SPOT QUESTIONS 4

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• SPOT QUESTIONS 4
• (Sept 2004)?

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Q1 Specimen of large resected thyroid. 1.
Diagnosis 2. Pathology 3. Complications of
disease 4. 5 specific complications of total
thyroidectomy
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Q2 Cut section of thyroid gland with nodule
history of young girl with family history of
thyroid cancer 1. Diagnosis 2. What would congo
red stain show? 3. Pre-operative investigations
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• Q3
• Ascending colon cut specimen
• 1. Diagnosis
• 2. Symptoms
• 3. Prognosis according to specimen findings

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Q4 Cut section of adrenal gland history of HT
and adrenal medullary tumour 1. Diagnosis 2.
Symptoms 3. Pre-operative work-up
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Q5 Hand with wasted thenar eminence muscles 1.
Diagnosis 2. Typical symptoms 3. Treatment
options
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Q6 History of multiple colonic polyps 1.
Diagnosis 2. Classification 3. Two specific
complications of resection 4. Other treatments
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Specimen of large resected thyroid. 1.
Diagnosis 2. Pathology 3. Complications of
disease 4. 5 specific complications of total
thyroidectomy
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• Multinodular goitre. May be non-toxic or with
  thyrotoxicosis (toxic MNG or Plummer disease).
  May contain foci of thyroid carcinoma (eg
  papillary cell or follicular cell)?
• MACRO asymmetrically enlarged, irregular cystic
  nodularity of gland associated with focal
  haemorrhage MICRO variable degree of
  colloid accumulation, follicular epithelial
  hyperplasia, and follicular involution with focal
  intervening areas of fibrosis, calcification and
  haemorrhage. PATHOGENESIS Repeated episodes
  of hyperplasia, nodule formation, degeneration
  (involution) and fibrosis. It occurs either in
  response to iodine deficiency or else, in
  iodine-replete areas, as the result of intrinsic
  heterogeneity of TSH receptors. MNG has a high
  familial incidence.
• Pressure effects oesophageal compression with
  dysphagia, tracheal compression, obstruction of
  superior vena cava, recurrent laryngeal nerve
  palsy. Cosmetic deformity. Bleed into nodule may
  cause pain or more importantly acute tracheal
  compression (especially retrosternal). Functional
  effects thyrotoxicosis tachycardia, CHF, AF,
  rarely hypothyroidism. May harbour malignancy.

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• Complications of surgery
• Recurrent laryngeal nerve injury (lt1 permanent,
  up to 5 temporary)?
• External laryngeal nerve injury
• Hypoparathyroidism ie hypocalcaemia (1-3
  permanent, 5-10 temporary)?
• Bleeding (5)?
• Wound infection, dehiscience, suture granuloma,
  keloid/unsightly scar
• Laryngeal oedema, tracheal malacia, need for
  tracheostomy
• Recurrent MNG or hyperthyroidism (5 in Graves'
  disease)?
• Need for life-long thyroxine medication

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Cut section of thyroid gland with nodule
history of young girl with family history of
thyroid cancer 1. Diagnosis 2. What would congo
red stain show? 3. Pre-operative investigations
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• Familial Medullary thyroid cancer. Arise from
  parafollicular C cells ultimobranchial body
  origin. RET proto-oncogene mutation (Chr10q).
  Rearrangement gene after irradiation ? papillary
  thyroid Ca
• Medullary thyroid carcinomas contain amyloid
  depositis, derived from altered calcitonin
  molecules. This amyloid turns salmon-red with
  Congo red, and there is yellow-green
  birefringence in polarized light.
• FNA cytology thyroid lesion under USS guidance.
  Serum calcitonin levels /- CEA. Staging USS or
  CT SCAN of neck and chest x-ray. In MEN need to
  exclude phaeochromocytoma (50) and parathyroid
  hyperplasia (80, but lt20 have hypercalcaemia).
  Familial medullary carcinoma may be
  isolated or occur with phaeochromocytoma often
  bilateral and hyperparathyroidism (MEN IIA). It
  may also occur with or without marfanoid habitus,
  multiple neuromas, and ganglioneuromatosis (MEN
  IIB). Hirschsprung's disease and lichen planus
  amyloidosis also occur in patients with familial
  medullary cancer.

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Ascending colon cut specimen 1. Diagnosis 2.
Symptoms 3. Prognosis according to specimen
findings
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• Ascending colon carcinoma (likely
  adenocarcinoma)?. ? Involving ileocaecal valve.
• Asymptomatic, lethargy, fatigue, weakness, weight
  loss, abdominal pain/discomfort (persistent,
  sometimes postprandial), abdominal mass, altered
  bowel function (rarely), obstruction (involving
  IC valve), appendicitis. Iron deficiency anaemia
  and positive faecal occult blood often first
  indication.
• Tumour extending beyond muscularis propria. ? LN
  status.
• Prognosis according to clinicopathological stage
  (TNM stage). Overall 50 5yr survival.
• TNM Stage I 80-95 Stage II 60-90 Stage III
  30-55 Stage IV 0-10
• Dukes Stage A 90 B 60 C 30 Distant METS 10
• Poor prognostic markers ve margins, apical LN
  involvement, perforation, obstruction, mucinous,
  poorly differentiated, vascular invasion,
  associated adenomas

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Colonic TNM

• T1 invades, no through, submucosa
• T2 invades not through, muscularis propria
• T3 invades not through, serosa, or through into
  non-peritonealized pericolic tissue
• T4 perforated peritoneum or invades adjacent
  structure
• N1 3 or less nodes
• N2 4 or more nodes
• N3 nodes along named vascular trunk
• M1 distant METS

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Cut section of adrenal gland history of HT,
palpitations and tremor 1. Diagnosis 2. Other
symptoms 3. Pre-operative work-up
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• Phaeochromocytoma benign or mailgnant
• Asymptomatic. Classically, episodic hypertension
  associated with triad of palpitations, headache
  and sweating. May also complain of anxiety
  (impending doom sensation), tremors, weight
  loss, dizziness, nausea and vomiting, abdominal
  discomfort, constipation, psychosis and visual
  blurring. Some patients have diarrhoea (due to
  VIP). Crisis precipitated by trauma or surgery.
• Diagnostic the best (and usually only test) is
  to measure fractionated 24hr urinary
  catecholamines and metanephrines. Measuring
  plasma free metanephrines is 97-100 sensitive
  and 85-95 specific. (Provocative tests using
  glucagon, histamine, or tyramine are not
  accurate and are potentially dangerous. Clonidine
  suppression tests are rarely used). Localisation
  Contrast-enhanced MDCT ABDO scan. MRI avoids
  radiation exposure and has characteristic bright
  appearance on T2 phase. MIBG may be helpful for
  localising extra-adrenal pheochromocytomas.
  Routine bloods (include Ca PO4), CXR, ECG.

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• Malignant HISTO features none, diagnosis is
  based on presence of metastases. METS to regional
  LN, liver, lung, bone.
• Familial syndromes with phaeochromocytomas
• MEN IIA and IIB
• Von Hippel-Lindau
• Von Recklinghausen
• Sturge-Weber

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Hand with wasted thenar eminence muscles 1.
Diagnosis 2. Typical symptoms 3. Treatment
options
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• Wasting of thenar eminence muscles from
  prolonged median nerve compression (carpal
  tunnel, supracondylar entrapment, cubital fossa
  entrapment, anterior interosseus nerve
  entrapment)?
• Principle clinical features are pain (burning or
  aching), numbness and tingling in median nerve
  distribution of hand (sparing palmar branch given
  off higher up). Symptoms are particularly worse
  after repetitious movement and at night, and on
  awakening the patient has to shake the hand to
  obtain relief. Patient often states hand feels
  clumsy, but with no specific weakness.
• Treatment conservative and operative (indicated
  here with thenar atrophy)?
• Non-surgical (includes treat underlying causes)
• Splint, wrist support for keyboard operators,
  modify activity, night splints, physiotherapy,
  anti-inflammatories, hydrocortisone injection,
  diuretics

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• Surgical
• Indications
• Persistent and progressive signs and symptoms
• Thenar atrophy
• Non-operative therapy failure
• Inability to perform job/daily activity
• Perform complete carpal tunnel release (open or
  laparoscopic)? under regional or general
  anaesthesia. Post-operative splinting then
  rehabilitation programme.

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• Causes (ARMPIT NAD)
• Acromegaly
• Rheumatoid arthritis
• Myxoedema
• Pregnancy
• Idiopathic
• Trauma (occupational)?
• Neoplasia
• Amyloidosis
• Diabetes
• Clinical assessment Symptoms, dysfunction. LOOK,
  sensory 2 point vibration, motor, provocative
  tests Tinel (pressing/tapping nerve), Phalen
  (prolonged wrist flexion), Carpal compression.

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History of multiple colonic polyps 1.
Diagnosis 2. Classification 3. Two specific
complications of resection 4. Other treatments
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• Large retroperitoneal tumour obliterating
  mesocolon. Likely desmoid tumour given probable
  FAP background. Differential malignant fibrous
  histiocytoma, liposarcoma, leiomyosarcoma,
  rhabdomyosarcoma, myxofibrosarcoma
• May behave benignly or aggressively. Divided into
  extra-abdominal, abdominal and intra-abdominal.
  Extra-abdominal occur principally in muscles of
  shoulder, chest wall, back and thigh. Abdominal
  desmoids generally in anterior ABDO
  musculoaponeurotic structures in women during or
  after pregnancy. Intra-ABDO desmoids tend to
  occur in mesentery or pelvic walls, often in
  patients with FAP (Gardner syndrome). A locally
  invasive non-metastasizing tumour that occurs in
  the mesentery or abdominal wall. These
  deep-seated fibromatoses lie in interface between
  exuberant fibrous proliferations and low-grade
  fibrosarcomas. Occur at any age, most frequently
  in teens to thirties.
• Local recurrence frequent and persistent when
  incompletely excised, anastomotic leak, ischaemic
  intestine
• Tamoxifen, NSAIDs, chemotherapy, radiotherapy

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Q7 1. Differential diagnosis 2. What features
on examination would you want to know? 3. How
would you manage?
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Q8 1. Diagnosis 2. Differential 3. Key points
on operation to remove
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Q9 Blunt ABDO trauma. 1. Diagnosis 2.
Classification of severity 3. Treatment options
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Q10 Intra-op photo of pancreatico-jejunal
anastomosis 1. What does this photo show? 2.
How else can you anastomose pancreas? 3. How can
you prevent the anastomosis shown from leaking?
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Q11 IOC finding 1. Diagnosis 2. Classification 3.
Treatment
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• Q12
• Previously healthy 12-year-old boy
• 1. Diagnosis
• 2. Natural history
• 3. Complications
• 4. Surveillance

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Photo of hand with ulcer on it 1. Differential
diagnosis 2. What features on examination would
you want to know? 3. How would you manage?
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• Benign inflammatory - ulcerated psoriasis,
  pyoderma gangrenosum infective fungal
  vascular ischaemic, vasculitic traumatic
  burn, infected graze Malignant SCC,
  in-situ SCC, Paget's disease, superficial
  multicentric BCC, amelanotic melanoma, Merkel
  cell.
• Painful/painless, size, depth, fixed/mobile/adhere
  nt to underlying tendons, distal nerve function
  and limb pulses, margins for excision/proximity
  to joint creases, associated infection
  cellulitis, lymphadenopathy, other possible
  neoplastic lesions.
• Malignant (likely) Punch biopsy to confirm
  histological diagnosis. Treat infection. Will
  then require complete excision with minimum 1cm
  margins. Full-thickness skin graft if overlying
  joint crease (from radial aspect distal forearm
  or retro-auricular or sternal depending on size),
  otherwise SSG from upper inner arm or
  thigh. Benign debride, dressings,
  antibiotics, anti-fungals, steroids

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Photo of mid-line neck lump 1. Diagnosis 2.
Differential 3. Key points on operation to
remove
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• Thyroglossal duct cyst.
• Differential lipoma, dermoid cyst, epidermal
  cyst, lymphadenitis, enlarged Delphic node with
  thyroid malignancy, enlargement of or neoplasia
  within thyroid pyramidal lobe, ectopic thyroid
  gland, thyroglossal duct carcinoma (arising
  within aberrant thyroid tissue, rare lt1)?
• Exclude lingual thyroid or thyroid pyramidal
  neoplasia. Resection with total excision of the
  cyst, the central hyoid bone and the entire
  fistulous tract extending to the foramen cecum,
  is mandatory for cure. This Sistrunk procedure
  has low recurrence rates (5). Avoid perforation
  of cyst. Meticulous haemostasis as wound
  haemorrhage may result in airway compromise.

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Transverse incision over cyst. Dissect cyst from
surronding structures. Divide sternohyoid
thryohyoid muscles at their insertion to expose
hyoid bone. Encircle hyoid bone with right angle
clamp 1cm from mid-point then divide with bone
cutter or cautery. Traction on divided hyoid to
help division of opposite side. Dissection
proceeds cephalad to the foramen caecum where
the tract and investing tissues are
suture-ligated.
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Blunt ABDO trauma. 1. Diagnosis 2.
Classification of severity 3. Treatment options
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• Splenic injury (Grade IV with devascularization,
  query contrast leakage posteromedially)?
• AAST Classification

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• Management
• Unstable or laparotomy for associated injuries ?
  splenic preservation where feasible, low
  threshold for splenectomy
• Interventional radiology with embolization
• Stable ? conservative, close observation
• 60 adults managed non-operatively with 80
  success (90 with children)?
• Most failure occur in 72 hrs but may occur at 2
  weeks. Risk of delayed re-bleed after NOM is
  1-8.
• Failure factors (increase grade (IV), contrast
  leak, age gt 55 yrs, degree of haemoperitoneum)?

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• Criteria for Non-op Management of Splenic Injury
• No indications for laparotomy (e.g. perforated
  viscous)?
• Hemodynamically normal after resus with
  crystalloid
• No injuries that preclude physical examination
  of the abdomen (e.g. significant brain injury,
  spinal cord injury)?
• Transfusion requirement lt3-4units/24 hour
  (PRBC)?
• Constant availability of surgical and critical
  care resources
• Advantages of NOM
• Avoidance of non-therapeutic laparotomies (with
  assoc cost morbidity)?
• Fewer intra-ABDO complications
• Reduced transfusion risk

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• Criteria for Failure of Non-op Management (from
  DSTC)?
• Haemodynamic instability
• Evidence of continued splenic haemorrhage
• Associated intra-abdominal injury requiring
  surgery
• Replacement of gt 50 patients blood volume
• Other
• Failed angio embolization of A-V
  fistulae/pseudoaneurysm
• Peritoneal signs/rebound tenderness

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Intra-op photo of pancreatico-jejunal
anastomosis (end to side)? 1. What does this
photo show? 2. How else can you anastomose
pancreas? 3. How can you prevent the anastomosis
shown from leaking?
A two-layer, end-to-side, duct-to-mucosa
retrocolic pancreaticojejunostomy
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• Pancreatico-jejunal end-to-side anastomosis
  likely post Whipples resection. A hand-sewn,
  two-layer, end-to-side, duct-to-mucosa retrocolic
  pancreaticojejunostomy.
• Pancreaticojejunostomy either end-to-side
  (including capsule to mucosa), end-to-end
  (two-layer invaginating, binding sleeve),
  end-to-end separate Roux loop to
  hepaticojejunostomy pancreaticogastrostomy
  end-to-side. With or without stent. Longitudinal
  panreaticojejunostomy /- limited pancreatic
  resection modified Puestow or Frey procedure or
  Beger procedure
• Well vascularized, tension free, technically
  secure anastomosis. Anastomosis by experienced
  pancreatic surgeon. Trans-anastomotic stent and a
  separate Roux loop. Meticulous haemostasis around
  anastomosis. Post-operative octreotide 100mcg Q8H
  iv will reduce consequence of minor leakage.
  Peri-anastomotic drain. No significant difference
  leak rate with fast-track reinstitution of
  enteral feeding.

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IOC showing choledochal cyst 1. Diagnosis 2.
Classification 3. Treatment
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• Todani classification (1977) according to site
  and shape
• Type 1 fusiform or saccular extra-hepatic
• Type 2 isolated protrusion or diverticular
  outpouching CBD
• Type 3 choledochocele with wide-mouth dilation
  CBD at confluence with the duodenum
• Type 4 intra- and extra-hepatic ducts. 4a
  multiple intra- and extra-hepatic, 4b multiple
  extra-hepatic.
• Type 5 multiple intra-hepatic with hepatic
  fibrosis (Caroli's)
• 85 are either types 1 or 4.
• Treatment
• Complete excision with roux-en-Y
  hepaticojejunostomy and simultaneous
  cholecystectomy
• Type III consider ERCP/Sx, Type II consider
  diverticulectomy
• LFTS CA19-9 six monthly, MRCP annually

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1. Diagnosis 2. Natural history 3.
Complications 4. Surveillance
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• Peutz-Jeghers syndrome with jejuno-jejunal
  intussusception
• An autosomal dominant disorder with high degree
  of penetrance. Tumour suppressor gene STK11
  (Chr19) is implicated in many. Characterized by
  the development of multiple hamartomatous
  gastrointestinal polyps, mucocutaneous pigmented
  lesions on the lips or buccal mucosa, and an
  increased risk of cancer within (gastric,
  intestinal, rectal) and outside the
  gastrointestinal tract (pancreatic, biliary,
  lung, breast, cervix fallopian tube,
  ovary/testis).
• Hamartoma A tumour-like, non-neoplastic
  disordered proliferation of mature tissues that
  are native to the site of origin
• Hamartomatous GI polyps may cause GI obstruction
  or intussusception as in this case. GI bleeding
  occult or overt. Adenomatous change occurs in
  3-6 of hamartomas. 20 life-time risk CRC, 5
  gastric.

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• - Annual upper and biannual lower endoscopy.
  Remove all polyps gt15mm size.
• Small bowel imaging every 2-3 years (? MRI)?
• Cervical smears. Breast screening. Testicular
  self annual physician examination.