Viva Week

Question 1

Describe the classification of renal impairment

Answer 1

Question 2

Describe the role of adjuvant immune checkpoint therapy in melanoma

Answer 2

• Can be used for metastatic (Stage IV) disease - funded in Aus/NZ
• Can be used for node-positive (Stage III) disease - not currently funded (register for trials)
• Keynote-6 demonstrated that Pembrolizumab (Keytruda, PD-1-mAb) is superior to Ipilumimab (CTLA4-mAb); 40% OS at 4 years for Pembro.
• Keynote-54 demonstrated that Pembrolizumab was superior to placebo for Stage III disease; 75% versus 60% DFS at 15 months
• Checkmate; Nivolumb+Ipilumimab or Nivolumab alone versus Ipilumab alone; Combination is better but more side effects.

Question 3

How is “on-table colonic lavage” performed?

Answer 3

1. Mobilise large colon; bring down splenic flexure
2. Excise tumour with oncological resection
3. Transect appendix at half-way and insert 12-14Fr Foley into caecum and inflate balloon
4. Vicryl tie to secure Foley
5. Place additional side square drape
6. Exteriorise bowel and place end into sterile camera-drape and secure with artery forceps; place distal end of camera drape into bucket on floor
7. Lavage with 6-8L of warmed normal saline
8. By now, any devascularised bowel will have demarcated; resect as required and anastomose.

Question 4

What are the indications for rib-plating?

Answer 4

• Flail chest with resultant respiratory failure requiring mechanical ventilation is the only indication for rib fracture fixation for which a strong evidence base exists.
• In this population, there are
  • reduced intubation times and
  • reduced tracheostomy requirements.

Question 5

What is thromboelastography?

Describe a thromboelastogram.

Answer 5

• TEG is a method of testing dynamic coagulation using a sample of blood either spun around a needle (ROTEM), or with a needle spun within it (TEG) to measure the speed and strength of clot formation.

Question 6

Describe the theatre set-up for a trauma

Answer 6

• Experienced assisstant and scrub nurse
• Headlight
• Warm theatre
• Bair Huggers
• Two Yankauer suckers
• 20 large packs
• Cell-saver
• Omnitract
• Vascular set and thoracotomy set
• Fogarty, Haemostatic agents, Shunts

Question 7

What is in Cyroprecipite?

What is in Fresh Frozen Plasma?

What is in Prothrombinex?

Answer 7

Cryoprecipitate

• Fibrinogen
• vWF
• Factor VIII
• Factor XIII

FFP

• All coagulation factors except platelets

Prothrombinex

• Factor II
• Factor VII
• Factor IX

Question 8

What are the indications for emergent surgery in Ulcerative Colitis?

What are the indications for elective surgery in Ulcerative Colitis?

Answer 8

Emergent indications (BUMP):

• Bleeding
• Unresponsive to medical therapy
• Mega-colon
• Perforation

Elective indications (3Ms):

• Malignancy or dysplasia
• Medical therapy failure
• Maturation failure

Question 9

What are the complications of ileo-anal J-pouches?

Answer 9

• Pouch failure in ~5-10%
  
  • Pouchitis
    
    • ~50% will suffer from this at some point
    • Treated with ABx and anti-inflammatory enemas, predisposes to dysplasia.
  • Poor function
    
    • Expect 6-8 BM per 24 hours
    • Tendency to improve over time
  • Pouch complications
    
    • Sepsis from leak
    • Stricture at anastomosis ~5-20%
    • Fistula to vagina or sinus to pelvis

Question 10

Describe the principles of vascular surgery in trauma

Answer 10

1. Prepare the patient for wide access
2. Proximal control
   
   • Consider adjuncts such as IR for junctional areas
3. Distal control
4. Temporise injuries in DCS; shunt
5. Repair injury with vascular surgeon
6. Adjuncts in vascular surgery
   
   • Fasciotomies
   • _Tissue coverag_e of vascular repairs

Question 11

What are the distinguishing features of common hepatic incidentallomas on CT and MRI?

Answer 11

• Haemangioma
  
  • Centripetal filling on arterial contrast
• FNH
  
  • Central feeding arteriole
  • Homogenous arterial enhancement with iso-enhancement of delayed phases
• Hepatic Adenoma
  
  • Blood and fat (heterogenous) components
  • Homogenous arterial enhancement with iso-enhancement of delayed phases
  • Young female on OCP
• HCC
  
  • Arterial enhancement with washout on later phases
  • Cirrhotic liver
  • DWI - restricts diffusion
• Cholangiocarcinoma
  
  • Heterogeneous minor peripheral enhancement with gradual centripetal enhancement
  • Often “absence of a mass” present; i.e IH duct dilatation without clear mass
  • DWI - restricts diffusion
• Metastases
  
  • Hypo-attenuating cannon-ball lesions
  • Most commonly gastrointestinal origin
  • Hyper-attenuating metastases from C.T.M.R.PnET tumours