Surgery Long Case Discussions

Surgery Long Case Discussions

Surgery long case discussions are crucial. They serve as a comprehensive test of a student’s ability to thoroughly assess a surgical patient. These discussions also show critical thinking. Examiners specifically focus on “high-yield” areas. They expect you to accurately diagnose the condition. You should articulate a strong rationale for your investigations. It is important to detail a full management plan, including surgical and non-surgical options. Confidently discussing potential complications is crucial. This ensures you show a robust understanding of the case’s core surgical principles.

Surgery Long Case: Obstructive Jaundice

Patient Summary

This is a 74-year-old female who presents with a history of progressive, painless jaundice. She reports associated generalized itching (pruritus), pale, clay-coloured stools, and dark urine. She also complains of loss of appetite, significant weight loss, and dyspeptic symptoms. There is no significant abdominal pain or fever. On examination, she is cachectic and deeply icteric with numerous scratch marks over her body. Her abdomen is soft, and a smooth, non-tender, palpable gallbladder is noted in the right upper quadrant. There is no free fluid.

What are the differential diagnoses (DDs)?

Given the classic presentation of painless, progressive obstructive jaundice with a palpable gallbladder in an elderly patient with weight loss, the differential diagnosis is centered on malignancy around the head of the pancreas. This is often termed “periampullary cancer.”

  1. Carcinoma of the Head of Pancreas: Most common cause (~75%).
  2. Cholangiocarcinoma: Cancer of the distal common bile duct.
  3. Ampullary Carcinoma: Cancer of the Ampulla of Vater. Often presents earlier and may have intermittent jaundice or melaena.
  4. Duodenal Carcinoma: Involving the ampulla.

Why Lymphoma? Lymphoma in the porta hepatis can cause external compression of the common bile duct, leading to obstructive jaundice. It should be considered, especially if there are associated night sweats and fever.

Can this be a medical jaundice? Unlikely. Medical (hepatocellular) jaundice typically presents with unwellness, but stools are not persistently pale, and the gallbladder is not palpable. The biochemical picture would show a predominant rise in transaminases (AST/ALT) rather than alkaline phosphatase (ALP).

Explain Courvoisier’s Law and its relevance here.

The Law: “In the presence of jaundice, if the gallbladder is palpable, the cause is unlikely to be a gallstone.”

The Rationale:

  • Malignant Obstruction (e.g., Pancreatic Cancer): The obstruction is gradual and progressive. The gallbladder, which is usually healthy and thin-walled, has time to slowly distend with backed-up bile, becoming enlarged and palpable without being tender.
  • Gallstone Obstruction: A stone passing into the common bile duct usually occurs in the context of chronic cholecystitis. The gallbladder is often chronically inflamed, fibrosed, and shrunken, and cannot distend even when the duct is blocked.

What is the exception? The main exception is a “double impaction,” where one stone blocks the common bile duct (causing jaundice) and another blocks the cystic duct (causing a mucocele of the gallbladder), making it palpable. Another exception is Mirizzi Syndrome.

How will you investigate this patient?

The investigation pathway is systematic: confirm obstruction, determine the level and cause, and stage the disease.

1. Biochemical Investigations:

  • Liver Function Tests (LFTs): Will show a cholestatic or obstructive picture:
    • Markedly elevated Alkaline Phosphatase (ALP) and Gamma-GT (GGT).
    • Elevated conjugated (direct) bilirubin.
    • AST/ALT may be mildly elevated.
  • Coagulation Profile (PT/INR): This is the most important initial blood test. Obstructive jaundice leads to malabsorption of fat-soluble Vitamin K, causing a prolonged PT/INR and risk of bleeding. This must be checked and corrected before any invasive procedure.
  • Tumour Markers: CA 19-9 (for pancreatic/cholangiocarcinoma) and CEA.

2. Imaging Investigations:

  • Ultrasound Scan (USS) of the Abdomen: This is the first-line imaging test.
    • What you expect: It will show dilated intrahepatic and extrahepatic biliary ducts (a dilated CBD is >7mm). It can often identify the level of obstruction and may show a mass in the head of the pancreas. It will also assess the gallbladder and screen for liver metastases.
    • Preparation: The patient should be fasting for at least 6 hours to ensure the gallbladder is distended and to reduce bowel gas.
  • Contrast-Enhanced CT (CECT) of the Abdomen and Pelvis: This is the key investigation for staging.
    • Purpose: It defines the pancreatic mass, its relationship to major blood vessels (SMA, portal vein), and detects nodal or distant metastases (especially in the liver and peritoneum). This is crucial for determining resectability.
    • Preparation: Check renal function (Urea, Creatinine) before giving IV contrast. Ask about allergies. Hold metformin.
  • MRI/MRCP: Provides more detailed imaging of the biliary tree and is superior to CT for visualising cholangiocarcinoma.
  • ERCP (Endoscopic Retrograde Cholangiopancreatography):
    • Role: Now primarily a therapeutic procedure rather than a first-line diagnostic test.
    • Purpose: It allows for brushing/biopsy of a stricture and, most importantly, palliative stenting to relieve the jaundice and pruritus.
What are the complications of obstructive jaundice?
  • Ascending Cholangitis: Infection of the static bile. Presents with Charcot’s triad (fever, rigors, RUQ pain) or Reynolds’ pentad (+ hypotension, confusion). This is a surgical emergency requiring urgent biliary drainage.
  • Coagulopathy: Vitamin K deficiency leading to prolonged PT/INR and bleeding risk.
  • Hepatorenal Syndrome (HRS): A functional renal failure that occurs in advanced liver disease. It is a diagnosis of exclusion with a very poor prognosis.
  • Acute Pancreatitis: Can be caused by the obstructing lesion.
  • Malnutrition and Cachexia: Due to the underlying cancer and malabsorption.
How would you manage this patient?

Management depends on the patient’s fitness and the stage of the disease, and is decided by a multidisciplinary team (MDT).

1. Pre-operative Optimization:

  • Correct the coagulopathy with IV Vitamin K. If INR is still high, FFP may be needed.
  • Optimize nutritional status.
  • Prevent contrast nephropathy during CT by ensuring adequate hydration.

2. Modes of Treatment:

  • Curative Treatment: For patients with early, resectable disease and who are fit for major surgery. The standard operation is a Pancreaticoduodenectomy (Whipple’s procedure).
  • Palliative Treatment: For patients with unresectable, locally advanced, or metastatic disease. The goal is to relieve symptoms.
    • Relief of Jaundice: The most common palliative intervention. This is usually done endoscopically with an ERCP and stent insertion. If ERCP fails, a Percutaneous Transhepatic Cholangiography (PTC) with drainage may be done.
    • Relief of Gastric Outlet Obstruction: If the tumour obstructs the duodenum, a surgical bypass (gastrojejunostomy) or endoscopic duodenal stenting may be performed.
    • Chemotherapy/Radiotherapy: Can be used for symptom control and to prolong survival.
Source: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of Pancreatic Cancer (2022).

Surgery Long Case: Dysphagia (Oesophageal Cancer)

Patient Summary

A 67-year-old male presents with a 3-month history of progressive difficulty in swallowing. Initially, he had trouble with solids like rice and bread, but now he struggles even with liquids. This has been associated with significant loss of weight and a poor appetite. He has a long history of smoking and beetle chewing. On examination, he is cachectic and shows signs of muscle wasting. There is no palpable epigastric mass or cervical lymphadenopathy. Bowel sounds are normal.

What features in the history suggest oesophageal carcinoma?

The history is highly suggestive of oesophageal cancer.

  • Progressive Dysphagia: This is the cardinal symptom. The progression from solids to liquids over a relatively short duration (weeks to months) is classic for a malignant stricture.
  • Significant Weight Loss (LOW): This is a major red flag for malignancy, caused by a combination of reduced oral intake and cancer cachexia.
    • – Age and Risk Factors: He is in the typical age group (>60 years) and has major risk factors for squamous cell carcinoma (the more common type in Sri Lanka), including smoking and beetle chewing.

What are the differential diagnoses (DDs)?

  • Benign Peptic Stricture: Usually associated with a long history of GORD. The dysphagia is typically less progressive.
  • Achalasia Cardia: A motor disorder. The dysphagia is paradoxically often worse for liquids than solids and is not as rapidly progressive. Patients may report regurgitation of undigested food.
How do you investigate this patient? (Diagnosis and Staging)

The investigation pathway follows two main branches: diagnosis/histology and staging.

1. Investigation for Diagnosis (How do you proceed?):

  • Upper GI Endoscopy (UGIE): This is the first and most important investigation.
    • Purpose: It allows direct visualization of the lesion (typically an ulcerating, fungating, or stricturing mass). Most importantly, it allows for multiple biopsies to be taken to obtain a histological diagnosis.
    • Preparation: The patient needs to be fasted for 6 hours. Informed consent is required.
    • How biopsy is sent: The biopsy samples are placed in a pot with formalin and sent to the pathology lab with a detailed request form.

2. Investigations for Staging (Assessing Mets):

Accurate staging is crucial to determine if the patient is a candidate for curative surgery.

  • Contrast-Enhanced CT (CECT) of the Chest, Abdomen, and Pelvis: This is the workhorse staging investigation.
    • Purpose: It assesses the local extent of the tumour (T-stage), involvement of regional lymph nodes (N-stage), and crucially, detects distant metastases (M-stage), most commonly in the liver, lungs, and distant nodes.
  • Endoscopic Ultrasound (EUS): This is the most sensitive investigation for assessing the depth of tumour invasion (T-stage) and the involvement of local lymph nodes (N-stage). It is more accurate than CT for local staging.
  • PET-CT Scan: Used to detect occult distant metastases that may not be visible on a standard CT scan.
  • Laparoscopy/Thoracoscopy: Can be used for final staging to look for small peritoneal or pleural metastases before proceeding with major surgery.
  • Bone Scan: Only if there is clinical suspicion (e.g., bone pain) of bone metastases.
How do you assess and optimize this patient before surgery?

Oesophagectomy is a major operation with high morbidity. Thorough pre-operative assessment and optimization are vital.

1. Nutritional Assessment and Optimization:

  • Why is it important? These patients are often severely malnourished, which significantly increases the risk of post-operative complications, especially anastomotic leaks and infections.
  • Assessment: Assess clinically (muscle wasting), anthropometrically (weight loss >10%, low BMI), and biochemically (low serum albumin).
  • Optimization: Options include enteral or parenteral feeding.
    • Enteral feeding is always preferred over parenteral nutrition as it maintains gut integrity and reduces septic complications.
    • Options include a nasogastric tube or, more definitively, a feeding jejunostomy placed either endoscopically or surgically prior to the main operation.

2. Assessment of Fitness for Surgery:

  • Respiratory Assessment: This is critical as the surgery involves a thoracotomy.
    • How to assess: Clinical assessment, Chest X-ray, and formal Pulmonary Function Tests (PFTs/Spirometry).
    • Optimization: The patient must stop smoking. Chest physiotherapy, including deep breathing exercises and use of an incentive spirometer, is crucial.
  • Cardiovascular Assessment: ECG and often an Echocardiogram are required to assess cardiac function.
What are the management options? (Curative & Palliative)

The treatment plan is decided by an MDT based on the stage of the disease and the patient’s fitness.

1. Curative Management (for non-metastatic, resectable disease):

  • Neoadjuvant Therapy: The current standard of care for most locally advanced but resectable oesophageal cancers is to give neoadjuvant chemoradiotherapy before surgery. This has been shown to improve survival rates compared to surgery alone.
  • Curative Resection (Oesophagectomy): This is a major operation involving removal of the oesophagus and reconstruction, usually using the stomach as a conduit (“gastric pull-up”). Different surgical approaches exist (e.g., Ivor Lewis, McKeown).

2. Palliative Management (for metastatic or unresectable disease, or unfit patients):

The primary goal is to relieve the dysphagia and improve quality of life.

  • Endoscopic Stenting: The placement of a self-expanding metal stent (SEMS) across the tumour is the most common method to restore the ability to swallow.
  • Radiotherapy / Chemotherapy: Palliative courses can help to shrink the tumour and alleviate symptoms.
  • Feeding Support: If swallowing is not possible, options include a feeding jejunostomy or a Percutaneous Endoscopic Gastrostomy (PEG) tube.
Source: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of Oesophageal Cancer (2022).

Surgery Long Case: PR Bleeding (Colorectal Cancer)

Patient Summary

A 70-year-old male presents with a 6-month history of painless, fresh per-rectal (PR) bleeding. He notes the blood is mixed with his stools. He also complains of a change in bowel habits, with increased frequency of stools, a sense of incomplete evacuation (tenesmus), and lower back pain. He has associated loss of appetite and loss of weight. On examination, he appears pale and anaemic. A digital rectal examination (DRE) reveals a hard, nodular mass on the anterior rectal wall, approximately 5cm from the anal verge. The examining finger is stained with blood on withdrawal.

What are your differential diagnoses (DDs)?

For an elderly patient presenting with PR bleeding and a change in bowel habits, the primary differential diagnosis is malignancy.

  1. Rectal Carcinoma: This is the most likely diagnosis given the combination of PR bleeding, tenesmus, altered bowel habits, weight loss, and a palpable mass on DRE.
  2. Sigmoid Colon Cancer: Can present similarly, but the mass would not be palpable on DRE. Tenesmus is less common.
  3. Inflammatory Bowel Disease (IBD – Ulcerative Colitis or Crohn’s): Less likely at this age of onset, but can present with bleeding and altered bowel habits. It’s an important differential in younger patients.
  4. Diverticular Disease: A common cause of massive, painless PR bleeding, but usually not associated with a palpable mass or tenesmus.
  5. Haemorrhoids: A very common cause of fresh PR bleeding, but the blood is typically on the paper or coating the stool, not mixed in. It does not cause tenesmus or weight loss. It’s crucial to exclude a more sinister diagnosis even if haemorrhoids are present.
How do you investigate this patient?

The goals are to confirm the diagnosis histologically, stage the disease accurately to guide treatment, and assess the patient’s fitness for surgery.

1. To Confirm the Diagnosis:

  • Colonoscopy: This is the gold standard first-line investigation.
    • Why? It allows for direct visualization of the entire colon and rectum. It will identify the rectal mass, and crucially, allows for biopsies to be taken for histological confirmation. It also serves to identify any other synchronous lesions (polyps or other cancers), which occur in about 5% of patients.
    • Preparation: Requires full bowel preparation (e.g., with polyethylene glycol solution) to clear the colon for adequate visualization.

2. To Stage the Disease:

  • Local Staging (T and N stage):
    • Pelvic MRI: This is the most important and mandatory investigation for staging a rectal cancer. It provides detailed images of the rectum, showing the depth of tumour invasion through the rectal wall and the status of the mesorectal lymph nodes. This information is critical for deciding on the need for neoadjuvant therapy.
    • Endorectal Ultrasound (ERUS): Can also be used for T-staging of early tumours.
  • Distant Staging (M stage):
    • Contrast-Enhanced CT of the Chest, Abdomen, and Pelvis (CECT CAP): This is the standard investigation to look for distant metastases. The most common site of metastasis from colorectal cancer is the liver, followed by the lungs.
  • Blood Investigations:
    • FBC: To quantify the degree of anaemia.
    • PT/INR: Baseline coagulation.
    • Tumour Marker (CEA – Carcinoembryonic Antigen): A baseline CEA level is taken. It is not a diagnostic test but is useful for monitoring response to treatment and for surveillance after surgery.
Source: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up for Localised Colon Cancer and Rectal Cancer (2020).
How do you manage this patient? (MDT Approach)

The management of rectal cancer is complex and must be discussed in a multidisciplinary team (MDT) meeting. The MDT includes surgeons, oncologists (medical and radiation), radiologists, and pathologists.

1. Neoadjuvant Therapy (Treatment before surgery):

  • Based on the pelvic MRI findings, if the cancer is locally advanced (threatening the circumferential resection margin or has involved lymph nodes), the patient will be offered neoadjuvant therapy.
  • The standard is a course of long-course chemoradiotherapy. This helps to shrink the tumour, increasing the chance of a successful curative resection and reducing the risk of local recurrence.

2. Surgical Management:

The type of surgery depends on the location of the tumour in the rectum (distance from the anal verge).

  • Anterior Resection: For tumours in the upper and mid-rectum. The rectum is resected, and an anastomosis is created between the colon and the remaining rectum. The goal is to preserve the anal sphincter. A temporary defunctioning ileostomy is often created to protect the anastomosis.
  • Abdominoperineal Resection (APR): For very low rectal tumours that involve the sphincter complex. The rectum and anus are removed completely, and the patient will have a permanent end colostomy.

A key principle of modern rectal cancer surgery is Total Mesorectal Excision (TME), which involves removing the entire envelope of fatty tissue (mesorectum) surrounding the rectum, as this contains the lymph nodes.

3. Adjuvant Therapy (Treatment after surgery):

  • Based on the final histology of the resected specimen, adjuvant chemotherapy may be offered to reduce the risk of systemic recurrence, especially if lymph nodes were positive.
His son is worried about getting colon cancer and requests a colonoscopy. How do you approach him?

This is an important issue of genetic risk and screening.

  1. Counseling:
    • First, provide empathy and address his concerns.
    • Explain that while most colorectal cancers are sporadic, there is a component of familial risk. Having one first-degree relative (parent, sibling, child) diagnosed with colorectal cancer slightly increases his lifetime risk.
  2. Screening Advice:
    • Based on international guidelines, individuals with one first-degree relative diagnosed with colorectal cancer at age 60 or older (like this patient) are generally advised to start screening at the standard age (e.g., 45-50 years).
    • If the relative was diagnosed at an age younger than 60, screening for the son should typically begin 10 years before the age of the relative’s diagnosis, or at age 40, whichever is earlier.
  3. Genetic Syndromes:
    • Briefly explain that a small percentage of colorectal cancers are due to high-risk genetic syndromes (like Lynch Syndrome or FAP). While less likely given the patient’s age, a more detailed family history should be taken to assess this risk. If there are multiple affected relatives or other related cancers, a referral to a clinical genetics service may be warranted.
  4. Recommendation: Advise him to discuss his specific risk with his general practitioner. A screening colonoscopy would be a reasonable option for him to consider, starting around age 40-50 depending on local guidelines.

Surgery Long Case: Breast Cancer

Patient Summary

A 65-year-old postmenopausal woman presents with a left breast lump she noticed 5 months ago, which has recently enlarged. For the past week, she has had intractable back pain. She has a history of passive smoking for over 30 years and underwent a TAH+BSO 15 years ago for a uterine pathology. On examination, there is a 5×4 cm, hard, irregular lump in the left inner lower quadrant. There are no skin or muscle attachments. Mobile lymph nodes are palpable in the ipsilateral axilla. The clinical diagnosis is Breast Carcinoma, clinically staged as T3N1M1, given the back pain is highly suspicious for a bone metastasis.

How do you diagnose a breast lump? (Triple Assessment)

Any patient with a discrete breast lump must undergo Triple Assessment. This is the standard of care and has a diagnostic accuracy of over 99%.

The three components are:

  1. Clinical Assessment:
    • A thorough history (including risk factors) and a full clinical breast examination, including the axilla and supraclavicular fossae.
  2. Radiological Imaging:
    • Mammogram: This is the primary imaging modality for women over 40. Features suggestive of malignancy include a spiculated mass, architectural distortion, and pleomorphic microcalcifications.
    • Ultrasound Scan (USS): Used in all age groups, especially in women under 40 (due to dense breast tissue) and as an adjunct to mammography. It can differentiate between solid and cystic lesions and is used to guide biopsies. A malignant solid lesion typically appears as an irregular, hypoechoic mass with a “taller-than-wide” orientation.
  3. Pathological Assessment (Tissue Sampling):
    • Core Biopsy (Tru-cut biopsy): This is the gold standard for pathological diagnosis. It is performed under ultrasound or mammographic guidance.
    • Why core biopsy over FNAC? A core biopsy provides a tissue sample, which has several critical advantages over a Fine Needle Aspiration Cytology (FNAC):
      • It provides a definitive histological diagnosis (e.g., Ductal Carcinoma vs. Lobular Carcinoma).
      • It allows for grading of the tumour.
      • Crucially, it provides enough tissue to test for tumour biology: Oestrogen Receptor (ER), Progesterone Receptor (PR), and HER2 status. These receptors are essential for guiding treatment decisions.
The histology report is Ductal Carcinoma NST, ER+, PR+, HER2-. What are the treatment options?

This patient has Stage IV (metastatic) breast cancer, as evidenced by the likely bone metastasis. The treatment intent is therefore palliative, not curative. The goal is to control the disease, manage symptoms, and maintain quality of life.

The treatment is primarily systemic, guided by the tumour biology (ER+, PR+, HER2-).

Systemic Therapy for ER+ Metastatic Breast Cancer:

  • First-Line Therapy: Endocrine (Hormonal) Therapy + Targeted Therapy.
    • The standard of care for first-line treatment of hormone receptor-positive, HER2-negative metastatic breast cancer is a combination of an Aromatase Inhibitor (AI) (e.g., Letrozole) and a CDK4/6 inhibitor (e.g., Palbociclib, Ribociclib). This combination has been shown to significantly improve progression-free survival compared to an AI alone.
  • Chemotherapy: Chemotherapy is generally reserved for patients with a high burden of visceral disease, rapid progression, or those who have become resistant to endocrine therapy.

Management of Bone Metastasis:

  • Local Radiotherapy: Palliative radiotherapy to the spine is highly effective for relieving the intractable back pain.
  • Bone-Modifying Agents: Patients should be started on a bone-modifying agent like Zoledronic acid (a bisphosphonate) or Denosumab. These drugs reduce the risk of skeletal-related events (like pathological fractures and spinal cord compression).

Role of Surgery: In the setting of metastatic disease, surgery on the primary breast tumour is generally not performed unless it is needed for local symptom control (e.g., an ulcerating or bleeding tumour).

Source: ESMO Clinical Practice Guidelines for the diagnosis, staging and treatment of patients with metastatic breast cancer (2021).
What are the members of the MDT?

The management of breast cancer requires a core multidisciplinary team. The key members are:

  • Breast Surgeon
  • Medical Oncologist
  • Radiation Oncologist (Clinical Oncologist)
  • Radiologist (specializing in breast imaging)
  • Pathologist
  • Breast Care Nurse Specialist (plays a vital role in patient support and coordination)

Extended members may include plastic surgeons, geneticists, palliative care specialists, and physiotherapists.

What is a sentinel lymph node biopsy (SLNB)?

SLNB is the standard-of-care surgical procedure for staging the axilla in patients with early-stage, clinically node-negative breast cancer.

  • Principle: The sentinel node is the first lymph node (or nodes) that receives lymphatic drainage from the primary tumour. If cancer cells spread, they will travel to this node first.
  • Procedure: A combination of a blue dye and a radioisotope is injected around the tumour. The surgeon then identifies and removes the sentinel node(s) for histological examination.
  • Significance: If the sentinel node is negative for metastasis, it is highly likely that the rest of the axillary nodes are also negative, and a full axillary lymph node dissection (which has higher morbidity, including lymphoedema) can be avoided. If the sentinel node is positive, further axillary treatment (either a full dissection or axillary radiotherapy) is required.

Surgery Long Case: Peripheral Vascular Disease (PVD)

Patient Summary

A 65-year-old male with a history of ischaemic heart disease, diabetes mellitus, and a 40-pack-year smoking history presents with a one-year history of cramping pain in his left calf. The pain comes on after walking about 100 meters and is reliably relieved by resting for a few minutes (intermittent claudication). Over the last month, he has developed pain in his forefoot at rest, which is worse at night and is relieved by hanging his foot over the side of the bed. He has a non-healing ulcer on his left great toe. On examination, his left foot is cool and pale, with a sluggish capillary refill. The femoral pulse is present, but the popliteal, dorsalis pedis, and posterior tibial pulses are all absent.

What is the diagnosis and what is the severity?

The diagnosis is Peripheral Arterial Disease (PAD) affecting the left leg.

The severity is Critical Limb-Threatening Ischaemia (CLTI). This is a vascular emergency.

The progression of symptoms clearly indicates the severity:

  • Intermittent Claudication: This was his initial symptom, indicating stable PAD.
  • Rest Pain: The development of pain in the foot at rest, especially at night, is a hallmark of progression to critical ischaemia. It signifies that blood flow is inadequate even to meet the basal metabolic demands of the tissue.
  • Tissue Loss (Ulceration): The non-healing ulcer on his toe is the final component of CLTI.

How diabetes causes intermittent claudication: Diabetes accelerates the process of atherosclerosis, leading to earlier and more severe blockages in the peripheral arteries. It also causes a peripheral neuropathy, which can mask ischaemic pain, meaning patients often present at a later, more advanced stage.

How do you approach and investigate this patient?

The approach is to confirm the diagnosis, assess the anatomy of the disease, and evaluate for systemic atherosclerosis.

1. Bedside Confirmation:

  • Ankle-Brachial Pressure Index (ABPI): This is the key initial investigation. It is the ratio of the systolic blood pressure at the ankle to that in the arm, measured with a Doppler probe.
    • Normal ABPI: 0.9 – 1.3
    • Claudication: Typically 0.5 – 0.9
    • Rest Pain / CLTI: Typically < 0.5
  • Can ABPI be higher than 1? Yes. An ABPI > 1.3 indicates heavily calcified, incompressible arteries, commonly seen in diabetic patients. This result is unreliable and masks the severity of the underlying disease.

2. First-Line Imaging:

  • Arterial Duplex Ultrasound Scan: This is the first-line investigation to map the disease. It is non-invasive and provides both anatomical information (locating the stenosis/occlusion) and haemodynamic data (measuring flow velocities).

3. Advanced Imaging for Intervention Planning:

  • CT Angiography (CTA): Provides a detailed 3D roadmap of the arterial tree from the aorta down to the feet, essential for planning endovascular or surgical intervention.
  • Digital Subtraction Angiography (DSA): This is the gold standard but is an invasive procedure. It is now typically reserved for cases where intervention is performed at the same time.

4. Assessing for Systemic Disease:

  • PAD is a marker for widespread atherosclerosis. It’s crucial to assess other vascular beds. This includes screening for carotid artery disease, coronary artery disease, and abdominal aortic aneurysm.
What are the management modalities for this patient?

This patient has CLTI, so the primary goal is urgent revascularization to save the limb.

1. Medical Management (Best Medical Therapy):

This is crucial for all PAD patients to manage cardiovascular risk, regardless of revascularization.

  • Risk Factor Modification: Absolute smoking cessation, optimal glycaemic control, and BP control.
  • Antiplatelet Therapy: Lifelong Clopidogrel 75mg daily is now often preferred over Aspirin.
  • Statin Therapy: High-intensity statin (e.g., Atorvastatin 80mg) for all patients.

2. Revascularization (Urgent):

The choice between endovascular and open surgery depends on the patient’s fitness, the anatomy of the lesion, and local expertise.

  • Endovascular Therapy (“keyhole”): This is now the first-line approach for many lesions.
    • Angioplasty: A balloon is used to stretch the narrowed artery open.
    • Stenting: A metal mesh tube is placed to keep the artery open.
  • Open Surgical Bypass: A conduit (either a vein from the patient, like the long saphenous vein, or a synthetic graft) is used to bypass the blocked arterial segment. E.g., a femoro-popliteal bypass.

3. Amputation:

  • This is the last resort for a limb that is no longer salvageable (e.g., extensive, irreversible tissue death/gangrene) or in a patient who is not a candidate for revascularization and has intractable pain. The goal is to remove the dead tissue, relieve pain, and allow for rehabilitation with a prosthesis.
Source: 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases; NICE Guideline [NG199] Peripheral arterial disease: diagnosis and management (2021).
What are potential complications of revascularization?
  • Reperfusion Syndrome: When blood flow is restored to a chronically ischaemic limb, the sudden washout of toxic metabolic byproducts (like potassium and acid) from the damaged muscle can cause systemic effects, including cardiac arrhythmias, acute kidney injury, and ARDS.
  • Compartment Syndrome: Swelling of the revascularized muscles within their tight fascial compartments can lead to a secondary ischaemic injury. It presents with severe pain that is out of proportion to the clinical situation. It is a surgical emergency requiring an urgent fasciotomy to release the pressure.

Surgery Long Case: Haematuria & LUTS (Bladder Cancer)

Patient Summary

A 70-year-old male, a retired painter with a long smoking history, presents with a 2-month history of painless, total haematuria. He has noticed some clots in the urine. He also complains of some lower urinary tract symptoms (LUTS), including increased frequency and urgency. He denies any loin pain. On examination, the patient is pale, but the abdomen is soft and non-tender with no palpable masses.

What are your differential diagnoses (DDs)?

Painless total haematuria in an elderly patient is bladder cancer until proven otherwise. This is the top differential diagnosis.

DDx for Painless Haematuria:

  1. Bladder Cancer (Transitional Cell Carcinoma – TCC): Most likely diagnosis given his age and risk factors (smoking, occupational exposure as a painter).
  2. Renal Cell Carcinoma (RCC): Can present with the classic (but rare) triad of haematuria, loin pain, and a palpable mass.
  3. Upper Tract TCC: Cancer in the renal pelvis or ureter.
  4. Prostate Cancer: Can cause haematuria, but usually presents with bladder outflow symptoms.
  5. Benign Causes: Such as a bladder stone, Benign Prostatic Hyperplasia (BPH), or benign renal cysts. However, malignancy must be excluded first.

The timing of the haematuria can give a clue to the location: initial (urethral), terminal (prostatic/bladder neck), or total (bladder or upper tract).

How do you investigate a patient with visible haematuria?

All patients with visible haematuria require urgent investigation to rule out malignancy. The standard pathway involves both imaging of the upper tracts and direct visualization of the lower tract.

1. First-Line Investigations:

  • Urine tests: A urine dipstick and microscopy (UFR) to confirm the presence of blood and rule out infection. Urine culture should also be sent.
  • Renal Function: Baseline Urea & Electrolytes (U&Es) are essential before any contrast imaging.

2. Investigation of the Upper Tracts (Kidneys and Ureters):

  • CT Urogram (CT IVU): This is the gold standard first-line imaging investigation for the upper tracts. It involves pre-contrast, arterial, nephrogenic, and delayed excretory phase imaging of the urinary system. It is excellent for detecting renal masses, upper tract TCCs, and stones.

3. Investigation of the Lower Tract (Bladder):

  • Urgent Flexible Cystoscopy: This is a mandatory investigation. A thin, flexible scope is passed into the bladder under local anaesthetic to directly visualize the bladder lining and look for any tumours. This is the most sensitive test for detecting bladder cancer.

So the standard diagnostic pathway is CT Urogram + Flexible Cystoscopy.

Source: EAU Guidelines on Urothelial Carcinomas (2023); NICE Guideline [NG2] Bladder cancer: diagnosis and management (2015).
A bladder growth is found. What is the next step in management?

If a tumour is identified on flexible cystoscopy, the next step is a procedure that both diagnoses and treats the initial lesion.

Transurethral Resection of Bladder Tumour (TURBT):

  • This is a procedure performed under general or spinal anaesthesia. A rigid cystoscope is used to resect (shave off) the tumour from the bladder wall in pieces.
  • It is a crucial procedure with three goals:
    1. Diagnosis: The resected tissue is sent for histology to confirm the cancer type and grade.
    2. Staging: The surgeon must take a deep resection to include a piece of the underlying bladder muscle (the detrusor muscle). The pathologist will then determine if the cancer is non-muscle-invasive (NMIBC) or has invaded into the muscle wall (muscle-invasive bladder cancer – MIBC). This is the single most important factor determining further treatment and prognosis.
    3. Treatment: TURBT completely removes the visible non-muscle-invasive tumour.
The histology shows muscle-invasive urothelial carcinoma. What is the next step?

Muscle-Invasive Bladder Cancer (MIBC) is a life-threatening condition that requires radical treatment. The patient’s case must be discussed in a specialist urology MDT.

1. Staging:

  • A CECT of the Chest, Abdomen, and Pelvis is performed (if not already done) to look for lymph node involvement or distant metastases.

2. Treatment Options for Localised MIBC:

There are two main curative-intent treatment options:

  • Radical Cystectomy with Urinary Diversion:
    • This is the gold standard surgical treatment. It involves the removal of the entire bladder, prostate, and seminal vesicles in men, or the bladder, uterus, and ovaries in women.
    • A form of urinary diversion must be created. The most common is an ileal conduit, where a segment of the ileum is used to create a channel to the skin, and the patient wears a urostomy bag. Other options include neobladder formation.
  • Trimodality Therapy (Bladder Preservation):
    • This is an alternative for patients who are not candidates for or do not wish to have a cystectomy.
    • It involves a combination of a thorough TURBT, followed by a course of external beam radiotherapy combined with concurrent chemotherapy.

Neoadjuvant Chemotherapy: For fit patients undergoing radical cystectomy, platinum-based neoadjuvant chemotherapy given before surgery has been shown to improve overall survival.

Surgery Long Case: PR Bleeding (Colorectal Cancer)

Patient Summary

A 67-year-old male presents with a 4-month history of intermittent, profuse per-rectal (PR) bleeding associated with abdominal pain and constipation. He denies tenesmus but reports a sense of incomplete evacuation. He has associated anaemic features but no relevant family history. On examination, he is pale with tenderness in the left iliac fossa (LIF). A Digital Rectal Examination (DRE) reveals a hard mass with contact bleeding.

What are your possible differential diagnoses (DDs)?

For an elderly patient presenting with PR bleeding and a change in bowel habits, the differential diagnosis must be prioritized towards malignancy.

  1. Sigmoid Colon Carcinoma: This is the most likely diagnosis, fitting the LIF pain, bleeding, and obstructive symptoms like constipation.
  2. Rectal Carcinoma: The DRE findings make this a strong possibility. Features like tenesmus, if present, would point strongly to a rectal lesion.
  3. Diverticular Disease: Can cause massive PR bleeding or chronic symptoms. Complicated diverticulitis can form an inflammatory mass, mimicking cancer.
  4. Inflammatory Bowel Disease (IBD): Less common to present at this age but can cause bleeding and abdominal pain.
How do you investigate this patient?

The goals are to confirm the diagnosis, stage the disease, and assess fitness for treatment.

1. To Confirm the Diagnosis:

  • Colonoscopy: This is the gold standard first-line investigation.
    • Why colonoscopy over flexible sigmoidoscopy? A full colonoscopy is essential to visualize the entire colon. This is crucial to look for synchronous lesions (a second cancer or pre-malignant polyps elsewhere in the colon), which occur in 5-10% of cases.
    • What do you look for? An ulcerating, polypoidal, or stricturing mass. Its location, size, and distance from the anal verge are noted.
    • What do you do? Take multiple biopsies from the lesion for histology. The biopsy sample is transported in a pot of formalin.

2. Staging Investigations (Place of CECT):

  • Contrast-Enhanced CT of the Chest, Abdomen, and Pelvis (CECT CAP): This is the primary staging modality.
    • Purpose: Its main role is to detect distant metastases (M-stage) and assess regional lymph nodes (N-stage).
    • What are the common sites of metastasis? The most common site is the liver, followed by the lungs, peritoneum, and bone.
  • Local Staging for Rectal Cancer: If the lesion is rectal, a high-resolution Pelvic MRI is mandatory for detailed local staging (T-stage and mesorectal node involvement), which guides the decision for neoadjuvant therapy.
If colonoscopy shows a proximal sigmoid cancer, how would you discuss the treatment plan?

The treatment plan is decided by a Multidisciplinary Team (MDT) based on the staging results.

  1. For Localised, Resectable Disease (No Mets):
    • The treatment is surgical resection. For a proximal sigmoid cancer, the surgery would be a Sigmoid Colectomy, typically with a primary anastomosis.
    • The principle is to remove the segment of colon containing the tumour along with its primary lymphatic drainage (high ligation of the inferior mesenteric artery).
  2. For Locally Advanced Disease:
    • Neoadjuvant (pre-operative) therapy is primarily used for rectal cancer, not typically for sigmoid colon cancer. Surgery is the first step.
  3. Adjuvant Chemotherapy: Post-operative chemotherapy is recommended for patients with Stage III disease (lymph node positive) and may be considered for high-risk Stage II disease to reduce the risk of recurrence.
  4. For Metastatic Disease:
    • Is it curative or palliative? This depends on the extent of metastasis. If there are a few, resectable liver or lung metastases (“oligometastatic disease”), a curative approach may still be possible, often involving chemotherapy followed by resection of both the primary tumour and the metastases.
    • If metastases are widespread and unresectable, the treatment intent is palliative, using chemotherapy and targeted agents to control the disease and prolong survival.
Source: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up for Localised Colon Cancer and Rectal Cancer (2020).
How do you prepare a patient for major colorectal surgery? (ERAS)

Modern pre-operative preparation follows the principles of an Enhanced Recovery After Surgery (ERAS) pathway.

  • Patient Counselling and Education: Explain the surgery, potential for a stoma, and the recovery pathway.
  • Pre-operative Optimization:
    • Anaemia Correction: Correct significant anaemia.
    • Nutritional Support: Ensure the patient is nutritionally optimized.
    • Exercise Tolerance: Assess fitness for surgery. A MET (Metabolic Equivalent of Task) score > 4 is a rough indicator of being able to withstand the physiological stress of surgery.
  • Key ERAS Components:
    • No prolonged fasting: Patients are allowed clear fluids up to 2 hours before surgery. Carbohydrate loading drinks are often given.
    • Selective Bowel Preparation: Full mechanical bowel preparation is no longer routine for right-sided colon surgery, and its use is selective for left-sided and rectal surgery.
    • Thromboprophylaxis and Antibiotic Prophylaxis.
    • Opioid-sparing multimodal analgesia (e.g., epidural or regional blocks).
What are the features and management of acute intestinal obstruction?

If a patient with a left-sided colon cancer presents with acute obstruction, this is a surgical emergency.

Cardinal Features:

  1. Abdominal Pain (colicky)
  2. Abdominal Distension
  3. Vomiting (can be late and faeculent)
  4. Absolute Constipation (failure to pass flatus or faeces)

Management (“Drip and Suck”):

  1. Resuscitation: IV fluids (“drip”) and correction of electrolyte abnormalities.
  2. Bowel Decompression: Insertion of a nasogastric (NG) tube on free drainage (“suck”).
  3. Urgent Investigations: Erect CXR (to look for perforation) and an urgent CT scan to confirm the level and cause of obstruction.
  4. Surgical Intervention:
    • Emergency Surgery: The classic operation for an obstructing left-sided colon cancer in an unprepared bowel is a Hartmann’s procedure (resection of the tumour, formation of an end colostomy, and closure of the rectal stump).
    • Stenting: As an alternative, an endoscopic stent can be placed across the tumour as a “bridge to surgery,” allowing the obstruction to be relieved and the patient to be optimized for a later, elective, single-stage operation.

Surgery Long Case: Breast Lump (Breast Cancer)

Patient Summary

A 68-year-old menopausal woman presents with a lump in her left breast, which has been present for several months and is now painful. She has noted some skin changes over the lump. She has no significant risk factors. On examination, there is a 3×3 cm hard lump with an irregular surface in the upper outer quadrant. There is associated skin puckering and tethering. A firm, mobile lymph node is palpable in the left axilla. The clinical diagnosis is breast carcinoma.

How do you approach this patient? (How you Mx / Triple Assessment)

Any patient with a discrete breast lump must undergo Triple Assessment. This is the standard of care for diagnosis.

The three components are:

  1. Clinical Assessment: A thorough history and a full clinical breast examination, including the axilla and supraclavicular fossae. Features suggestive of malignancy include a hard, irregular, painless lump, with skin changes (puckering, peau d’orange) or nipple changes (retraction, discharge).
  2. Radiological Imaging:
    • Mammogram and Ultrasound: For a woman over 40, both a mammogram and a breast ultrasound are performed.
      • Mammogram: Features of malignancy include a spiculated mass, architectural distortion, and pleomorphic microcalcifications.
      • Ultrasound: A malignant lesion is typically an irregular, hypoechoic, “taller-than-wide” solid mass with posterior acoustic shadowing. It is also used to assess the axillary lymph nodes and to guide the biopsy.
  3. Pathological Assessment (Tissue Sampling):
    • Core Biopsy: This is the gold standard. An ultrasound-guided core biopsy of the breast lump AND the suspicious axillary lymph node should be performed. This provides the histological diagnosis, tumour grade, and, crucially, the receptor status (ER, PR, HER2).
What are the common skin changes and what is their reason/pathophysiology?
  • Puckering and Tethering: This is caused by the growing tumour infiltrating and shortening the suspensory ligaments of Cooper, which pulls the overlying skin inwards.
  • Peau d’orange (“skin of an orange”): This is caused by tumour cells blocking the dermal lymphatics. The subsequent oedema is tethered by the hair follicles, causing the characteristic pitted appearance. It is a sign of locally advanced disease.
  • Nipple Retraction: Caused by the tumour infiltrating and shortening the major lactiferous ducts behind the nipple.
  • Ulceration/Fungation: Occurs when the tumour directly infiltrates and breaches the skin.
What is the management plan? (MDT approach, surgery, etc.)

The management plan is formulated by a multidisciplinary team (MDT) based on the tumour stage, tumour biology (receptor status), and patient factors.

1. Staging: After the initial diagnosis, staging investigations (CECT of chest, abdomen, pelvis, and often a bone scan) are performed to look for distant metastases.

2. Treatment for Early / Locally Advanced Breast Cancer (Curative Intent):

The treatment involves a combination of local and systemic therapies.

  • Local Treatment (Surgery and Radiotherapy): To control the disease in the breast and axilla.
    • Surgery for the Breast:
      1. Breast Conserving Surgery (BCS / Wide Local Excision): The tumour is removed with a margin of normal tissue. This is almost always followed by radiotherapy to the remaining breast tissue.
      2. Mastectomy: Removal of the entire breast. Indicated for larger tumours, multicentric disease, or patient preference.
    • Surgery for the Axilla:
      1. Sentinel Lymph Node Biopsy (SLNB): If the axilla is clinically and radiologically negative.
      2. Axillary Lymph Node Dissection (ALND): If the axillary nodes are proven to be positive on pre-operative biopsy.
  • Systemic Treatment (Chemotherapy, Endocrine Therapy, Targeted Therapy): To treat micrometastatic disease. The choice depends on the receptor status.
    • Neoadjuvant Therapy: Chemotherapy or endocrine therapy given *before* surgery. It is used for large or locally advanced tumours to shrink them, which can improve surgical outcomes and potentially allow for breast conservation.
    • Adjuvant Therapy: Systemic therapy given *after* surgery to reduce the risk of recurrence.
What are the treatment options based on receptor status?

The receptor status (ER, PR, HER2) is the most important factor guiding the choice of systemic therapy.

Receptor Status Description Systemic Treatment
ER/PR Positive, HER2 Negative (Luminal) The most common type. The cancer’s growth is driven by hormones. Generally has a good prognosis. Endocrine (Hormonal) Therapy is the mainstay. Options include Tamoxifen (for pre- and post-menopausal women) or Aromatase Inhibitors (for post-menopausal women). Adjuvant chemotherapy may be added for high-risk cases.
HER2 Positive The cancer cells overexpress the HER2 protein, leading to more aggressive growth. Prognosis was historically poor but has been transformed by targeted therapy. Anti-HER2 Targeted Therapy is essential, given in combination with chemotherapy. The cornerstone drug is Trastuzumab (Herceptin).
Triple Negative (ER-, PR-, HER2-) The cancer is not driven by hormones or HER2. It is often more aggressive and has a higher risk of early recurrence. Chemotherapy is the only effective systemic treatment. Immunotherapy (e.g., Pembrolizumab) is now also used in this group, often in the neoadjuvant setting.
Source: ESMO Clinical Practice Guidelines for early breast cancer (2019).

Surgery Long Case: Dysphagia

Patient Summary

A 60-year-old gentleman with a history of alcohol use and betel chewing presents with a 3-month history of progressively worsening dysphagia. He initially had difficulty swallowing solids, which has now progressed to liquids. He reports significant weight loss but no loss of appetite. He also complains of some regurgitation of undigested food. There are no other significant symptoms. Examination is largely unremarkable, but he appears cachectic. A left supraclavicular lymph node (Virchow’s node) is palpable.

What are your differential diagnoses (DDs)?

In an elderly patient with progressive dysphagia and weight loss, the primary diagnosis is malignancy.

  1. Oesophageal Carcinoma: This is the most likely diagnosis. The progressive nature (solids then liquids), short duration, weight loss, and presence of risk factors (alcohol, betel chewing) and a Virchow’s node strongly support this.
  2. Benign Oesophageal Stricture: Usually due to long-standing GORD. Dysphagia is often less progressive, and significant weight loss is less common.
  3. Achalasia Cardia: A primary motility disorder. Dysphagia is typically for both solids and liquids from the outset and is often intermittent and long-standing.
  4. Extrinsic Compression: From a lung cancer or enlarged mediastinal lymph nodes.
How would you investigate this patient? (Initial management)

The initial management focuses on confirming the diagnosis and assessing the patient’s general condition.

  1. Initial Investigation: Upper GI Endoscopy (UGIE)
    • This is the first-line and most important investigation for a patient with dysphagia.
    • Procedure: It allows direct visualization of the oesophagus and stomach. A malignant lesion typically appears as an ulcerating, fungating (cauliflower-like), or stricturing mass.
    • Action: Multiple biopsies (at least 6-8) must be taken from the lesion to obtain a histological diagnosis (e.g., Squamous Cell Carcinoma or Adenocarcinoma).
    • Preparation: The patient must be fasted for 6 hours. Informed consent explaining the procedure, risks (bleeding, perforation), and benefits is crucial.
  2. Initial Assessment:
    • Nutritional assessment: This is a key concern. Assess the degree of weight loss and look for signs of malnutrition.
    • MET Score / Exercise Tolerance: Assess the patient’s fitness for potential major surgery.
The biopsy confirms Squamous Cell Carcinoma. How do you stage the tumour?

Accurate staging is essential to determine the treatment plan (curative vs. palliative).

  1. Contrast-Enhanced CT of the Neck, Chest, Abdomen, and Pelvis (CECT):
    • This is the standard initial staging investigation.
    • Why include the neck? To look for cervical lymphadenopathy.
    • Purpose: It assesses the local extent of the primary tumour, looks for regional lymph node involvement (N-stage), and screens for distant metastases (M-stage). Common sites of metastasis are the liver, lungs, and distant nodes (including coeliac and supraclavicular nodes).
  2. PET-CT Scan: This is now routinely used for staging oesophageal cancer. It is more sensitive than CT alone for detecting small nodal and distant metastases and can significantly alter the management plan.
  3. Endoscopic Ultrasound (EUS): The most accurate test for local (T and N) staging, assessing the depth of tumour invasion and involvement of nearby lymph nodes.
How do you manage this patient? (Management options)

Management is decided by a specialist upper GI MDT.

1. Curative Intent Management (for localised, resectable disease):

  • Neoadjuvant Therapy: The standard of care is to give pre-operative (neoadjuvant) chemoradiotherapy or chemotherapy. This has been shown to improve survival outcomes.
  • Surgery (Oesophagectomy): This involves surgical resection of the oesophagus with reconstruction, usually using the stomach pulled up into the chest or neck. It is a major operation with significant morbidity.

2. Palliative Management (for metastatic or unresectable disease):

The primary goal is to relieve dysphagia and improve quality of life.

  • Endoscopic Stenting: Placement of a self-expanding metal stent (SEMS) is the most common method to restore swallowing.
  • Palliative Radiotherapy/Chemotherapy: Can be used to shrink the tumour and improve symptoms.
  • Nutritional Support: This is paramount. Options include:
    • Feeding Jejunostomy: A tube placed surgically into the jejunum.
    • PEG (Percutaneous Endoscopic Gastrostomy): Not suitable if the tumour obstructs the path of the endoscope.
    Oral hygiene is very important to prevent aspiration pneumonia.
Source: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up of Oesophageal Cancer (2022).

Surgery Long Case: Peripheral Vascular Disease

Patient Summary

A 77-year-old male with a 50-year history of smoking and poorly controlled diabetes presents with a non-healing wound on his left big toe for 2 weeks. He has experienced pain in his left foot at rest for the past month, which is worse at night. He has a history of a right above-knee amputation for a similar problem 2.5 years ago. On examination, the left big toe shows signs of dry gangrene. The foot is cool and pale with absent popliteal and foot pulses. The femoral pulse is palpable but weak. There are no femoral or carotid bruits.

What is the diagnosis and its severity? What is critical limb ischaemia?

The diagnosis is Peripheral Arterial Disease (PAD). The severity is Critical Limb-Threatening Ischaemia (CLTI).

Critical Limb-Threatening Ischaemia (CLTI) is the most severe manifestation of PAD. It is defined by the presence of one or more of the following:

  1. Ischaemic Rest Pain: Continuous pain requiring opiate analgesia for ≥2 weeks.
  2. Tissue Loss: Ulceration or gangrene on the foot or toes.
  3. Objective haemodynamic criteria: Ankle pressure <50 mmHg or toe pressure <30 mmHg.

This patient has both rest pain and tissue loss, confirming the diagnosis of CLTI. The toe wound indicates that the tissue is dying due to insufficient blood flow.

How would you investigate this patient?

Investigations are to confirm severity, map the anatomy for intervention, and assess systemic disease.

1. Basic Investigations & Assessment of Fitness:

  • Bloods: FBC (for anaemia), U&Es/Creatinine (essential before contrast imaging), HbA1c (to assess diabetic control), Lipid Profile.
  • ECG and Echocardiogram: To assess for co-existing coronary artery disease and cardiac function.

2. Vascular Investigations:

  • Ankle-Brachial Pressure Index (ABPI): The first step to objectively confirm PAD. In this patient, it would be expected to be <0.5.
  • Arterial Duplex Ultrasound: The primary imaging modality. It is non-invasive and maps the location and severity of stenoses or occlusions from the aorta down to the ankle.
  • CT Angiogram (CTA) or Digital Subtraction Angiogram (DSA): These are used for detailed pre-procedural planning.
    • CTA vs DSA: CTA is non-invasive and provides a 3D anatomical map. DSA is invasive (requiring an arterial puncture) but is the gold standard for detail and allows for simultaneous intervention (angioplasty/stenting). DSA uses an iodine-based contrast medium injected directly into the arteries.
Where is the lesion located, and what is Leriche’s syndrome?

The examination findings help localize the level of occlusion.

  • Site of Occlusion: Since the femoral pulse is weak and distal pulses are absent, the most significant disease is likely in the aortoiliac segment, with further disease extending down into the femoro-popliteal segment.
  • Leriche’s Syndrome: This refers specifically to atherosclerotic occlusion of the aortoiliac bifurcation. The classic triad of symptoms is:
    1. Bilateral buttock/thigh claudication.
    2. Absent or diminished femoral pulses.
    3. Erectile dysfunction (impotence) in males.

This patient’s presentation with absent femoral pulses and impotence (a common finding) is highly suggestive of an aortoiliac lesion like Leriche’s syndrome.

How would you manage this patient?

The management of CLTI is urgent and requires a multidisciplinary approach involving vascular surgeons, radiologists, and diabetologists.

1. Immediate Ward Management (as an HO):

  • Analgesia for rest pain.
  • Optimize medical therapy (antiplatelets, statin, glycaemic control).
  • Keep the leg in a dependent position to maximize perfusion.
  • Protect the heel and foot from pressure sores.
  • Urgent referral to the vascular surgery team.

2. Definitive Management:

The goal is urgent revascularization to save the limb.

  • Endovascular Therapy: Angioplasty and stenting of the aortoiliac and femoro-popliteal segments is often the first-line approach.
  • Surgical Bypass: If endovascular options are not suitable, open surgery is performed. For aortoiliac disease, an aortobifemoral bypass is the classic operation. For femoro-popliteal disease, a fem-pop bypass is performed, preferably using the patient’s own saphenous vein as a graft.

3. Wound Management:

  • Once blood flow is restored, the gangrenous toe will need to be amputated. Revascularization must be performed *before* major amputation to ensure the amputation site will heal.
Source: 2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases; NICE Guideline [NG199] Peripheral arterial disease: diagnosis and management (2021).

Surgery Long Case: Obstructive Jaundice (Batch 30)

Patient Summary

A 68-year-old female presents with a two-month history of yellowish discoloration of her eyes. This was followed by generalized pruritus, dark urine, and steatorrhea. She has no significant risk factors for pancreatic cancer. On examination, she is deeply jaundiced with generalized scratch marks and nodular hepatomegaly. A palpable gallbladder was not detected.

What are the main problems and your main differential diagnoses (DDx)?

Main Problems Identified:

  1. Surgical (Obstructive) Jaundice: Based on the clinical features of deep jaundice, pruritus, dark urine, and pale stools (steatorrhea).
  2. Malnutrition: Secondary to loss of appetite (LOA) and malabsorption.

Main Differential Diagnoses:

The age and presence of nodular hepatomegaly (suggesting liver metastases) point towards a malignant cause.

  1. Pancreatic Head Carcinoma: The most common cause of painless obstructive jaundice in this age group.
  2. Cholangiocarcinoma: A cancer of the bile ducts. Can be intra- or extrahepatic.
  3. Gallstone Disease (Choledocholithiasis): Obstruction of the common bile duct by a gallstone. While common, the progressive nature and nodular liver make this less likely as the primary cause.
  4. Lymphoma: Compression of the bile duct by enlarged porta hepatis lymph nodes.
How would you manage this patient as the House Officer (HO)?

The management involves a structured plan to confirm the diagnosis, assess for complications, and assess fitness for potential intervention.

  1. Confirm the Diagnosis:
    • Biochemical Tests: Request Liver Function Tests (LFTs) expecting a cholestatic picture (high ALP, GGT, and conjugated bilirubin).
    • Imaging: Arrange an urgent Abdominal Ultrasound Scan (USS). This is the first-line imaging test to look for biliary duct dilatation, gallstones, a mass in the head of the pancreas, and liver metastases (nodular liver).
  2. Assess for Complications:
    • FBC: To check for anaemia.
    • PT/INR: This is the most important blood test to assess for coagulopathy due to Vitamin K malabsorption.
    • U&Es/Serum Creatinine: To assess renal function before contrast studies and to screen for hepatorenal syndrome.
  3. Assess Fitness for Surgery/Anaesthesia:
    • Group and Save, baseline ECG.

If the USS is inconclusive or confirms a suspicious mass, the next investigation is a staging Contrast-Enhanced CT (CECT) of the chest, abdomen, and pelvis.

A superb radiologist says there’s no biliary dilatation. Now what?

This is a challenging clinical scenario. Jaundice without biliary duct dilatation points towards a few key possibilities:

  1. A Medical Cause of Jaundice: The primary problem might be hepatocellular (e.g., severe hepatitis, drug-induced liver injury, primary biliary cholangitis) or an infiltrative disease of the liver (e.g., widespread metastases, lymphoma). The nodular liver would fit with infiltrative disease.
  2. Proximal Biliary Obstruction: There could be a blockage high up in the biliary tree, at the confluence of the right and left hepatic ducts (a Klatskin tumour/hilar cholangiocarcinoma). In this case, only the intrahepatic ducts would be dilated, which might be missed or misinterpreted.
  3. It’s the Wrong Patient: A possibility to always consider in an exam setting!

How to proceed: Review the LFTs. If they are highly suggestive of cholestasis (very high ALP), then a proximal obstruction is still likely. The next best imaging modality would be an MRCP (Magnetic Resonance Cholangiopancreatography), which provides excellent non-invasive visualization of the entire biliary tree.

Who are the people in the MDT?

A specialist Hepato-Pancreato-Biliary (HPB) multidisciplinary team meeting is essential to plan management. The core members include:

  • HPB Surgeon
  • Gastroenterologist / Endoscopist
  • Radiologist
  • Oncologist (Medical and Radiation)
  • Pathologist
  • Anaesthetist
  • Clinical Nurse Specialist / Stoma Care Nurse
  • Dietitian / Nutritionist
  • Social Worker
  • The patient and their family are also central to the decision-making process.

Surgery Long Case: Bladder Outflow Obstruction

Patient Summary

An 84-year-old male with a good functional status (MET score >7) presents with an 8-month history of Lower Urinary Tract Symptoms (LUTS), mainly storage symptoms (frequency, urgency). He has a history of two episodes of painless haematuria and three UTIs. A Digital Rectal Examination (DRE) is suggestive of benign prostatic expansion. His bladder is not palpably distended.

Given the age and symptoms, what are the most likely DDx?

In an elderly male with LUTS and haematuria, the main differential diagnoses are prostate-related.

  1. Benign Prostatic Hyperplasia (BPH): This is the most common cause of LUTS in this age group. The DRE findings of a smooth, symmetrically enlarged prostate with a preserved median sulcus support this.
  2. Prostate Cancer: This is the most important differential to exclude. Haematuria can be a symptom. DRE findings suggestive of cancer would include a hard, nodular, asymmetrical gland with loss of the median sulcus.
  3. Bladder Cancer: Haematuria is a cardinal symptom, and bladder irritation from a tumour can cause storage LUTS.
  4. Bladder Stones or UTI: Can cause storage LUTS and haematuria.
What investigations would you do? And what do you look for in each?

Investigations aim to assess the severity of symptoms, evaluate for complications, and differentiate between BPH and prostate cancer.

  • Basic Investigations:
    • Urine Full Report (UFR): To check for haematuria and signs of infection (white cells, nitrites).
    • Urine Culture: If infection is suspected.
    • Serum Creatinine / U&Es: This is a crucial investigation to assess for impaired renal function due to chronic bladder outflow obstruction (obstructive uropathy).
  • Specific Investigations:
    • Prostate-Specific Antigen (PSA): A blood test. Before performing a PSA, the patient must be counselled about the implications of the test (it is not a cancer test, can have false positives and false negatives, and may lead to further investigations like a biopsy). A high or rising PSA is suspicious for cancer.
    • Ultrasound of the Kidneys, Ureters, and Bladder (USS KUB): This is the key initial imaging. It looks for:
      • Upper tract changes: Hydronephrosis and hydroureter, which indicate back-pressure changes.
      • Bladder changes: Bladder wall thickening, stones, or tumours.
      • Prostate: Estimates prostate volume.
      • Post-Void Residual (PVR) volume: A high PVR indicates inefficient bladder emptying.
How do you differentiate between BPH and Prostate CA? What scoring system is used for biopsy?

While DRE and PSA can be suggestive, the definitive differentiation requires a biopsy.

Definitive Investigation:

  • Multi-parametric MRI (mpMRI) of the Prostate: This is now the recommended investigation before a biopsy. It is highly sensitive for detecting clinically significant prostate cancer. If the mpMRI is negative, a biopsy may be avoided.
  • Trans-rectal Ultrasound (TRUS) Guided Prostate Biopsy: This is the definitive diagnostic test. If the mpMRI shows a suspicious lesion, the biopsy can be targeted to that area (fusion biopsy).

Gleason Scoring System:

  • The biopsy tissue is examined by a pathologist who assigns a Gleason Grade (from 3 to 5) to the two most common patterns of cancer seen.
  • The two grades are added to give a Gleason Score (e.g., 3+4 = 7).
  • A higher Gleason score indicates a more aggressive, poorly differentiated cancer with a worse prognosis.
Source: EAU Guidelines on Prostate Cancer (2023); NICE Guideline [NG131] Prostate cancer: diagnosis and management (2021).
If the diagnosis is BPH, how would you manage it?

Management is based on symptom severity, which can be quantified using the International Prostate Symptom Score (IPSS).

  • Conservative Management (Watchful Waiting): For mild symptoms. Involves lifestyle advice (e.g., reducing evening fluid intake, avoiding caffeine).
  • Medical Management: For moderate to severe symptoms.
    • Alpha-blockers (e.g., Tamsulosin): These relax the smooth muscle of the prostate and bladder neck, improving flow. They work quickly.
    • 5-alpha-reductase inhibitors (e.g., Finasteride): These shrink the prostate gland over time (takes 3-6 months to work). They are most effective for larger prostates.
    • Combination therapy is often used.
  • Surgical Management: For patients with severe symptoms refractory to medical therapy, or those who develop complications (e.g., refractory urinary retention, bladder stones).
    • Transurethral Resection of the Prostate (TURP) is the traditional gold standard operation.

What is TURP Syndrome? A rare but serious complication of TURP, caused by systemic absorption of the hypotonic glycine irrigation fluid. It leads to dilutional hyponatraemia, fluid overload, and glycine toxicity, presenting with confusion, nausea, hypertension, and bradycardia.

isira

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