BMJ Clinical Review: General Surgery

177 Pages·2015·4.82 MB·English

by  Gophal K Mahadev

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BPP School of Health is collaborating with BMJ to publish a series of major new reference titles across a number e
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of subject areas. each volume presents a range of important reference material on specific clinical topics. The i
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content of each volume has been carefully selected from the wealth of information contained in the extensive w
recent archives of The BMJ and published in the various editions of the journal. These books will provide an S
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General Surgery
This volume deals with a series of important issues in general surgery. Among the many topics discussed are;
n The modern management of incisional hernias
n Splenic trauma
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n Crohn’s disease i
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n Gallstones a revieW:
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n Bariatric surgery for obesity and metabolic conditions in adults r
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issues in oncology which are examined in the book include ductal carcinoma of the breast, diagnosis and i
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management of anal intraepithelial neoplasia and anal cancer, oesophageal cancer, the diagnosis and treatment w GenerAL SUrGerY
of gastric cancer, the management of women at high risk of breast cancer and post-mastectomy breast
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The BMJ Clinical review Series along with companion volumes in other ranges which are under development on
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research Methods, Ten Minute Consultations and easily Missed Diagnoses, provides a succinct, accurate, up to a eDiTeD BY
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date and easy accessible library of information on a broad series of medical issues which are relevant to clinicians

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at all levels in the medical profession. For further information on these series and the other titles we publish, GOPAL K. MAHADev & eLeFTHeriA KLeiDi
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please go to our web site; www.bpp.com/medical-series r
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SHGSST15.indd 1-3 13/08/2015 11:21
BMJ Clinical Review:
General Surgery
Edited by
Gopal K Mahadev & Eleftheria Kleidi
First edition August 2015
A note about copyright
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About the publisher
BPP Learning Media is dedicated to supporting aspiring professionals with top quality learning
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About The BMJ
The BMJ (formerly the British Medical Journal) in print has a long history and has been
published without interruption since 1840. The BMJ’s vision is to be the world’s most influential
and widely read medical journal. Our mission is to lead the debate on health and to engage,
inform, and stimulate doctors, researchers, and other health professionals in ways that will
improve outcomes for patients. We aim to help doctors to make better decisions. BMJ, the
company, advances healthcare worldwide by sharing knowledge and expertise to improve
experiences, outcomes and value.
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Contents
About the publisher iii
About The BMJ iii
About the editors vi
Introduction to General Surgery vii
Treatment of breast infection 1
J Michael Dixon, Lucy R Khan
Ductal carcinoma in situ of the breast 8
Nicola L P Barnes, Jane L Ooi, John R Yarnold, Nigel J Bundred
Management of women at high risk of breast cancer 14
Anne C Armstrong, Gareth D Evans
Post-mastectomy breast reconstruction 20
Paul T R Thiruchelvam, Fiona McNeill, Navid Jallali, Paul Harris, Katy Hogben
Dyspepsia  28
Alexander C Ford, Paul Moayyedi
The diagnosis and management of hiatus hernia 33
Sabine Roman, Peter J Kahrilas
Diagnosis and management of Barrett’s oesophagus 38
Janusz Jankowski, Hugh Barr, Ken Wang, Brendan Delaney
Oesophageal cancer 44
Jesper Lagergren, Pernilla Lagergren
The diagnosis and management of gastric cancer 49
Sri G Thrumurthy, M Asif Chaudry, Daniel Hochhauser, Muntzer Mughal
Percutaneous endoscopic gastrostomy (PEG) feeding 56
Matthew Kurien, Mark E McAlindon, David Westaby, David S Sanders
Bariatric surgery for obesity and metabolic conditions in adults 61
David E Arterburn, Anita P Courcoulas
Gallstones 72
Kurinchi S Gurusamy, Brian R Davidson
Acute pancreatitis 77
C D Johnson, M G Besselink, R Carter
Pancreatic adenocarcinoma 83
Giles Bond-Smith, Neal Banga, Toby M Hammond, Charles J Imber
Crohn’s disease 89
Rahul Kalla, Nicholas T Ventham, Jack Satsangi, Ian D R Arnott
iv
Ulcerative colitis 97
Alexander C Ford, Paul Moayyedi, Steven B Hanauer, Joseph B Kirsner
Laparoscopic colorectal surgery 104
Oliver M Jones, Ian Lindsey, Chris Cunningham
The modern management of incisional hernias 108
David L Sanders, Andrew N Kingsnorth
Modern management of splenic trauma 115
D R Hildebrand, A Ben-sassi, N P Ross, R Macvicar, F A Frizelle,
A J M Watson
Islet transplantation in type 1 diabetes 120
Hanneke de Kort, Eelco J de Koning, Ton J Rabelink,
Jan A Bruijn, Ingeborg M Bajema
Renal transplantation 126
Paul T R Thiruchelvam, Michelle Willicombe, Nadey Hakim,
David Taube, Vassilios Papalois
Management of anal fistula 131
Jonathan Alastair Simpson, Ayan Banerjea, John Howard Scholefield
Management of faecal incontinence in adults 137
Mukhtar Ahmad, Iain J D McCallum, Mark Mercer-Jones
Diagnosis and management of anal intraepithelial
neoplasia and anal cancer 143
J A D Simpson, J H Scholefield
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About the editors
Mr Gopal K Mahadev is a Consultant Surgeon with specialist interest in Breast Oncoplastic
and General Surgery. He is member of Court of Examiners for MRCS with the Royal College of
Surgeons of England & FRCS Intercollegiate Board and also involved in Quality Assurance of
Assessments. He has worked as Senior Lecturer (Hon) in Medical Education and is a teacher,
trainer, examiner and mentor for Medical Students, Surgical trainees as well as Consultants.
Mrs. Eleftheria Kleidi is a Specialty Registrar in Upper Gastrointestinal Surgery at Leighton
Hospital, Crewe. She qualified from the Medical School of the University of Crete in 2004.
After her foundation years, she started her training in general surgery in Athens and obtained
her CCT in 2013. Since then, she has been specialising in UGI surgery and Bariatrics and was
awarded the scholarship of the College of Surgeons of Greece for training in the UK. She
completed her PhD in Bariatrics at the University of Athens in 2015.
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Introduction to General Surgery
Surgery continues to progress as new technology, techniques and knowledge are incorporated
into the care of surgical patients. The creation of new books with updated and concentrated
knowledge in the field has always been a necessity. As Theodore Billroth quoted, in the
19th century: “It is a most gratifying sign of the rapid progress of our time that our best
textbooks become antiquated so quickly”.
General surgery is no longer an integrated specialty and is divided into a set of clearly
defined subspecialties. However, the surgical challenges remain the same. These include
the evolution of surgical practical performance, the efficient decision-making about patient
management and the meticulous post-operative care. In this book, we have attempted
to contribute to the advancement of the latter two challenges, by carefully selecting and
compiling clinical reviews from the BMJ.
Clinical reviews from the BMJ provide a clear, up to date account of each topic including
broad update of recent developments and their likely clinical applications in primary and
secondary care. Its aim is to also stimulate readers to read further and therefore each article
additionally indicates other sources of information. The clinical reviews provide a thorough,
useful, readable and understandable knowledge on general surgery and surgical oncology.
Updated principles and techniques are presented on the topics in various specialities. We
expect this book to be used as an adjunct to the expansion of knowledge on surgical fields.
This book is designed to be equally useful to medical students, trainees in general surgery,
Medical practitioners with an interest in expanding their knowledge in gastrointestinal
pathologies and candidates for postgraduate exams from the concentrated and evidence-
based knowledge encountered in this book. We do hope that you will find this book useful
towards this direction.
vii
viii
Treatment of breast infection
J Michael D ixon, p rofessor of surgery and consultant surgeon1 2 ,
Lucy R   Khan,  s pecialty registrar breast surgery2

1 Breakthrough Research Unit, A cohort study of American women reported that 10% SOURCES AND SELECTION CRITERIA
Edinburgh Breast Unit, Western of women who breast feed have mastitis,1 and a recent
General Hospital, Edinburgh EH4 We conducted a Medline search using the key words “breast
Cochrane review reported the incidence to be as high as
2XU, UK infection”, “mastitis”, and “breast abscess”. This review
33%. 2 Breast abscesses are seen less often, but when they
focuses on parenchymal breast infection, with brief mention of
2 Edinburgh Breast Unit do develop delays in referral to a specialist surgeon may infections of the skin overlying the breast. We do not include
Correspondence to: J M Dixon occur. A recent survey in the United Kingdom found that infection associated with implants. We selected articles that
[email protected] many surgical units have no clear protocols for managing provided the best evidence available. Our experience from
patients with breast infection who are referred to hospital.3 clinical practice is huge, and we have included many of the
Cite this as: BMJ 2011;342:d396
Some surgeons aspirate breast abscesses under local lessons learnt over the many years that we have managed
DOI: 10.1136/bmj.d396 anaesthesia, whereas others use general anaesthesia. patients with breast abscesses.
The management of breast infection has evolved over the
http://www.bmj.com/content/342/
bmj.d396 past two decades, with advances in both diagnosis and acquired in hospital.1 7 Other organisms responsible include
treatment. A new concept is bedside ultrasound, and this streptococci and S taphylococcus epidermidis. Organisms
plays an important part in current management. responsible for non-lactating breast infections include
We review management of breast infection in the primary bacteria commonly associated with skin infections but
care setting and after hospital referral. The review is based also include enterococci and anaerobic bacteria such as
on our current practice and the best quality evidence Bacteroides spp and anaerobic streptococci.8 Patients with
available. Few randomised controlled trials deal with this recurrent breast abscesses have a higher incidence of mixed
topic, and most breast specialists have adopted their flora (20.5% in those with recurrence v 8.9% with a single
own protocols for clinical management, loosely based on episode), including anaerobic organisms (4.5% v 0%).4
published algorithms, and largely dictated by their specific
patient population and their clinical practice setting. This Investigating and managing breast infection in lactating
review provides a resource for those who see breast women
infection infrequently. Appropriate timely referral will help Who gets it and how do they present?
avoid unnecessary morbidity for patients. Lactating breast infection is most commonly seen within the
first six weeks of breast feeding, although it can develop
What kinds of breast infection are there? during weaning. The infection arises initially in a localised
Infection can occur in the parenchyma of the breast or segment of the breast and can spread to the entire quadrant
the skin overlying the breast (fig 1 ) . Parenchymal breast and then the whole of the breast if untreated.
infections can occur in lactating and non-lactating breasts. A review of 946 cases of lactational mastitis in the United
One cross sectional analysis of 89 patients with breast States found that women often gave a history of difficulty
with breast feeding and many had experienced engorgement,
abscesses requiring surgical intervention found that 14%
poor milk drainage, or an excoriated nipple.9 Population
were lactational and 86% were non-lactational.4
based studies have shown that risk factors for abscess
formation include maternal age over 30 years, gestational
Which micro-organisms are implicated?
age greater than 41 weeks, and a history of mastitis.1 0 1 1 The
An up to date retrospective case series shows that during
examining doctor may see erythema, localised tenderness,
lactation the most common organism responsible is
localised engorgement, or swelling. Some women present
Staphylococcus aureus ,6 including strains of meticillin
with fever, malaise, and occasionally rigors.
resistant S aureus (MRSA), particularly if the infection was
SUMMARY POINTS
• Early prescription of appropriate antibiotics reduces the rate of breast abscess Fat Rib
development
• Refer to hospital all patients whose infection does not settle rapidly after one course of
Skin associated Pectoralis
appropriate antibiotics abscess major muscle
• U se ultrasound routinely in patients referred with a suspected abscess to see whether pus Lactational abscess Intercostal
is present muscle
Central or
• Breast abscesses can usually be treated in the outpatients department by repeated subareolar abscess
aspiration or mini-incision and drainage under local anaesthesia
• Patients whose inflammatory changes do not settle after a course of antibiotics may have
Peripheral
inflammatory breast cancer; in such cases perform imaging and image guided core biopsy
parenchymal
if a localised suspicious abnormality is present abscess
• Recurrent central infection is usually associated with periductal mastitis—a smoking
related disease—and total duct excision is often needed Fig 1 Diagram showing common sites and types of breast infection5
1