Year 3 - Surgery | Thalia Börsch
Surgery
Table of Contents
Upper gastrointestinal conditions ........................................................................................................... 3
Gastric cancer .................................................................................................................................... 3
Oesophageal cancer .......................................................................................................................... 6
Peptic ulcer disease ........................................................................................................................... 8
Lower gastrointestinal / colorectal conditions ....................................................................................... 12
Colorectal carcinoma (colon cancer) ................................................................................................ 12
Diverticular disease (Diverticulosis) .................................................................................................. 16
Chronic inflammatory bowel disease: Ulcerative colitis ..................................................................... 18
Chronic inflammatory bowel disease: Crohn’s disease ..................................................................... 23
Perianal conditions: Anal abscess and fistula ................................................................................... 27
Perianal conditions: Fissure.............................................................................................................. 29
Perianal conditions: Haemorrhoids ................................................................................................... 31
Hepato-Pancreato-Biliary ..................................................................................................................... 34
Acute pancreatitis ............................................................................................................................. 34
Biliary Cancer: Cholangiocarcinoma and gallbladder CA .................................................................. 38
Acute (Ascending) Cholangitis.......................................................................................................... 41
Acute cholecystitis ............................................................................................................................ 43
Chronic pancreatitis .......................................................................................................................... 45
Liver cancer: Hepatocellular CA ....................................................................................................... 48
Pancreatic cancer (including Whipple procedure) ............................................................................. 51
Urological conditions ............................................................................................................................ 54
Urinary tract cancer .......................................................................................................................... 54
Benign prostatic hyperplasia (BP) .................................................................................................... 57
Prostate cancer ................................................................................................................................ 60
Renal tract stones: Nephrolithiasis ................................................................................................... 63
Urological emergencies .................................................................................................................... 67
Acute Abdomen ................................................................................................................................... 73
Differential Diagnosis of Acute Abdomen.......................................................................................... 73
Appendicitis ...................................................................................................................................... 76
Diverticulitis ...................................................................................................................................... 78
Ectopic pregnancy ............................................................................................................................ 81
Inguinal Hernia (Leistenhernie)......................................................................................................... 84
Femoral Hernia (Oberschenkelhernie) .............................................................................................. 87
Ischaemic colitis (colonic ischaemia) ................................................................................................ 89
Intussusception ................................................................................................................................ 91
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, Year 3 - Surgery | Thalia Börsch
Mesenteric Ischaemia: Acute (AMI) and Chronic (CMI) .................................................................... 93
Bowel Obstruction ............................................................................................................................ 96
Ovarian (adnexal or tubo-ovarian) torsion......................................................................................... 99
Testicular torsion ............................................................................................................................ 100
Paralytic Ileus: Functional/Adynamic bowel obstruction .................................................................. 102
Gastrointestinal / Bowel Perforation................................................................................................ 105
Primary Peritonitis (Spontaneous bacterial peritonitis – SBP) ......................................................... 107
Volvulus and intestinal malrotation ................................................................................................. 110
Vascular Surgical conditions .............................................................................................................. 113
Abdominal aortic aneurysm (AAA) .................................................................................................. 113
Aortic dissection ............................................................................................................................. 116
Carotid arterial disease / stenosis (CAS) ........................................................................................ 119
Peripheral vascular/arterial disease ................................................................................................ 121
Venous diseases: Varicose veins and chronic venous insufficiency ............................................... 124
General Conditions ............................................................................................................................ 126
Necrotising soft tissue infections .................................................................................................... 126
Skin lesions .................................................................................................................................... 128
Orthopaedic conditions & emergencies .............................................................................................. 132
Compartment syndrome ................................................................................................................. 132
Hip dislocation/luxation (risk of Avascular ....................................................................................... 134
necrosis)......................................................................................................................................... 134
Hip replacement / Joint replacement: Arthroplasty.......................................................................... 135
Neck of femur fractures (NOF) ....................................................................................................... 136
General principles of fractures: Especially Open fractures .............................................................. 138
Osteomyelitis .................................................................................................................................. 141
Septic Arthritis (Infectious arthritis) ................................................................................................. 143
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, Year 3 - Surgery | Thalia Börsch
Upper gastrointestinal conditions
Gastric cancer
Risk Factor / Aetiology
- Highest incidence in South Korea, Mongolia and Japan, more common in males, older people
- Exogenous risk factors: diet rich in nitrates / salt, H. pylori infection, nicotine use, Epstein-Barr
virus, low socioeconomic status, obesity
- Endogenous risk factors:
➔ Gastric conditions: chronic atrophic gastritis and pernicious anaemia, Achlorhydria (due to
Menetrier disease), gastric ulcers. Partial gastrectomy, adenomatous gastric polyps,
gastroesophageal reflux disease
➔ Hereditary factors: positive family history, blood type A, hereditary nonpolyposis colorectal
cancer
Pathophysiology / Classification
- H. pylori: triggers inflammation of mucosa causing atrophy and intestinal metaplasia
Gastric adenocarcinoma (95%):
- Commonly located on lesser curvature, arises from
glandular cells in stomach
- Lauren classification
➔ Intestinal type gastric CA: typically localised,
polypoid glandular formation, similar to an
ulcerative lesion with clear raised margins,
common located on the lesser curvature
➔ Diffuse type gastric CA: no clear border, spreads
earlier, infiltrative growth, diffuse spread in gastric
wall, linits plastica (gastric wall thickening and leather bottle appearance), composed of
signet ring cells (worse prognosis, round cells filled with mucin with a flat nucleus in the cell
periphery), associated with E-cadherin mutation
➔ Intermediate type: least common type
Other gastric cancer types:
- GI stromal tumours (GISTs): malignant mesenchymal neoplasm of the GI tract that arises from
interstitial cells of Cajal or precursors, treatment involves surgical removal and treatment with
tyrosine kinase inhibitors such as imatinib or dasatinib
- Neuroendocrine tumours (including carcinoids): start in endocrine cells of stomach, grow slowly
and normally don’t spread
- Lymphomas: start in immune cells like MALT lymphoma (95% caused by H. pylori)
- Others: squamous cell carcinomas, small cell carcinomas, leiomyosarcomas
Signs & Symptoms
Early stage
- Often asymptomatic, loss of appetite /
nausea
Later stages: presentation with advanced
stages in 50%
2Virchow node 1Sister Mary Joseph node
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, Year 3 - Surgery | Thalia Börsch
- General signs: weight loss (may be
due to decreased calorie intake due to
pain), signs of chronic iron deficiency
anaemia, palpable tumour
- Signs of gastric outlet obstruction:
dyspepsia, dysphagia, abdominal
epigastric pain, early satiety, vomiting
Signs of upper Gi bleeding:
haematemesis, melena
- Signs of metastatic disease: 3Malignant acanthosis nigricans 4Leser-Trelat sign
hepatomegaly, ascites, left
supraclavicular adenopathy (Virchow node), palpable umbilical nodule (Sister Mary Joseph
node), palpable mass on DRE (Blumer shelf), ovarian mass (Krukenberg tumour) plus
complications
- Paraneoplastic syndromes: Leser-Trelat sign, malignant acanthosis nigricans
Investigations
- Confirmatory tests: upper endoscopy with biopsy, upper GI series (barium studies)
- Labs: anaemia, positive faecal occult blood test, renal and liver function tests, serologic markers
(tumour markers like CA 72-4, CA 19-9, CEA; TNF-alpha), HER2 testing
- Imaging:
➔ Endosonography: depth of tumour invasion, lymph node involvement
➔ Abdominal ultrasound
➔ CT scan (abdomen, pelvis, thorax): lymph node involvement, detection of distant
metastases
➔ PET-CT/diagnostic laparoscopy: for occult metastases that could have been missed during
endoscopy or on CT scan
Differential diagnosis
Gastric conditions: gastric ulcer, Gastroesophageal reflux disease (GERD), Menetrier disease, non-
ulcer dyspepsia
Management
Early-stage disease
- Endoscopic mucosal tumour resection
- Subtotal or total gastrectomy
- H. pylori infection treatment / eradication
Late-stage disease
- Perioperative chemotherapy or radiotherapy: as neoadjuvant / adjuvant therapy, Trastuzumab
is indicated for HER2-positive gastric adenocarcinomas
- Surgery:
➔ Total gastrectomy and lymphadenectomy: complete resection of stomach with blind closure
of the proximal duodenum, resection of the lesser and greater omentum, radical
lymphadenectomy
➔ Subtotal gastrectomy: resection of body ad pylorus of stomach with blind closure of the
duodenal stump, radical lymphadenectomy
➔ Roux-en-Y gastric bypass: surgical technique used in the reconstruction of gastric passage
to prevent GI obstruction after gastrectomy / bariatric surgery
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