosis of the liver.

Keratoacanthoma See molluscum sebaceum.

Killian’s dehiscence The weak point between the cricopharyngeal and

thyropharyngeal muscles through which pharyngeal mucosa can herniate,

leading to the formation of a pharyngeal pouch.

‘Kiss’ cancer Cancer implanted in one area by local contact from

another affected site, e.g. cancer of the lip, vulval labium.

Klein’s sign Right iliac fossa pain that moves to the left when the patient

turns on to his left side. It can be associated with mesenteric lymphadenitis

and Meckel’s diverticulum.

Klippel–Trenaunay syndrome A condition of the lower limb char-

acterized by congenital varicose veins, deep vein abnormalities, bony and

soft tissue deformity, limb elongation, and capillary naevi.

Köhler’s disease Osteochondritis of the navicular bone. This can be

one of the causes of a painful limp in a child under 5y of age.

Krukenberg tumour An ovarian tumour arising from transcoelomic

spread of a primary gastric carcinoma.

EPONYMOUS TERMS AND RARITIES

769

Ladd’s bands Persistent ﬁ brous bands between the small bowel mesen-

tery and liver, which can lead to obstruction of the second part of the

duodenum. They are commonly associated with incomplete rotation of

the bowel.

Laugier’s hernia A rare form of femoral hernia that enters the thigh

through a defect in the pectineal part of the inguinal ligament.

Li–Fraumeni syndrome An inherited predisposition to cancer thought

to be due to mutation of the p53 tumour suppressor genes.

Linitis plastica Also known as leather bottle stomach. Submucosal pro-

liferation of ﬁ brous tissue secondary to carcinoma of the stomach leads to

gastric wall thickening and a reduction in stomach volume and plasticity.

Because it spreads readily along the mucosa plane and presents late, its

prognosis is poor.

Lipodystrophy Excessive fat deposition in the legs that may be mistaken

for oedema.

Livedo reticularis Cyanotic skin mottling due to vasospasm of the arte-

rioles with concomitant capillary dilatation.

McBurney’s point Lies one-third of the way along a line drawn from

the right anterior superior iliac spine to the umbilicus. It is the classical

point of maximal tenderness in acute appendicitis and the centre point for

the gridiron (McBurney’s) incision used in open appendicectomy.

McMurray’s test This is used to identify medial meniscal tears. With

the patient supine, the knee is ﬂ exed and foot rotated medially and later-

ally while bringing the knee to 90* of ﬂ exion. Discomfort or a click is noted

in the presence of a tear.

Madelung’s deformity Dorsal subluxation of the lower end of the

ulna that is congenital or traumatic in origin.

Maisonneuve’s fracture The triad of a medial malleolar fracture, spiral

fracture of the neck of ﬁ bula, and separation of the distal tibioﬁ bular joint

found in severe ankle trauma.

Malgaigne’s bulges Bulges seen above the inguinal ligament in thin indi-

viduals on coughing or straining. They are variants of normal and do not

represent inguinal hernias.

Mallory–Weiss syndrome/tear Haematemesis resulting from pro-

longed violent vomiting, leading to mucosal tears in the cardia of the

stomach.

Marble bone syndrome See osteopetrosis.

Marfan’s syndrome A rare inherited collagen disorder characterized

by tall stature, arachnodactyly (webbed ﬁ ngers), lens subluxation, and the

development of saccular and dissecting aneurysms, particularly of the tho-

racic aorta. Aortic regurgitation may occur due to aortic root dilatation.

Marion’s disease A rare cause of bladder outﬂ ow obstruction in young

men due to narrowing of the bladder neck.

CHAPTER 22 Eponymous terms and rarities

770

Marjolin’s ulcer A longstanding venous ulcer that fails to heal in which

squamous cell carcinoma develops.

Maydl’s hernia The presence of a double loop of bowel within the

neck of a hernia, ‘W’ in shape, where strangulation of the middle loop

can occur.

Medullary sponge kidney Is due to dilatation of the terminal col-

lecting ducts of the kidney, which predisposes to the formation of renal

calculi.

Meigs’ syndrome Ascites and pleural effusions associated with benign

ovarian tumours.

Meleney’s gangrene A form of necrotizing fasciitis mostly seen after

abdominal surgery.

Ménétrier’s disease Hypertrophy of the gastric mucosa, most typi-

cally proximally, resulting in hypochlorhydria and hypersecretion of gas-

tric juices, leading to protein loss. Patients may present with epigastric

discomfort and peripheral oedema. There is no associated increased risk

of gastric cancer.

Meralgia paraesthetica Numbness and hyperalgesia around the lat-

eral thigh following entrapment of the lateral cutaneous nerve of the thigh

as it passes beneath the inguinal ligament.

Mesentericoparietal hernia of Waldeyer An internal paraduode-

nal hernia that lies medially and inferior to the third part of the duodenum.

It may present with recurrent episodes of abdominal pain and vomiting

due to small bowel obstruction.

Meyer–Weigert’s law In patients with complete ureteric duplica-

tion, it is the lower pole ureter that reﬂ uxes because its mucosal tunnel

through the bladder wall is shorter.

Milia Small, white, superﬁ cial facial spots derived from hair follicles. They

appear in newborn babies and following skin grafting and dermabrasion

and are treated by expression.

Mills’ manoeuvre When the forearm is pronated while holding the

elbow straight, pain over the common extensor origin is consistent with

extensor tenosynovitis (tennis elbow).

Milroy’s disease Lymphoedema, presenting from adulthood onwards,

resulting from congenital aplasia of the lymphatic trunk.

Mirrizi’s syndrome Obstructive jaundice resulting from impaction of

a gallstone in the cystic duct, which presses against the common hepatic

duct, causing extrinsic compression.

Molluscum contagiosum Small, pale, ﬁ rm nodules with a characteris-

tic central depression that follow infection with the pox virus. They tend

to regress with time although they can be treated by curettage.

Molluscum sebaceum A solitary skin tumour that grows rapidly over

6–8 weeks and involutes over about 6 months to leave a residual scar. It

has the appearance of a dome-shaped lesion with a central keratin-ﬁ lled

EPONYMOUS TERMS AND RARITIES

771

crater and can be mistaken both clinically and histologically for a well-

differentiated squamous cell carcinoma.

Mondor’s disease of the breast Superﬁ cial thrombophlebitis affect-

ing the veins of the breast. Initially, there may be tenderness which is fol-

lowed by ﬁ brosis and contraction, resulting in skin dimpling.

Morgagni hernia A congenital diaphragmatic hernia that presents

in early adult life with dyspnoea or as an incidental mediastinal mass.

Abdominal contents expand into the anterior mediastinal compartment

through a persistent defect in the anterior diaphragm.

Morgagni’s syndrome See hyperostosis frontalis interna.

Murphy’s sign Pain and tenderness in the right upper quadrant directly

beneath the ninth costal upon deep inspiration while the examiner’s ﬁ n-

gers rest over the edge of the lower thoracic margin at this point. It is due

to an inﬂ amed gall bladder and the patient may be unable to fully inspire

because of the pain.

Myositis ossiﬁ cans Ectopic bone formation arising within haematoma

in muscle following soft tissue injury.

Nail–patella syndrome An inherited condition characterized by radial

head subluxation, small patellae, and absent or deformed nails.

Narath’s hernia A rare form of femoral hernia that extends anterior to

the femoral artery beneath its investing fascia.

Nelson’s syndrome The presence of skin hyperpigmentation and accel-

erated growth of a pituitary tumour following bilateral adrenalectomy for

pituitary-dependent Cushing’s. It results from loss of pituitary feedback.

Nutcracker oesophagus Alternative name for diffuse oesophageal

spasm—the presence of long-duration, high-intensity peristaltic contrac-

tions in the oesophagus, which may be associated with chest pains and

dysphagia.

Obturator sign The aggravation of right iliac fossa pain upon passive

internal rotation of the right hip in patients with appendicitis where the

appendix lies adjacent to obturator internus.

Osteogenesis imperfecta An inherited collagen disorder, resulting in

fragile bones that fracture easily, blue sclera, deafness, and soft teeth.

Osteopetrosis (Albers–Schönberg disease, marble bone dis-

ease) An inherited disorder of bone, resulting in increased bone density,

fractures, and anaemia. The recessive form is less severe than the auto-

somal dominant form.

Osteopoikilosis Infantile, patchy, long bone sclerosis (found radiologi-

cally) associated with yellow skin lesions. It has autosomal dominant inher-

itance and is of no clinical signiﬁ cance.

Oxycephaly An autosomal dominant condition characterized by sten-

otic sutures, resulting in a tower-shaped skull, prominent nose, and a lat-

eral squint. Facial deformities are also common. Mental retardation, optic

atrophy, and deafness can also occur.

CHAPTER 22 Eponymous terms and rarities

772

Painful arc syndrome Shoulder pain occurring between 70* and 110*

of abduction due to the passage of an inﬂ amed supraspinatus tendon

between the acromion process and head of humerus. The subacromial

space is narrowest at this point, leading to impingement.

Pancreas divisum Arises when the ventral and dorsal pancreatic buds

fail to fuse during embryological development. Consequently, the main

pancreatic duct drains via an accessory ampulla. The vast majority of

patients are asymptomatic although it may be one of the causes of chronic

pancreatitis.

Panda sign Bilateral black eyes following a head injury, suggestive of a

base of skull fracture involving the anterior cranial fossa.

Parkes–Weber syndrome Bony and soft tissue limb overgrowth

resulting from multiple arteriovenous ﬁ stulas. Lipodermatosclerosis,

ulceration, and high cardiac output failure may also occur.

Paterson–Brown Kelly syndrome The association of a pharyngeal

web with dysphagia and iron deﬁ ciency anaemia. There is an increased risk

of post-cricoid carcinoma.

Peau d’orange Localized oedema found in breast cancer where the skin

of the breast has the pitted appearance of an orange skin.

Pendred syndrome Familial association of deafness and goitre with

peroxidase deﬁ ciency (involved in the synthesis of thyroxine).

Phalen’s test The reproduction of discomfort and paraesthesia of the

ﬁ ngers in the distribution of the median nerve (lateral three and half ﬁ n-

gers) when the wrist is held in ﬂ exion. It is due to compression of the

median nerve as it passes beneath the ﬂ exor retinaculum through the

carpal tunnel.

Phlegmasia alba dolens A swollen, white, oedematous limb, occa-

sionally seen in patients with severe iliofemoral venous thrombosis.

Progression to phlegmasia caerulea dolens may occur.

Phlegmasia caerulea dolens A blue, swollen, oedematous limb fol-

lowing severe proximal venous thrombosis. This may progress to venous

gangrene as circulatory congestion and stasis occur.

Plagiocephaly Development of an asymmetrical skull arising from the

early closure of sutures on one side of the skull.

Plummer–Vinson syndrome See Paterson–Brown Kelly syndrome.

Pneumatosis cystoides intestinalis Gas-ﬁ lled cysts within the intes-

tinal and mesenteric walls, most commonly affecting the small intestine.

These can be seen on plain abdominal X-rays.

Pneumaturia The passage of ﬂ atus in urine, which can arise from a

colovesical ﬁ stula (e.g. diverticular disease, carcinoma, inﬂ ammatory

bowel disease) or urinary tract infection in diabetics where the glucose is

fermented by the infecting organism.

Poland’s syndrome An association between pectoral muscle abnor-

mality, absence or hypoplasia of the breast, and characteristic hand

EPONYMOUS TERMS AND RARITIES

773

deformity of hypoplasia of the middle phalanges and skin webbing

(synbrachydactyly).

Pott’s carcinoma of scrotum Squamous cell carcinoma of the scro-

tum, associated with chronic exposure of the scrotal skin to aromatic car-

cinogens in coal-derived chimney soot. Now more commonly associated

with exposure to heavy metals and mineral oils, particularly the ones used

in the cotton industry.

Pott’s disease of the spine Tuberculosis of the spine, leading to bony

destruction and vertebral collapse which leads to kyphosis and spinal

compression.

Pott’s peculiar tumour A large trichilemmal cyst, commonly occur-

ring on the scalp, which can ulcerate and resembles a squamous carcinoma

(both clinically and histologically). They are benign, but may recur after

excision. They rarely undergo malignant transformation.

Pott’s puffy tumour Osteomyelitis of the skull bones following

untreated frontal sinusitis. This results in overlying scalp inﬂ ammation and

swelling.

Proctalgia fugax Severe recurrent rectal pain in the absence of any

organic disease. Attacks may occur at night, after bowel actions, or follow-

ing ejaculation. Anxiety is said to be an associated feature.

Pseudomyxoma peritonei Disseminated mucinous tumour within

the peritoneal cavity. Commonly due to ruptured ovarian or appendiceal

mucinous neoplasms. Locally recurrent and potentially fatal, even with

heroic surgery and chemotherapy.

Ranula A saliva-containing cyst in the ﬂ oor of the mouth that has a soft,

bluish submucosal appearance.

Raspberry tumour A tender, granulomatous mass arising from the

posterior urethral meatus.

Redcurrant jelly stool A description attributed to the bloodstained

stool found in intussusception.

Reidel’s thyroiditis Thyroiditis characterized by a marked ﬁ brotic reac-

tion, leading to a hard, non-tender thyroid gland. Thyroid function tends

to be normal and differentiation from malignant disease can be difﬁ cult as

ﬁ ne needle aspirates tend to be acellular.

Reinke’s oedema The presence of generalized oedema of the upper

vocal cords in response to noxious stimuli.

Reiter’s syndrome The triad of polyarthritis, conjunctivitis, and ure-

thritis as a result of venereal infection, usually chlamydia. The initial attack

lasts for 4–6 weeks although some patients develop chronic symptoms.

Rendu–Osler–Weber syndrome Hereditary haemorrhagic tel-

angiectasia; a rare autosomal dominant condition characterized by the

presence of haemangiomas affecting the lips, buccal cavity, nasopharynx,

and whole GI tract. These may bleed, resulting in episodes of harmatem-

esis, haematuria, melaena, epistaxis, or anaemia that are self-limiting.

CHAPTER 22 Eponymous terms and rarities

774

Richter’s hernia A form of strangulated hernia in which only part of

the bowel lumen becomes strangulated, leading to incomplete intestinal

obstruction with ischaemia and gangrene of the strangulated part.

Rovsing’s sign Pain and tenderness in the right iliac fossa produced by

palpation of the left iliac fossa. It may be found in acute appendicitis.

Sabre tibia Occurs in late syphilis where new formation of subperiosteal

bone results in bowing.

Saint’s triad The association between cholelithiasis (gallstones), hiatus

hernia, and diverticular disease.

Scheie’s syndrome An autosomal recessive skeletal disorder associ-

ated with corneal clouding, cardiac anomalies, and epiphyseal dysplasia.

Scheuermann’s disease A disease that predominantly affects young

adolescent males where vertebral growth plates are affected by osteo-

chondrosis or aseptic necrosis, resulting in back pain and progressive

kyphosis.

Schmorl’s node A lucent area with surrounding new bone formation

in a vertebral body, resulting from extrusion of the nucleus pulposus into

the vertebral body.

Sever’s disease Osteochondritis of the posterior epiphysis of the os

calcis near the insertion of Achilles tendon.

Shoveller’s fracture A stable cervical injury resulting from fracture of

the spinous process of C7 due to either trauma or muscular contraction.

Sinding–Larsen’s disease Osteochondritis of the distal part of the

patella.

Sister Joseph’s nodule The appearance of umbilical nodules in the

presence of advanced intra-abdominal carcinoma, typically stomach, but

also large bowel, ovarian, or occasionally, breast.

Sjögren’s syndrome The presence of keratoconjunctivitis sicca,

salivary gland involvement (leading to xerostomia, i.e. dry mouth), and

rheumatoid arthritis or other mixed connective tissue disorders. Primary

Sjögren’s is characterized by the ﬁ rst two features whereas secondary

Sjögren’s has all three.

Spigelian hernia A rare type of hernia due to defects within the inter-

nal oblique aponeurosis as it interdigitates with the anterior and posterior

rectus sheath. Peritoneum and visceral contents may herniate through

these small defects.

Stevens–Johnson syndrome Also known as erythema multiforme,

characterized by ulceration that has a characteristic target appearance

and results from drug allergies (particularly to sulphonamides and bar-

biturates), mycoplasmal infections, or idiopathically. The lesions may be

associated with conjunctivitis, tracheitis, and dysphagia.

Stewart–Treves syndrome The development of angiosarcoma in a

chronically lymphoedematous limb, in this particular case, following radical

mastectomy for breast cancer.

EPONYMOUS TERMS AND RARITIES

775

Sump syndrome Due to the collection of stones and debris in the

distal common bile duct following choledochoduodenostomy, resulting in

epigastric pain, cholangitis, and pancreatitis.

Thrombophlebitis migrans Increased coagulability of blood associ-

ated with visceral cancers, particularly adenocarcinomas.

Tietze’s disease Also known as costochondritis. Affects the costal car-

tilages, resulting in chest pain that can be reproduced by pressure to the

affected cartilages.

Tinel’s sign Transient ﬁ nger paraesthesia that follows percussion of the

median nerve proximal to the wrist in patients with median nerve com-

pression due to carpal tunnel syndrome.

Treacher Collins syndrome Also known as mandibulofacial dysosto-

sis. An autosomal dominant condition characterized by symmetrical exter-

nal and middle ear, zygoma, and mandibular hypoplasia, parrot-beaked

nose, absence of medial lower eyelashes, dental crowding, and abnormal

palpebral ﬁ ssures.

Trichlobeozars See beozars.

Troisier’s sign Enlargement of the left supraclavicular lymph node due

to advanced metastatic gastric carcinoma.

Trousseau’s sign Phlebothrombosis of the superﬁ cial leg veins associ-

ated with gastric cancer.

Umbolith An umbilical concretion of desquamated skin, which can lead

to infection.

Ureterocele A cystic dilatation of the intravesical submucosal ureter. It

is often associated with other congenital anomalies, including duplicated

ureters.

VACTERL syndrome The association of vertebral (V), anorectal

(A), cardiovascular (C), tracheo-oesophageal (TE), renal (R), and limb

(L) anomalies. Progesterone and oestrogen intake during early pregnancy

have been implicated.

Vermooten’s sign Digital rectal examination reveals a doughy, dis-

placed, or absent prostate in the presence of an intrapelvic rupture of the

prostatic urethra.

von Hippel–Lindau disease An inherited disorder characterized by

cerebellar and spinal cord haemangioblastomas, retinal angiomas, and an

increased risk of visceral cancers, particularly renal cell carcinoma.

von Recklinghausen’s disease (neuroﬁ bromatosis type I)

Autosomal dominant inherited nodular thickening of nerve trunks, associ-

ated with patchy skin pigmentation (café-au-lait spots). Malignant trans-

formation of these neuroﬁ bromas tends to occur only in this particular

subgroup of patients and their prognosis is poor.

von Rosen’s sign Congenital dislocation of the hip. Results in a click

when the hip is ﬂ exed and adducted, then ﬂ exed and abducted, as this

causes the femoral head to dislocate and relocate.

CHAPTER 22 Eponymous terms and rarities

776

Waldenström disease Necrosis of the articular cartilage of the head

of femur following a slipped femoral epiphysis. This leads to stiffness or

complete loss of movement in that hip.

Waterhouse–Friderichsen syndrome Bilateral adrenal cortical

necrosis due to septicaemia (meningococcal, pneumococcal, streptococ-

cal), haemorrhage, or burns.

Whipple’s triad Fasting hypoglycaemic attacks with blood glucose less

than 2.5mmol/L, relieved by glucose, and associated raised insulin levels.

These are characteristic of an insulinoma.

Whitaker test Can be used to assess the degree of ureteric obstruc-

tion. Saline is perfused into the kidney via a renal puncture at a rate of

10mL/min and the pressure gradient measured across the ureteric–vesical

junction. Ureteric obstruction is indicated by a pressure difference greater

than 20cmH

O. Less than 15cmH

O is normal.

Youssef ’s syndrome A ureterovesical ﬁ stula that presents with

monthly episodes of haematuria.

Zenker’s diverticulum A pharyngeal pouch that occurs though the

dehiscence of Killian, between cricopharyngeus and inferior constrictors

of the pharynx. There is usually a history of food sticking and regurgita-

tion. Progressive weight loss, dysphagia, and aspiration pneumonia can also

occur.

Zollinger–Ellison syndrome Intractable duodenal ulceration due to

elevated levels of circulating gastrin levels. There is an association with

men type I. Diagnosis is conﬁ rmed by acid secretion tests which show

elevated resting levels. Secretin challenge elevates gastrin levels in G-cell

hyperplasia, but not G-cell tumours.

KEY REVISION POINTS

777

Anatomy and physiology

key revision points index

Chapter 2

Anatomy of the breast 31

Pelvic anatomy 39

Physiology of blood groups 97

Physiology of coronary blood ﬂ ow 107

Monitoring/measuring lung function 109

Physiology of diuretics 113

Physiology of haemostasis 119

Chapter 3

The four stages of wound healing 146

Chapter 4

Anatomy of the lower pharynx and larynx 187

Venous drainage of the upper limb 193

Anatomy of the internal jugular vein 199

Anatomy of the rectum 217

Chapter 5

Anatomy and physiology of the salivary glands 227

Chapter 6

Anatomy of the thyroid gland 257

Anatomy of the adrenal gland 269

Chapter 7

Anatomy and physiology of the oesophagus 275

Anatomy and physiology of the stomach 287

Anatomy and physiology of the small instestine 289

Anatomy of appendicectomy 299

Chapter 8

Physiology of bile 312

Anatomy of the portal circulation 323

Chapter 9

General considerations in assessing a patient

with a hernia 337

Anatomy of the inguinal canal 339

Anatomy of the femoral canal 341

KEY REVISION POINTS

778

Chapter 10

Anatomy of the prostate 363

Anatomy of the kidney 375

Chapter 11

Colorectal resections 397

Anorectal physiology 407

Anatomy of the large bowel 409

Anatomy of the anus 413

Chapter 17

Coronary artery anatomy 621

Anatomy of heart valves 629

Mediastinal anatomy 639

Chapter 18

Anatomy of the thoracic outlet 645

779

Index

ABCDEs 478–9

abdomen

acute emergencies in

children 426–7

acute pain 302–4, 303

distension 28, 426

evaluation 34–5

gynaecological causes of

pain 306–7

intra-abdominal abscess

308, 420, 421

investigations 36–7

quadrants 35

trauma 482–3

abdominal aortic aneurysm

652–3

ruptured 654–5

screening 164

abdominal ﬂ aps 618

abdominal wall 335–51,

440–1, 440–55

ABO antibodies 97

ABO antigens 97

above the knee amputation

662

abscess 176–7

absolute risk reduction 7

acanthosis nigricans 758

acetabular fracture 534

achalasia 274–5

achondroplasia 758

acidaemia 94

acid–base balance 94–5

acid burns 607

acinic cell carcinoma 230

acromioclavicular joint

dislocation 526

actuarial survival 9

acute abdominal pain 302–4

acute anorectal angle 217

acute anorectal pain 414–15

acute appendicitis 298–9

acute cholecystitis 316

acute diverticulitis 404

acute haematemesis 294–5

acute haematogenous

osteomyelitis 558–9

acute haemolytic reaction 98

acute idiopathic penoscrotal

oedema of childhood

367

acute infective colitis 396,

397

acute inﬂ ammation 144–5

acute limb ischaemia 642–3

acute lung injury 138–9

acute lymphadenitis 714

acute pancreatitis 143,

332–4

acute parotitis 228–9

acute peritonitis 300–1

acute rectal bleeding

416–17

acute rejection 676–7, 678

acute thyrotoxic crisis

258–9

acute upper gastrointestinal

perforation 296–7

acute urinary retention 113,

386–7

acute variceal haemorrhage

330–1

adaptive immunity 677

Addisonian crisis 53

adenocarcinoma

bladder 376

gall bladder 328

kidney 374–5

lung 632

oesophagus 282

prostate 378–9

salivary gland 230–1

small bowel 292

adenoid cystic carcinoma

230

adenolymphoma 230

adenomatous polyps 398–9

adenomyomatosis, gall

bladder 758

adiposa dolorosa 758

administration 5

adrenal gland 269

adrenaline 132

adrenogenital syndrome

758

Adson’s test 644

advanced polypectomy 403

advanced trauma life

support 478

advance statements 15

aerocele 758

AIDS 637

Albers–Schönberg disease

771

Albright’s hereditary

osteodystrophy 758

Albright’s syndrome

758

albumin 66, 93

alcohol withdrawal 116

aldosterone-producing

adenomas 266

alemtuzumab 680–99

alkalaemia 94

alkali burns 607

alkaline phosphatase 171

Allen’s test 197, 644, 758

allergic reactions 98

allo- 677

alloantigen 677

allogenicity 677

allograft 594

allorecognition 676, 677

alpha-fetoprotein (AFP) 171

α-haemolytic streptococci

174

Altmeier’s perineal rectal

resection 407

amastia 758

amaurosis fugax 658, 758

amazia 758

amniotic ﬂ uid embolism

155

amoebiasis/amoebic liver

abscess 706–7

AMPLE history 479

ampullary carcinoma 328

amputation 662–3, 754–5

anaemia 182–3, 708–9

anaerobes 175

anaesthetic premedication

anaphylactic shock 100

anaphylaxis 98

anastomotic leakage 420–1

aneurysms 652–3

angiodysplasia 417, 759

angiography 41

angiomyoneuroma 759

angiosarcoma 759

liver 329

animal bites 612

anion gap 94

ankle fracture 544–5

ankyloglossia 759

anorectal malformation 439

anorectal pain 414–15

anorectal physiology 407

anoscopy 38

anterior cord syndrome 556

antibioma 759

antibiotic prophylaxis 72, 73

antibody 677

antiemetics 115

antiﬁ brinolytics 97

antigen 677

INDEX

780

antigen-presenting cells

(APC) 677

antiplatelets 73

anti-rhesus antibodies 97

antisepsis 78

antithrombin III 180

anti-thymocyte globulin

680–99

anus anatomy 413

aortic disruption 481

aortic regurgitation 54,

628–9

aortic stenosis 54, 628

aortoenteric ﬁ stula 674, 759

APACHE III 122

APC 677

Apert’s syndrome 759

aphthous ulcers 759

apnoea test 685–99

apophysis 474

apoptosis 143

appendicectomy 299,

736–7

appendicitis 298–9

appendix testis 767

aprotinin 97

Arnold–Chiari malformation

759

arrhythmias 55–6

arterial hypertension 55

arterial monitoring 128, 129

arterial puncture and lines

196–7

arterial ulcers 149

arteriovenous

malformations 656–7

arthritis

osteoarthritis 568–9

septic 562–3

arthroplasty 586–7

ascariasis 718

Askanazy cell tumour 759

aspiration cytology

breast 31

neck 32–3

aspirin 73, 180

asplenia 759

assisted spontaneous

breathing 130

asthma 59

athelia 759

atherosclerosis 152

atrial ﬁ brillation 620

DC cardioversion 188

atropine 133

audit 12–13

auscultation

abdomen 35

neck 32

peripheral vascular

disease 40

autograft 594

autologous blood

transfusion 96

average 6

AVPU 479

axillary hyperhidrosis 645

axillary node sampling and

clearance 242

axontemesis 564

azathioprine 680–99

back pain 578–80

backwash ileitis 392

bad news 4

Baker’s cyst 760

balanitis xerotica obliterans

364, 757–6

Ballance’s sign 760

bariatric surgery 290–1

barium enema 37

Barlow test 458

Barrett’s oesophagus 280,

760

Barton’s fracture 511

basal cell carcinoma 602–3

Bascom II procedure

744–5

base deﬁ cit 94

base excess 94

basilic vein 193

basiliximab 680–99

battery 14

Battle’s sign 760

Bazin’s disease 764

B-cell receptors 676

B-cells 677

Beckwith–Wiedemann

syndrome 440–55, 760

belatacept 680–99

bell-shaped curve 6

below knee amputation 662,

663, 754–5

benign prostatic hyperplasia

362–3

Bennett’s fracture

dislocation 504

benzodiazepine

premedication 71

β-haemolytic streptococci

174

beta-human chorionic

gonadotrophin (β-HCG)

171

bezoars 760

Bier spots 760

bile 312, 316

bilharziasis 712–13

biliary colic 316–17

biliary tree cancer 328–9

bilirubin 312

biphasic deﬁ brillators 190

biphasic positive pressure

ventilation (BiPAP) 131

bites 612

bitumen burns 608

BK virus 679

bladder

cancer 376–7

exstrophy 764

intraperitoneal rupture 768

bleeding 180–1, 620

bleeding per rectum 29

blind loop syndrome 760

blood-borne infection 99,

178–9

blood grouping 97

blood groups 97

blood products 96–7

blood tests, post-operative

blood transfusion 96

blue naevus 760

blunt cardiac injury 481

Bochdalek hernia 760

body mass index (BMI) 66

body surface area 631

Boehaave’s syndrome 760

bone healing 494–7

bone remodelling 495

bone tumours 574–7

Bornholm’s disease 248, 761

bowel habits 29

bowel preparation 70–1

bowel sounds 35

Bowen’s disease 761

boxer’s fracture 504–5

brachial plexus injuries

566–7

brain death 16

brainstem-dead organ

donors 19, 685–6

brainstem death 16, 685–99

brainstem reﬂ exes 685–99

branchial cyst, sinus and

ﬁ stula 224–5

Branham’s test 761

breaking bad news 4

breast

abscess 248, 249

acute pain 248–9

augmentation 617

cancer 240–3

cysts 246

evaluation 30–1

ﬁ broadenoma 246

ﬁ brocystic disease 246,

248, 249

infections 246

lumps 240

Mondor’s disease 771

reconstruction 618

reduction 616

screening 164–5, 244–5

INDEX

781

traumatic fat necrosis 247

wide local excision 752

Brodie’s abscess 561

Brown–Sequard syndrome

556

Budd–Chiari syndrome 761

Buerger’s disease 644

Buerger’s test 40

bunions 584–5

bupivacaine 218

burns 604–8

Buschle–Lowenstein tumour

761

Buscopan

CA 19–9 171

calcaneum fracture 546–7

calcineurin inhibitors 680–99

calcitonin 171

calcium stones 358

Callisen’s hernia 761

callus 494–5

Calot’s triangle 734, 761

Campath 680–99

Campbell de Morgan spots

761

cancer

biliary tree 328–9

bladder 376–7

breast 240–3

colorectal 399, 400–1

en cuirasse 761

gall bladder 328–9

head and neck 232–4, 234

kidney 374–5

liver 328–9

lung 632–3

pancreatic 326–7

penis 380–1

prostate 378–9

risk factors 163

screening 164–6

skin 602–3