ISB MRCS course notes on colonic disorders.

Prepared and edited by A.H Boaziza.

Vascular surgery ISB MRCS course notes.

Prepared and edited by A.H Boaziza.

Case discussion (MRCS scenario)

A 58 year old male presents with bilateral painless parotid gland swelling, there is no evidence of facial nerve palsy, he provided a history of generalised lymphadenopathy occuring some years previously but he cannot recall when exactly, furthur testing shows a positive p24 antigen test.

On examination the parotid glands looks symmetrically enlarged and non tender, there is no evidence of dry eye or dry mouth, dental hygiene looks acceptable.

Q: What is the most likely cause of parotid gland enlargement in this case?

#Salivary_Glands
#Case_Scenario

Case discussion (MRCS scenario)

A 36 year old female patient has recently underwent cadaveric renal transplant for focal segmental glomerulosclerosis from an unrelated donor, following establishment of the vascular anastomosis the surgeon releases the clamps and notes good flow and the graft appears well perfused, on the ward the patient experienced sudden anuria, following bladder irrigation this was resolved and the patient was discharged on Immunosuppression, 7 months later she presents with diarrhea, fever, and generalised lymphadenopathy and jaundice, she looks systemically unwell.

*Q1: Describe the type of graft given to this patient by source and by location?

Q2: What is the most common cause of postoperative anuria following renal transplant?

Q3: Describe the most important HLA antigen to be matched?.

Q4: If the surgeon releases the vascular clamps and notes immediate graft swelling and dusky discoloration of the graft, in such case what is the mechanism of graft rejection?.

Q5: At 7 months, what is the most likely cause of her presentation?*
#Case_Scenario
#Organ_Transplant

Case discussion (MRCS scenario) 39 year old lady has undergone surgery for breast cancer. As part of the histopathology report the pathologist provides the surgeon with a Nottingham Prognostic Index score of 6.4. He also states that the tumour size is 2cm.…

Sterile and infected pancreatic necrosis

◼️Pancreatic necrosis is a focal or diffuse area of non-viable pancreatic parenchyma which develop as a complication of severe acute pancreatitis, once necrosis develop it is commonly called "Necrotizing pancreatitis".

◼️Pancreatic necrosis can be identified on CT scan with pancreatic protocol as a non-enhancing area when intravenous contrast is delivered, it simply mean that the area is devascularised and dead as it is not taking up the contrast.

◼️Commonly, acute necrotic collections develop, they are defined as collection of fluid around or within the pancreas in association with pancreatic necrosis resulting from peripancreatic fat lysis, and they have no definable wall, in a period of over 4 weeks, they develop an inflammatory capsule surrounding the necrotic area and it is referred to as walled off necrosis.

◼️Initially, the necrosis is sterile, but often become secondarily infected, probably because of gut bacterial translocation, this concept is the drive behind allowing enteral nutrition in acute pancreatitis patients rather than the policy of "resting the pancreas" by keeping the patient nil by mouth, there is now strong evidence to avoid this policy and give the patient enteral nutrition as soon as possible as this protects the gut and prevent bacterial gut translocation and have been shown in numerous clinical trials that it is not harmful in anyway.

◼️Sterile pancreatic necrosis should not be drained or interferred with, however, if the patient shows signs of sepsis, a CT scan is urgently sought, presence of gas bubbles in the pancreatic parenchyma suggests infected necrosis, this is a dangerous complication with a mortality rate of 50%.

◼️Initially a percutaneous aspiration under CT guidance is done, if purulent fluid is present, then the widest possible drain should be inserted percutaneously, materials are often thick with particulate matter and regular flushing is often needed, repeat imaging and repeat drain insertion is usually needed in majority of patients.

◼️Antibiotic therapy should be started promptly, and later guided by sensitivity results from the aspirated fluid.

**◼️Pancreatic necrosectomy is a highly challenging operation, it should be thought of as last resort when other measures have failed to control sepsis, this can be done by a midline laparotomy approach especially if necrosis involves pancreatic head, if gallstones are the initial cause then a cholecystectomy should be included, if necrosis involves the body or tail of pancreas then a retroperitoneal approach via a left flank incision is preferrable.**

◼️It is not uncommon, that after a necrosectomy, furthur necrosis appear, few techniques has been developed to overcome this, non of them have clear advantage over the other, the first way is Beger method, in which closed continuous irrigation is done via several double lumen and single lumen catheters, the irrigation occurs in the debrided cavity and involve instillation of 1L of saline into the cavity and draining this over several hours and the process is repeated.

◼️Another way to go about this, is closed drainage where penrose drains and closed suction drains are applied to the cavity.

**◼️Open packing**, in which the cavity is packed and the incision is left open, with the intention of coming back to theatre for repacking until a granulating cavity is established.

**◼️Bradley method** involves a series of relaparotomies every 48 to 72 hours and repeat debridement until the cavity is granulating.

#Pancreas