Bailey 28th Updates Part 1 Br Dr RRM.pdf

Bailey 28th
Edition INICET
Updates- Part 1
FOR INI CET PG 2023 and
For INI CET SS 2023 ( General part)
Bailey updates by Dr Rajamahendran – Surgery Faculty
Doctutorials

Topic 1 : Necrotising Pancreatitis
• A Diabetic patient presented with complaints of trauma, followed rapidly spreading
infection as shown. False statement is
a. Infection is usually polymicrobial- But monomicrobial with Beta Hemolytic Streptococci
may be seen
b. Dish water pus is seen on examination
c. Hyperbaric oxygen is very helpful
d. Biopsy of facial layer confirms the diagnosis
e. Second look operation may not be needed
( Ref Bailey and Love 28th Edition Page 33, 58 and 456, 645)
Bailey updates by Dr Rajamahendran

Necrotizing Pancreatitis
• Severely Rapidly progressing Infection of Soft tissue and Fascia associated with significant morbidity
and mortality
• Most commonly Polymicrobial ( but monomicrobial with Gr A Streptococcus also seen frequently)
• It is termed Fournier’s gangrene when it affects the perineal area and Meleney’s gangrene when it
involves the abdominal wall.
• The underlying pathology includes acute inflammatory infiltrate, extensive necrosis, oedema and
thrombosis of the micro vasculature. The area becomes oedematous, painful and very tender.
• The skin turns dusky blue and black secondary to the progressive underlying thrombosis and necrosis.
• There is usually a history of trauma or surgery with wound contamination.
• Diabetes mellitus is the most common comorbidity, although up to 30% of patients may not
have any comorbidities.
• It remains primarily a clinical diagnosis and surgical treatment should not be delayed if suspicion is
high.

Finger Probe test
• The subdermal spread of gangrene is always much more extensive than appears from initial
examination.
• The diagnosis is made on clinical grounds.
• Creatinine kinase levels may show enormous elevation and biopsy of the fascial layers will confirm the
diagnosis
• The finger test can be used in the diagnosis of patients who present with suspected necrotising
fasciitis. The area of suspected involvement is first infiltrated with local anaesthesia.
• A 2-cm incision is made in the skin down to the deep fascia.
• Lack of bleeding is a sign of necrotising fasciitis.
• On some occasions, a dishwater-coloured fluid is noticed seeping from the wound.
• A gentle, probing manoeuvre with the index finger covered by a sterile glove is then performed
at the level of the deep fascia.
• If the tissues dissect with minimal resistance, the finger test is positive.

IOC
• Tissue biopsies are then sent for frozen section analysis.
• The characteristic histological findings are obliterative vasculitis of the subcutaneous vessels, acute
inflammation and subcutaneous tissue necrosis.
• If either the finger test or rapid frozen section analysis is positive, or if the patient has progressive
clinical findings consistent with necrotising fasciitis, immediate operative treatment must be initiated.

• Renal failure may occur as a result of hypovolaemia and cardiovascular collapse caused by septic
shock.
• The rate of progression is dramatic and unless aggressively treated it leads to serious
consequences with mortality approaching 70%.
• Treatment consists of appropriate intravenous antibiotics with urgent radical surgical debridement.
• A second look operation is usually planned in 24–48 hours depending on clinical response.
• Multiple debridements may be required.
• High-dose penicillin G along with broad-spectrum antibiotics, such as third-generation cephalosporins
and metronidazole, are given intravenously.

New update – Hyperbaric Oxygen role?
• The cornerstone of management is surgical excision of the necrotic tissue.
• The devitalised tissue is removed generously, going beyond the area of induration. The wound is
lightly packed with gauze and dressed
• This process is repeated daily as the necrosis is prone to spread beyond the edges of the excised
wound.
• In patients who survive, this results in a large wound, which will require skin grafting or fap coverage.
• Recently, the role of hyperbaric oxygen (HBO) has become more established with a reduction in
mortality in patients treated with HBO (9–20%) compared with patients who did not receive HBO
(30–50%).

Topic 2 Surviving Sepsis Guidelines
Regarding the latest update of Sepsis six- the components includes all except
a. IV fluid challenge
b. IV antibiotics
c. Oxygen
d. Blood transfusion
( Ref Bailey 28th Page 59)

• The Surviving Sepsis Campaign continually develops and updates resources and implementation tools
to further its mission of reducing sepsis and septic shock.
• The sepsis bundle, also known as the resuscitation bundle, is a combination of evidence-based
objectives that must be completed within 6 hours for patients presenting with severe sepsis, septic
shock and/or lactate >4 mmol/L.
• The Sepsis Six is the name given to a bundle of medical therapies designed to reduce mortality in
patients with sepsis.
• Drawn from international guidelines that emerged from the Surviving Sepsis Campaign, the Sepsis Six
was developed by the UK’s Sepsis Trust.

The components of the Sepsis Six are
• Give three to patients: (1) intravenous fluid challenge, (2) intravenous antibiotics, (3)
oxygen and monitor urine output;
• Take three from patients: (4) blood cultures, (5) full blood count, (6) lactate.

Topic 3 : Comparison of Cutting and Coagulation in Diathermy
True/ False: regarding the Cutting and coagulation properties of monopolar diathermy
a. Cutting has low voltage current
b. Coagulation has 94%off and 6% on time of current flow
c. Coagulation has extensive lateral spread of energy
d. Coagulation works better when probe is held just above the tissue with no contact or minimal
contact

Comparison of Cutting Vs Coagulation
currents

Topic 4: Drain Placements
• Current role of Drain placement- the following surgeries drains are considered
routinely except:
a. Modified radical mastectomy
b. Colonic surgery
c. Esophageal surgery
d. Pancreatic surgery
( Bailey 28th Page 114)

Drain updates

Topic 5: Obesity and Day Care surgery
As per 2019 guidelines, ( SOBA Red flags ) Bariatric patients are contraindicated to
undergo Day Care Surgery if following are seen except
a.IHD
b.SaO2 is< 94%
c. STOP BANG score <5
d.OS- MRS >3
( Bailey 28th Edition page 301)

SOBA Guidelines
• Traditionally there has been caution treating patients who have a higher BMI as a day case.
• Guidance from the Association of Anaesthetists of Great Britain and Ireland/BADS in 2019 states that
‘even morbidly obese patients can be safely managed in expert hands, with appropriate resources’.
• Preoperative assessment of patients should routinely include STOP-BANG (Snoring, Tiredness,
Observed apnoeas, Pressure [hypertension], Body mass index, Age, Neck circumference, Gender) to
identify undiagnosed OSA (obstructive sleep apnoea).
• The Society for Obesity and Bariatric Anaesthesia (SOBA) Guideline for Anaesthesia of the obese patient
identifies a number of risk factors that may make day surgery unsuitable, e.g. poor functional capacity,
oxygen saturation <94% on air, STOP-BANG ≥5

Topic 5: Pericardial Tamponade
False statement regarding penetrating Trauma causing pericardial tamponade
a.Classical presentation is elevated CVP+ Low BP+ Muffled heart sounds
b.E Fast is most reliable diagnostic tool
c. Pericardiocentesis is done immediately
d.Neck veins may be flat if there is any other massive bleeding associated
Bailey 28th Page 375

Topic 6: Concept of two depth Burns
Nikolsky sign ( Peeling of skin ) is absent- the burns is
a.Epidermal
b.Superficial Dermal
c. Deep dermal
d.Full thickness

Topic 7: Molecular classification of Breast cancer
Claudin Low type of Breast cancer is characterised by
a. Hormone receptor negative, HER 2 negative, Claudin low
b.HR +ve, HER2 negative, ki 67 high
c. Ki 67 low, Claudin high
d.HER 2 +, ER, PR+Ve, Claudin Low

Topic 8 : FLIP
Endoluminal Functional Lumen Imaging Planimetry is used for
a. Diagnosing cancer depth
b. Detect GERD Scores
c. Guide to intraoperative end point of completeness of myotomy for achalasia
d. Used to diagnose Zenker

Topic 8 : FLIP ( Ref Bailey 28th Page 1113)

Topic 9: Eckardt Score
• Eckardt score to monitor the response of treatment for Achalasia includes
a.Weight loss
b.Dysphagia
c. Retrosternal pain
d.Regurgitation
e.All the above

Topic 10: Caustic Injuries
The following statement is false about the treatment of Caustic injuries
a. No role for gastric lavage or neutralisation of acid or alkali
b. No evidence of use of steroids as systemic or Intralesional to reduce stricture
c. Long strictures cannot be dilated and hence posterior mediastinal route is used to
bring stomach to neck
d. Zargar classification is used for caustic damage

Corrosive stricture concepts
• A stricture can form early and may be resistant to dilatation
• There is not enough evidence to support routine use of systemic steroids, intralesional injection of
steroid or topical mitomycin C to reduce stricture formation.
• Endoscopic dilatation should be gradual, as the perforation rate is higher than in other forms of
strictures.
• Long strictures are often resistant to dilatation.
• Oesophagectomy or bypass surgery may be required.
• Oesophagectomy has the advantage of removing the oesophagus with its long-term risk of malignancy.
However, surgery is difficult because of scarring and adhesions to the mediastinum, thus a bypass
operation may be preferable.
• The gastric conduit is placed in the retrosternal route to reach the neck.
• When it is also damaged and cannot be used, a colonic interposition is the alternative.
• The native oesophagus can be left in situ as the risk of dilatation and resultant mucocele is low.

Topic 11: Rockall Score
• Rockall score value of 3 is given for
a. Malignancy causing bleeding
b. Spurting vessel in Duodenal ulcer
c. Liver failure
d. BP<100 mmHg

Rockall score

Topic 12: ALPPS Procedure for Extended Liver
resection
ALPPS Is a procedure done for cases when there is
a. FLR inadequate
b. Children
c. Old age
d. Cirrhotic livers

ALPPS’ stands for Associating Liver Partition and Portal
vein Ligation for Staged hepatectomy and was frst
described in 2011.
• It is the most recent modification of techniques developed to facilitate two-stage hepatectomies for
resection of widespread or extensive liver tumours and employs the remarkable capacity of the liver to
regenerate.
• ALPPS involves two stages.
• Initially the right portal vein is ligated and, depending on the distribution of the tumour within the
liver, transection is performed as for a formal hemi hepatectomy or left lateral segmentectomy (in situ
splitting).
• In contrast to a classical hepatectomy, the liver containing the tumour(s) is left in situ and remains
vascularised by the right hepatic artery and the biliary and systemic venous drainage, represented by
the right bile duct and hepatic veins, preserved.
• The second stage of the procedure is performed 1–2 weeks after the first stage following CT
demonstration of adequate hypertrophy; the involved liver is resected after division of the right
hepatic artery, bile duct and hepatic vein. Initially ALPPS was associated with significant morbidity
and mortality but modifications of the technique, particularly a reduction in the amount of liver
transected, improved results.

TOPIC 13: PSA screening
• PROTECT Trial update in UK says
a. PSA Screening mandatory from 60 years
b. PSA Screening must from 50 years
c. PSA Screening not done
d. PSA Screening+ MRI is must

Ref Bailey and Love 28th Edition page 1532

Topic 14: Nephron Sparing Surgery in RCC
• The following are indications of Nephron sparing surgery in RCC
except
a. Tumors <4cm
b. Selected tumors 4-7 cm
c. Renal failure cases
d. Bilateral tumors
e. All above
Bailey 28th Edition page 1483

Nephron-sparing surgery (Partial
nephrectomy)
• Small renal masses (tumours <4 cm)
• Well-selected tumours between 4 - 7 cm
• Bilateral tumours
• Tumours in solitary kidneys
• Patients with pre-existing renal dysfunction.

Topic 15 Refeeding Syndrome Update
• A patient is considered to develop Refeeding syndrome is- one or
more of the following seen except
a. BMI<18.5
b. Weight loss >15% in 3-6 months
c. No nutritional uptake for 10 days
d. Low Potassium while starting to refeed
( Ref Bailey update 28th Page 340)

• Nutritional support in this group of patients should be started at a maximum
of 10 kcal/kg per day, aiming to increase levels slowly to meet full needs by 4–
7 days.

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