Abdominal wall hernias

Hernias are abnormal protrusion of an organ through a weakness/defect in the body wall that contains it. Classifications include groin hernias, ventral abdominal wall hernias (umbilical, femoral), incisional, Spigelian, and lumbar hernias. Inguinal hernias are the commonest types of abdominal wall hernias (~75%). Male are affected 15-times more frequently. Hernias are more common in smokers, patients with underlying connective tissue disorders (Ehlers Danlos Syndrome, Marfan syndrome), and patients with increased intra-abdominal pressure (obesity, heavy lifting, chronic cough, and chronic straining during defecation and urination). Hernias present as incidental finding on imaging, asymptomatic lumps, painful lumps, or incarcerated or strangulated hernias. Clinical history and examination are the mainstay of diagnosis. Most hernias are treated with surgical repair (open or laparoscopic). Conservative wait and watch policy is indicated in some cases.

Carotid artery stenosis

Carotid disease is often asymptomatic but can lead to strokes, transient ischaemic attacks (TIA), or amaurosis fugax. This chapter explores the pathogenesis of the disease and examines the investigations often used to diagnose the severity of the carotid stenosis. It details the ABCD scoring system for TIA evaluation and the features in the carotid ultrasound scan that are used to establish the degree of stenosis. A recommended approach to managing symptomatic and asymptomatic carotid disease is described.

Surgical management of liver metastasis

The liver is the most common site for metastases. Perioperative investigations are explored and are critical to the decision as to whether liver metastases should be treated with curative intent. Careful preoperative staging and discussion at a multidisciplinary team meeting is standard practice in established units. This chapter examines surgical management options as well as the neoadjuvant therapies. It details a treatment algorithm for synchronous metastatic colon cancer. It explores newer techniques for improving resectability.

Pancreatic cancer

Pancreatic cancer is the tenth most common cancer in the UK and is most often incurable at diagnosis. Presentation is generally with weight loss, jaundice, and or abdominal pain. Abdominal ultrasound, CT and MRI may be diagnostic. Tissue diagnosis is not usually necessary, but endoscopic ultrasound can obtain fine needle samples. The serum marker CA19-9 may be raised, but is not a screening test. Potentially curable lesions need careful multidisciplinary assessment for resectability, and a thorough assessment of patient fitness. The Whipple procedure is discussed as well as laparoscopic pancreatectomy. Adjuvant chemotherapy and palliative gemcitabine therapy are also covered.

Constipation in adults

Constipation is often a multifactorial condition and requires careful history and examination. Definition is according to the Rome criteria. A holistic approach is required with attention to diet, lifestyle, and patient education, as well as laxative treatment. The latest medical treatments including prucalopride and lubiprostone are discussed with specific indications. Few patients will require formal investigation, but those who do need a structured approach which is covered in this chapter.

Gastric cancer

Gastric cancer presents in the majority of cases at a locally advanced/metastatic stage. Initial investigations should be on the dyspepsia pathway. Multiple biopsies are necessary from any suspicious endoscopic lesions. Accurate staging and MDT assessment is essential for optimum patient selection for surgery. Endoscopic resection can now be recommended for very early lesions with good prognostic features. In gastrectomy, controversy exists across the world as to the extent of lymphadenectomy. This is discussed, as well as neoadjuvant and adjuvant oncological therapy.

Achalasia

Achalasia is an unusual motility disorder and is poorly understood. Accurate diagnosis is essential with a management plan tailored to severity of disease. The chapter describes diagnosis and management pathways including the place of dilatation, management of difficult cases with surgical myotomy, as well as a summary of newer treatments.

Principles of nutritional support

Malnutrition is a commonly found risk factor in hospitalized patients. All hospital patients, especially the high-risk ones, should be offered nutritional screening. Methods of screening include MUST (Malnutrition Universal Screening Tool) and the patient should have a thorough clinical assessment and investigations. The patient should meet adequate calorie requirement either by oral or enteral or parenteral nutrition. Malnourished patients receiving nutrition supplements demonstrated lower infection rates and shorter length of hospital stay compared to no supplements.

Sepsis and septic shock

Sepsis is very common; however, goal–directed therapy significantly helps to reduce mortality rate following septic shock. Sepsis Six should be delivered within one hour of initial diagnosis of sepsis. The sepsis resuscitation and management bundle includes delivery of high flow O2, blood culture, measurement of lactate, empirical antibiotic therapy, and IV fluid resuscitation and renal support.

Venous thromboembolism (VTE) prophylaxis

Venous thromboembolism is a common but largely preventable complication following surgery. However, fatal complications can occur as a result of pulmonary embolism following deep vein thrombosis. A structured risk assessment should be performed preoperatively in all surgical patients and thromboprophylaxis measures should be tailored according to patient- and procedure-related factors. These measures include anticoagulation with low molecular weight heparin and the use of mechanical compression devices.