- •CONTENTS
- •PREFACE
- •ABBREVIATIONS
- •GENERAL AND COLORECTAL
- •CASE 1:
- •ANSWER 1
- •CASE 2:
- •ANSWER 2
- •CASE 3:
- •ANSWER 3
- •CASE 4:
- •ANSWER 4
- •CASE 5:
- •ANSWER 5
- •CASE 6:
- •ANSWER 6
- •CASE 7:
- •ANSWER 7
- •CASE 8:
- •ANSWER 8
- •CASE 9:
- •ANSWER 9
- •CASE 10:
- •ANSWER 10
- •CASE 11:
- •ANSWER 11
- •CASE 12:
- •ANSWER 12
- •CASE 13:
- •ANSWER 13
- •CASE 14:
- •ANSWER 14
- •CASE 15:
- •ANSWER 15
- •CASE 16:
- •ANSWER 16
- •CASE 17:
- •ANSWER 17
- •CASE 18:
- •ANSWER 18
- •CASE 19:
- •ANSWER 19
- •CASE 20:
- •ANSWER 20
- •UPPER GASTROINTESTINAL
- •CASE 21:
- •ANSWER 21
- •CASE 22:
- •ANSWER 22
- •CASE 23:
- •ANSWER 23
- •CASE 24:
- •ANSWER 24
- •CASE 25:
- •ANSWER 25
- •CASE 26:
- •ANSWER 26
- •CASE 27:
- •ANSWER 27
- •CASE 28:
- •ANSWER 28
- •CASE 29:
- •ANSWER 29
- •CASE 30:
- •ANSWER 30
- •CASE 31:
- •ANSWER 31
- •CASE 32:
- •ANSWER 32
- •CASE 33:
- •ANSWER 33
- •CASE 34:
- •ANSWER 34
- •CASE 35:
- •ANSWER 35
- •CASE 36:
- •ANSWER 36
- •BREAST AND ENDOCRINE
- •CASE 37:
- •ANSWER 37
- •CASE 38:
- •ANSWER 38
- •CASE 39:
- •ANSWER 39
- •CASE 40:
- •ANSWER 40
- •CASE 41:
- •VASCULAR
- •CASE 42:
- •ANSWER 42
- •CASE 43:
- •ANSWER 43
- •CASE 44:
- •ANSWER 44
- •CASE 45:
- •ANSWER 45
- •CASE 46:
- •ANSWER 46
- •CASE 47:
- •ANSWER 47
- •CASE 48:
- •ANSWER 48
- •CASE 49:
- •ANSWER 49
- •CASE 50:
- •ANSWER 50
- •CASE 51:
- •ANSWER 51
- •CASE 52:
- •ANSWER 52
- •CASE 53:
- •ANSWER 53
- •CASE 54:
- •ANSWER 54
- •CASE 55:
- •ANSWER 55
- •CASE 56:
- •ANSWER 56
- •UROLOGY
- •CASE 57:
- •ANSWER 57
- •CASE 58:
- •ANSWER 58
- •CASE 59:
- •ANSWER 59
- •CASE 60:
- •ANSWER 60
- •CASE 61:
- •ANSWER 61
- •CASE 62:
- •ANSWER 62
- •CASE 63:
- •ANSWER 63
- •CASE 64:
- •ANSWER 64
- •ORTHOPAEDIC
- •CASE 65:
- •ANSWER 65
- •CASE 66:
- •ANSWER 66
- •CASE 67:
- •ANSWER 67
- •CASE 68:
- •ANSWER 68
- •CASE 69:
- •Questions
- •ANSWER 69
- •CASE 70:
- •ANSWER 70
- •CASE 71:
- •ANSWER 71
- •CASE 72:
- •ANSWER 72
- •CASE 73:
- •ANSWER 73
- •CASE 74:
- •ANSWER 74
- •CASE 75:
- •ANSWER 75
- •CASE 76:
- •ANSWER 76
- •CASE 77:
- •ANSWER 77
- •CASE 78:
- •ANSWER 78
- •CASE 79:
- •ANSWER 79
- •CASE 80:
- •ANSWER 80
- •CASE 81:
- •ANSWER 81
- •EAR, NOSE AND THROAT
- •CASE 82:
- •ANSWER 82
- •CASE 83:
- •ANSWER 83
- •CASE 84:
- •ANSWER 84
- •CASE 85:
- •ANSWER 85
- •NEUROSuRGERY
- •CASE 86:
- •ANSWER 86
- •CASE 87:
- •ANSWER 87
- •CASE 88:
- •ANSWER 88
- •CASE 89:
- •ANSWER 89
- •ANAESTHESIA
- •CASE 90:
- •ANSWER 90
- •CASE 91:
- •ANSWER 91
- •CASE 92:
- •ANSWER 92
- •CASE 93:
- •ANSWER 93
- •CASE 94:
- •ANSWER 94
- •POSTOPERATIVE COMPLICATIONS
- •CASE 95:
- •ANSWER 95
- •CASE 96:
- •ANSWER 96
- •CASE 97:
- •ANSWER 97
- •CASE 98:
- •ANSWER 98
- •CASE 99:
- •ANSWER 99
- •CASE 100:
- •ANSWER 100
Vascular
CASE 53: reSt pain in the loWer limb
history
A 70-year-old man presents to the emergency department complaining of a dull pain in the dorsum of the right foot for the past 6 weeks. The pain is worse at night, waking him from sleep, and is relieved by hanging his leg over the edge of the bed. For the past week he has been sleeping in a chair to alleviate the pain. He is known to have hypertension and hypercholesterolaemia. His past history includes coronary artery bypass grafting 6 years ago. He lives with his wife and is fully independent.
examination
The right foot has a red tinge and is swollen. The right little toe is dusky. The right foot feels cool when compared with the left, with delayed capillary refill. The femoral pulse is palpable on both sides. Popliteal, dorsalis pedis and posterior tibial pulses are palpable on the left leg, but pulses below the femoral are absent on the right. The ABPI measures 0.9 on the left and 0.35 on the right.
The patient is admitted for an urgent duplex ultrasound, which suggest occlusion of the right superficial femoral artery. The following day an intra-arterial angiogram is carried out (Figure 53.1).
Figure 53.1 angiogram of the right lower limb.
Questions
•How do you explain the symptoms and signs?
•A decision is made to carry out arterial reconstruction – what choices of graft materials are available?
•What are the complications of surgery?
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100 Cases in Surgery
ANSWER 53
Pain in the foot that is worse at night and is relieved by dependence is classical of ischaemic rest pain and is the result of poor tissue perfusion and oxygenation. An ABPI of 0.35 is compatible. Discolouration of the toe suggests impending gangrene. The patient should be made comfortable using opiate analgesia. He should be treated with low-molecular-weight or unfractionated heparin, pending investigation and treatment.
The angiogram reveals occlusion of the superficial femoral artery on the right (Figure 53.2). The popliteal artery reforms at the level of the knee via collateral vessels. If attempts at recanalizing the vessel using angioplasty are unsuccessful, then the patient should be considered for a femoral-popliteal bypass graft.
Figure 53.2 arterial angiogram showing occlusion of the right superficial femoral artery and the popliteal artery reforming at the knee (arrows).
The material of choice for bypass grafting is autogenous vein. The long saphenous vein is most widely used but arm veins/the short saphenous vein are other options if the long saphenous vein has already been used (e.g. previous bypass, coronary artery grafting) or is small in calibre. Other options include prosthetic grafts (e.g. Dacron, polytetrafluoroethylene) or umbilical vein allografts. The long-term patency of prosthetic grafts is inferior compared with autogenous vein.
!Complications of bypass surgery
• Early: |
• Late: |
||
• |
haemorrhage |
• |
graft stenosis/occlusion |
• |
graft thrombosis |
• |
Delayed wound healing |
• |
Compartment syndrome |
• |
graft sepsis |
• |
Deep vein thrombosis/pulmonary |
• |
anastomotic false aneurysms |
• |
embolism |
• |
limb loss |
Cardiorespiratory complications |
|
|
KEY POINTS
•rest pain indicates inadequate tissue perfusion.
•urgent investigation and treatment is required to salvage the limb.
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Vascular
CASE 54: poStoperative limb SWelling
history
You are asked to review a 68-year-old woman on the ward. She had an anterior resection for a rectal tumour 5 days ago. Postoperative recovery has been unremarkable and she has started to eat and drink and opened her bowels today. You have been asked to examine her as she is complaining of pain and swelling of the left leg. There is no history of trauma to the leg.
examination
Her temperature is 37.5°C and her pulse rate is 99/min. The abdomen is soft and non-tender. The left leg is swollen to mid-thigh, with erythema of the skin. The calf feels warm and is tender to touch. The foot pulses are normal.
INVESTIGATIONS
|
|
Normal |
haemoglobin |
11.5 g/dl |
11.5–16.0 g/dl |
White cell count |
16.7 × 109/l |
4.0–11.0 × 109/l |
platelets |
360 × 109/l |
150–400 × 109/l |
Sodium |
143 mmol/l |
135–145 mmol/l |
potassium |
4.6 mmol/l |
3.5–5.0 mmol/l |
urea |
9.5 mmol/l |
2.5–6.7 mmol/l |
Creatinine |
71 μmol/l |
44–80 μmol/l |
C-reactive protein (Crt) |
100 mg/l |
<5 mg/l |
Questions
•What is the most likely diagnosis? What are the differentials?
•What investigation should be carried out next?
•What are the risk factors associated with this condition?
•How should this condition be treated?
•What are the long-term sequelae of this condition?
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100 Cases in Surgery
ANSWER 54
The most likely diagnosis is a deep vein thrombosis (DVT). Clinical examination is notoriously inaccurate for making the diagnosis, as the degree of swelling and pain varies and patients can be symptomless.
!Differential diagnoses
•Cellulitis
•lymphangitis
•Soft tissue injury
•lymphoedema
•haematoma
•arterial insufficiency
•ruptured baker’s cyst
A normal D-dimer assay (fibrin degradation products) would usually exclude a diagnosis of DVT, but is not useful in this case as the recent surgery means that it will be positive regardless. The diagnosis is best confirmed using duplex ultrasonography of the deep veins.
!Risk factors for deep vein thrombosis
• age |
• lower-extremity fractures |
• bed rest |
• haematological |
• pregnancy |
• thrombocytosis |
• oral contraceptive pill |
• polycythaemia |
• major surgery |
• protein S deficiency |
• medical |
• protein C deficiency |
• major trauma |
• antithrombin iii deficiency |
• burns |
• Factor v leiden |
Anticoagulation is the mainstay of treatment, aimed at preventing extension of the thrombus and reducing the risk of pulmonary embolism. Therapeutic low-molecular-weight heparin and warfarin are commenced at the same time. Heparin is stopped when the international normalized ratio (INR) becomes therapeutic. The target INR is usually in the range of 2–3. Some authorities do not treat DVT confined to the calf because of the very low risk of pulmonary embolism.
DVT can result in venous hypertension, and long-term consequences include the post-thrombotic syndrome, which consists of leg pain, swelling, lipodermatosclerosis and ulceration.
KEY POINTS
•treatment should be commenced once a Dvt has been diagnosed clinically.
•the diagnosis is confirmed with ultrasound.
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