1. The following are absorbable sutures a. Catgut b. Silk c. Polyamide (Nylon) d. Polyglyconate (Maxon) e.

Polyglactin (Vicryl)

Suture materials The purpose of a suture

to hold a wound together in good apposition until such time as the natural healing process is sufficiently well established to make the support from the suture material unnecessary and redundant.

Choice of a suture

Choice of suture depends on:

o o o o o

Properties of suture material Absorption rate Handling characteristics and knotting properties Size of suture Type of needle

Natural suture materials

Absorbable
o

Catgut - Plain or chromic

Non-Absorbable
o o o

Silk Linen Stainless Steel Wire

Synthetic suture materials

Absorbable

o o o o

Polyglycolic Acid (Dexon) Polyglactin (Vicryl) Polydioxone (PDS) Polyglyconate (Maxon)

Non-Absorbable
o o o

Polyamide (Nylon) Polyester (Dacron) Polypropylene (Prolene)

Absorbable suture are broken down by either:

Proteolysis (e.g. Catgut) Hydrolysis (e.g. Vicryl, Dexon)

Catgut

Made from the submucosa of sheep gastrointestinal tract Broken down within about a week Chromic acid delays hydrolysis Even so it is destroyed before many wounds have healed

Silk

Strong and handles well but induces strong tissue reaction Capillarity encourages infection causing suture sinuses and abscesses

Vicryl

Tensile strength
o o o

65% @ 14 days 40% @ 21 days 10% @ 35 days

Absorption complete by 70 days

Polydioxone

Tensile strength

o o o

70% @ 14 days 50% @ 28 days 14% @ 56 days

Absorption complete by 180 days

Common errors of suture use

Too many throws. Increases foreign body size. Causes stitch abscesses Intra-cuticular rather than subcuticular sutures causing hypertrophic scars Holding monofilament sutures with instruments reduces tensile strength by over 50% Holding butt of needle causes needle and suture breakage

2. Peutz Jeghers Syndrome a. Is an autosomal recessive condition b. Often presents with anaemia in childhood c. Is characterised by circumoral mucocutaneous pigmented lesions d. Is associated with adenomatous polyps of the small intestine e. Malignant change occurs in 2-3% of polyps
Benign colonic polyps

A polyp is a pedunculated lesion Not all polyps are tumours Not all polypoid tumours are benign Not all benign tumours are polypoid

3. Regarding peptic ulceration a. H. pylori is a gram-positive bacillus b. Duodenal is more common than gastric ulceration c. Zollinger-Ellison syndrome is associated with gastrin hyposecretion d. H2-blockers will heal 85-95% of duodenal ulcers in 8 weeks e. Triple therapy can eradicate H. pylori in 80% of patients in one week

4. Head Injuries a. More than 1 million people are seen in UK hospitals each year with head injuries b. Skull X-rays can exclude an intracerebral haematoma c. Raised intracranial pressure is associated with an increase in cerebral perfusion d. Cushing's response consists of a rise in blood pressure and fall in heart rate

e. Pupillary dilatation usually occurs on the same side as the intracerebral haematoma

5. During surgery on the submandibular gland a. An incision on the lower border of the mandible is safe b. The submandibular gland is seen to wrap around the posterior border of mylohyoid c. The facial artery and vein are divided as they course through the deep part of the gland d. The hypoglossal nerve is seen to loop under the submandibular duct e. Damage to the lingual nerve will cause loss of sensation to the posterior third of the tongue

6. Regarding pancreatic carcinoma a. 90% are ductal adenocarcinomas b. Less than 20% occur in the head of the gland c. The usual presentation is with pain, weight loss and obstructive jaundice d. Ultrasound has a sensitivity of 80-90% in the detection of the tumour e. Less than 20% of patients are suitable for curative surgery

7. Regarding the management of major trauma a. Deaths follow a trimodal distribution b. X-rays after the primary survey should be of AP Cervical spine, chest and pelvis c. Cardiac tamponade is characterised by raised BP, low JVP and muffled heart sounds d. Assessment of uncomplicated limb fractures should occur during the primary survey e. Deterioration of the casualty during the primary survey should lead to the secondary survey

8. Regarding appendicitis a. The risk of developing the illness is greatest in childhood b. Mortality increases with age and is greatest in the elderly c. 20% of appendices are extraperitoneal in a retrocaecal position d. Faecoliths are present in 75-80% of resected specimens e. Appendicitis is a possible diagnosis in the absence of abdominal tenderness

9. Regarding stones in the gallbladder a. Cholesterol stones are the most common

b. Pigment stones are due increased excretion of polymerised conjugated bilirubin c. Are not a risk factor for the development of gallbladder carcinoma d. 90% of gallstones are radio-opaque e. A mucocele of the gallbladder is caused by a stone impacted in Hartmann's pouch

10. Stones in the common bile duct a. Are found in 30% of patients undergoing cholecystectomy (Without pre-op ERCP) b. Can present with Charcot's Triad c. Are suggested by an bile duct diameter >8mm on ultrasound d. ERCP, sphincterotomy and balloon clearance is now the treatment of choice e. If removed by exploration of the common bile duct the T-tube can be removed after 3 days

Peptic ulcer disease

Number of admissions for uncomplicated disease is falling Incidence of complications rated to NSAID use is increasing

Helicobacter pylori

H. pylori is gram-negative spiral flagellated bacterium Produces urease

Important in the aetiology of peptic ulcers and gastric cancer Found in:

o o o
Investigation

90% patients with duodenal ulceration 70% patients with gastric ulceration 60% patients with gastric cancer

The organism can be detected by Microscopy silver or Giemsa staining of antral biopsies Culture difficult and requires special culture techniques Rapid urease test colour changes due to change in pH
13

C or 14C breath test Ingested radioactive urea is broken down to carbon dioxide

Serology detected immunologically using an ELISA

Sensitivity and specificity of H. pylori diagnostic tests Test Rapid urease Culture Microscopy Carbon breath test Serology Sensitivity (%) 90 80 90 Specificity (%) 90-95 100 90

95

95

98

100

Medical management of peptic ulcer disease H2 Antagonists

65% healing at one month 85% healing at two months If stop treatment - 90% recurrence at 2 years If maintenance therapy - 20% recurrence at 5 years

Proton Pump inhibitors 90 - 100% healing at 2 months Low recurrence on long term maintenance

H. Pylori eradication 80% cured with dual or triple therapy Two weeks amoxycillin, metronidazole and omeprazole Short term recurrence rates low Long term recurrence rates are at present unknown Drugs have changed the need for ulcer surgery over last 20 years Admissions for elective surgery have significantly reduced The number of complications however remain unchanged May be increasing due to increased NSAID use in elderly

Bleeding and perforation still have mortality of >10%

History of peptic ulcer surgery Harberer (1882) - First gastric resection for benign ulcer Billroth (1885) - Billroth II Gastrectomy Von Fiselberg (1889) - 'Valve' to prevent bile reflux through gastroenterostomy Hofmeister (1896) & Polya (1911) - Retrocolic anastomosis Dragstedt (1943) - Truncal vagotomy Visick (1948) - Truncal vagotomy and drainage Johnson & Wilkinson (1970) - Highly selective vagotomy

Billroth I gastrectomy Originally described for the resection of distal gastric cancers Still used in gastric cancers if radical gastrectomy is inappropriate Later applied in the treatment of benign gastric ulcers Useful if ulcer situated high on the lesser curve or bleeding ulcer that requires resection Less effective than Polya Gastrectomy for duodenal ulcers

Billroth II / Polya gastrectomy Initially described for duodenal ulceration but rarely performed today Some form of vagotomy is the surgical treatment of choice for uncomplicated DU Occasionally used below a high gastric ulcer Ulcer invariably heals after surgery Useful in recurrent ulceration following previous vagotomy When constructing the anastomosis need to consider: Antecolic vs. retrocolic anastomosis Hofmeister valve so as direct bile in to the efferent loop Isoperistaltic vs. anteperistalitic anastomosis

Current surgical options Indications for surgical treatment of duodenal ulceration are:

Intractability Haemorrhage Perforation Obstruction

Aims of surgery are:

To cure the ulcer diathesis with The lowest risk of recurrence and complications

Surgical options for duodenal ulceration Operations for duodenal ulceration reduce acid production by the stomach Cephalic phase reduced by vagotomy Antral phase reduced by antrectomy May require gastric drainage procedure to overcome effects of vagotomy on gastric drainage

Open surgical procedures Truncal vagotomy and pyloroplasty Truncal vagotomy and gastrojejunostomy Truncal vagotomy and antrectomy Highly selective vagotomy Anterior seromyotomy and posterior truncal vagotomy

Laparoscopic peptic ulcer operations

Thoracoscopic truncal vagotomy and pyloric stretch Truncal vagotomy and pyloric stretch Highly selective vagotomy Posterior truncal vagotomy and selective anterior vagotomy Posterior truncal vagotomy and anterior seromyotomy

Post gastrectomy complications Percentage Recurrent ulceration Diarrhoea Dumping Bilious vomiting Iron deficiency anaemia B12 deficiency Folate deficiency

16 14 10

12

14 32

Post vagotomy complications Percentage Diarrhoea Dumping Bilious vomiting Bibliography 2 2 <2

Classification of large bowel polyps

Epithelial

o o o o o o o
Juvenile polyps

Adenomas - tubular, villous, tubulovillous Metaplastic polyps

Mesodermal Lipoma Leiomyoma Haemangioma

Hamartoma Juvenile polyps Peutz-Jeghers syndrome

Commonest form of polyp in children Can occur throughout large bowel but are most common in the rectum Usually present before 12 years Present with Prolapsing lump or rectal bleeding Not pre-malignant Treated by local endoscopic resection

Peutz-Jeghers syndrome Rare familial disorder Circumoral pigmentation and intestinal polyps Polyps found throughout gut but most common in the small intestine

Presents in childhood with bleeding, anaemia or intussusception Polyps can become malignant

Metaplastic polyps

Small plaques approximately 2 mm in diameter Pathogenesis unknown Not pre-malignant

Adenomas Benign epithelial neoplasm They are pre-malignant Risk of malignancy increases with size Malignancy more common in villous rather than tubular lesions

Most adenomas are asymptomatic 10% of population over 45 years have adenomatous polyps If do become symptomatic usually present with bleeding, mucous discharge or prolapse Villous adenomas may produce hypokalaemia but this is rare Diagnosis is often by sigmoidoscopy or colonoscopy Full colonoscopy essential to exclude other lesions Treatment is by transanal excision or colonoscopic snaring Patients require regular colonoscopic surveillance

Familial adenomatous polyposis Aetiological factor in 1% of colorectal cancers Its is an autosomal dominant Due to mutation on long arm of chromosome 5 Mutation induces proliferation of mucosa throughout GI tract Develop colonic polyps in teens or early 20s Untreated progresses to cancer by 30s Screening by rigid or flexible sigmoidoscopy

Safe alternative to colonoscopy as rectal sparing rarely seen Start late teens and continue until 40 yrs and polyp free. Extra-colonic manifestations:

o o o o o o o o

Osteomas. epidermoid cysts = Gardeners Syndrome Gastroduodenal polyps Desmoid tumours Congenital hypertrophy of retinal pigmented epithelium

Surgical options: Panproctocolectomy and ileostomy Restorative panproctocolectomy Subtotal colectomy and ileorectal anastomosis NB will require surveillance of rectal stump

Hereditary non-polyposis colorectal cancer syndrome

Accounts for 5-10% of colorectal cancers Results in mainly right sided cancers Increased risk of other gastrointestinal, urological and gynaecological malignancy Diagnosed by having 3 affected relatives, in 2 generations and one patient <50 years Recommend to start colonoscopic screening starting 5 years before youngest affected relative.

Bibliography Campbell W J, Spence R A J, Parks T G. Familial adenomatous polyposis. Br J Surg 1994; 81: 1722 - 33.

Questions 11-20 11. Regarding crystalloid solutions a. Normal saline contains 154 mmol sodium and 154 mmol of chloride b. 3 litres of dextrose saline in a day will provide 90 mmol of sodium c. 2 grams of potassium chloride is equal to 57 mmol of the salt d. Hartmann's solution contains calcium and bicarbonate e. The daily maintenance potassium requirement of a 40 Kg woman is about 40 mmol

12. Regarding colloid solutions a. Human albumin has a molecular weight of 69 kDa b. Albumin has a half life in the circulation of about 15 hours c. Gelatins (e.g. Haemaccel) are polysaccharides with a MW of about 35 kDa d. Dextrans reduce platelet aggregation and can induce anaphylaxis e. 6% Hydroxylethyl Starch (HES) is synthetic polysaccharide derived from amylopectin

13. Central parenteral nutrition a. Is a hypo-osmolar solution b. Typically contains 14-16g nitrogen as D-amino acids c. Typically contains about 250g glucose d. Is associated with metabolic disturbances in about 5% patients e. Can induce derangement of liver function tests

14. Solitary thyroid nodules a. Are more prevalent in women b. In the adult population less than 10% are malignant c. More than 50% of scintigraphically cold nodules are malignant d. The risk of a hot module being malignant is negligible e. Should be surgically removed in all patients

15. Regarding abdominal wall hernias a. Almost 100,000 hernia operations are performed annually in the United Kingdom b. 20% of inguinal hernias are indirect c. In women inguinal hernias are as common as femoral hernias d. The mortality assocaited with strangulation is over 10% e. The mortality has reduced dramatically over the past 30 years

16. The femoral canal a. Lies lateral to the femoral vein b. Has the inguinal ligament as its anterior border c. Has the lacunar ligament as its lateral border d. Has the pectineal ligament as its posterior border e. Contains the lymph node of Cloquet

17. Intermittent claudication

a. Affects less than 1% of men over the age of 50 years b. At 5 years 10% of claudicants will have progressed to an amputation c. At 5 years 20% of claudicants will have died from ischaemic heart disease d. Is usually associated with an ankle / brachial pressure index (ABPI) > 0.7 e. Is associated with a fall in the ABPI on exercise with delayed recovery

18. The pathology of ulcerative colitis a. Shows full thickness inflammation b. The rectum is almost always involved c. 10% patients have terminal ileal disease d. Enterocutaneous or intestinal fistulae are common e. The serosa is usually normal

19. Regarding surgery for ulcerative colitis a. 30% patients with total colitis will require surgery within 5 years b. Panproctocolectomy and pouch formation is appropriate as an emergency operation c. Pouches can be fashioned as 'S' 'J' or 'W' loops d. Over 90% patients with a pouch have perfect continence e. With a pouch the mean stool frequency is about 6 times per day

20. Regarding benign breast disease

a. Cyclical mastalgia is the commonest reason for referral to the breast clinic b. Fibroadenomas are derived from the breast lobule c. Lactational breast abscesses are usually due to Staph aureus d. Duct ectasia is more common in smokers e. Atypical lobular hyperplasia is associated with an increased risk of breast cancer