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204
Manipal Manual of Surgery
• Allen’s test: Ask the patient to clench his fist tightly.
Compress the radial and ulnar arteries at the wrist
with your thumbs. Wait for 10 seconds and ask the
patient to open his hands. Pallor can be seen in the
palm. Now release pressure on the radial artery and
watch for blood flow. Repeat the test for the ulnar
artery. If there is occlusion in either artery, colour
changes occur slowly in the fingers (Fig. 28.8).
• Elevated Arm Stress Test (EAST): The patient is
asked to abduct the shoulders to 90 degrees and to
flex the elbow. Then he is asked to pronate/supinate
the forearms continuously. Appearance of symptoms
suggests thoracic outlet syndrome.
• A hard mass may be visible or palpable in the root of
the neck (Type I).
• On palpation of the supraclavicular region, a thrill
may be felt, and on auscultation, a bruit may be heard
in cases of post-stenotic dilatation.
Differential Diagnosis
A patient who presents with a few neurological symptoms and signs in the upper limb with a cervical rib
may be having some other causes for those symptoms.
Hence, it is important to exclude other causes.
. Cervical spondylosis: This should be considered as
1
a possibility in patients >40 years.
2. Cervical disc protrusion and spinal cord tumours
may mimic cervical rib with prominent neurological
features.
3. Carpal tunnel syndrome may occur due to various
causes such as myxoedema, rheumatoid arthritis, and
malunited Colles’ fracture. Predominant features of
median nerve involvement, more so in menopausal
women, give a clue to the diagnosis.
4. Raynaud’s phenomenon
5. Costovertebral anomalies
6. Pancoast tumour
Section II • General Surgery
Fig. 28.8: Allen’s test
Investigations
1. X-ray neck may show a cervical rib (Types I, II, and III).
Interestingly, Type IV variety—a fibrous band which
cannot be diagnosed by X-ray or by any other investigation—usually gives rise to symptoms (Fig. 28.9).
2. Cervical disc protrusion and spinal cord tumours
may have prominent neurological features and, thus,
may mimic cervical rib. When in doubt, ask for an MRI.
3. Duplex scan of the affected limb to detect any
aneurysm. It may also detect a thrombus.
4. CT angiography to define the exact nature of the
arterial dilatation and thrombus.
Fig. 28.9: X-ray of the neck showing cervical rib
Treatment
I. Conservative
• Patients with mild neurological symptoms are
managed by shoulder girdle exercises or correction
of faulty posture.
II. Surgery (Key Box 28.8)
• Presence of vascular symptoms and signs are the
definite indications for surgery.
• Excision of the cervical rib including the periosteum
is called extraperiosteal excision of cervical rib (so
that it will not regenerate). This is combined with
cervical sympathectomy if vascular symptoms are
predominant.
• If there is a thrombus in the subclavian artery, it is
removed and the artery is repaired (Fig. 28.10).
• At exploration, if a cervical rib is not found, the
scalenus anterior muscle is divided. This is called
scalenotomy. If hyperabduction syndrome is
diagnosed, pectoralis minor is divided at its insertion
into the coracoid process (Key Box 28.9).
Upper Limb Ischaemia and Gangrene
Key Box 28.8
Cervical Rib Surgery (Figs 28.11 and 28.12)
Remove cervical rib
Repair subclavian artery
Restore circulation
Reduce vasospasm—sympathectomy
Recognise other causes
Key Box 28.9
If Cervical Rib is not Found
Scalenotomy
Division of pectoralis minor, scalenus anterior
Extraperiosteal resection of the first rib
205
Fig. 28.11: Cervical rib at surgery
Fig. 28.10: Subclavian artery is exposed to repair the dilatation
and remove the thrombus
A summary of cervical rib is given in Fig. 28.13.
Fig. 28.13: Summary of cervical rib
Fig. 28.12: Cervical rib removed
Section II • General Surgery
206
Manipal Manual of Surgery
AXILLARY VEIN THROMBOSIS
• Patients present with swelling of the arm after intense
activity from the dominant hand
• Hypertrophy of the subclavius muscle may also
cause compression of the subclavian-axillary vein
(sportsman)
• Peripheral pulses will be normal
• Venography to diagnose thrombus
• Thrombolysis or, if necessary, venotomy and
removal of the thrombus and 1st rib (if it is the cause
of obstruction) are the treatment modalities.
• Axillary vein thrombosis is also a complication of
axillary block dissection, especially where extensive
nodal dissection has been done.
VASCULITIS SYNDROMES
SU27.3: Describe clinical features, investigations and
principles of management of vasospastic disorders.
TAKAYASU’S ARTERITIS (Pulseless disease, large vessels
arteritis)
• It is of unknown aetiology.
• Commonly affects females (85%).
• It is a panarteritis involving the aortic arch and its
branches. The subclavian artery is involved in 85%
of cases.
Clinical Features
It starts as a generalised inflammatory disease—fever,
body ache, malaise, and arthralgia.
• Upper limb claudication (Key Box 28.10)
• Absence of peripheral pulses
• Hypertension is common (occurs in 50% of cases) due
to renal artery involvement.
• A bruit may be heard over the subclavian artery
• Visual disturbances may occur due to involvement
of retinal arteries. Late blindness may occur.
Pathology
It is a panarteritis, involving all layers of elastic arteries.
Thrombosis and stenosis may occur later.
Investigations
• C-reactive protein is elevated as part of an acute phase
response (nonspecific).
• Duplex-Doppler ultrasound and MR angiography
may diagnose the site of obstruction and blood flow
pattern.
Treatment
• Very early cases benefit with steroid therapy, e.g. tablet
prednisolone 30–50 mg/day (anti-inflammatory
effect). Cyclophosphamide may be tried when other
measures fail (immunosuppressive effect).
• Vascular reconstruction—difficult.
GIANT CELL ARTERITIS
• It is also called temporal arteritis.
• An elderly woman presenting with severe headache
is the common presentation.
• Fever and malaise may also be present.
• Involvement of various arteries results in various
symptoms (Key Box 28.11).
• Palpable, pulsatile, tender temporal arteries clinch the
diagnosis.
• Biopsy of the temporal arteries reveal giant cell
granulomas, comprising mainly CD4+ T lymphocytes.
Key Box 28.10
Vasculitis Syndromes
Aetiology is inflammatory or immunological.
Uncommon causes of upper and lower limb ischaemia.
Women are affected more than men.
Multiple small vessel involvement.
Symptoms are confusing, depending upon organ
involvement.
Ischaemic changes are minimal and superficial when
it involves the limbs.
Steroids are useful in controlling the disease.
Immunosuppression should be tried carefully.
Section II • General Surgery
Key Box 28.11
Symptoms and Artery Involved
Vessel involved Symptoms
Temporal artery Headache
Facial artery Jaw pain
Retinal artery Sudden blindness
Upper limb artery Claudication
Coronary artery Myocardial infarction
• Treated with prednisolone 60–80 mg/day, which is
slowly tapered over 1–2 years.
• Relapses and remissions are common.
Upper Limb Ischaemia and Gangrene
207
POLYARTERITIS SYNDROME
• This includes microscopic polyarteritis (more common)
and polyarteritis nodosa (less common).
• This syndrome also has an inflammatory reaction.
• Ischaemia of the lower limbs and upper limbs may
occur due to involvement of small vessels.
• Abdominal pain is due to the involvement of visceral
vessels.
• Involvement of renal arteries causes loin pain, haema-
turia, and hypertension.
• Treatment is similar to the other diseases mentioned
above.
SYSTEMIC SCLEROSIS
• It was earlier called ‘collagen vascular disorder’
because there is obstruction of the small vessels by
collagen deposition.
• Now it is included under vasculitis syndromes because
of its association with an inflammatory reaction.
• Ischaemic changes occur in the fingers and toes.
Necrosis and ulceration are common.
• Oesophageal involvement results in dysphagia.
• Small bowel sclerosis results in disordered motility
and malabsorption.
• Sympathectomy and vasodilators may be useful.
• Raynaud’s symptoms may be controlled with calcium
channel blockers and nitrates.
GANGRENE
SU27.4: Describe the types of gangrene.
Please note: Principles of amputation are given in opera-
tive surgery chapter, page no. 1282.
Definition
Macroscopic death of tissue with superadded putrefaction. It affects the limbs, intestines, appendix, etc. In this
chapter, differential diagnoses of gangrene of the limbs
are considered.
Pregangrene (Key Box 28.12)
Rest pain, colour changes at rest and with exercise,
oedema, hyperaesthesia, and skin ulcerations are due
to inadequate blood supply to the limb. These changes
are described as pregangrenous changes in the limb.
Classification of Gangrene
. Cardiovascular causes
1
• TAO
• Atherosclerotic gangrene
• Acute embolic gangrene
• Syphilitic gangrene
• Raynaud’s disease
• Cervical rib
• Vasculitis syndrome
• Polycythaemia
2. Neurological causes: Hemiplegia, paraplegia, bedsore.
3. Traumatic gangrene: Direct—thrombosis; indirect—
crush injuries.
4. Physical causes: Sunrays, radiation, corrosive acids.
5. Drugs: Ergotamine.
6. Diabetic gangrene.
7. Acute infective gangrene: Boil, carbuncle, cancrum
oris, gas gangrene.
Clinical Features of Gangrene (Key Box 28.13)
• A part which is gangrenous is a dead portion of the
body. It has no arterial pulsations, venous return, or
capillary filling.
• It has no sensation.
• The colour is initially pale and later changes to dusky
grey and finally black. The black colour is due to the
disintegration of haemoglobin and the formation of
iron sulphide.
• The gangrenous part has to be treated with surgical
excision or debridement, which may amount to disarticulation of the toe or even amputation.
• Gram-positive, gram-negative, and anaerobic orga-
nisms multiply in this segment and may produce
septicaemia. Thus, this may precipitate multiorgan
failure, including renal failure, adult respiratory
distress syndrome (ARDS), cardiac failure, etc.
Key Box 28.12
Pregangrene—Symptoms
Rest pain is the main symptom
Pallor on elevation
Congestion on dependent position
Guttering of veins
Poor capillary filling
Thickening or scaling of skin
Key Box 28.13
Signs of Gangrene
Loss of pulsation
Loss of colour
Loss of temperature
Loss of sensation
Loss of function
Section II • General Surgery
208
Manipal Manual of Surgery
Clinical Types (Table 28.2)
Table 28.2 Comparison of dry gangrene and wet gangrene
Dry gangrene Wet gangrene
Cause Slow occlusion of the arteries Sudden occlusion of the arteries
Involvement of part Small area is gangrenous due to presence Large area is affected due to absence of collaterals
of collaterals
Local findings Dry, shrivelled and mummified Wet, turgid, swollen, oedematous
Line of demarcation Usually present Absent
Crepitus Absent May be present
Odour Absent Foul odour due to sulphurated hydrogen produced
by putrefactive bacteria
Infection Not present Usually present
Diseases TAO, atherosclerosis Emboli, ligatures, crush injuries
Treatment Conservative amputation Major amputation is necessary
VARIOUS TYPES OF GANGRENE (Figs 28.14 to 28.19)
Fig. 28.14: Peripheral gangrene due to sepsis and vasopressors Fig. 28.17: Left medial 2 fingers gangrene due to TAO
Fig. 28.15: Emboli at the brachial artery resulting in massive
gangrene of the hand (wet gangrene)
Fig. 28.18: View of the dorsum of the hand
Section II • General Surgery
Fig. 28.16: Case of SLE. Observe pulp of fingers
Fig. 28.19: Embolic gangrene of fingers
Upper Limb Ischaemia and Gangrene
209
SPECIAL TYPES OF GANGRENE
CANCRUM ORIS
• It is an extensive ulcerative disease of the cheek
mucosa occurring in malnourished children.
• Precipitating factors are:
–
Malnourishment
– Major infectious diseases, such as diphtheria,
whooping cough, typhoid, measles, and kala azar.
• As a result of these factors, opportunistic organisms,
such as Vincent’s organisms (Borrelia vincentii and
B. fusiformis) multiply and cause multiple ulcers,
erosions, and later, fibrosis.
• Occasionally, as the disease progresses, the whole
thickness of the cheek may be lost.
Treatment of Cancrum Oris
1. Ryle’s tube feeding
. Improve nutrition—IV fluids, parenteral nutrition (in
2
severe cases)
3. Appropriate antibiotics: Penicillin + Metronidazole
400 mg three times a day for 7–10 days.
4. Reconstructive surgery may be necessary later.
5. Chlorhexidine mouthwash
GANGRENE FOLLOWING INTRA-ARTERIAL
DRUG INJECTION
• Inadvertent intra-arterial injection of thiopentone
into one of the high divisions of the brachial artery,
(congenital anomaly)—usually the ulnar—will result in
severe burning and blanching of the hand (Figs 28.20
and 28.21).
• After the injection, initial signs and symptoms occur
very fast (within 15–20 seconds). It consists of intense
forearm pain and mottling of the skin over the hand.
• Minutes later, discolouration and nail bed pallor
become evident. Approximately 3 to 4 hours later,
the symptoms progress to paraesthesias and pronounced hand weakness.
• Rapid development of signs indicative of necrosis (by
the eighth day) requires the patient to undergo fasciotomies, multiple debridements, and skin grafts for
cosmesis.
• If this complication is noticed, the following steps
(measures) have to be taken immediately.
Complications of Cancrum Oris
• Fibrosis causing restriction of jaw movements.
• Septicaemia, toxaemia, and death.
ACROCYANOSIS
• It is also called ‘hereditary cold extremities’.
• It presents as persistent cyanotic discolouration of
the hands when exposed to cold due to intermittent
spasm of small peripheral vessels.
• It commonly affects the hands and, rarely, the feet.
• Generally, it is mild and nonprogressive.
DRUG ABUSE AND GANGRENE
• Abuse of the drugs is an important cause of gangrene
in modern days.
• Inadvertent injection of drugs into an artery may lead
to thrombosis of the artery, resulting in acute
ischaemia—commonly in the brachial artery.
• Emergency treatment in symptomatic cases includes
heparinisation and infusion of dextran.
• In severe cases, emergency angiography and intra-
arterial thrombolysis is considered.
Fig. 28.20: Gangrene following intra-arterial injection
Fig. 28.21: Management of inadvertent brachial artery injections
Section II • General Surgery
210
Manipal Manual of Surgery
Treating a Case of Inadvertent Intra-arterial Injection
Step 1: If iatrogenic, maintain the intra-arterial catheter
in place—do not remove it.
Step 2: Identify the progression of the disease—colour
changes, necrosis, gangrene.
Step 3: Initiate anticoagulation—diluted heparin, intra-
venous and subcutaneous.
Step 4: Institute symptomatic relief and plan for
rehabilitation—analgesics, brachial plexus block
(analgesia and vasodilatation) physiotherapy.
Step 5: Elevation of extremity, antibiotics, antiplatelet
anticoagulant therapy.
Step 6: Perform specific interventions—angiogram,
intra-arterial thrombolysis, vasodilators, prostacyclins,
sympathectomy, corticosteroids.
Step 7: Aim is to save the limb—last resort is amputa-
tion.
MISCELLANEOUS
Ergot and Gangrene
• Ergot preparations are used over a long period in
patients with migraine.
• Ergotamine gangrene occurs in those who eat bread
infected with Claviceps purpurea. Example: Dwellers
on the shores of the Mediterranean Sea and the
Russian Steppes.
SUBCLAVIAN STEAL SYNDROME (Fig. 28.22)
• It refers to the development of symptoms in either
the brain or in the arm due to subclavian artery
obstruction.
• Due to the obstruction, blood supply to the arm is
provided by the collaterals which develop due to
reversed blood flow from the basilar artery. The
Fig. 28.22: Subclavian steal syndrome
basilar artery is formed at the base of the skull by the
joining of 2 vertebral arteries. The basilar artery
supplies blood to cerebellum, brain stem, and
occipital lobes. Thus, symptoms may be vertebrobasilar or may occur in the arm (Key Box 28.14).
• Javid test: Pressure on the common carotid artery
produces a weak radial pulse on the ipsilateral side.
• Surgical correction is by endarterectomy, a bypass
graft, or transluminal balloon angioplasty is another
alternative.
Key Box 28.14
Subclavian Steal Syndrome
It is more common on the left side
Vertebrobasilar symptoms—dizziness, vertigo, imba-
lance
Arm symptoms—fatigue, pain with exercise, para-
esthesias, coolness and heaviness on the affected side
Asymmetrical radial pulses or difference of 20 mmHg
systolic pressure between the upper limbs.
Section II • General Surgery
Upper Limb Ischaemia and Gangrene
211
1. Which of the following is usually not a feature of
Raynaud’s disease?
A. Radial artery pulsations are absent
. The upper limb is involved
B
C. Cervical sympathectomy is helpful
D. Pallor, cyanosis, and rubor are the colour changes
during the attack
2. The following are true for cervical sympathectomy
except:
A. It raises the threshold at which spasm occurs
. The entire stellate ganglion has to be removed
B
C. It is the treatment of choice in hyperhydrosis
D. Up to the 3rd thoracic ganglion has to be removed
3. Which muscle is the landmark to the thoracic outlet?
A. Scalenus anticus B. Scalenus medius
. Scalenus posterior D. Levator scapulae
C
4. The following are components of giant cell arteritis
except:
A. Severe headache is a presenting complaint
. The temporal artery is usually not involved
B
C. A biopsy from the artery reveals giant cell
granulomas
D. CD4+ T lymphocytes are found in histopathology
5. Hypertension is a common finding in the following
conditions except:
A. Polyarteritis nodosa
. Phaeochromocytoma
B
C. Polycystic disease of kidney
D. Hyperthyroidism
6. Which of the following is the treatment of choice
for cervical rib with ischaemia?
A. Excision of the rib
. Excision of the rib with cervical sympathectomy
B
C. Excision of the rib with division of the pectoralis
minor
D. Excision of the rib with division of the scalenus
anticus
7. The following are true for the subclavian artery
except:
A. A cervical rib may compress it
. It gives rise to the internal mammary artery
B
C. Post-stenotic dilatation occurs once it is compressed
by a cervical rib
D. It continues as the axillary artery at the medial
border of the first rib
8. Compression of the subclavian artery is detected by
which clinical test?
A. Froment’s sign B. Adson’s test
. Allen’s test D. Halsted test
C
9. The following are causes of splinter haemorrhages
except:
A. Bacterial endocarditis B. Cervical rib
. Scleroderma D. Aortic regurgitation
C
10. The following are true about subclavian steal
syndrome except:
A. It is more common on the left side
B
. It presents with vertebrobasilar symptoms
C. Both radial arteries are normal
D. Significant arm symptoms are present
11. The following are the causes of upper limb ischaemia
except:
A. Ergotamine alkaloids
B
. Cervical rib
C. TAO
D. Atheroma of the brachial artery
12. Which is the test to detect the dominant arterial
supply for hand circulation?
A. Froment’s sign B. Adson’s test
C
. Allen’s test D. Halsted test
13. Nicoladoni Branham sign refers to:
A. Compression causing bradycardia
B
. Compression causing tachycardia
C. Hypotension
D. Systolic filling
14. The most common cause of an acquired AV fistula is:
A. Bacterial injection B. Fungal infection
C
. Blunt trauma D. Penetrating trauma
15. Bilateral pulseless disease in the upper limbs is
caused by:
A. Aortoarteritis
. Coarctation of the aorta
B
C. Fibromuscular dysplasia
D. Buerger’s disease
Answers
1. A 2. B 3. A 4. B 5. D 6. B 7. D 8. B 9. D 10. C
11. D 12. C 13. A 14. D 15. A
Section II • General Surgery
29
Lymphatics, Lymph Vessels
and Lymphoma
Lymphoedema—anatomy and physiology
Lymphatic circulation
Primary (congenital) lymphoedema
Secondary lymphoedema (acquired)
Lymphangiography
INTRODUCTION
Lymphatics and lymph vessels play the role of draining
waste fluid from the body. Hence, they are vulnerable
to various infections. The lymphatics are connected to
a group of lymph nodes and drain into veins. Hence,
infections of the lymphatics give rise to enlarged lymph
nodes. In this chapter, significant surgical diseases
affecting the lymphatics and lymph nodes are discussed.
LYMPHOEDEMA
SU27.7: Describe pathophysiology, clinical features,
investigations and principles of management of lymphedema, lymphangitis and lymphomas.
Definition
Accumulation of lymph in the extracellular, extravascular compartment and subcutaneous tissues
resulting in enlargement of the limb. It is a protein-rich
interstitial fluid.
Hodgkin’s lymphoma
Non-Hodgkin’s lymphoma
Burkitt’s lymphoma
Sézary’s syndrome
Chyluria
Fig. 29.1: Complication of filariasis—elephant leg, elephantiasis
of scrotum and ram’s horn penis
• Elephantiasis of the penis caused by filarial organisms
produces ram’s horn penis (Fig. 29.1).
Anatomy and Physiology
Common Sites of Lymphoedema
• Lower limbs are the most common site.
• Upper limbs.
• Scrotum: Elephantiasis of the scrotum is caused by
filarial organism (Wuchereria bancrofti).
gical Anatomy of the Lymphatic System
Sur
• Lumbar trunks: Receive lymphatics from the lower
limbs
• Intestinal trunk: Receive lymphatics from the GIT
• These trunks combine to form the cisterna chyli,
which later twins into the thoracic duct (45 cm)
212
Lymphatics, Lymph Vessels and Lymphoma
213
• The thoracic duct also drains lymph from left
jugular, left subclavian, and left bronchomediastinal
trunks.
• The right lymphatic duct (1.25 cm) drains lymph from
right jugular, right subclavian, and right bronchomediastinal trunks and enters into the junction of
right IJV and subclavian veins.
• The cisterna chyli is a lymphatic channel that receives
lymphatic drainage from the lower limbs and GIT. It
is found inferior to the aortic hiatus of the diaphragm,
beyond which it continues as the thoracic duct.
Functions of the Lymphatic System
• To return protein-rich fluid to circulation through
lymphaticovenous junctions in the jugular area.
• This fluid includes water, electrolytes, and low mole-
cular weight substances such as polypeptides, growth
factors, and cytokines.
• It also includes macromolecules, such as fibrinogen,
albumin, and globulin.
• Transport of cholesterol, long chain fatty acids,
triglycerides, and fat-soluble vitamins (A, D, E, K)
by intestinal lymph into circulation. They bypass
the liver and enter circulation through the cisterna
chyli and thoracic duct into the left internal jugular
vein (lymph from lower limbs, abdomen, and left
arm).
• The right lymphatic duct drains into the right internal
jugular vein (lymph from head and right arm).
Components of the Lymphatic System
• Lymphatic channels (Fig. 29.2).
• Lymphoid organs—lymph nodes, spleen, Peyer’s
patches, thymus, tonsils.
• Circulating cells—lymphocytes and mononuclear
immune cells.
Lymphatic Circulation (Fig. 29.3)
• Lymph flow is largely due to intrinsic lymphatic con-
tractility by lymphangiomas (segment of lymphatics).
• A transient increase in interstitial pressure secondary
to exercise and limb movements also helps to a certain
extent.
• Valves prevent reflux in the lymphatics.
Types of Lymphoedema
1. Primary (congenital) lymphoedema
. Secondary lymphoedema
2
Fig. 29.3: Lymphatic circulation
Risk factors for lymphoedema (Key Box 29.1)
Key Box 29.1
Risk Factors for Lower Limb Lymphoedema
Inguinal block dissection, e.g. carcinoma penis,
melanoma
Postoperative pelvic radiotherapy
Varicose vein stripping and vein harvesting
Obesity
Fig. 29.2: Major lymphatics and lymphatic ducts
Risk Factors for Upper Limb Lymphoedema
Axillary block dissection, e.g. carcinoma breast
Radiation fibrosis, scar formation
Advanced cancer—breast with axillary lymph nodes
Obesity
Chronic infection
PRIMARY (CONGENITAL) LYMPHOEDEMA
INTRODUCTION
• Incidence is 1 in 6000 persons.
• Lymphoedema is confined to the epifascial plane.
Section II • General Surgery