2020 Surgery test for foreign students

(Total score 100 marks)

1. Term explanation (total 40, 5 marks each)
1）Barrett’s esophagus
Definition : Barrett’s esophagus is a condition in which tissue that is similar to the
lining of your intestine replaces the tissue lining your esophagus. Doctors call this
process intestinal metaplasia.

Upper GI endoscopy and biopsy

endoscope to see inside your upper GI tract,
a biopsy with the endoscope by taking a small piece of tissue from the lining of
your esophagus.

in endoscopic mucosal resection, your doctor lifts the Barrett’s tissue, injects a
solution underneath or applies suction to the tissue, and then cuts the tissue off.
The doctor then removes the tissue with an
endoscope. Gastroenterologists perform this procedure at certain hospitals and

outpatient centers

Surgery. Surgery called esophagectomy is an alternative to endoscopic therapies. Many

doctors prefer endoscopic therapies because these procedures have fewer
complications. Esophagectomy is the surgical removal of the affected sections of
your esophagus.

2）Early gastric cancer

  Surgery (Early or Advanced Cancer)

 Sub-total or partial gasterectomy: Distal tumours which involve the lower ½,

 Total gasterectomy: Proximal tumours which involve the fundus, cardia or
body.
 Inoperable tumors: Whenever possible it is advisable to do even a limited gastric
resection. If resection is impossible an anterior gastrojejunostomy is done.
 Chemotherapy for gastric cancer (Pre-operative & post-operative)
 Radiotherapy (Pre-intra & post-operatively)

3）Flail chest

.
A flail chest occurs when a segment of the rib cage breaks under extreme stress and
becomes detached from the rest of the chest wall. 
1. Management Intubation & Ventilation. Rarely indicated Indicated for hypoxia
due to pulm. contusions. Double lumen tracheal tube. each lumen connected
to a different ventilator. each lung may require drastically different pressures
and flows to adequately ventilate.
2. Management Chest Tube Insertion To treat hemothorax To treat
pneumothorax
– Management Rib Fracture Fixation Usually not required Preferred choice before
intubation & ventilation
surgical stabilization of a flail chest is performed under general anesthesia with a
double lumen endotracheal tube in order to obtain a selective pulmonary exclusion that
allows exploration of the pleural cavity and lung parenchyma.

4）Horner’s syndrome
The treatment of Horner syndrome depends on the location and cause of the lesion or
tumor. In some cases surgical removal of the lesion or growth may be appropriate.
Radiation and chemotherapy may be beneficial to patients with malignant tumors.
5）Acepsis
6）Glasgow coma scale
7）Tumor
8）Surgical infection
2. Giving short-answers to following questions. (total 60, 10 marks each)
1) How many examinations should be done for the patient with brian
tumor?
History
Physical examination
Auxiliary examination :
CT (Computed tomography);
MRI (Magnetic Resonance Imaging);
DSA( Digital Subtraction Angiography);
EEG (Electroencephalogram)

DIAGNOSIS
Clinical Diagnosis or history•
A clinical diagnosis consist of information the physician gathers during a
comprehensive examination. • Medical History including the specific nature of S&S •

Neurological Examination or physical examination

- Testing of reflexes & assess visual, cognitive, sensory, and motor function. • Doctor
also examines your eyes to look for swelling caused by a tumor pressing on the
nerve that connects the eye and brain. • After clinical diagnosis suspects the tumor
the next diagnostic step is Tumor Imaging
Radiological Diagnosis • The modern era of CNS imaging began with the introduction
of CT in 1973 & with MRI in 1979. • The availability of sensitive imaging allows for
earlier tumor detection and has revolutionised the diagnosis and management of
brain tumors. • Tumor Imaging are classified into 3 categories : • Static Imaging •
Dynamic Imaging • Computer Integration Imaging
Static Imaging.... • Static neurological imaging includes CT and MRI, which are
noninvasive techniques that provide accurate anatomical and functional analysis of
intracranial structures. CT Scan : • CT uses ionizing radiation, thin bands of x-rays, to
produce images of slices of brain tissue. • It was the first brain imaging technique to
allow determination of tumor size. • Contrast enhancement helps to identify isodense
tumor from surrounding parenchyma, hypodense lesions in edematous areas, and
optimal sites for tumor biopsy.
• After surgical intervention, CT can be used to confirm the proper tissue biopsy site
and determine the success of tumor resection. • Although MRI has become the
preferred method, CT scanning offers lower cost, a shorter scanning time, and a
more sensitive method to detect calcification and bony involvement.
Magnetic Resonance Imaging : •MRI is the imaging procedure of choice •MRI uses
magnetic fields •MRI is superior to CTin detecting & localizing tumor as well as
evaluating edema, hydrocephalus or hemorrhage. •MRI is more sensitive imaging
modality •Contrast enhancement with gadolinium sharpens the definition of lesion •
MRI enhanced with gadolinium can distinguish between edema and tumor • Not all
high grade astrocytoma enhance with gadolinium , and MRI may imitate
abnormalities seen in low grade astrocytomas • MRI also cannot accurately predict
tumor typeor grade of malignancy, for which biopsy is
Dynamic Imaging.... It includes : • Positron emission tomography (PET) • Single
photon emission CT (SPECT) • Magnetic Resonance Spectroscopy (MRS) •
Functional MRI PET Scan : • It is non-invasive and uses cyclotron and specific
isotopes to obtain info about metabolism and physiology of the tumor and
surrounding tissue. • It uses radioactive markers to measure glucose metabolism
which is useful to determine the grade of primary brain tumor. It also helps in study of
metabolic effect of chemotherrapy, Radiation therapy and steroids on the tumor. • It is
expensive & less reliable in patient with heavy dose of chemo therapy
SPECT Scan : •It is functional imaging technique evolved from PET scan & uses
isotopes w/o cyclotron to assess cerebral blood flow and determining tumor location.
•It is used to identify high- & low- grade tumor to differentiate between tumor
recurrence and radiation necrosis. •It is used pre-op with static imaging to localize
highest metabolic area of tumor for biopsy. • SPECT is less sensitive method to
obtain physiological information on tumors. • It is more readily available and less
expensive.
Magnetic Resonance Spectroscopy : •It is a non-invasive technique used in
conjunction with static MRI to measure the metabolism of brain tumors. •It has been
proved to differentiate successfully normal brain from malignant tumor and recurrent
tumor from radiation necrosis. •It also has been used to document early treatment
response and provide information regarding histological grade of astrocytomas. •
Magnetic resonance angiography (MRA) generates images of blood vessels without
 dye or ionizing radiation to evaluate the blood flow and position of vessels leading to
the brain tumor.
Functional Magnetic Resonance Imaging : •It uses a conventional MRI scanner fitted
with echo planar technology to map cerebral blood flow at the capillary level. •Its
intended purpose is to provide information regarding the diffusion of contrast into
tumor, resulting in better resolution of tumor and edema. • It can also be used to
identify the motor, sensory, and language areas of the brain or the functional
eloquent cortex.
Computed Integration Imaging... • Modern computer technology allows for the two-
and three- dimensional reconstruction of identical planes in cranial space by
combining tumor images from different modalities, including CT, MRI, PET, and
SPECT. • Computed integration imaging involves the simultaneous display of images
from different techniques in a single imaging system that is transposed to a reference
stereotactic frame. • This development has resulted in significant advances in
stereotactic biopsy, interstitial radiotherapy, and laser-guided stereotactic resection. •
It provides a safer, more accurate method of tissue acquisition and biopsy. • A correct
tissue diagnosis can be made in 95% of
Biopsy • Surgical biopsy is performed to obtain tumor tissue as part of tumor
resection or as a separate diagnostic procedure. • Stereotactic biopsy is a computer-
directed needle biopsy. When guided by advanced imaging tools, stereotactic biopsy
yields the lowest surgical morbidity and highest degree of diagnostic information. •
This technique is frequently used with deep-seated tumors in functionally important or
inaccessible areas of the brain in order to preserve function.
Laboratory Diagnosis • Laboratory testing is often used to further assess focal
deficits during the diagnosis and management of brain tumors. • Perimetry is the
measurement of visual fields used when evaluating tumors near the optic chiasm. •
Electroencephalography (EEG) is used to monitor brain activity and detect seizures
but has limited value during screening because EEG findings are often normal in
clients with brain tumors. • Lumbar puncture is used to analyze CSF, which is useful
in the diagnosis and detection of dissemination of certain brain tumors. • Audiometry
and vestibular testing are useful for diagnosing tumors in the cerebellopontine angle.
• Endocrine testing is used to examine endocrine abnormalities with tumors in the
pituitary gland and hypothalamus.

2) What is hypovolemic shock? How to treat it?

syndrom characterized by decreased circulating blood volume (hypovolemia),
which results in reduction of effective tissue perfusion pressure and generalized
cellular dysfunctions.Forms:Hemorrhagic shockNon-hemorrhagic hypovolemic
shock

Initial treatment of shock states Causative treatment – STOP losses Volume repletion
Inotropic therapy Vasomotor therapy
11  TREATMENT OF HYPOVOLEMIC SHOCK
Causative treatment – STOP losses essential role surgical treatment (when
appropriate)emergency surgery for ongoing hemorrhage

12  TREATMENT OF HYPOVOLEMIC SHOCK

volume replacementVascular access siteSolutions for volume replacementRhythm of
administration

13  TREATMENT OF HYPOVOLEMIC SHOCK

Volume replacement – SITE of VASCULAR ACCESSPeripheral vascular accessMultiple
access (2-4 veins)Large peripheral cathetersExternal jugular veinAdvantages:Short
time of instalationRequires basic knowledge and simple matherialsMinor
complications (hematomas, cutaneous seroma, etc.)Disadvantages:The diameter of
peripheral catheter must be adapted for peripheral veins dimensionsVascular access
can be lost (restless patient, during transportation); must be changed at hours;no
catecholamines administration (except in emergency for a short time period,until a
central venous access is available)Central venous accessAfter peripheral vascular
access is established and volume replacement is initiatedReliable and long lasting
venous access (7-10 days)Allows CVP measuring and guiding of treatmentAllows the
administration of catecholamines and hypertonic substancesRisk of complication (at
instalation – pneumothorax, cervical or mediastinal hematoma, cardiac dysrhytmias;
during utilization – infection, gas embolism)

14  TREATMENT OF HYPOVOLEMIC SHOCK

Volume replacement - Solutions for volume replacementIsotonic crystalloid
solutionsHypertonic crystalloid solutionsColloid solutionsWhole blood and red blood
cellsFresh-frozen plasmaPlatelets

15  TREATMENT OF HYPOVOLEMIC SHOCK

Solutions for volume replacement-Isotonic crystalloid solutionsNormal saline (NaCl
0,9 %), Ringer solution, lactated Ringer solutionsAdvantages:easy
availablecheapreduced risksDisadvantages:Small volume effect (out of 1000ml
infused solution – ml remains intravascullarly, the rest is distributed to the interstitial
space)short duration of volume effectrisk of interstitial edema, metabolic
hyperchloremic acidosis-Hypertonic crystalloid solutionshypertonic saline (NaCl
7,4%)Efficient blood volume resuscitation with small solution volume (water is
atracted from interstitial space )Avoidance of fluid overload and peripheral
edemamay result in acute pulmonary edema

16  TREATMENT OF HYPOVOLEMIC SHOCK

Solutions for volume replacementColloid sollutionsDextrans: Dextran 70, Dextran
40Gelatines: Gelofusin, Haemacel, EufusinHetastarch: Haes, Voluven,
RefortanHuman albumin 5%, 20%Advantages:Good volume effectLong duration of
volume effectDisadvantages:expensiverisk for anaphylactic reactionsinterfere with
blood groups determinationcan induce/ aggravate coagulation disorders

17  TREATMENT OF HYPOVOLEMIC SHOCK

Solution for volume replacementBlood and blood products are not volume
solutionsOnly isogroup isoRh bloodOnly after restauration of intravascular volume
with cristalloid /colloid solutions;For correction of oxygen transportIn case of
posthemorragic anemia (after volume replacement) or ongoing hemorrhageIn case
of massive blood transfusion – add fresh-frozen plasma and platelet concentrate

18  TREATMENT OF HYPOVOLEMIC SHOCK

Volume replacementRHYTHM OF ADMINISTRATIONRhytm of administration depends
on:Ongoing losses / stopped lossesRhytm of losses – rapid (minutes, hours) or slow
(days) instalationFor the patient with hypotension – normal saline (2000 ml in the
first minutes)after the first minutes - volume replacement continues depending on
the clinical and hymodinamic parameters (BP, HR, etc..)

19  TREATMENT OF HYPOVOLEMIC SHOCK

Volume replacement –MONITORING THE TREATMENT EFFICIENCYClinical
parametersnormalisation of BP, HR, pulse amplitude, skin colour and temperature,
mental status, urinary outputHemodynamic parametersNormalization of CVP, PCPB,
DC, RVS, soLaboratory parametersNormalization of acid-base balance, liver, renal
tests, Hb şi Ht, so

20  TREATMENT OF HYPOVOLEMIC SHOCK

Inotropic supportOnly after volume replacementUsed to improve cardiac
outputDobutamineinotropic positive supportperipheral arterial vasodilatation

21  TREATMENT OF HYPOVOLEMIC SHOCK

Vasopressor therapyNOT RECOMMENDED (may aggravate peripheral hypoperfusion
and metabolic acidosis)EXCEPTIONSOnly temporaryIn case of ongoing hemorrhage,
which outruns the possibilities of volume replacementOnly until surgical procedure
stops the hemorrhage (emergency surgical treatment)Noradrenaline, dopamine,
adrenaline

3) What are the main complications of gastric ulcer?

Complications Peptic ulcer l Hemorrhage l Perforation l Obstruction l
Canceration * Hemorrage is the most common complication * Perforation is
the most lethal complication.

Complications Peptic ulcer Hemorrhage

* Haemtemesis: Patients with haematemesis are more severe than ones with
melaena alone. * Melaena: The black tarry melaenic stools distinguish from
bright red rectal bleeding colonic or perianal lesions the greyish-greenish stool
by using of iron supplements

Peptic ulcer Management

* Assessment of severity ,* Resuscitation *, Diagnosis of the cause of

haemorrhage, * Observation *, Specific treatment

Complications Peptic ulcer Assessment and Resuscitation * Marked

tachycardia (pulse> 110) * Hypotension (blood pressure < 110 systolic) *
Signs of hypovolaemic shock. Cold sweaty pallid skin. Weak rapid pulse.
Irregular breathing. Dry mouth. Dilated pupils. Reduced flow of urine *
Haemoglobin level below 90 mg/L If there above presentations Immediate
blood transfusion is indicated to expand the circulating volume, restore
cardiac output, and blood pressure.

Complications Peptic ulcer Only when the haemodynamic status of the patient
is stable, we should attempt to diagnose the cause of the bleeding. Causes *
Duodenal ulcer - approximately 40% * Chronic gastric ulcer - 20% * Acute
ulcers - 20% with analgesic ingestion (NSAID) * Oesophageal varices - 10% *
Other 10% causes. Mallory-Weiss lesions: Violent vomiting causes the tearing
of the tissues around the junction of the gastric-oesophagus resulting in
bleeding. Reflux oesophagitis. Gastric tumours Diagnosis Exact diagnosis
using endoscopy is essential

Complications Peptic ulcer Observation

* All patients should be in an intensive care ward of hospital

* Noting any further haematemesis or melaena *

Vital signs should be monitored at least hourly *

Haemoglobin level estimated twice daily until the patient is stable *

Central venous monitoring is indicated in elderly subjects

 * Continuous gastric aspiration is helpful in detecting continued or
recurrent bleeding

* Indications continued bleeding or rebleeding: - haematemesis - the

aspiration of fresh blood from the stomach - significant changes in the
pulse, blood pressure, central venous pressure - a marked drop in
haemoglobin level

3.

4. Complications Peptic ulcer Specific treatment for bleeding peptic ulcer * H

2 -receptor antagonists: increasing p. H of stomach produces, if p. H>6. 0 *
aggregation of platelet PPI(proton pump inhibitors): * coagulation of plsma
induces Hematischesis * Endoscopy provides an opportunity to render
treatment to reduce the chances of rebleeding: - Injection of a dilute
solution of adrenalin causes vasoconstriction - Thermal coagulation can be
achieved using a heater probe or Nd. Ya laser * Surgery - over 60 years of
age with chronic peptic ulcers, continued or recurrent bleeding. - severe
bleeding and the signs of oligaemic shock regardless of their age, the
presence of recurrent or continued bleeding.
 Complications Peptic ulcer Gastric outlet obstruction DU 80% Prepyloric
ulcer Pyloric channel ulcer Spasm or oedema (medical treatment)
temporary fibrosis (surgery) permanent Stenosis Obstruction

Complications Peptic ulcer Gastric outlet obstruction Clinical presentation *

Symptoms . Vomiting: stale food recognized which consumed > 5 hours.
Alkalosis. Sodium and potassium depletion. Weight loss * Physical signs .
Succussion splash and visible peristalsis (by distended stomach) * Diagnosis .
endoscopy gastrointestinal. radiography

5.
Complications Peptic ulcer Gastric outlet obstruction Treatment. Initial
treatment includes fluid and electrolyte replacement . Normal saline
supplemented with potassium is given intravenously. Gastric distension is
alleviated by nasal gastric suction. H 2 -RA or Omeprazole are given
intravenously. If obstruction due to severe fibrotic strictures and carcinoma
require surgery
Complications Peptic ulcer Perforation The sudden pouring of acid content
into the peritoneal cavity . severe abdominal pain. shock. vomiting. marked
abdominal rigidity. absent bowel sound. air under the diaphragm shown by X-
ray examination Treatment- operation should be performed as soon as
possible after perforation

Complications Peptic ulcer Gastric carcinoma * 1 -2% GU only * Warning.

Long and chronic history of GU. Refractory GU. > 45 y. Ulcerated cancer can
heal just only ulcer area but cancer; therefore, endoscopy+biopsy+follow up *
Notice !. Up to 5% of GU being benign on radiological and endoscopic criteria
turn out to be malignant. . All GU should be biopsied. . All GU must follow up
to healing.

1) Would you please briefly talk about the treatment of cancer?

2) The four common pathology types of lung cancer？
3) What signs suggest continued bleeding within the pleural cavity after
chest trauma?