Journal Club

Next journal club - 13th December 2010
Presenter : Dr. Krishna

Radiofrequency Ablation in Barrett's Esophagus with Dysplasia
The New England Journal of Medicine
May 28, 2009
Vol 360 No 22

Background
Barrett’s esophagus, a condition of intestinal metaplasia of the esophagus, is associated
with an increased risk of esophageal adenocarcinoma. We assessed whether
endoscopic radiofrequency ablation could eradicate dysplastic Barrett’s esophagus
and decrease the rate of neoplastic progression.
Methods
In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic
Barrett’s esophagus in a 2:1 ratio to receive either radiofrequency ablation
(ablation group) or a sham procedure (control group). Randomization was stratified
according to the grade of dysplasia and the length of Barrett’s esophagus. Primary
outcomes at 12 months included the complete eradication of dysplasia and intestinal
metaplasia.
Results
In the intention-to-treat analyses, among patients with low-grade dysplasia, complete
eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared
with 22.7% of those in the control group (P<0.001). Among patients with highgrade
dysplasia, complete eradication occurred in 81.0% of those in the ablation group,
as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of
patients in the ablation group had complete eradication of intestinal metaplasia, as
compared with 2.3% of those in the control group (P<0.001). Patients in the ablation
group had less disease progression (3.6% vs. 16.3%, P = 0.03) and fewer cancers
(1.2% vs. 9.3%, P = 0.045). Patients reported having more chest pain after the ablation
procedure than after the sham procedure. In the ablation group, one patient had
upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture.
Conclusions
In patients with dysplastic Barrett’s esophagus, radiofrequency ablation was associated
with a high rate of complete eradication of both dysplasia and intestinal metaplasia and
a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Need help.

I'm seeking help from the medical officers/registrar for contributing more to our blogspot. You are required to jot down the question and answers during our morning discussion i.e. journal club, RECAP etc.. then post it our blogspot.

Pls email me if you are interested so i can give clearance.

Thank you,

Zairul

The Major have spoken!

Thanks to Major (Dr.) Ngoo for his contribution. Gun-salute!

Question for Part II (Viva) Ms

Principles of surgery tables (i) and (ii)

1. Scenario: 70 years old man PR bleed came to you. Whilst assessing him, the patient developed torrential PR bleed. You are preparing to take him to OT for emergency total colectomy. Patient’s daughter came and asked about (a) her father’s prognosis, (b) whether you can guarantee that his father will recover.

2. You said no guarantee. So she said no need to go for OT because the patient is already old and unlikely to survive anyway. So what do YOU want to do now?

3. So you would still proceed with emergency surgery. But her daughter would not consent it. What next?

4. So you would get 2 consents from senior consultants for the patient. But your anaesthetist would not agree to consent. Furthermore, your anaesthetist is agreeable with the patient’s daughter, that is, no need surgery. What next?

5. Ok the patient survived and thanked you for saving him. Tell me the body’s physiology of this patient when he was losing blood per-rectally (Answer: discuss Baskett’s classification of shock…read Prof Mike Wyatt’s article in Surgery International published just before exams).

1. You are a senior consultant. Your elective OT has listed a 7 y/o boy for herniotomy, a 70 y/o Diabetic man for some surgery, and two other middle-aged ladies for operations too. Tell me the principles of organizing the OT list.

2. You said pre-operative work-up must be done. What is the concern here? (Answer: make it safe for surgery) and how do you address the concern? (Answer: tell all the characteristics of Safe Surgery initiative by WHO)

3. Now, how would you prepare the patients individually? (Answer: focus more on diabetic man, whether he has good DM control, diet-controlled, OHA-controlled, or insulin-controlled DM).

4. How would you prioritise?

5. Why would you prioritise?

6. Why should a young boy go before an elderly diabetic man? If you do not list the boy as the first in the list, what difficulties will your run into?

7. Can you prioritise the diabetic man instead, and if so, give your reasons.

1. Tell me in what situations of trauma that patients can be managed conservatively?

2. In what situation of abdominal trauma would you consider conservative management?

3. Tell me about the grading of solid organ injury and how you would re-act to it.

4. So a patient with abdominal trauma came to you, how would you assess for bleeding intra-abdominally and how this would influence your management (what parameters come to mind and how do you address this).

5. What would make you go for operative management subsequently?

1. As a surgeon, what influences your surgical incision. Tell me the principles of creating a surgical wound.

2. You commonly encounter surgical patients needing dialysis. Tell me, in what situations would dialysis be required.

3. You said renal failure. Can you tell me about renal failure, how you would assess for it and what are the implications of renal failure?

4. What types of dialysis do you know of and how do you choose.

5. You said haemodialysis through a femoral access. Tell me what are the complications associated with central venous catheterization.

6. The patient ended up needing a long-term haemodialysis. How would you go about this?

7. Where do you want to create your haemodialysis access?

8. What are the principles of creating a haemodialysis access?

Pathology Table

If given picture slides, start with, “I can see (describe like you see an alien)…”

Questions using picture slides – this is variable

1. A man’s buttock with a huge swelling (describe). It drained pus. What are the possibilities? Who gets this type of swelling? What is the possible micro-organism? What are the other more sinister causes of this swelling ? (Answer: psoas abscess, tuberculous spinal abscess)

2. Bilobar structure joined in the middle, lobulated (Dx: thyroid gland, multinodular goiter)

   1. What is this and why do you say so?

   2. So you say it is a multinodular goiter, what is your management?

   3. You want to offer total thyroidectomy. What are the complications?

   4. What if you do a subtotal thyroidectomy ?

3. Interjected question

   1. You mention tumour thrombus. What is your understanding of it?

   2. Give other examples where you get tumour thrombus apart from renal carcinoma

Using picture slides – this is variable

1. bladder calculi and prostate gland (identify the specimens and mention why)

   1. What is the relationship?

   2. What is the effect of bladder outlet obstruction?

   3. What is the effect of bladder calculi?

2. CT scan (please describe >> cystic lesion of the right kidney, loss of architecture of the left kidney)

   1. What do you think this is?

   2. How do you diagnose renal cell carcinoma? (Answer: change in Hounsfield unit on CT scan by 20-25, pre and post contrast)

   3. What treatment would you offer assuming that the contralateral kidney is normal?

Non-picture slide question:

1. What is an incidentaloma and give some examples.

2. How would you go about investigating for one?

3. What would suggest to you that an incidentaloma needs to be treated?

Operative table:

As I describe the procedure, he will intercept and focus on fine nitty, gritty details.

1. How do you perform a femoral embolectomy ?

2. How do you consent the patient for the surgery?

3. What sizes of Fogarty’s catheter would you prepare and how do you prepare it?

4. So you would obtain proximal and distal control. What would you be using ?

   1. So you said vascular loops. How do you apply them? Are you going to use vascular clamps?

   2. How do you keep your loops taut?

5. Hold on, before you perform the arteriotomy, would you not want systemic heparinisation? What dose of heparin ?

6. What arteriotomy incision would you make and why?

   1. So you choose a longitudinal incision, why not a transverse?

   2. So what is the problem with a transverse incision?

   3. What is the problem with a longitudinal incision?

7. So you have opened up the vessel, and you said you will assess from proximal inflow but usually there will be poor inflow anyway, otherwise you will not end up with an acute limb ischaemia. What catheter size would you choose for proximal embolectomy?

   1. How about distally?

   2. And how much air or water are you inflating the balloon catheter with?

8. Would you be satisfied after removing the emboli?

1. Describe how you would go about a performing a proximal ureterolithotomy.

2. How do you identify the 12^th rib?

3. Do you muscle cut or muscle split?

4. So you have seen the ureter and you said that you want to apply distal and proximal control. Is that really necessary?

   1. Ok I agree with proximal control but why do you think it is important?

   2. How about distal control, is it necessary?

   3. Now you have removed the stone, what else would you do?

   4. You said you want to insert a ureteric stent, which type and how do you place it?

   5. How are you going to manage the stent?

Good luck !

KS Ngoo
Nov 2010

Rise again...

It has been a long time since the last entry...

Question that was being asked during my previous part II exam in USM. I hope these will help, can't remember everything exactly. For those who would like to contribute pls email it to me at zairulazwan@gmail.com, I will post it in this blogspot for the rest..

Long case:

- bilateral staghorn calculi with hydronephrosis

- causes of renal calculi

- risk factors developing renal calculi

- need to know the difference between DTPA and DMSA

- which is the commonest type of renal stone

Short case:

1. An elderly lady with large thyroid swelling and lymph node

- made a diagnosis of papillary thyroid carcinoma

- was ask for other differential diagnosis

- how to manage

- if the patient refuse for surgery what other modalities of treatment?

2. A young man with abdominal incisional hernia

- had laparotomy due to MVA

- was ask of type of repair; open vs laparoscope

- what type of mesh to use

- this patient had a burst abdomen after the laparotomy, was ask what are the most likely causes and how to prevent burst abdomen

3. A young lady with lipoma over the clavicle, about 3 x 4cm

- differential diagnosis

- how to differentiate between the differential

- for excision biopsy where would you place you incision

- show how you do 'slip' sign

- what is dercam disease?

Viva:

1. Pathology table

showed specimen / pictures, alhamdullilah no histopathology slides

a) dilated small bowel - intussusception of small bowel

- why you say this is small bowel?

- causes of intussusception?

b) picture of resected small bowel with 3 polypoidal lesions

- described the picture

- associated disease

c) partial gastrectomy specimen

- possible reason of gastrectomy

d) cut opened stomach with ulcer

- described and show the edges of the ulcer

- how to do classify stomach CA

- what is Borrmann and Laurens classification

e) Hip X-ray with multiple lytic lesion and pathological fracture neck of femur

- most likely primaries

d) MRCP film

- delineate the anatomy

- what is the most likely diagnosis - it was a cholangiocarcinoma... i think

e) Cut specimen of an abdominal aortic aneurysm

- how many ways to classify aneurysm

- difference between true and false aneurysm

- causes of AAA

f) A picture of a gangrene leg

- describe the gangrene and the edges

- how do you investigate and manage

- if this was due to a snake bite, what type of snake would cause it?

- type of venom i.e. neurotoxic, myotoxic, hemotoxic

2. Principal 1

a). was ask about retroperitoneal hematoma

- how to classify abdominal trauma? - blunt vs penetrating injury

- structures in each zone

- how do you manage for each zone

- when do you go in or observe

b). abdominal wound dehiscence and burst abdomen

- how to classify wound dehiscence

- what clinical signs to say wound dehiscence

- how to manage

3. Principal 2

a.) patient post laparotomy for PGU developed fever

- causes of postop fever

- how to investigate and manage

b.) patient post total thyroidectomy,

i. when do you stop carbimazole and propanolol? why?

ii. pt complain of numbness, what would you checked?

iii. what treatment to administer for hypocalcemia?

iv. what are the complication of hypocalcemia?

c.) was ask about body response to injury/surgery

i. talked about the erb and flow phase, what happen during these phase

ii. post op IVD to give all NS or mixture of NS and dextrose, why?

4. Operative

a.) Patient with obstructed sigmoid tumour

- how to do take consent for this patient?

- talked about hartmanns or colostomy

- what is hartmanns procedure

b.) how to do you do hemithyroidectomy

- post-op what do you look for?

c.) what is informed consent?

d.) what is suture and how to do classify sutures?

- give example

- where does cat-gut comes from? cattle - sheep

- which part of sheep does catgut comes from

- where does silk sutures comes from

There might be more, if later i recall i will post it..

All the best to those who are going to sit for the final exams

' Try your best and let Allah do the rest'

' To succeed is easier than to fail' ... (Fadzilah Kamsah)