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The Wales Foundation Trainee Surgical Society MRCS HIGH-YIELD REVISION SERIES HPB SURGERY Bishow Karki , MRCS, PG Cert ( HPE) ST3 Transplant Surgery, Northern General Hospital 28 March 2024 DISCLOSURE eMRCS PassTest NO CONFLICT OF INTEREST TO DECLARE CONTENTS Brief Intro on MRCS HPB Surgical Anatomy Surgical Jaundice Benign & Malignant HPB MRCS Syllabus The syllabus is divided into 10 modules: Module 1 Basic science knowledge relevant to surgical practice  Module 2 Common surgical conditions  Module 3 Basic surgical skills  Module 4 The assessment and management of the surgical patient  Module 5 Perioperative care of the surgical patient  Module 6 Assessment and early treatment of the patient with trauma  Module 7 Surgical care of the paediatric patient  Module 8 Management of the dying patient  Module 9 Organ and Tissue Transplantation  Module 10 Professional behaviour and leadership skills  Ref. Intercollegiate Committee for Basic Surgical Examinations I Guide to the intercollegiate MRCS examination I 2018 Section 3: T opics and Skills that may be examined in the MRCS MODULE 1 BASIC SCIENCE Objective  To acquire and demonstrate sufficient knowledge of the basic scientific principles within the six categories listed below to understand, investigate and manage the common surgical conditions specified in module 2:  1 applied surgical anatomy 2 applied surgical physiology 3 applied surgical pathology (principles underlying system-specific pathology) 4 pharmacology as applied to surgical practice 5 microbiology as applied to surgical practice 6 imaging Ref. Intercollegiate Committee for Basic Surgical Examinations I Guide to the intercollegiate MRCS examination I 2018 Section 3: T opics and Skills that may be examined in the MRCS Module 2 Common congenital and acquired surgical conditions  Gastrointestinal disease  Presenting symptoms or signs  Jaundice To include the following conditions Benign and malignant disease of the Liver, Gall bladder, Pancreas and Spleen Ref: Johns Hopkins Medicine Ref. Intercollegiate Committee for Basic Surgical Examinations I Guide to the intercollegiate MRCS examination I 2018 MRCS Part A Questions Single best answer (SBA) format I Five Possible Answers   Paper 1 Applied Basic Science  Time : 180 minutes No. of Questions: 180 Paper 2 Principle of Surgery in General  Time: 120 minutes No. of Questions: 120 Ref. Intercollegiate Committee for Basic Surgical Examinations I Guide to the intercollegiate MRCS examination I 2018SURGICAL ANTOMYSURGICAL ANTOMYSURGICAL ANTOMYSURGICAL ANA TOMY 1 2 3 4SURGICAL ANA TOMY 1 2 3 4SURGICAL ANTOMY Jaundice PRE-HEPATIC HEPATOCELLULAR POST-HEPATIC Hemolytic Anemia Alcoholic Liver Disease Gallstones • Sickle Cell Disease Viral Hepatitis Sclerosing Cholangitis • G6PD Autoimmune Hepatitis Cholangiocarcinoma • Hereditary Primary Biliary Cirrhosis Stricture Spherocytosis Hepatocellular Pancreatic Cancer Carcinoma Strictures Gilbert Syndrome Abdominal Masses Obstructive Jaundice PRE-HEPATIC HEPATOCELLULAR POST-HEPATIC Hemolytic Anemia Alcoholic Liver Disease Gallstones • Sickle Cell Disease Viral Hepatitis Sclerosing Cholangitis • G6PD Autoimmune Hepatitis Cholangiocarcinoma • Hereditary Primary Biliary Cirrhosis Stricture Spherocytosis Hepatocellular Pancreatic Cancer Carcinoma Strictures Gilbert Syndrome Abdominal Masses Obstructive Jaundice Location Bilirubin ALT/AST ALP Prehepatic Normal or High Normal Normal Hepatic High Elevated Elevated Post Hepatic Very High Moderate Very High ElevationBilirubin MetabolismObstructive Jaundice Surgical Jaundice : Gallstones Features History of Biliary Colic or episodes of cholecystitis Obstructive type History & Test Results Small Calibre Gallstones passing through the Cystic Duct Mirrizi: stone may compress bile duct Surgical Jaundice : Gallstones Features History of Biliary Colic or episodes of cholecystitis Obstructive type History & Test Results Small Calibre Gallstones passing through the Cystic Duct Mirizzi: stone may compress bile duct Surgical Jaundice :Cholangitis Triad? Surgical Jaundice :Cholangitis Charcot's Triad of Symptoms Pain I Fever I Jaundice Ascending Infection of bile ducts by E Coli Surgical Jaundice :Pancreatic Cancer Features ? Name of the Law? Surgical Jaundice :Pancreatic Cancer Painless Jaundice with palpable Gallbladder -Courvoisers Law Direct Occlusion of bile duct or pancreatic duct by tumour Surgical Jaundice 1. Bile Duct Injury 2. Metastatic Disease 3. Cholangiocarcinoma 4. Septic Patients Surgical Jaundice : Investigation First Line: USS AP Pancreatic Ca Suspicion: Pancreatic Protocol CT Liver Ca & Cholangiocarcinoma : MRI I MRCP For Staging: PET Scan If MRCP fails to provide info then ERCP Other Option: EUS Blood Tests: Routine Blood I CEA I CA 19.9 I AFPSurgical Jaundice QUESTION 1 80-year-old man admitted with 1. Whipple Procedure jaundice and investigation 2. Laparotomy and Formation of Hepaticojejunostomy demonstrates Ca HOP . ERCP attempted but the surgeon is unable 3. Percutaneous Transhepatic to cannulate the ampulla. What is Cholangiogram & Drain the best course of action? 4. External beam radiotherapy 5. Laparotomy and Duodenostomy QUESTION 1 80-year-old man admitted with 1. Whipple Procedure jaundice and investigation 2. Laparotomy and Formation of Hepaticojejunostomy demonstrates Ca HOP . ERCP attempted but the surgeon is unable 3. Percutaneous Transhepatic to cannulate the ampulla. What is Cholangiogram & Drain the best course of action? 4. External beam radiotherapy 5. Laparotomy and Duodenostomy QUESTION 2 A lady presents with 1-day history 1. Cholecystitis of RUQ pain associated with septic 2. Cholangitis 3. GB Empyema and jaundiced and tenderness in right upper quadrant . Likely 4. GB Abscess Diagnosis? 5. Liver Abscess QUESTION 2 A lady presents with 1-day history 1. Cholecystitis of RUQ pain associated with septic 2. Cholangitis 3. GB Empyema and jaundiced and tenderness in right upper quadrant . Likely 4. GB Abscess Diagnosis? 5. Liver Abscess Gallstones & GB Related Diseases Biliary Colic: Colicky Abdominal Pain I Worst Post Prandial I If GS then Lap Chole Acute Cholecystitis: RUQ Pain I Fever I Murphey’s + I USS and Lap Cholecystectomy Gallbladder Abscess: RUQ Pain I Swinging Pyrexia I Systemically Unwell USS +/- CT I Cholecystectomy (Subtotal) I Percutaneous Drainage Cholangitis: RUQ Pain I Septic I Jaundice I RUQ Pain > Fluid Resus I Abx I ERCP Gallstone Ileus: H/O Cholecystitis I Known GS I SBO > Laparotomy Enterotomy (Proximal) Fistula not interfered Acalculous Cholecystitis: Systemically Unwell patient I Diabetic I Organ Failure Fit Lap Chole I Unfit Percutaneous Cholecystostomy MRCS OSCE : Obstructive Jaundice 1. Explain Bilirubin Metabolism 2. In what form does bilirubin circulate in plasma? 3. Clotting Abnormality? 4. What is ALP? 5. Findings in USS? 6. The function of Bile ? 7. How do bile salts help in the emulsification of fat? 8. Constituents of Bile? 9. What is Urobilinogen and how it's formed? 10. What is enterohepatic circulation? 11. Causes of Jaundice? QUESTION 3 60 year-old Patient presents with 1. PTC & Stent jaundice and temperature 39’ . 2. PTC & Drain 3. ERCP & Stent Known Gallstones . Blood Cultures Gram negative Bacilli. Imaging 4. USS shows bile duct 120mm in diameter. 5. MRCP Best Treatment option? QUESTION 3 60 year-old Patient presents with 1. PTC & Stent jaundice and temperature 39’ . 2. PTC & Drain 3. ERCP & Stent Known Gallstones . Blood Cultures Gram negative Bacilli. Imaging 4. USS shows bile duct 120mm in diameter. 5. MRCP Best Treatment option? Pancreatitis Function of Pancreas Endocrine: Islets Cells of Langerhans 1. Alpha: Glucagon 2. Beta: Insulin 3. Delta: Somatostatin 4. PP Cells: Pancreatic Polypeptide Exocrine: Pancreatic Enzymes 1. Enterokinase 2. Lipase 3. AmylaseAETIOLOGY : Acute PancreatitisPathogenesis : Pancreatitis Acute Pancreatitis : Scoring System GLASGOW CRITERIA: PANCREAS At least 3 of the criteria indicates Severe Episode For ITU Admission Acute Pancreatitis : Scoring System RANSON’s CRITERIA : GALAW - CHOBBS At Admission GALAW: Glucose I Age I LDH I AST I WBC At 48 Hrs CHOBBS: Calcium I Haematocrit I O2 I BUN I Base Deficit I Sequestrated Fluid Other: Balthazar CT Scoring System APACHE II Acute Pancreatitis Mx Investigation : Differential • Amylase? Usually, 3X more Hyperamylasaemia diagnostic 1. Acute Pancreatitis • Both false Positive & Negative 2. Pancreatic Pseudocyst Results 3. Mesenteric Infarct • Serum Lipase is more sensitive ( longer Half-Life) 4. Perforated Viscus 5. Acute Cholecystitis 6. Diabetic Ketoacidosis Assessment Severity • GLASGOW • RANSON Acute Pancreatitis Complications Local : Hepatobiliary Respiratory • Pseudocyst • Jaundice • ARDS • Abscess • Portal vein Thrombosis • Pleural Effusion • Necrotising pancreatitis Systemic Death • Splenic Vein • Hypovolemic Shock Thrombosis • Haemorrhagic Pancreatitis GI • Multi-Organ Failure • Ileus • Bleed Metabolic : Hypocalcaemia Acute Renal failure Hypoalbuminemia Haematological (DIC) Hypoxemia Acute Pancreatitis Mx Nutrition : Operative Management • TPN Acute Pancreatitis + GS: ERCP I Lap • Enteral Feeding: NJ Tube Chole Taking into account Extensive Necrosis: FNA ( culture) 1. Premorbid nutritional status 2. Current nutritional needs 3. Estimated return to normal feeding Infected Necrosis : IR Drain Surgical NecrosectomyDiagnosis ? Pancreatic Pseudocyst Collection of amylase-rich fluid enclosed in a wall of fibrous or granulomatous tissue. Requires 4 weeks or more from the onset of attack. Symptoms Epigastric Swelling I Dyspepsia I Vomiting I Fever Complications Rupture I Infection I Bleeding from Splenic Vessels I CBD Obstruction I GOO Pancreatic Pseudocyst Mx More common with chronic pancreatitis, however, can occur after acute pancreatitis Most (up to 40%) will resolve spontaneously within approx. 1 week Manage expectantly for at least 6 weeks (ideally 3mo). Most will resolve in this period, wait time also allows the wall to mature. Consider intervention if >6cm in diameter or symptomatic/infected Often associated with pancreatic duct abnormality > Need ERCP or MRCP before intervention Pancreatic Pseudocyst Mx.. Cystogastrostomy Cystojejunostomy Pancreatic Pseudocyst Mx.. Cystogastrostomy Cystojejunostomy QUESTION 4 60-year-old alcoholic develops 1. Pancreatectomy acute pancreatitis and is making 2. Emergency Cystogastrostomy 3. Elective Cystogastrostomy slow but reasonable progress. Has persisting Ileus and CT undertaken? 4. ERCP This demonstrates a large 5. Staging laparotomy to assess pseudocyst. This is monitored by severity repeat CT scanning which shows no resolution and he is now complaining of early satiety. What is the best course of Action? QUESTION 4 60-year-old alcoholic develops 1. Pancreatectomy acute pancreatitis and is making 2. Emergency Cystogastrostomy 3. Elective Cystogastrostomy slow but reasonable progress. Has persisting Ileus and CT undertaken? 4. ERCP This demonstrates a large 5. Staging laparotomy to assess pseudocyst. This is monitored by severity repeat CT scanning which shows no resolution and he is now complaining of early satiety. What is the best course of Action?Benign Liver Lession 1. Haemangioma 2. Adenoma 3. Polycystic liver disease 4. Pyogenic liver abscess 5. Amoebic liver abscess 6. Hydatid Cyst Liver Haemangioma Most common liver tumours, male predominance, equal distribution in liver • Congenital vascular malformations, generally asymptomatic • Can cause pain, compressive symptoms • Rarely haemorrhage, inflammation, or coagulopathy Investigation : CT I MRI Treatment • Asymptomatic > observation (regardless of size, no risk of rupture) • Symptomatic > resection Liver Cell Adenoma Rare I associated with OCP & androgen steroid use • Malignant transformation in 10% • Risk of rupture increases with size: 30% risk of spontaneous bleeding with tumours> 5 cm Can present with pain, abdominal fullness, abnormal LFTs, or bleeding from rupture Treatment • Small lesions > discontinue OCPs & may regress • Larger lesions (> 4 cm) or no regression after stopping OCPs > resect • Ruptured > IR POL YCYSTIC LIVER DISEASE Usually occurs in association with polycystic kidney disease Autosomal dominant disorder Symptoms may occur as a result of capsular stretch PYOGENIC LIVER ABSCESS Most common, > 80% Usually secondary to biliary tract infection (E. coli), GI source (diverticulitis, appendicitis) Common symptoms Fever I RUQ pain I Jaundice may be seen in 50% Treatment Percutaneous drain and antibiotics AMEOBIC LIVER ABSCESS The most common extraintestinal manifestation of amoebiasis Between 75 and 90% of lesions occur in the right lobe Symptoms Fever I Right upper quadrant pain Treatment Metronidazole rarely needs drainage HYDA TID CYST Seen in cases of tapeworm parasite Echinococcus granulosus infection Characteristic double-walled cyst on CT External laminated hilar membrane and an internal enucleated germinal layer Treatment Albendazole followed by surgical excision Do not aspirate or spill > cause anaphylaxis Percutaneous aspiration is contra indicated HYDA TID CYST Seen in cases of tapeworm parasite Echinococcus granulosus infection Characteristic double-walled cyst on CT External laminated hilar membrane and an internal enucleated germinal layer Treatment Albendazole followed by surgical excision Do not aspirate or spill > cause anaphylaxis Percutaneous aspiration is contra indicated QUESTION 5 A 40-year-old man with 1. PET CT Scan long-standing chronic hepatitis is 2. Liver MRI 3. USS Guided Liver Biopsy being followed up. Recently his AFP is noted to be increased and an 4. Laparoscopic Biopsy abdominal USS demonstrates a 2 5. Segmental Resection of Segment V cm lesion in segment V of the liver. What is the appropriate course of action? QUESTION 5 A 40-year-old man with 1. PET CT Scan long-standing chronic hepatitis is 2. Liver MRI 3. USS Guided Liver Biopsy being followed up. Recently his AFP is noted to be increased and an 4. Laparoscopic Biopsy abdominal USS demonstrates a 2 5. Segmental Resection of Segment V cm lesion in segment V of the liver. What is the appropriate course of action? Hepatocellular Carcinoma Risk factors (causes of liver inflammation) HBV I HCV I cirrhosis of any cause I Aflatoxin inherited errors of metabolism (hemochromatosis, alpha 1 antitrypsin deficiency), CT scan: Hypervascular lesions Hyperintense in arterial phase I Hypodense during delayed phase Characteristic lesion on imaging + elevated AFP = no biopsy needed ( risk of Tumor seeding) Most Common site of Mets: Lung Hepatocellular Carcinoma Mx Resection indicated for cure if solitary mass without major vascular invasion and adequate liver function (i.e. low grade with normal function or Child A without portal htn) Resection is possible but controversial for limited major vascular invasion or multifocal disease that is resectable. No cirrhosis or Childs A and early stage > resection Moderate to severe cirrhosis and early-stage > Transplant P ANCREA TIC CANCER Adenocarcinoma (ductal epithelial Clinical features origin) • Weight loss Risk factors: Smoking, diabetes, • Painless jaundice adenoma, familial adenomatous • Epigastric discomfort (due to polyposis invasion of the coeliac plexus) Mainly occur in the head of the • Pancreatitis pancreas (70%) • Trousseau's sign: migratory Spread locally and metastasizes to the superficial thrombophlebitis liver P ANCREA TIC CANCER Invx USS: May miss small lesions CT (pancreatic protocol) Unresectable on CT > No further staging needed PET/CT for those with operable disease on CT alone ERCP/ MRI for bile duct assessment Staging lap to exclude peritoneal disease P ANCREA TIC CANCER Mx HOP: Classic Whipple’s I PPPD I SMA/ SMV resection Ca body & tail: Poor prognosis I distal panc. if operable disease Adjuvant chemotherapy for resectable ERCP and stent for jaundice & palliation Surgical bypass (Gastro-Jej) may be needed for duodenal obstruction SAMPLE TEXT “The Aim of the survey was to explore the views of prospective mentees and mentors regarding mentorship and the proposed Contents NTSMP National Transplant Surgery Mentorship Programme endorsed by UK Transplant Surgery Trainee Society Herrick Society” SAMPLE QUESTION A lady presents with 1-day history 1. Cholecystitis of RUQ pain associated with septic 2. Cholangitis 3. GB Empyema and jaundiced and tenderness in right upper quadrant . Likely 4. GB Abscess Diagnosis? 5. Liver AbscessTHANK YOU ! ANY QUESTIONarki47@gmail.co m S ?