UM 1 Mock 2 16.8.

18
 Discuss role of interventional radiology in management of surgical diseases.
 Discuss pathology and management of salivary gland tumors.
 Discuss various management options of biliary calculi.
 Describe indications, preoperative preparation, operative steps and postoperative care about
anterior restorative resection (ARR) for rectal cancer.
Interventional Radiology

Definition

 Interventional radiology is a subspecialty of radiology which extends conventional diagnostic

examination to active performance of various therapeutic procedures under image guidance.

Percutaneous Biopsy

 Possible for most radiologically detected abnormalities.

 Fluoroscopy or CT guided biopsy in the chest.
 Ultrasound or CT guidance biopsy in the abdomen.
 Complicationsinclude haemorrhage, pancreatitis, pneumothorax and seedling of the needle
track by tumour.

Drainage of Abscesses or Fluid Collections

 Almost any fluid collection in the chest, abdomen or pelvis may be considered for percutaneous
catheter drainage under ultrasound or CT guidance.
 It has largely replaced surgery as the initial treatment of choice.

Hepatobiliary Interventions

 Liver biopsy
o Targeted towards a focal lesion or taken from the right lobe of liver in diffuse disease.
o Plugged liver biopsy
 seal the track of the biopsy needle after obtaining specimens
o Transjugular liver biopsy
 for non-targeted tissue collection.
 Percutaneous biliary procedures
o Percutaneous transhepatic cholangiography and drainage (PTCD) or percutaneous
biliary drainage
 Indication for PTCD
 Palliative decompression for advanced or unresectable malignant
obstruction
 Biliary obstruction with severe pruritus, sepsis, hepatic failure
 Preoperative decompression when waiting time is too long
 Options include
 Balloon dilatation
 Simple external drainage
 Internal/ external drainage
  Stent insertion(plastic or expanding metal)
 Interventional radiology of the gall bladder
o Percutaneous cholecystostomy
 Indications
 Decompression and drainage in acute cholecystitis and empyema
 To develop an access tract for stone extraction and dissolution
 Biliary drainage
 Percutaneous Treatment of Liver Tumors
o Injection of liquid agents such as alcohol, acetic acid and doxorubicin beans
o Heating the tumour by use of laser or radiofrequency probes
o Freezing the tumour by cryotherapy.
 Transjugular intrahepatic portosystemic shunt (TIPSS)
o For the relief of portal hypertension
o In patients with recurrent variceal bleeding who are resistant to sclerotherapy or
endoscopic banding
o The major complication is hepatic encephalopathy.

Gastrointestinal Intervention

 Enteric strictures
o Esophageal strictures
 Dilatation with fluoroscopic guidance.
 Esophageal stent placement
 Rigid plastic stents (Celestin or Atkinson tubes)
 self expanding metal stents.
o Pyloric strictures and gastric outflow obstruction
 Balloon dilatation
 Self-expanding metal stents
o Colorectal Strictures
 Self-expanding metal stents
 Palliatively to relieve obstruction in patients unfit for operation.
 To allow optimization of the patient prior to surgery
 Percutaneous gastrostomy and gastrojejunostomy
o Can be achieved using fluoroscopy.
o Provides a more comfortable route to maintain nutrition is patients who are suffering
from upper aerodigestive tract malignancy or those with difficulty to swallow as a result
of a previous cereberovascular accident.

Urological Interventions

 Percutaneous nephrostomy
 o Relief of urinary obstruction
 To preserve renal functions
 To allow effective treatment of infection
 To allow assessment of recoverable renal function
o Access for further manipulations/procedures
 Antegrade pyelography and Whitaker test
 Stone therapy /stone removal e.g. Percutaneous nephrolithotomy
 Foreign body removal
 Biopsy and removal of urothelial tumours from kidney and upper ureter
 Percutaneous endopyelotomy
 Antegradestenting and/or balloon
o Urinary diversion
 ureteric injury or fistula
 Percutaneous ureteric stent insertion
o In the management of malignant ureteral obstruction
o In the treatment of ureteral fistulae, strictures and calculi

Vascular Interventions

 Percutaneous transluminal angioplasty

o to treat vascular stenotic / occlusive disease in many different sites, including coronary,
mesenteric and renal arteries as well as the lower limb circulation
 Vascular stenting
o Arterial
 Renal arteries
 stenosis within 1 cm of renal artery origin or occlusions
 Aortoiliac disease
 Iliac occlusions
 Flow limiting dissections
 Failure to dilate with angioplasty or residual pressure gradient
 Recurrent stenosis following angioplasty
o Venous
 Malignant superior vena cava syndrome
 Percutaneous therapeutic embolization
o Gastrointestinal embolization
o Embolization of traumatic haemorrhage
o Gonadal vein embolization in the treatment of symptomatic varicocele.
o Embolization for Arteriovenous malformations
 Intravascular thrombolysis
o acute thromboembolic disease in the lower limb.
o iliofemoral venous thrombus
 o thrombo-occlusive disease of the central upper body veins.
 Inferior vena cava filters
o In patients with contraindications to, or recurrent emboli despite anticoagulation.
Salivary Gland Tumors

Tumours of minor salivary glands

 Arise in submucosal seromucous glands

 Occur anywhere in the upper aerodigestive tract;
o Common sites
 palate, upper lip and retromolar regions.
o Less common sites
 nasal and pharyngeal cavities.
 Clinical Features
o A well-defined rubbery lump is
o Benign tumours present as painless, firm, slow-growing swellings.
o Overlying ulceration - rare.
o Malignant tumours are mostly low grade and present as apparently benign lumps.
o They have a firm consistency, and the overlying mucosa may have a varied
discolouration from pink to blue or black.
o High-grade lesions usually become necrotic with ulceration as a late presentation.
 Management
o Benign tumours
 Less than 1 cm in diameter, can be managed by excisional biopsy, and the defect
left to heal by secondary intention.
 Greater than 1 cm in diameter, a 3 mm punch biopsy (dermatological punch) is
recommended to establish a diagnosis prior to formal excision.
o Malignant neoplasms
 Low grade and early stage can be managed by wide excision with burring down
of the underlying bone and then left to heal by secondary intention.
 Those that have perforated the palate may require partial or total maxillectomy.

Tumours of the sublingual glands

 Extremely rare and usually (90%) malignant.

 They present as a rubbery painless swelling in the floor of the mouth.
 Pain or lingual nerve paresthesia indicate a high-grade tumour.
 Management
o Formal punch biopsy prior to formulating a treatment planfor all sublingual gland
tumors
o Treatment requires en block wide excision involving the overlying mucosa and the
adjacent periosteum with simultaneous neck dissection depending on the stage of the
disease. Oncoplastic surgery
o Immediate reconstruction of the intraoral defect
  Radial artery forearm free flap
 Anterolateral thigh flap
 pedicled pectoralis major flap

Tumours of the submandibular gland

 Uncommon
 About 60–70% of submandibular gland tumours are benign
 The swelling cannot, on clinical examination, be differentiated from submandibular
lymphadenopathy.
 Most salivary neoplasms, even malignant tumours, are often slow-growing, painless swellings.
 Clinical features of high-grade malignant salivary tumours
o facial nerve weakness
o rapid enlargement of the swelling
o induration and/or ulceration of the overlying skin
o cervical node enlargement.
 Investigation
o The initial investigation of choice is ultrasound with fine- needle aspiration cytology
(FNAC)/True-Cut biopsy.
o Once it is established that a tumour is present, computed tomography (CT) and MRI
scanning will highlight the relationship of the tumour to other anatomical structures.
o Open surgical biopsy is contraindicated as this may seed the tumour into surrounding
tissues.
 Management
o Benign tumours can be safely removed by meticulous dissection outside the
submandibular capsule.
o The management of malignant salivary gland tumours is governed by the stage and
clinical grade of the lesion.
o The larger and more aggressive the lesion, the more radical is the surgery required.
o Wideclearance of the submandibular triangle with some form of neck dissection is
normally the treatment of choice.
o Adjuvant radiotherapy is usually dictated by pathological findings such as close margins
and high-grade cancers.

Tumours of the parotid gland

 The most common site for salivary tumours.

 Clinical features
o Tumours of the superficial lobe (most common)
 slow-growing, painless swellings below the ear
 in front of the ear
  in the upper aspect of the neck.
o Tumours of the accessory lobe
 persistent swellings within the cheek.
o Tumours of the deep lobe
 parapharyngeal mass causing difficulty in swallowing and snoring.
 Classification
o Some 80–90% of tumours of the parotid gland are benign, the most common being
pleomorphic adenoma.
o Malignant salivary gland tumours are divided into
 Low-grade malignant tumours (e.g. acinic cell carcinoma)
 High-grade malignant tumours
o Among primary parotid malignant tumours, mucoepidermoid carcinoma is the most
common, followed by adenocystic carcinoma.

 Investigations
o The initial imaging modality of choice is ultrasound as it demonstrates if the lump is
intrinsic to the parotid or not. It also facilitates accurate sampling of the lesion by FNAC
or True-Cut biopsy.
o Subsequently, CT and MRI are the most useful imaging techniques
o Open surgical biopsy is contraindicated unless evidence of gross malignancy is present
 Management
o Parotidectomy
 The aim of parotidectomy is to remove the tumour with a cuff of normal
surrounding tissue.
 Types
 Conservative parotidectomy - the facial nerve is spared
 Radical parotidectomy
 o the facial nerve is excised en bloc with the tumour.
o performed for patients in whom there is clear histological
evidence of a high-grade malignant tumour (e.g. squamous cell
carcinoma) with invasion of facial nerve
 Superficialparotidectomy
o the part of the gland superficial to the facial nerve is removed.
o the most common procedure for parotid gland pathology
o Usually used to manage low grade and low stage malignant
tumors
 Deep lobe parotidectomy - the part of the gland beneath the nerve is
removed
 Total parotidectomy is when both are dissected and removed.
 Extracapsulardissection
o does not require formal facial nerve dissection and is a less
invasive technique with reduced morbidity.
o an oncologically sound technique for benign parotid gland
tumours.
Management of Biliary Calculi

Gall stones (Cholelithiasis)

 Clinical presentation
1 o May remain asymptomatic
 Biliary colic (10–25% of patients)
 Right upper quadrant or epigastric pain
 Radiate to the back.
 May be colicky but more often is dull and constant.
 May last for minutes or even several hours.
2 o Obstructive jaundice
 Result if the stone migrates from the gallbladder and obstructs the common bile
duct.
3 o Gallstone can lead to bowel obstruction (gallstone ileus).
4 o H/oAcute cholecystitis
 Symptoms do not resolve but progress to continued pain with fever and
leukocytosis
 The patient may have right upper quadrant tenderness that is exacerbated
PE
during inspiration by the examiner's right subcostal palpation (Murphy’s sign).
 A mass may be palpable as the omentum walls off an inflamed gallbladder.
 In the majority of cases the process is limited by the stone slipping back into the
body of the gallbladder and the contents of the gallbladder escaping by way of
the cystic duct.
5 o Empyema gall bladder
 If resolution does not occur.
6 o Perforation of gall bladder
 The wall may become necrotic and perforate, with development of localised
peritonitis.
 Usually, the inflamed gall-bladder is usually localised by omentum which
contains the perforation.
 Uncommonly, the abscess may then perforate into the peritoneal cavity with a
septic peritonitis.
7 o Mucocele of gallbladder
 Non-tender, palpable gallbladder resulting from complete obstruction of the
cystic duct with reabsorption of the intraluminal bile salts and secretion of
uninfected mucus by the gallbladder epithelium.
 Investigations
o While the presentation and examination may suggest acute cholecystitis, a definitive
diagnosis can only be made following appropriate imaging studies (US or CT).
o Ultrasonography - to confirm the diagnosis.
 o MRCP - to exclude choledocholithiasis if jaundice is present
o CT - if there is any concern regarding the diagnosis or presence of complications such as
perforation
 Treatment
1) o For asymptomatic gallstones
 It is safe to observe patients
 Prophylactic cholecystectomy
 For diabetic patients
 Those with congenital haemolytic anaemia and
 Those patients who are undergoing bariatric surgery for morbid obesity
2) o For patients
3
with symptomatic gallstones
 Cholecystectomy is the treatment of choice.
1 In more than 90% of cases, the symptoms of acute cholecystitis subside with
conservative measures.
 Non-operative treatment is based on four principles:
2

 Nil per mouth (NPO) and intravenous fluid administration.

 Administration of analgesics.
 Administration of antibiotics.
 Subsequent management. When the temperature, pulse and other
physical signs show that the inflammation is subsiding, oral fluids are
reinstated, followed by a regular diet.
4
3)  Cholecystectomy may be performed on the next available list, or the patient
may be allowed home to return later when the inflammation has completely
resolved.
o Assessment of severity
 Tokyo Consensus Guidelines for severity grading of acute cholecystitis.
3  Grade III (severe) acute cholecystitis
 Grade II (moderate) acute cholecystitis
1  Grade I (mild) acute cholecystitis
o In patients with grade I disease
 Cholecystectomy is a safe and low risk operative procedure.
o In patients with grade III disease
 Operative intervention and cholecystectomy should be performed depending
on the status of the patient
 If the patient has comorbid conditions, a percutaneous cholecystostomy can be
performed under ultrasound control. An interval cholecystectomy will be
required once the patient's condition has stabilized.
4) o The timing of surgery in acute cholecystitis
 Remains controversial
 Early intervention within the first week
 safe and shortens the total hospital stay
  conversion rate in laparoscopic cholecystectomy is higher
 delayed approach
 should wait approximately 6 weeks for the inflammation to subside
before operating.

Common Bile Duct Stones (Choledocholithiasis)

 Clinical Features
o Pain: It may be biliary colic; nonspecific abdominal pain; pain of ascending cholangitis,
pain of pancreatitis.
o Jaundice—most common clinical manifestation.
o Fever with chills and rigors.
o Charcot's triad of ascending cholangitis.Stone moves proximally and floats, obstruction
is relieved and symptoms subside (Intermittent features).
 Intermittent pain (may be colicky)
 Intermittent fever
 Intermittent jaundice
o Reynold's pentad of acute obstructive cholangitis (suppurative cholangitis—
5%).Sometimes obstruction persists causing
 Persistent pain
 Persistent fever
 Persistent jaundice
 Shock (toxicity) and
 Altered mental status
o Steatorrhoea and darkening of urine.
o Pruritus.
 Investigations
o US abdomen may show gallstones, dilated CBD >8 mm which suggests biliary
obstruction. Sensitivity for CBD stones is only 65%.
o CT scan is the most sensitive investigation for CBD stones; it shows stones, location,
ductal stricture or block, ductal dilatation, intrahepatic biliary changes and stones.
Helical CT cholangiography is also useful but bilirubin level should be normal which is
the limitation.
o MRCP is noninvasive investigation which delineates biliary tree anatomy and pathology
clearly; but it is not therapeutic.
o Blood: Total count may be raised; LFT deranged with raised bilirubin (direct) and alkaline
phosphatase. PT INR and platelet count should be done. Serum amylase and lipase
should be done to rule out associated pancreatitis.
o EUS (endosonography) is useful and accurate but it is invasive.
o ERCP identifies pathology, site of block, stones, etc. (95% sensitivity). It is therapeutic
also for extraction of biliary stones and stenting.
 o PTC is done only when indicated like in those with previous gastrectomy, failed ERCP.
PTC is not routinely needed. PTC can be therapeutic also in extracting the stones and
stenting.
 Treatment
o Preoperative management
 Injection Vit. K 10 mg IM once a day for 5 days or FFP infusion to correct the
prothrombin time.
 IV antibiotics (cefoperazone, cefotaxime).
 Correction of dehydration.
 IV mannitol daily 200 ml BD to prevent hepatorenal syndrome.
1)o ERCP—Therapeutic, i.e. endoscopic papillotomy (sphincterotomy) and stone extraction
through Dormia basket or balloon catheter; or fragmenting the stone and extraction; or
removal through baby endoscope. CBD stent is placed in situ.Once CBD stones are
extracted through ERCP, laparoscopic cholecystectomy is done.
2)o Open cholecystectomy and CBD exploration
 After the removal of gallbladder, on table cholangiogram is done through cystic
duct to see any stones in CBD. Using stay sutures choledochotomy is done
(opened longitudinally) to remove stones in CBD.
 After choledochotomy, stones are removed using Des
Jardin'scholedocholithotomy forceps.
 T-tube (Kehr's) is then placed in the CBD and kept for 14 days.
 After 14 days a postoperative T-tube cholangiogram is done to see for free flow
of dye into the duodenum, so that T-tube can be removed.
3) o Laparoscopic CBD exploration is becoming popular with availability of expertise and high
technology imaging and instruments.
4) o Open choledochoduodenostomy/ Open choledochojejunostomy
 These procedures attain complete drainage of bile.
 Postoperatively they may often require long-term antibiotics.
 Indications for choledochoduodenostomy/choledochojejunostomy:
 Multiple CBD calculi with distal narrowing (Funnel syndrome). ™
 Papillary stenosis.
 Impacted calculi.
 Biliary sludge—symptomatic.
 Residual stones.
 Sphincter of Oddi dysfunction/stenosis.
 Primary CBD stones.
 Previous choledochotomy.
 Marked CBD dilatation
 Prerequisite for choledochoduodenostomy:
 CBD should be more than 1.4 cm and stoma should be 2 cm.
 Advantages of choledochoduodenostomy are:
  Bile leak is minimal/not there. ကုသျခင္း
 Beneficial as a permanent remedy in multiple stones/sludge/
stenosis/strictures/intrahepatic stones.
 Problem with choledochoduodenostomy:
 Sump syndrome.
o CBD distal to the choledochoduode-nostomy acts as a reservoir
with stasis of food particles, bile, stones and sludge.
o Often it causes cholangitis and narrowing of the stoma of
choledochoduodenostomy.
Anterior Restorative Resection

Indications

 For the upper and middle third of rectum tumors

Preoperative preparation

 Mechanical bowel preparation

o using a combination of diet, purgatives and enemas
o to reduce intra-operative contamination and the risk of surgical site infection.
 Stoma care nurse
o For siting of a temporary or permanent ileostomy or colostomy.
 Counseling
o About the complications of the procedure, and particularly about the risks of pelvic
autonomic nerve damage causing bladder and sexual disturbance, especially impotence
in males.
 Prophylactic systemic antibiotics
o To reduce the risk of surgical site infection.

Operative Steps

 Position
o Place the patient in the lithotomy Trendelenburg (Lloyd-Davies) position.
o Insert an indwelling Foley catheter into the bladder.
 Incision
o Make a midline incision downwards from the umbilicus to the symphysis pubis.
o If mobilization of the splenic flexure is required, the incision will need to be extended
upwards
 Assess
o Palpate the liver for occult metastases, examine the colon and entire small bowel, look
for enlarged mesenteric and para-aortic nodes and examine the peritoneal cavity and
pelvis for metastases.
o Note the relation of the tumour to the peritoneal reflection and decide whether it is
mobile, adherent to other organs or fixed within the pelvis.
 Action
o Mobilization and resection of the colon
 Mobilize the left side of the colon by dividing the congenital adhesionsthat bind
the sigmoid colon to the abdominal wall in the left iliac fossa.
  Assess the length of colon required to achieve a tension-free anastomosis: if the
planned proximal resection margin will reach to the pubic symphysis, it will
reach to the pelvic floor.
 If necessary, mobilize the splenic flexure and the left half of the transverse
colon, preserving the omentum unless there are metas-tases present in it.
 Mobilize the left colon by pulling it to the right on its mesentery. Identify the left
ureter and gonadal vessels and sweep them away from the mesocolon.
 To enter the mesorectal plane lift the sigmoid loop vertically. Divide the
peritoneum on the right side to expose the inferior mesenteric artery and follow
it proximally to its origin and distally into the loose areolar tissue of the
mesorectal plane. Push away the tissue containing the pelvic nerve plexus which
lies deep to the vessels.
 Make a similar incision in the peritoneum of the left side to produce a window
with artery above and nerves below. Clamp, divide and ligate the artery close to
its origin from the aorta. Divide the inferior mesenteric vein below the lower
border of the pancreas. Select a suitable area to transect the proximal colon and
divide the mesentery up to this point. Transect the bowel and pack the proximal
colon and small bowel out of the way in the upper abdomen. The specimen can
now be pulled anteriorly to facilitate the pelvic dissection.
o Rectal mobilization and pelvic dissection
 The extent of rectal mobilization depends upon the level of the tumour. If it is
below the peritoneal reflection, mobilize the rectum and mesorectum down to
the pelvic floor.
 Dissect the plane between presacral fascia and mesorectum from the sacral
promontory to the tip of the coccyx. Take care to visualize and preserve the
presacral nerves.
 As the posterior dissection deepens, divide the peritoneum over each side of
the pelvis, mid-way between the rectum and pelvic side-wall, uniting the
incisions anteriorly in the midline 1 cm above the peritoneal reflection,
overlying the seminal vesicles anterolaterally.
 Dissect between the seminal vesicles and the rectum to expose the rectovesical
fascia. Incise this and dissect distally in the male to the lower border of the
prostate. In the fe-male, dissect distally between the rectum and vagina as far
down as necessary to achieve adequate mobilization of the tumour.
 While retracting the rectum first to one side and then the other side of the
pelvis, continue dissecting in the avascular plane between the mesorectum and
pelvic side wall.
 Lift the rectum and tumour out of the pelvis and select a suitable site for
division of the rectum. Provided you have performed a total mesorectal
excision, a 1 to 2-cm distal margin of rectum is sufficient to achieve a curative
resection. If you are performing a stapled anastomosis, leave an extra 8 mm of
rectal wall to be excised in the distal ‘doughnut'.
  Irrigate the rectum through the anus with aqueous 10% povidone-iodine
solution. If only a small cuff of sphincter and rectum remains, swab it out with
the same solution.
 Divide the rectum below the stapler or clamp with a long-handled scalpel.
Remove the specimen containing the rectal carcinoma, the complete
mesorectal envelope and inferior mesenteric pedicle.
o Unite
 Staple or suture the anastomosis, depending upon the level of anastomosis,
ease of access to the pelvis and the obesity of the patient.
 Sutured anastomosis
 Insert vertical mattress sutures into the posterior layer but do not tie
them. Hold each suture with artery forceps until they have all been
inserted.
 Have the sutures all held taut while you push down the proximal colon
until its posterior edge is in contact with the rectum. This is the
‘parachute' technique. Tie the sutures with the knots within the lumen.
Hold the two most lateral sutures and cut the others. Suture the
anterior layer using interrupted seromuscular inverting sutures, again
inserting them all before tying them.
 Stapled anastomosis
 Insert a purse-string suture into the end of the proximal colon. Insert
the anvil of a 28-mm or 31-mm stapling gun and tie the purse-string
suture as tightly as possible.
 Introduce the body of the CEEA gun through the anus and open it,
guiding the spike of the gun through the posterior aspect of the rectal
stump in the middle and just behind the staple line. Remove the spike if
it is detachable and connect the anvil to the cartridge.
 Operate the gun to approximate the anvil to the cartridge while
ensuring that the vaginal vault and any loops of small bowel are not
trapped in the closing stapler. Fire the staple gun to construct the
anastomosis. Open the gun two full turns to separate the anvil from the
cartridge and rotate it 360o clockwise and again anti-clockwise to
ensure the anasto-mosis is free before gently extracting it from the
anus.
 Check the integrity of the stapled anastomosis:
 Examine the ‘doughnuts' of colon and rectum removed from the gun.
They should be complete. Identify the distal dough-nut and send it for
histological examination.
o Perform a digital rectal examination to exclude any palpable
abnormality.
o Checklist
  Wash out the paracolic gutter with warm isotonic saline and make sure there is
no bleeding, particularly in the region of the splenic flexure and spleen.
 Check that the anastomosis is not under tension and that the proximal colon is
viable.
 Drain the pelvis to prevent an infected pelvic haematoma, using a suction drain
inserted through a stab wound in the left iliac fossa. Meticulous haemostasis is
preferable.
 Replace the small bowel and cover it with the omentum before closing the
abdomen

Postoperative Care

 A nasogastric tube is occasionally required to deflate the stomach for better exposure of the
transverse colon and splenic flexure. Re-move it at the end of the operation before the reversal
of anaesthesia.
 Postoperative feeding can be started as early as the day of operation, or on the first
postoperative day if there is no evidence of nausea or abdominal distension.