Mock short written 1

Matthew Ng
Q1. A 82yo female presents to your clinic with faecal incontinence. She has T2DM,
short-distance intermittent claudication and Crohn’s disease. She has had multiple past
small bowel resections, setons placed for complex perianal fistulae, and four normal
vaginal deliveries. She ambulates with a two-wheeled frame and stops once to catch
her breath while walking in from the waiting room.
What factors are contributing to this patient’s faecal incontinence?
Faecal incontinence is often a multifactorial issue, as in this case. Contributing factors include:

- (Physiological) Stool consistency

 Looser stool is more difficult to retain
o Crohn’s disease / small bowel resections – potential short gut
 less water retention = looser stool
o Mucus in stool
o (If constipated / Obstructed defecation – then overflow)
- (Anatomical) Sphincter / pelvic floor
 Sphincter injury – stretch or interruption – can render the sphincter unable
to retain stool
o Internal anal sphincter injury
o External anal sphincter injury
o Vaginal deliveries
o Crohn’s disease-related sphincter disease
o Fistulotomies
o (Rectal prolapse)
- (Patient functional) Physical fitness / mobility
 Limited ability to make it to the toilet in time
o Age
o Comorbidities
 T2DM
 Short distance claudication
 Shortness of breath
o Slow ambulation
 2WF

How would you manage this patient?

Assessment:

- History:
o Past history as indicated above
o Incontinence history:
 Solid, liquid, or gas?
 How much? How often?
 Stress incontinence or urge incontinence
o Stool consistency - Presence of constipation / diarrhoea
o Previous interventions:
 Stool thickeners, softeners
 Stool bulking agents
  Operations, including sphincter and SNS
- Examination:
o Exclude prolapse, rectocoele,
o PR – assess sphincter tone and anal canal length
o Assess fistulae size / setons
- Investigations:
o Endoanal USS – to assess sphincter integrity
o Anal manometry – to assess sphincter strength – internal vs external
o Defecating proctogram – if suspicion of obstructed defecation (not likely given this
hx)
o Endoscopy – to exclude malignancy

Medical management

- Stool bulking agents – dietary fibre / supplementation

- Stool softeners – for constipation – Movicol, coloxyl+senna, etc
- Antimotility agents – for diarrhoea – Loperamide, codeine
- Comorbidity optimisation
o Optimisation of fitness – Cardio/respiratory, vascular optimisation
o Mobility optimisation – physiotherapy
o Crohn’s – gastroenterology assessment and consideration of infliximab if perianal
crohns disease
- Pelvic floor strengthening exercises – pelvic floor physiotherapy

Surgical management

- Likely to be inappropriate for this elderly comorbid lady

- Treatment of the issues as identified
o Sphincter issues:
 Optimisation of Crohn’s disease / perianal sepsis
 Seton changeover
 Sutured plication repair of the anal sphincters – if injury
o Prolapse:
 Perineal options
 Delorme’s vs Altemeier’s rectal prolapse surgery
 Abdominal options
 Ventral mesh rectopexy +/- resection
o Sacral nerve stimulator
 For recalcitrant cases where sphincter tone is the primary issue
 Cost issue
 Contraindicated in sepsis
o Last resort: If difficult to manage then can consider colostomy formation
 May improve quality of life
 Won’t improve Crohn’s disease
 Won’t improve stool quality
Q2. You are performing endoscopy on a 48yo M with reflux oesophagitis. He
presented initially with LA grade B oesophagitis, which has not improved despite 6
weeks of pantoprazole, 40mg bd. He is obese (BMI 38) but has no other
comorbidities.
List the ways in which gastro-oesophageal reflux disease can manifest.
Symptoms

- Asymptomatic
- (Typical) Oesophageal
o Heartburn – retrosternal burning
o Acute oesophagitis pain – sharp retrosternal
o Waterbrash / volume reflux
o Acid brash
o Dysphagia / Odynophagia
o Bleeding / anaemia
- (Atypical) Extra- oesophageal
o Respiratory – recurrent pneumonia, asthma, chronic cough
o ENT
 Chronic rhinitis / Chronic sinusitis
 Chronic otitis media / middle ear effusion
 Tonsillitis
 Pharyngitis / laryngitis
 Globus pharyngeus
o Dental erosions
o Halitosis
- Endoscopic
o Reflux oesophagitis
 Bleeding, pain, anaemia
o Benign stricture
 Schatzki ring,
 dysphagia
o Malignancy

What are your recommendations regarding management for this patient?

We should assess his reflux disease further:

- Endoscopy – currently performed

o Biopsies for H. pylori
o Assess for Barrett’s
o Exclude hiatal hernia
o Exclude
- pH monitoring if uncertain diagnosis
- Contrast swallow study
- Often will also perform manometry to exclude dysmotility disorder and failure of
progression that may present like reflux.

Treatment of GORD can be divided into lifestyle, medical and surgical options.

Lifestyle:
 - Reduction in contributing agents
o Large meals
o Alcohol
o Smoking
o Caffeine
- Weight loss
o Screen/Optimise other obesity-related complications
- Earlier night-time meals
- Remaining upright after meals for 2hrs
- Propping up end of the bed

Medical:

- PPI management
o May require uptitration if patient very obese
o Idiosyncratic response to medications - Can rotate brand / medication to other PPI
- Glycopeptide coating – eg Gaviscon
- (other options include H2Antagonist, Antacids)
- H.pylori eradication

Surgical:

- See below

What are the surgical options for management of GORD? Describe the symptomatic
outcomes, side effects, and expected effects on reflux-related disease.
Surgical options:

- Fundoplication +/- hiatal hernia repair

o Aims: to recreate a high-pressure lower oesophageal sphincter
 Hiatal hernia cruroplasty to maintain position of the lower oesophageal
sphincter
 Hiatal hernia will be added if there is an associated hiatal hernia
o Multiple variations with fundoplication
o Complete Nissen 360 degree wrap
o Incomplete posterior 180 degree, 270 degree (Toupet)
o Anterior 90 degree (Dor), 180 degree
- Improves symptoms in majority of patients
o Often incomplete resolution of symptoms
o Can usually downgrade or come off medical therapy
- Temporary duration of efficacy
o Wrap and cruroplasty stretch over time
o Expected duration of effect 10-15 years
o Re-do surgery much more difficult owing to scar
- Side effects:
o Dysphagia
 Expect abnormal swallow for 3-6 months
 Temporary reduction in dietary consistency – fluids  purees  soft diet
o Inability to burp
 Variable ability
  May be temporary
- Oesophagitis
o Should reduce the degree of inflammation
o Reduces benign stricture formation.
- Barrett’s oesophagus
o No clear association with regression
o No reduction in cancer risk
- Malignancy –
o No reduction in cancer risk

Roux-en-Y gastric bypass

- Low pressure bariatric option if patient is overweight

- BMI >35 and GORD meets criteria for bariatric procedure
Q3. A 45yo F presents to you with a left-sided thyroid nodule. She has had no
previous head/neck or thyroid surgery. Ultrasound-guided FNA returns with atypia of
uncertain significance.
What are the differentials for this finding on FNA?
Bethesda 3

- Normal thyroid tissue

- Benign
o Thyroid adenoma (eg follicular)
o Hurthle cell adenoma
o Thyroiditis – Hashimoto, Grave’s
- Malignant
o Papillary thyroid cancer
o Follicular thyroid cancer
o Hurthle cell neoplasm
o Medullary thyroid cancer
o Anaplastic thyroid cancer

How would you manage this patient?

Bethesda 3 has a 5-15% risk of malignancy, so this warrants further investigation.

Full history / Examination

- Examine lump
- Thyroid hormone excess symptoms / signs (tremor, anxiety, palpitations, heat intolerance)
- Malignancy risk factors
o Family history of thyroid cancer
o Personal history of cancer
o Head/neck radiation exposure
- Associated endocrine cancer systems
o Marfanoid appearance
o Phaeochromocytoma

Bloods

- TSH, T4/T3
- Consider calcitonin
- PTH / CMP
- Baseline general bloods – FBE / UEC / LFT /Coag

Consider TIRADS

- If high risk on TIRADS – then consider diagnostic hemithyroidectomy

Repeat USS guided FNA

- If Bethesda 2 then accept as benign and surveil

- If Bethesda 3-4 then diagnostic hemithyroidectomy
- If Bethesda 5-6 then treat as per thyroid cancer
o <1cm hemithyroidectomy
o >4cm total thyroidectomy
 o 1-4cm hemithyroidectomy or total thyroidectomy based on imaging risk factors

Preoperative vocal cord check

How would your management differ if a flexible laryngoscopy demonstrated a right-sided

vocal cord palsy?
- Left thyroidectomy carries a risk of left-sided RLN injury
- Bilateral vocal cord palsy is a rare but devastating complication of thyroid surgery
- The risk is ~3% per case, many of which are temporary

Assess cause for Right RLN palsy

- History/examination
o Past head/neck surgery, past chest surgery
o Past head/neck irradiation
- Investigations: CT Brain/ Neck / Chest to exclude tumours / lesions which may be
contributing
o Intracranial lesions
o Carotid sheath tumours – carotid body, glomus, schwannomas of the vagus
o Pancoast tumour

If cause found then address the cause

If no cause found then:

- Confirm right RLN palsy present and persistent (repeat flexible laryngoscopy)
- Higher threshold to perform thyroidectomy
- Preoperative MDT to ensure unit consensus
- Bethesda 5/6 still require thyroidectomy
- Bethesda 3-4 more likely to pursue multiple repeat FNA biopsy and/or observation
o Note 5-15% risk for malignancy in Bethesda 3, 15-30% in Bethesda 4
o 3% RLN risk
 Surveillance – serial USS 3-6 months + clinical examination
 Rapid growth / ETE  repeat FNA or diagnostic hemithyroidectomy
- Bethesda 1-2 not proceeding to thyroidectomy anyway

Intraoperative precautions:

- NIM monitoring – Check signal at start of case via vagus stimulation

- Positive identification of RLN including any branches
- Bipolar forcep dissection to minimise heat transfer
- Superior pole first technique
- Check nerve monitor at end of case
o If signal loss then confirm loss of transmission with laryngeal palpation
o If confirmed loss of transmission then treat as bilateral nerve palsy

Postoperative

- Potential bilateral nerve palsy

- Decide with anaesthetist based on staffing / ICU
o Trial of extubation on table
o Delayed trial of extubation in OT in 48hrs with surgeon on standby for tracheostomy
 - Referral to ENT service for monitoring and consideration of delayed definitive management
o Medialisation and posterior vocal cordotomy for airway

If larynx appears intact

- Close postoperative monitoring in HDU

- Early flexible laryngoscopy upon awakening to confirm cord mobility
Q4. A25yo M presents with a pilonidal abscess. He has two episodes of pilonidal
abscess in the last 2 years, managed with simple incision and drainage.
How would you manage this acute episode?
Resuscitation – ABCDE per CCrISP protocol

Antibiotics initially – Augmentin Duo Forte 875/125mg bd initially

Acute pilonidal abscess requires incision and drainage for sepsis control

- GA, lateral position, prep/drape

- Laterally placed incision
- Clearance of any inspissated hair
- Washout of abscess cavity
- Temporary packing

What are the options for definitive management of pilonidal sinus disease?
Nonsurgical

- Shaving / laser / depilation of hair in the natal cleft

Conservative

o For simple disease

- Pit-picking
- Tract ablation / Cautery procedures

Surgical

- Excision of natal cleft and primary closure

o For simple disease
- Excision of natal cleft and healing by secondary intention
- Excision of natal cleft with flap repair closure
o Karydakis
o Limberg flap (Rhomboid)
- Minimal excision surgery – Bascom’s cleft-lift

How do you minimise the chance of disease recurrence when performing definitive
management of pilonidal sinus disease?
Preoperative

- Treatment of any sepsis with incision/drainage

- Imaging to define extent of complex disease (MRI)
- Optimisation of comorbidities

Operative

- Eradicate disease
o Excision of all pilonidal sinus tracts en-bloc
- Minimise contamination
o Removal of all hair in the area
o Alcoholic preparation solution
 o Adhesive drapes
- Well-vascularised tissue
- Off-midline closure
- Dissolving sutures (avoid pit reformation at suture entry points)
- Flattening of the natal cleft – any technique above
- Drains – not shown to reduce wound infection or recurrence rates

Postoperative

- Meticulous cleaning
- Removal of all hair from the area until completely healed
- Surveillance
Q5. A 68yoM farmer presents with a 23mm scaly lesion on his right cheek. He has no
other medical or surgical history. Punch biopsy reveals a squamous cell carcinoma.
What is the recommended management for this lesion?
- History / examination
o Previous skin cancer resection
o Identify other skin lesions
o Exclude locoregional or distant spread
 Cervical LN / virchow’s node
o Risk factors for recurrence
 Immunosuppression
 Previous radiation therapy
- 23mm is high-risk for metastatic disease
o Also higher risk of metastasis based on location on head/neck
o Exclude lymph node metastasis + Virchow’s node
o If present, then PET staging to exclude distant spread
o Discussion in MDT
- Main specimen resection:
o 1cm margin ideally
o Taken en-bloc down to underlying fascia
o Closure with flap / graft given size of defect
o Consideration of Moh’s surgery
- If distant metastasis –
o Treatment palliative
o Resection + chemotherapy + radiation therapy
- If nodal disease, but no distant metastasis:
o Treatment potentially curative
o Resection of disease + modified radical cervical lymph node dissection +
chemotherapy+radiation therapy
- If no clinical nodal disease
o Treatment likely curative
o Resection of disease
o Add sentinel node biopsy to exclude nodal metastasis.

What factors are associated with increased risk for distant spread?
- Lesion:
o T stage
o
o Size >2cm
o Location on head/neck
o Depth >6mm
o Poorly differentiated disease
o Recurrent disease
o Perineural invasion / Nerve symptoms
o Lymphovascular invasion
o Nodal spread
 o Marjolin’s ulcer (in area of previous scars
- Patient factors:
o Immunosuppression
o Poor self-care / delayed recognition
- Operative factors
o Positive margins / inadequate margins

What is the role for radiotherapy in SCC of the skin?

Radiotherapy has a role as adjuvant therapy for cutaneous SCC

- Post-resection for high-risk disease

o Large >2cm radial >6mm depth
o LVI / PNI
o Poorly differentiate
o Concern re potential for spread
o Close margins that cannot be further excised
- Adjuvant post-lymphadenopathy
- Or as delayed salvage adjuvant therapy for local recurrence

Palliative treatment:

- For control of local recurrence

- Bleeding
- Pain / neurological symptoms
- Definitive control for oligometastatic disease

Cautions:

- Maximal lifetime dose of radiation

- Potential to cause issues in certain areas – eg glaucoma
Q6. A 35yoM, previously fit and healthy, presents with sudden onset acute epigastric
pain. He is febrile (T38.1), tachycardic (HR140) and hypotensive (BP 85/40).
Examination reveals generalised peritonism, and you believe he has a perforated
peptic ulcer, secondary to chronic NSAID use.
He is a recent traveller from a COVID19 hotspot, and has a 5 day history of coryzal
symptoms.
Describe how you would manage this patient.
Perforated peptic ulcer

- Full COVID PPE

- Resuscitation / CCrISP protocol
o Airway
o Breathing
o CDE
o 2x largebore IV cannula
o Fluid resuscitation targeted to euvolaemia and good urine output 0.5-1ml/kg/hr
- History/Examination
- IV antibiotics
o Ceftriaxone / metronidazole
- PPI -80mg IV BD
- CXR
- Bloods – FBE / UEC / LFT / CRP / Lactate / Coag
- NBM / NGT decompression
- ICU/HDU referral – potentially may require vasopressor supports postoperatively
- Negative pressure room

Generalised peritonitis and septic shock is a contraindication to conservative management of

perforated peptic ulcer

- Exploratory laparotomy
- Washout and drains
- Closure / reconstruction of perforation as appropriate

How does his COVID19 risk alter your management?

- Patients should be managed as a high-risk suspected COVID patient
o placed in droplet and contact precautions
o COVID swab on arrival
o NGT insertion is a high-risk procedure and may be postponed until in theatre post
intubation
o CXR may be mobile rather than in-department to minimise cross-contamination.
- Patient with generalised peritonitis and septic shock should be managed as an emergency
case
o Decision to be made in conjunction with anaesthetic team and COVID/ID team
o No delay to theatre
o COVID confers a high perioperative mortality (40%+)
- Intubation / AGP under full precautions (N95 / face shield / Gown +gloves)
- Operation under full precautions (N95 / face shield / Gown+gloves)
o Covid safe theatre setup
  Doff on / doff out
 Second anaesthetic team on standby
 Second scout nurse as external courier
- Extubation / AGP under full precautions
- Manage in ward as suspected COVID with COVID precautions for care, until the swab returns
negative
- Monitor for upper respiratory tract signs/symptoms and reswab / reinstate COVID
precautions if symptoms arise

When are staff most at risk of COVID19 transmission, and how should this risk be
minimised?
- Aerosol generating procedures
o Intubation/extubation
o Suction of aerodigestive tract
o NGT insertion
o Nebuliser
 Ambulance
 ED
 Anaesthetics
 Surgeons
- Whilst doffing PPE
- Risk minimisation
o Minimise use of AGP
o Full COVID precautions – N95 / Faceshield / Gown/Gloves +/- oversuit
 Intubating teams may elect to utilise Pressurised air-purifying respirators
o Single room
 Droplet + contact aprecautions
 Minimise staff / family visitation
o Doffing protocol
 Gown /gloves first
 Hand hygiene
 Face shield
 Hand hygiene
 N95 mask
 Hand hygiene
 New mask
o Minimising staff and duration of exposure
 Minimal staff in procedures
 Limit trainee exposures to the procedures / visitation
 Most experienced member for most expeditious procedure
 Anaesthetists
 Anaesthetic nurse
 Scrub/scout
Q7. A 20yo M is referred to you with bilateral breast enlargement. Ultrasound and
mammogram demonstrate no discrete breast mass.
What are the causes for gynaecomastia?
- Physiological
o Physiological oestrogen production
o Neonatal
o Pubertal 10-16yo
o Elderly >60yo
- Pathological
o Increased oestrogen production
 Hepatocellular carcinoma
 Testicular tumour
 Obesity
o Decreased oestrogen degradation
 Cirrhosis / liver failure
 Haemochromatosis
 Wilson’s
 Hep B/C
 Alcoholic liver disease
o Decreased testosterone production
 Klinefelter’s
 Cryptorchidism
 Mumps
 Irradiation / hypopituitarism
o Hyperthyroidism – Increased testosterone/oestrogen  reduction peripherally 
oestrogen>testosterone
o Hypothyroidism – reduced testosterone
- Pharmacological
o HRT / OCP use
o Antipsychotics Valproate, tricyclic antidepressants.
o Testosterone suppression eg prostate medications (Dutaseteride)
o Spironolactone
o Cannabis / heroin
- Idiopathic 25%
- Pseudogynaecomastia – fat pad in obese men

What investigations would you arrange for this patient?

- USS / MMG of breast -already done
- FBE / UEC
- LFT
- TSH (+/- T4/T3)
- Alpha fetoprotein
- Beta HCG
- Prolactin
- FSH/LH
- Oestrogen, testosterone
- Drug history
 - Clinical examination of testicles

His serum B-HCG is elevated. How would you manage this finding?
Suspicion for testicular cancer

o (Germ cell tumour – either gonadal or extragonadal)

 Seminoma
 High-grade choriocarcinoma
 Teratoma
- Re-examination of testicles
- USS testicles to identify testicular cancer
- Consider referral to urology
- If urology unavailable, and suspicious testicular lesion identified, then
o Inguinal orchidectomy
o High ligation of spermatic cord
o Testicle and spermatic cord taken with lymphatics and sent for histology
- MDT
- Adjuvant chemotherapy
Q8. A 48yo F presents to you acutely jaundiced with mild epigastric discomfort.
2 years ago she underwent a bariatric Roux-enY gastric bypass surgery.
Ultrasound demonstrates gallstones in the gallbladder with a CBD diameter of 11
mm.
What are your options for biliary decompression?
- Laparoscopic cholecystectomy + transcystic CBD exploration
- Open cholecystectomy + transcystic CBD exploration
- CBDE without cholecystectomy
- PTC + biliary drain insertion
- ERCP / stone trawl
o Will be difficult post RYGB with long limbs
o Can be performed via gastric remnant
- Percutaneous transjejunal cholangiogram
o If the jejunal stump was brought to the abdominal wall as an access limb

You decide to perform a laparoscopic cholecystectomy. There is a stone impacted in the

gallbladder neck with obliteration of the hepatocystic triangle.

What is the grading of this condition, and what is the operative management for each grade of
disease?
Mirizzi Syndrome

- Grade 1 – extrinsic compression of CHD

o Treat with careful cholecystectomy
o Low threshold to involve HPB or subtotal cholecystectomy if dissection difficult
o Biliary stenting preop if possible to keep the system open
- Grade 2 – Impaction at neck, CHD/CBD tissue loss <1/3 circumference
o Likely to require reconstruction or resection
o Stent for decompression and refer to HPB surgeon
 Possible to repair over T tube, or choledochoplasty using GB tissue
- Grade 3 – Impaction at neck, CHD/CBD tissue loss 1/3-2/3 circumference
o Likely to require resection
o Stent for decompression and refer to HPB surgeon
 Operation of choice is bile duct excision and hepatico-jejunostomy
- Grade 4 – Impaction at neck, CBD/CBD tissue loss >2/3 circumference
o Likely to require resection
o Stent for decompression and refer to HPB surgeon
 Operation of choice is bile duct excision and hepatico-jejunostomy
- Grade 5 – Cholecystoenteric fistulation
o Need to exclude gallstone ileus
o Often the biliary system is already decompressed via fistula
o Will require subspecialist input – referral to HPB for consideration of repair