What are the characteristics of breast cysts and what is their prognosis?
Flattened epithelium derived from lobular-ductal unit forming round, symmetrical lumps. Occasionally painful but almost always benign.
Often associated with fibrocystic change (fibrosis, cysts and hormone-driven breast pain)
What are the characteristics of adenocarcinoma and what is their prognosis?
Women 25-35 years
Highly mobile, firm, smooth,painless
1/3 regress, 1/3 stay the same, 1/3 get bigger
What are the benign tumours of the breast?
Hamartomas (disorganised growth of normal tissue)
Adenomas
Duct papillomas
Phyllodes tumours (tumour arising from periductal stroma)
What are the most common types malignant of breast cancer?
Invasive adenocarcinomas arising from terminal ducts (invasive ductal carcinoma) or lobular units (invasive lobular carcinoma). These have a poor prognosis.
Rarer types (tubular carcinoma, mucinous carcinoma) have better prognosis
What is Paget’s disease?
Spread of intraductal carcinoma –> nipple
Reddening, thickening and scaling of nipple and areola resembling eczema .: consider with any rash!!
What is the spread of breast cancer?
Local –> adjacent breast, skin (-> tethering), pectoral muscles (deep fixation)
Lymphatic –> lymphatics of skin (peau d’orange), axillary nodes and internal mammary chain
Vascular –> bone, brain, liver, lung
What are the risk factors for breast Ca?
Western culture
PMHx breast Ca
FH breast Ca (BRCA1,2 and p53 = 5% of cases)
Proliferative breast disease
Increased oestrogen exposure (early menarche, late menopause, nulliparity/1st child > 30 years, not breast feeding, HRT and COC)
Obesity and alcohol
How sensitive is mammography and what features of cancer would you see?
Sensitivity 88% women >40 (worse in women <35 so not performed)
Presence of a mass
Microcalcification (benign = coarse and chunky, malignant = fine and linear)
Architectural distortion
Asymmetry
How would you image the breast?
Mammography
USS (solid vs cysts)
How would you biopsy a breast lump and what are the sensitivities and differences between techniques?
Fine needle aspiration cytology (FNAC) - 95% sensitivity, can detect malignancy, cannot stage
Core biopsy - 97% sensitivity, can stage
Excisional biopsy - staging and first step in controlling local disease
Punch biopsy - vs Paget’s disease of the nipple
How would you manage fibroadenoma, fibroadenosis, and cysts?
Fibroadenoma - excision only if concern vs. diagnosis, cosmesis or symptoms
Fibroadenosis - reassurance, anti-inflammatories, hormone or cellular manipulation (linoleic acid, COC pill, cyst aspiration)
Cyst - repeated aspiration, hormone manipulation if multiple recurrent cysts
What is the staging of breast cancer?
Stage 1 - confined to breast, mobile
Stage 2 - confined to breast, mobile, nodes in ipsilateral axilla
Stage 3 - tumour fixed to muscle, skin involvement larger than tumour
Stage 4 - complete fixation of tumour to chest wall, distant metastases
Management of breast cancer
Wide local excision - breast conserving, eu combined with local radiotherapy
Simple mastectomy - vs large tumours, central location, complications (eg. ulcers). Adjuvant radiotherapy rarely required
Endocrine therapy - best vs ER +ve tumours - Anti-oestrogens (Tamoxifen), Lutenising hormone releasing hormone antagonists, aromatase inhibitors
Monoclonal antibodies - Traztuzumab (Herceptin) vs HER-2 +ve
Chemotherapy - anthracyclines, cyclophosphamide, 5-FU methotrexate vs high risk features
Radiotherapy - vs sym from bone/liver/brain mets
Management of regional lymph nodes in breast cancer
Axillary node sampling = retrieve minimum 4 nodes, avoids disruption lymph drainage BUT inadequate for treatment (adjuvant radiotrX if +ve)
Axillary node clearance = treatment of axilla BUT increased risk lymphoedema
Sentinel node biopsy = ID +ve drainage nodes with radioactive tracer and then remove avoiding major axillary surgery
What is the Nottingham Prognostic Index and what are it’s survival rates?
NPI = 0.2 x tumour size cm + histological grade + nodal status
10yr survival with only surgery
5.4 = 20%
How would you investigate a breast lump?
1) Clinical exam
2) Radiology - USS 35
3) Histology/cytology - FNA or core biopsy
What are the types of nipple discharge and what are their causes?
Milky - pregnancy, hyperprolactinaemia
Clear - physiological
Green - perimenopausal ,duct ectasia, fibroadenotic cyst
Blood stained - Carcinoma, intraduct papilloma, REFER!!!
Describe the structure of the breast
The breast overlies ribs 2-6 with an axillary tail extending into the axilla. It is composed of 15-20 lobes seperated by fibrous septa which acts as suspensory ligaments and attaches the breast to the pectoral mm beneath
The retromammary space is a layer of loose areolar tissue between the deep fascia of the breast and mm
What is the vasculature of the breast?
aa = Internal and intercostal aa perforating branches
Axillary –> L thoracic and thoracoacrromial branches
vv follow aa
What are the lymphatics of the breast?
L quadrants –> axillary lymph nodes and pectoral
M quadrants –> internal thoracic (behind sternum so v. hard to treat)
Which quadrant do the majority of breast cancers originate in?
Outer L quadrant (60%)
What are the important urological symptoms and how would you classify them?
Storage sym = urgency, frequency, nocturia
Voiding sym = hesitancy, poor stream, post micturition dribble, incomplete emptying
Misc sym = haematuria, dysuria
What is the difference between a keloid and a hypertrophic scar?
Hypertrophic scar = follows boundaries of wound
Keloid scar = grows over boundaries of wound
How do you manage keloid scars?
Do NOT try to re-excise them!!
Corticosteroid injections
In the presence of parotid swelling what should you check and why?
Facial nn function (mm of facial expression), divides into its five branches within the parotid gland
When would you use clips instead of stitches?
Mainly if there is a concern about post-op bleeding. Clips can be removed rapidly whereas stitches take longer.
How do x-rays cause damage?
Ionising radiation
What is the difference between dose-dependent and dose-independent x-ray damage?
Dose-dependent = burns etc. Dose-independent = cancer
What are the fortes of CT and MRI?
CT = bone MRI = soft tissue
What is “windowing”?
MRI gives images in approx 2000 shades of grey. Humans can only see 15 or so. Windowing allows focusing in on a specific part of that spectrum and better images to be given.
What are the definitions and infection rates of clean, potentially contaminated, contaminated and dirty operations?
Clean - Infection rate 2-5%, does not enter colonised viscus/lumen of body, eu = skin commensals
Potentially contaminated = infection rate 10%, enters colonised viscus/lumen but under controlled conditions,
Contaminated = infection rate 20%, contamination present without obvious infection eg. vs penetrating injury with intestinal spillage
Dirty = infection rate >30%, surgery when active infection already present
What constitutes pre-op evaluation?
Identification & details of patient Diagnosis & proposed op Cardiac and respiratory exam PMHx vs complicating factors Relevant laboratory/diagnostic factors Informed consent Advise patient re. nature of procedure Expected benefits and possible risks Need for HDU/ICU care
What constitutes operative records?
Pre-op and post-op Dx
Important anatomical and physiological observations about pt
Operative procedure performed and incision used
Name of surgeonn and anaesthetist
Anaesthetic used
Estimated blood loss and fluid given during procedure
Results of intraoperative tests
Complications
Tubes/drains/prosthesis used and location
Condition of pt at end of surgery
What constitutes post-op assessment?
Dx Pt condition Vital signs Analgesia assessment Activity restrictions? Wound care Tube and drain care Dietary requirements? Fluids & meds aB prophylaxis
What are the indications for rigid sigmoidoscopy/proctoscopy?
Sigmoidoscopy = examination of rectum --> rectosigmoid junction Proctoscopy = examination of anal canal
Any sym suggesting colonic neoplasia Inflammatory BD Taking biopsies of pathology within direct visualisation Before ano-rectal ops/procedure Proctoscopy can treat haemorrhoids
What are the indications for flexible sgmoidoscopy?
Visualises up to descending colon
Screening for CRC Pre-op eval before anorectal surgery Surveillance of previous Dx malignancy Removal of rectal foreign body Endoluminal stent insertion for strictures, balloon dilatation, decompression Haematochezia (passing fresh blood)
What are the indications for a tube thoracostomy?
(Chest drain)
Anything in lungs (pneumo-, haemo-, haemopneumo-, hydro-, chylo-, empyema, plearal effusion)
Post op for thoracotomy, oesophagectomy, cardiac surgery
Where should you insert a chest drain?
“Safe triangle”
A. border lat dorsi, L. border pec major, horizontal level of nipple, apex at axilla
Aim for upper border of lower rib to avoid neurovascular bundle
What sites should you use for central venous access?
Internal jugular vein (right= preferred)
Lies in carotid sheath, A. to SCM in upper neck, carotid = anteromedial
Subclavian also possible
What is a urostomy?
Ureters –> short length of disconnected ileum
Eu = right sided and indistinguishable from ileostomies unless looking at contents
What are the gastrostomies/jejunostomies?
Narrow calibre, flush to the skin in left upper quadrant. Oft contain indwelling tubes/catheters
Primary use = direct feeding
What are the indications for urethral catheterisation?
Acute/chronic urinary retention
Monitor urinary output in critically ill patient
Perioperative monitoring of urinary output
Incontinence
Aid to abdominal or pelvic surgery
What are the alternatives to urethral catheterisation?
Suprapubic catheterisation - MUST have distended bladder. Mandatory if pelvic trauma and suspected urethral injury
Ultrasound guided drainage - as it says
What are the complications of catheterisation?
Infections Paraphimosis Creation of false passages Urethral strictures & perforation Bleeding
What are the different types of drains available?
Active drains = suction to drain collections
Passive drains = dependent on gravity or capillary action although reversal in pressures and infection is possible
Open drains = ALWAYS passive –> stoma/dressing
Closed drains = –> container with or without suction (active or passive)
What is shortening of a drain?
Gradual removal of a drain to allow healing from the bottom of the wound upwards while still allowing removal of any collections
What are the complications of drains?
Damage to structures
Route of infection
Do not always drain properly –> false sense of security
Can you sample urine for analysis and culture from a catheter bag?
No no no no NO!
What is a Swan-Ganz catheter?
Catheter used to measure pulmonary artery pressure
What is the difference between primary, secondary and reactionary haemorrhage?
Primary = Immediately after surgery
Reactionary = within 24h, thought to occur as fluid volume increases and ruptures vessels
Secondary = up to 10 days post op, eu following secondary infection
What would you use to treat secondary infection of a surgical wound?
Eu = skin flora .: Flucloxacillin
Consider vs. anaerobes if v. unwell = metronidazole
MRSA = vancomycin
What are the indications for a central venous catheter?
Critically ill needing continuous monitoring of fluid levels
Infusion of irritating or narrow therapuetic window agents (cytotoxic/inotropic)
Long term parenteral nutrition, chemotherapy or prophylactic aB
Frequent blood sampling
Haemodialysis
What is a Quinton catheter?
Non-tunneled central venous catheter
What is a Hickman/Groshong catheter?
Tunneled central venous catheter
What is a PICC line?
Peripherally inserted catheter, eu in arm and advanced to SVC
What are the indications for a Swan-Ganz catheter?
Arterial catheter allowing for measurement of pulmonary arterial Pa
Diagnosis of shock
Dx of idiopathic pulmonary hypertension, valvular disease, PE, intracardiac shunts, cardiac tamponade
Mx of complicated AMI, multiorgan failure, severe burns, haemodynamically unstable pts
What is Allen’s test?
Test to ensure collateral blood supply present to hand via radial and ulnar aa
Elevate hand and ask pt to make fist for 30s
Occlude both ulnar and radial aa
When blanched release ulnar aa Pa and colour return in 7-10s MAX
What are the indications for arterial catheterisation?
Frequent ABG or blood sampling
Continuous invasive BP monitoring
If unable to measure BP (burns, morbid obesity)
What are the complications of central venous catheterisation?
Haemorrhage Arterial (subclavian/carotid) or thoracic duct puncture Pneumothorax/air embolus Thrombosis Sepsis
What are the 4 stages of wound healing and how long do they last?
1) Haemostasis = immediate (platelet aggregation, clotting & complement activated –> thrombus and reactive vasospasm)
2) Inflammation = 0-3 days (vasodilation and capillary permeability, neutrophils amplify inflammatory response, macrophage secrete growth factors and cytokines)
3) Proliferation = 3 days - 3 weeks (fibroblasts migrate and synthesise collagen, angiogenesis stimulated by hypoxia)
4) Remodelling = 3 weeks - 1 year (re-orientation and maturation of collagen fibres)
What is granulation tissue?
Combination of capillary loops and myofibroblasts, bleeds easily. Think skin under scab which is removed to soon.
What is the difference between primary intention and secondary intention?
Primary intention = wound edges can be clearly apposed and are clean (think cuts)
Secondary intention = wound edges cannot be clearly apposed and heal by granulation tissue filling in gap and being covered by epitehlium
Should you immediately close an untidy wound?
NO! First need to debride it and excise dead tissue, particularly if heavily contaminated and >6 hours old. Closure should occur at 48-72h assuming granulation tissue healthy and no further complications
When should you remove sutures from the head/face, upper limb and abdomen/lower limb?
Head/face = 5 days
Upper limb = days
Abdomen and lower limb = 10 days
What is shock?
Acute circulatory failure of sufficient magnitude to compromise tissue perfusion
What are the types of shock?
Hypovolaemic Cardiogenic Septic shock Anaphylactic shock Neurogenic shock
What are the causes of hypovolaemic shock?
Revealed haemorrhage
Concealed haemorrhage
Extensive burns (fluid loss from skins)
Sepsis (fluid in interstitial tissues)
Dehydration
Bowel obstruction (fluid sequestered in bowel)
Excessive urinary fluid loss (DKA, acute tubular necrosis, diuretics)
Accumulation of fluid in peritoneal cavity (acute pancreatitis, ascites, generalised peritonitis)
What are the causes of cardiogenic shock?
Reduction in cardiac output, eu = direct myocarrdial damage
Ventricular arrythmia
MI/ischaemia
Valve dysfunction
Metabolic/electrolyte disturbances
Massive PE
Tamponade
Tension pneuomthorax
What are the causes of septic shock?
Overactivation of innate immune system
Infection Trauma/surgery Severe burns Necrotic tissue Toxic shock syndrome (super-absorbent tampons)
What are the causes of anaphylactic shock?
Generalised type I IgE mediated hypersensitivity reaction
What are the causes of neurogenic shock?
Impaired SNS outflow from spinal cord
Epidural anaesthesia,
Spinal cord injury
What are the effects of shock on the lung, heart, brian, kidney, GI and skin?
Lung = tachypnoea
Heart = Reduced diastolic, increased HR, reduced cardiac output, may –> ischaemic chest pain, arrhythmias, infarction
Brain = Decreased cerebral perfusion, pt –> agitated, confused, drowsy, unresponsive
Kidney = Hypotension –> reduced urine output & impaired renal fXn
GI = reduced perfusion –> impaired motility and absorption
Skin = cool, clammy, grey peripherally (except sepsis where = opposite)
What are the characteristics of hypovolaemic shock?
Skin = pale Sweating Temp = cold Pulse = weak Peripheries = shut down Cap refill = >2s CVP/JVP = low Mental status = restless
What are the symptoms of cardiogenic shock?
Skin = pale Sweating = present Temp = cold Pulse = weak Peripheries = shut down Cap refill = >2s CVP/JVP = HIGH Mental status = quiet
What are the symptoms of septic shock?
Skin = flushed Temp = warm Pulse = bounding Peripheries = Vasodilatation Cap refill = >2s CVP/JVP = low Mental status = drowsy
What are the symptoms of anaphylactic shock?
Skin = urticarial rash Temp = warm Pulse = bounding Peripheries = vasodilatation Cap refill = >2s CVP/JVP = low Mental status = variable
What common surgical conditions lead to disseminated intravascular coagulation?
Sepsis Transfusion reaction Drug reaction Transplant rejection Aortic aneurysm surgery
What is disseminated intravascular coagulation?
Widespread activation of coagulation resulting from the formation of intravascular fibrin, fibrin degradation products, consumption of platelets and clotting factors, and ultimately thrombotic occlusion of vessels.
Basically clot like stink then bleed like stink.
What are the types of surgical infection?
Superficial Incisional Infection
Deep Incisional Infection
Organ/Space Infection
What are the principles of prophylactic antibiotics in surgery?
Identification of at risk pts = Op/pt factors
Choice of antibiotic = Cephalosporins, often with metronidazole
Dose and timing = Eu = parenteral at induction then 2 doses to complete 24h course
Route of administration = IV (best), Oral (minor), Rectal, Topical
Long term prophylaxis = vs. eg splenectomy
What are the characteristics of impetigo?
Thin-walled vesicle with golden crust on erythematous base
Caused by Strep or Staph
Usually affects face and limbs
What are the characteristic features of erythrasma?
Mild localised infection caused by corynebacterium
Asymptomatic or mildly itchy between toes and flexures
Well defined, reddish brown (coral pink lesions under Woods light), may = with scale
What are the symptoms of staphylococcal scalded skin syndrome?
Rapidly developing fever Irritability Skin tenderness Erythema Blisters and superficial erosions
What bacteria are you likely to encounter in a human bite wound and what antibiotics would you prescribe?
S. Aureus
Beta-haemolytic streptococci
E corrodens
Anaerobes
First generation cephalosorin (Cephalexin) or Pneinicillinase-resistant penicillin (dicloxacillin/nafcillin/cloxacillin/oxacillin)
What are the likely bacteria you would encounter in a dog or cat bite and what antibiotics would you prescribe?
S Aureus
Beta haemolytic step
P multocida
First gen cephalosporin (Cephalexin) OR Penicillinase resitant penicillin (oxacillin/cloxacillin/nafcillin/dicloxacillin)
What are the features of anaerobic gangrene (gas gangrene)?
Caused by clostridium perfringens
Initially = gas in affected tissues and skeletal mm Then = oedema with spreading gangrene and systemic signs (sepsis?)
How would you treat gas gangrene?
Aggressive debridement and fasciotomies
Penicillin 2g/4h IV and metronidazole
What are the symptoms of synergistic spreading gangrene?
A.k.a necrotising fasciitis
Caused by aerobes and synergistic anaerobes
Severe wound pain and may = gas in tissues
Manage with systemic support, antibiotics, excision of involved tissues
A pt post op has a fever, what should you check?
Wound (infection, haematoma) Cannula sites (infection) Chest (pulmonary collapse, infection, infarction, subphrenic abscess) Legs vs DVT Rectal exam (pelvic abscess) Urine Stool
What antibiotics would you prescribe for staph infection?
Cephalosporins, particularly cefuroxime
Gentamicin
What antibiotics would you use to treat MRSA?
Vancomycin
Teicoplanin
Fuisidic acid
What antibiotics would you prescribe to treat Strep infection?
Penicillin Erythromycin Cephalosporins Clindamycin Mupirocin (topical)
What antibiotics would you prescribe to treat an enterococci infection?
Ampicillin + glycoside e.g. teicoplanin
What antibiotics would you use to treat a gram -ve rod infection?
e.g. E. coli, klebsiella, proteus, salmonella, enterobacter
Cephalosporins
Piparacillin
Tazobactam
Aminoglycosides (gentamicin, streptomycin, amikacin)
What antibiotics would you use to treat an anaerobic infection?
Metronidazole
What are the common locations for intra-abdominal abscess formation?
Alongside organ of origin = paracolic in diverticulitis, parapancreatic after infective pancreatitis
Pelvic = following pelvic sepsis (appendicitis)
Subphrenic = following upper GI perf
What are the clinical features of an abscess?
Malaise and anorexia Localised, constant abdominal pain Swinging fever peaking in excess of 38.5 twice/day Tachycardia following temperature Mass
How would you investigate an intra-abdominal abscess?
CT scan
USS only if pelvic abscess and pt not fit for CT
What are the steps in abscess drainage and how would you dress the drained abscess?
Drain pus
Remove necrotic material
Small abscess = dry dressing
Deep abscess = leave open until healed with granulation tissue eg. corrugated drain/ribbon gauze soaked in aB