E38 Mock Oral #1 With Caitlin Cahill and Greg Knapp

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Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it. Welcome to a special recording of Cold Steel. In an effort to deliver creative and innovative content, we’re excited to bring you a mock oral examination. Not to worry no resident was hurt during the creation of this podcast but my cohost Ameer Farooq was kind enough to act as a guinea pig and be the examinee. So thanks to Ameer for his continued bravery and mental toughness. I’d like to invite you to listen to the next wonder of the world and extravaganza so remarkable and leave you breathless, you’ll laugh you’ll cry, but you won’t forget. Our examiners today may not be household names quite yet, but they are destined for big things. In the left corner wearing red today, and an undisclosed weight is Caitlyn the assassin Cahill. Caitlyn grew up in Montreal and completed her undergrad at McGill. She eventually went on to residency in Ottawa and is now enjoying her first year of a colorectal fellowship. This has given her ample opportunity to develop a plan to attack towards our examinee today. In the right corner, wearing red as well and weighing in chiseled and pharmacologically enhanced 222 pounds is your second examiner Dr. Greg the hammer Knapp. The Hammer grew up on the mean streets of Grimsby, Ontario. He barely escaped, but eventually managed to McMaster for medical school and Dalhousie for surgical residency. He worked for years and is now a star surgical oncology fellow. Greg has been plotting rebuttal for Ameer since the incident known as the Pickle Problem as best said by Apollo Creed in the final scene of Rocky three “Ting, Ting.”

Caitlin Cahill  02:15

Okay, so you have a 47-year-old male, he’s previously healthy and he presents to the emergency department with a 14 hour history of severe epigastric pain and vomiting. His temperature is 38.2, heart rate 140, blood pressure 97 over 68 and SATs are 96% on room air. In the emerge he gets two liters of Ringer’s lactate and some basic labs are drawn. His white count is 19, haemoglobin 155, bilurubin is 34, ALT/AST are around 100 and lipase is 17,000. A CT scan shows a calcified gallstone in the gallbladder, a four millimeter common bile duct, moderate abdominal ascites, marked peripancreatic inflammation and necrosis of the entire pancreatic body which is 80% of the gland. How will you manage this patient and discuss the role for antibiotics?

Ameer Farooq  03:12

So this is a 47-year-old male who’s presenting with severe acute necrotizing pancreatitis with gallstone origin. This patient needs to be treated with supportive therapy. And this patient appears to be potentially at high risk of getting quite ill. So I would consider admitting this patient to the intensive care unit if I felt that the patient’s trajectory was that on a worsening course. Otherwise, I would continue with fluid resuscitation of this patient as well as good pain control. I would attempt to establish nutritional access for this patient, either orally via NG or nasoduodenal or masojejunal feeding. And finally, in terms of antibiotics, I would not start this patient on antibiotics unless they developed obvious air in the gland or had some other feature to suggest an infection or or or if they continue to worsen in the intensive care unit, then I might reconsider antibiotics but I would not give them antibiotics at this point.

Caitlin Cahill  04:47

Okay, so the patient is admitted to the general surgery ward. Despite significant IV fluid administration four hours later, his heart rate is still 120, his urine output is 10 to 15 cc an hour. His abdomen is progressively distended and the patient is confused and agitated. He now requires four liters of oxygen by nasal prong and is desaturating to 88%. His temperatures 38.6 What is your management now?

Ameer Farooq  05:17

So, this patient is continuing to deteriorate on the general surgery ward. And he likes likely need more intensive monitoring in the form of ICU care. And so I would consult my ICU colleagues for admission in the intensive care unit and monitor his urine output closely and particularly monitor for abdominal compartment syndrome.

Caitlin Cahill  05:54

Okay, so the patient has transferred to the ICU. Within two hours of being there, he’s intubated. A chest X-ray shows a left pleural effusion. His saturation improves on A/C ventilation with a PEEP of 10 and FiO2 of 60%. How would you advise the ICU to manage his nutrition?

Ameer Farooq  06:14

So these patients can be fed orally, I would ask the ICU to continue to feed this patient with NG feeds. And if he doesn’t tolerate that, then ask them to get our radiology colleagues to to put the tube further down either into the duodenum or into the jejunum that could continue with enteral feeds in that form.

Caitlin Cahill  06:42

So his abdomen remains distended with no stool per rectum. his bladder pressure is 22 millimeters of mercury. Abdominal X ray shows a distended stomach distended small bowel. There’s a small amount of air in the left colon, his peak respiratory pressures have not increased over the course of the day, urine output remains poor at 10 cc per hour. Discuss the diagnosis and management of abdominal compartment syndrome.

Ameer Farooq  07:08

So the abdominal compartment syndrome is a constellation of findings that are manifestations of increased intra-abdominal pressure. These include renal failure, and respiratory failure, as well as potentially intra-abdominal ischemia. So these would be manifested in in the forms of an increase in creatinine, poor urine output as well as increase in ventilatory pressures. Another potential marker of this is bladder pressures over 20. So certainly this patient has some features of abdominal compartment syndrome. However, I don’t know what the creatinine is. And the respiratory pressures have also not increased over the course of the day. To manage abdominal compartment syndrome, I would consider first adjunctive therapy such as paralyzing the patient. But ultimately, if, if the patient continued to have compartment syndrome, the ultimate management would be decompressive laparotomy.

Caitlin Cahill  08:42

So over the course of the next seven days, the patient improves. He is awake alert and weaning off of the ventilator, NJ feeds are going well and his labs are normalizing. On post admission day 10, his heart rate jumps to 115, his temperature is 39.5 and his white blood cell count goes from 14 to 22. What would you like to do?

Ameer Farooq  09:04

So given that there’s a change in the patient’s picture, I would repeat this patient’s CT scan to see if there’s been any change after I sorry, after repeating a history and physical exam to see if there’s any obvious sources for what looks like a septic picture. So for example, an infected line or skin rash, I would repeat a CT scan.

Caitlin Cahill  09:34

So you get a CT abdomen and pelvis and there’s a walled off fluid collection comprising the body of the pancreas posterior to the stomach. There’s rim enhancement effect and a few small collections of air in the fluid collections. What is the diagnosis and how will you manage this?

Ameer Farooq  09:51

So I would consider so this is a peripancreatic fluid collection. Their walled or walled off necrosin. I would consult my HPB colleagues for their suggestions, as well as review the images with my interventional radiology colleagues. Given that he has a fever as well as collections of air, he might be a candidate for drain. But certainly I would have my HPB colleagues look at this as well and get their suggestions prior to intervening as it may affect further interventions down the road.

Caitlin Cahill  10:44

Okay, so so what exactly do you want to do?

Ameer Farooq  10:47

I would drain these this fluid collection.

Caitlin Cahill  10:50

Okay, anything else?

Ameer Farooq  10:52

I would also potentially I would also start this patient on antibiotics.

Caitlin Cahill  10:56

Okay, what kind?

Ameer Farooq  10:58

I would use IV meropenem.

Caitlin Cahill  11:03

When would you recommend this patient undergo a cholecystectomy?

Ameer Farooq  11:07

This patient could go undergo a cholecystectomy once they were out of the way, once their necrotizing, pancreatitis had completely settled down. So obviously, I would wait for this patient to be out of the intensive care unit and be at home and I’d probably wait two to three months prior to recommending a cholecystectomy just to allow any ongoing inflammation from the patient pancreatitis to settle down.

Caitlin Cahill  11:40

Okay, that’s it. Good job.

Ameer Farooq  11:43

Thank you. That was a good one.

Caitlin Cahill  11:49

And so should I debrief?

Ameer Farooq  11:50

Yeah, that’d be great.

Caitlin Cahill  11:52

Okay, perfect. So, so I think you did really well, like in terms of knowledge and content, no concerns at all, you answered everything pretty much perfectly. So I just made a few notes here. Yeah, so in the beginning, that’s really good. So I think one of your strengths is that you’re good at sort of summarizing the situation and kind of like, and I think that’s a form of you mentally, making sense of the story and everything in your head. So I think that’s really good. But at the same time, just be careful to not be too wordy, because you do lose some time. And like, I didn’t actually time this, but in the actual exam, the questions will be, you know, five or 10 minute questions. And so you just don’t want to lose time being a little too wordy. So like, for example, when we got to the CT scan, I just sort of like moved you along, because I knew you like you said what you wanted to do, but then you started going down a little bit of a rabbit hole of discussion as to why and I was like, Hey, I know. Okay, good. I just wanted you to say CT scan. But no, that was really good. I really don’t have too much to say otherwise.

Ameer Farooq  13:06

I hope Dr. Ball didn’t have a seizure listening to me talk about this pancreatitis patient.

Chad Ball  13:15

No that that was good, Ameer, I agree with Caitlin, your your style was good. Your flow was good. You didn’t use a lot of extra words. You were pretty directed. It’s interesting question that way, you know, if you’re an examinee, and and you feel that the content of the question is a little bit off, and that can happen. You know, the content in that particular question, you know, is a bit off, there’s not in terms of in terms of purely what you should do there, there really is no scenario where you should intervene in that patient with percutaneous techniques or endoscopic techniques before 30 days. That patient’s getting better. They don’t need antibiotics. There’s a whole bunch of nuance there that really will be limited to someone who does a lot of pancreatitis as a pancreas surgeon. And that doesn’t necessarily mean the answers that you’re that they’re looking for are going to be correct.

Ameer Farooq  14:08

Yeah. So this is one of the things Dr. Ball, like if, you know, if you look at salvaging over they’ll all talk about putting in a drain for someone who has air in a collection and fever. So I kind of knew that that’s where this was going. But I know certainly looking at your you know, the work that you put out that that’s not something that I might want real life.

Chad Ball  14:31

You know, I think the important point is not the individual question or the or the nature of what might be off about it. The important point is how you’re going to address that mentally and then verbally exam question. I think it is okay to say you know, traditional dogma would say do this and then sort of deliberate like you like you have, but if you’re concerned you can also say, but you know, in my experience in a high volume pancreatitis service, for example, would be this other alternative pathway or approach, which is reasonable as well. And I think just showing that sort of level of nuance if it makes you feel better and answering the question is okay, as long as as Caitlin says, you’re moving along quickly.

Caitlin Cahill  15:15

Yeah. And we had that sort of teaching as well, when we were preparing. Especially for subjects where there might be a little bit of institutional variation and how patients are managed. It’s very reasonable to say, at my institution, like this is how this would be managed, or in my training, this is how I manage this patient for topics that you know, there could be some difference in what the textbooks say to what is done in real life or even across the country, because that’s something that we found at the review course, was at different places manage things, slightly different. So I think, for example, in Calgary, I think you guys do some operative debridement through the stomach, is that right? Like through the back wall of the stomach? Whereas I’ve never seen that in my life. And, you know, the traditional kind of teaching is don’t operate on these patients. So there’s obviously variation and how things are managed. So I think that’s fine to at least acknowledge that.

Ameer Farooq  16:21

Yeah, Okay. Perfect. Thanks, Caitlin. All right, Greg. I think you’re up.

Greg Knapp  16:33

So, Ameer, I am going to time you. And so we try to make this if you do get a bit long winded, then I’ll either move you along or you won’t finish the station.

Ameer Farooq  16:46

Okay.

Greg Knapp  16:47

Okay. So here we go. So you see a 52-year-old woman with a new mass in the right breast at the 12 o’clock position. She’s got a BMI of 32. No past medical history to speak of. No relevant family history, and no significant breast health history. No skin changes on exam. There’s no obvious asymmetry, perhaps a bit of a fullness, difficulty to it’s difficult to palpate this lesion. Again, although maybe there’s a fullness at the 12 o’clock position. You’re axillary exam is negative, and she is perimenopausal. She comes with a with a diagnostic mammogram. She’s got a 3.3 by 3.5 centimeter speculated mass with internal calcifications. No other lesions in the breast. There’s one enlarged lymph node 1.2 centimeters with four millimeters of cortical thickening, that is suspicious. She is reported as a BIRADS 5. Core biopsy comes back in the breast as invasive ductal grade III ER +, PR -, HER2- axillary node is also positive for invasive ductal carcinoma. What is the next step in her management.

Ameer Farooq  18:02

So this is a 52-year-old female with a new breast cancer at a positive axillary node. This patient should be sent to medical oncology for consideration of neoadjuvant chemotherapy followed by either followed by a surgical resection.

Greg Knapp  18:25

Is there anything else that you would do at this time?

Ameer Farooq  18:27

I would also conduct a staging workup to including a CT chest, abdomen pelvis to ensure there is no other metastatic disease plus or minus an MRI if she had any neurological symptoms.

Greg Knapp  18:44

Any other staging investigations?

Ameer Farooq  18:46

I would do a CBC, Lytes and creatinine as well an LDH and a bone scan.

Greg Knapp  18:56

So patient has a CT chest, abdomen, pelvis, and no evidence of metastatic disease CBC is normal. LFTs are classic normal.Bone scan new evidence of metastatic disease. So what would you recommend at this point?

Ameer Farooq  19:09

So I would recommend that this patient be sent to medical oncology for consideration of neoadjuvant chemotherapy because of the positive axillary node.

Greg Knapp  19:26

This patient has a clip placed in the evolved node. She received six cycles of FEC-D. Repeat diagnostic mammogram and ultrasound demonstrates the primary breast lesion has responded three centimeters by 2.8. So it’s still evident. Clipped axillary node is measured at 0.8 centimeters with equivocal cortical thickening. Your clinical exam is unchanged. Patient wishes to have breast conserving surgery. What will you offer this patient?

Ameer Farooq  20:00

So, given that this patient would like to have breast conserving therapy that would be appropriate in this scenario, I would offer the patient a wire localized lumpectomy and set them on lymph node biopsy with with blue dye as well as liquid scintigraphy.

Greg Knapp  20:25

The patient has a lumpectomy plus lymph node biopsy with removal of the clip node. The final pathology is a T2N1 adenocarcinoma grade two negative margins LVI present, two of three nodes are positive with three millimeters of disease, no extra nodal extension, what would you offer? Or would you offer this patient any additional treatment? And then what adjuvant treatment would you expect this patient to be offered?

Ameer Farooq  20:55

So although this patient appears to only have T2N1, this is in the context of the patient having had neoadjuvant chemotherapy, given that she has not had a complete pathologic response, I would offer the patient a axillary lymph node dissection. The alternative would be to discuss this at a multidisciplinary or sorry, I would discuss this at a multidisciplinary tumor board meeting for any inputs from our radiation oncology colleagues as to whether axillary no dissection versus axillary radiation would be best for this patient. But I would offer this patient axillary lymph node dissection. This patient is ER +, PR -, HER2-. So I expect that this patient would would potentially be offered further adjuvant chemotherapy but no additional hormonal therapy.

Greg Knapp  22:06

Would she receive any other adjuvant treatment to the breast?

Ameer Farooq  22:11

Yes, she would receive radiation as well.

Greg Knapp  22:16

Would this candidate be a can’t with this patient be candidate for antihormonal therapy?

Ameer Farooq  22:26

She is ER + but PR -? She might be a candidate for hormone hormonal therapy.

Greg Knapp  22:36

Okay. That’s it. Well.

Ameer Farooq  22:42

Oh, boy. All right. Let me have it.

Greg Knapp  22:48

So. So again, you’re I think you’re warming up a little bit so that I thought that your I thought that your flow was your flow is better, your quicker. A little bit less a bit more to the point. In terms of going through that station, you certainly hit all the high points. I think you know that this would. Yeah, there were no, there were no red flags. So you move through it quickly. You hit all the key decision points. I think just remember on a couple times, I did have to kind of rephrase or ask you another question. And that’s okay. They think, you know, in my, in my experience, they would do that. That may be a little bit you know, as standardized as it is, it may still be a little bit examiner-dependent. The only thing I would kind of comment on from a content point of view is two things. One, I think that your answer about how the axilla would be managed was perfect. I still think that on a oral exam, the standard of care for this patient would still be axillary lymph node dissection, but I think it’s super appropriate to say exactly what you did, which was, you know, this would be discussed in a multidisciplinary tumor board. You know, the axilla needs some additional treatment, whether or not it’s ax dissection, or, you know, targeted axillary therapy is kind of like the the absolute perfect answer. And so that was a thought that was done very well. In terms of adjuvant therapy, so she’s already received her chemotherapy, her full dose of chemotherapy up front. So her adjuvant therapy, and this was not a make or break question, you know, would be, obviously a whole breast, whole breast radiation, she’d likely would receive axillary radiotherapy, and then she would receive hormonal, antihormonal therapy, probably as tamoxifen transitioning to an AI because she’s peri-menopausal. But you know that that’s kind of nuanced stuff. But I think that you know that that certainly wasn’t the like surgical red flag decision making point in this station. So.

Caitlin Cahill  25:12

All right. So 38-year-old RCMP officer was shot in the abdomen at close range while doing a routine traffic stop. You’re on call and are notified that the patient is five minutes from the hospital tachycardic and hypotensive. What will you do before the patient arrives in the emergency department?

Ameer Farooq  25:34

So I would do I ask the routing department to put out a level one call out. This would mobilize the the emergency department team, including nurses, respiratory therapist, another emerge physician as well as prepare the as well as prepare the trauma bay having two chest two chest tube trays available. And I would assign roles prior to the patient arriving the emergency department. I would also alert the blood bank that we might need blood.

Caitlin Cahill  26:15

So the patient arrives he’s GCS 15, talking and moaning in pain. His heart rate is 120 blood pressure 90 over 45. There is a two centimeter hole in the epigastrium and a one centimeter hole in the posterior right flank. There is bleeding and a bullet hole at the left elbow. What is your initial management?

Ameer Farooq  26:39

So I would completely I would do my primary surveys with airways patent. I would put the patient on oxygen put the patient on monitors. I would start the patient on I would call for a massive transfusion protocol. I would establish good IV access. I would inspect the patient from head to toe to ensure that there were no other bullet wounds or injuries besides the one that I’ve seen. And I would get obtain a chest X-ray and pelvic X-ray as well. Yeah, that’s why we do as well as they would do a abdominal FAST and pericardial FAST.

Caitlin Cahill  27:31

So the chest X-ray is normal. The abdominal X-ray and pelvic X-ray show that there’s free air in the abdomen, no metal fragments are seen. The vital signs are the same heart rate is 120 blood pressure 90 over 45 What is your next step in management?

Ameer Farooq  27:47

So this patient needs to go to the operating room. So I would call up to the OR and book this as a zero trauma laparotomy I would and I would mobilize a team I would also ask for the patient we started giving some started on so are we given tranexamic acid.

Caitlin Cahill  28:13

Okay, so the patient has brought to the OR for an emergency trauma laparotomy. You identify a transverse colon injury with feculent contamination, a transverse colon mesenteric injury with profuse bleeding, distal pancreatic injury, the patient’s heart rate is 110 blood pressure is 90 over 50 after two units of packed red blood cells. In the OR now, how will you manage this case?

Ameer Farooq  28:41

And otherwise do we have any information about the patient’s physiology such as from their ABG as well as if they’re on any pressors or any other? No?

Caitlin Cahill  28:52

No extra information.

Ameer Farooq  28:53

Okay. So this this patient is sick but but stable. I would control the bleeding first by quickly resecting that portion of the transverse colon and stapling off the ends. I would inspect the pancreatic injury given that this patient is a is a stable complete a the distal pancreatectomy and then ask the anesthetist that the patient remains stable as to whether I can complete my reconstruction in terms of the colon.

Caitlin Cahill  29:42

So you perform a segmental transverse colectomy. This is left in discontinuity, a drain is left adjacent to the pancreatic injury. A temporary abdominal closure is placed and the patient is brought to the ICU. The patient is stabilized in the ICU and brought back to the OR 24 hours later. At this time the colon appears healthy, there is no further bleeding and no other injuries are identified. The distal pancreas appears contused. How will you manage this case?

Ameer Farooq  30:14

I would complete a an extended right hemicolectomy with a primary anastomosis to complete my resection for the for the colon injury. I would examine the pancreas closely to see if there is any involvement of the pancreatic duct. If there does not appear to be any evidence of pancreatic duct disruption, I would leave wide drainage and, and leave the pancreas as is. I would also ask a HPB colleague to potentially ultrasound the pancreatic duct to ensure that there’s no pancreatic duct.

Caitlin Cahill  31:04

So the patient stabilizes over the next few days. His elbow was pinned three to four days later by ortho. He develops a pancreatic leak identified by the drain fluid. His balls resumed their function. He’s stable and transferred to the ward on post-op day five. On post-op day seven the patient suddenly worsens clinically and appears septic with diffuse peritonitis. How will you manage the patient?

Ameer Farooq  31:32

So this patient needs to be started on antibiotics resuscitated and taken back to the operating room for a relook laparotomy as I’m concerned for an anastomotic leak.

Caitlin Cahill  31:47

Okay, get a CT scan that shows free air and an infected hematoma in the pancreatic bed. What do you think is happening and what is your management plan?

Ameer Farooq  31:58

So as I said, I’m worried that this this patient has either missed interreg injury or anastomotic leak. I started this patient on antibiotics and resuscitate them with fluid and then take them back to the operating room for a washout and management and definitive management of any injuries.

Caitlin Cahill  32:25

So you bring the patient back to the operating room and you find an anastomotic leak. There is an infected hematoma in the pancreatic bed but no acute bleeding. How will you manage the anastomotic leak?

Ameer Farooq  32:37

This patient will get an end ileostomy. And wide drainage of the area of the pancreatic bed if there isn’t already drains there. Otherwise I would not explore the hematoma or disrupt that.

Caitlin Cahill  33:00

Okay and what will you do with the colonic stump?

Ameer Farooq  33:03

The the colonic stump, I would mature as a mucus fistula.

Caitlin Cahill  33:11

So the patient recovers well. His bowels recover and he returns to the ward. On post-op day seven from his take back, so post-op 14 from the initial trauma, the patient crashes on the ward and a code is called. He is brought to the ICU after ROSC heart rate is 150 blood pressure 75 over 30. The abdomen is tense, what is your management?

Ameer Farooq  33:38

So, this patient is hypotensive, I would obtain stat labs in forms in a form of an ABG. And and resuscitate the patient with fluids. If the patient was could tolerate it I would obtain a CT scan here. But obviously, if the patient was continued to deteriorate, I would take the patient back to the operating room but I would I would obtain the CVC and CT if at all possible.

Caitlin Cahill  34:19

You bring the patient back to the operating room. His abdomen is filled with fresh blood, this massive bleeding appears to be coming from behind the pancreas, the patient is very unstable, what is the likely source of this bleed and what is your management?

Ameer Farooq  34:35

So I would be concerned that this is this represents an erosion of the pancreatic leak into like the the splenic artery or one of the post-pancreatic blood vessels but most likely the splenic artery. I would obtain exposure to the splenic artery artery approximately and distally, which would likely involve doing it distal pancreatectomy. And, and tie off the splenic artery. Oh boy.

Caitlin Cahill  35:17

So trauma ones are, are definitely like a little bit harder just mentally, at least for me, because I feel like, like a trauma in real life is really fast paced. And so then on the exam, like you have that kind of like, sympathetic response in your body as if it’s a real trauma, but it’s still just an oral exam. So I think, I think so the beginning was really great, like preparing the emergency department, you hit all of the points there. Once the patient arrives, and they’re asking your initial management. So for the exam, you just want to have your traumas feel like you just have it like ready to roll off your tongue, you know, I’ll approach this patient in standard ATLS fashion with my primary survey, ABCDE, I’ll have blah, blah, blah, you know, you just want to list it all off. It’s, it’s, it’s just a schpeel that should fall out of your mouth. So yours was just a little bit disorganized and wasn’t rehearsed. So that’s just a matter of practice. Otherwise, I think your management was good. When you were in the OR for the first time, I think you were a little bit thrown off about like how, like you ultimately you did all the right things. But again, in a trauma situation where there’s multiple injuries, like your first thing is always manage the bleeding. You mentioned communication with anesthesia, which is great. And then just take each injury one at a time, you know, obviously, in the real life situation, you’re not able to necessarily be super methodical like 1234. You know, there’s multiple hands in the belly, etc. But in the exam situation, you, you know, you can’t do everything all at once. So just take each injury one at a time. So for the bleeding, I’ll do this for the colonic injury, I’ll do this. So these are just like ways to be a little less less stressed in the face of the trauma question. But yeah, otherwise, I thought, like, your management was really good. You know, again, if it’s, if the next slide isn’t exactly what you would have done, that’s totally fine. It happens all the time. You just roll with it. And yeah, no, no specific concerns. I thought that was good.

Ameer Farooq  37:28

Yeah, I was a bit thrown off because to me, like the pH and the, like, not just the heart rate, and the blood pressure would have dictated what I did. So I wasn’t, I was, uh, you know, like I was, in two minds as to what I would do like, I would probably do the do the resection, stop the bleeding, and then recoup and see where I was at. Because if the patient was stable, I probably would just do everything, all the definitive stuff right off the bat. But but certainly, certainly, you know, I take your point about being systematic in just describing it.

Caitlin Cahill  38:09

And you not always have all that information, right? Like, there’s a lot of times where this slide is not going to have the information and the examiner is not going to provide it like it’s not on the slide. It’s not there.

Chad Ball  38:22

Yeah, I think that’s a good point Ameer. You know, I can, knowing you well, I’m sitting here watching you answer this question, what you’re thinking I’m sure is, well, we don’t treat gunshots based on ATLS dogma Right? We In fact, we treat them the opposite c comes before a for example. And then, as you pointed out, your progression and your cadence and your pathway in that case depends entirely on that first and probably second ABG. But you know, Caitlin’s points important too. The examiners, that may not be their area, person that wrote that question may not understand that nuance, and may take you in a totally different direction. So you have to be malleable, like you were in terms of putting you in a different place. And I suspect that this question was probably written to show actually poor management because there was two obviously subsequent complications that peak to the level you had to take them back to the operating theatre. I mean, that’s it. That’s an absolute disaster of a man of a case and of management up front, right, it’s very poor. So they probably want you to talk about complications and reacting to them and recognizing. You did great.

Ameer Farooq  39:32

Okay. Thank you guys, again, for the for the feedback.

Greg Knapp  39:40

This is a 52-year-old male with a referral from his family physician concerning a new peri-anal lesion, non healing time six months. On exam, the lesion is as shown. What is your differential diagnosis?

Ameer Farooq  39:59

Okay, so I would be worried about benign and malignant causes of this lesion. Certainly I’d be concerned here about this patient having a squamous cell carcinoma. This patient could have condyloma acuminata. This patient can have a Buschke-Lowenstein tumor. Benign causes I suppose, could be skin tags, inflammatory changes from chronic Crohn’s proctitis. That wouldn’t mean differential. Sorry, this is suppose a long-standing infection as well in terms of very large this could theoretically look like this.

Greg Knapp  40:54

Okay. Past medical history, patient is otherwise healthy no comorbidities. Social history he works as an accountant lives with his male partner 15 pack-year smoking history occasional alcohol use, no medications no known drug allergies. On exam lesion is about four centimeters in diameter ulcerated firm. there’s no obvious involvement into the anal canal. It is there’s also though a firm, palpable lymph node in the right groin. Remainder of the exam is unremarkable. What is the next step?

Ameer Farooq  41:33

I would perform an examination under anesthesia for this patient to get biopsies of this lesion as well as perform a fully endoscopy. I would also obtain a FNA of the palpable lymph node in the right groin.

Greg Knapp  41:57

So the biopsy of the node and the peri-anal lesion comes back as a poorly differentiated squamous cell carcinoma, what further investigations would you order?

Ameer Farooq  42:07

So, I would stage this patient. So I would obtain a CT chest, abdomen and pelvis looking for metastatic disease. I would also obtain an MRI of the pelvis to characterize the local involvement of this of this lesion. I would obtain baseline metrics such as a CTC a CBC, lytes, creatinine and liver enzymes.

Greg Knapp  42:35

And any additional investigations?

Ameer Farooq  42:38

No. Sorry, no no further investigations.

Greg Knapp  42:43

So you order a CT chest, abdomen, pelvis. There’s no evidence of distant metastases, but they do see the suspicious node in the right groin as well as a suspicious node in the mesorectum. MRI the pelvis lesion involves the external sphincter. No other adjacent organs, the PET scan, there is FDG avidity at the primary and in the right inguinal node, and the mesorectal node is mildly avid. Patient is also HIV negative. What is the T-stage of this squamous cell carcinoma?

Ameer Farooq  43:23

Remind me how big it was?

Greg Knapp  43:25

Four centimeters.

Ameer Farooq  43:27

Okay. This is sorry, this is a T-four lesion.

Greg Knapp  43:37

So what are the components of the Nigro protocol or non-operative management of anal canal squamous cell carcinoma??

Ameer Farooq  43:45

So Nigro protocol would involve chemotherapy and radiation. The chemotherapy is Mitomycin C and 5-FU. And as well as radiation. The likelihood of a complete clinical response in this scenario is approximately 70 to 80%.

Greg Knapp  44:12

Great, so the patient receives a single dose Mitomycin followed by a four day infusion of 5-FU and then receives concurrent with that 50 Gray’s over 25 fraction 25 fractions. This includes the mesorectum, inguinal and iliac nodes. When do you want to see the patient back for follow up?

Ameer Farooq  44:35

I’d like to see the patient back for follow up in six to eight weeks after the completion of their after the completion of their treatment.

Greg Knapp  44:49

Okay. So yes, you see the patient at 4 and 8 weeks after completion of treatment. Regression is quite obvious. At 12 weeks, however, there appears to be a response. There still a response but residual, a residual lesion is obvious on exam. What is your next step?

Ameer Farooq  45:10

I would continue to follow this patient for up to six months with monthly visits and physical examinations to see a document that the lesion continues to regress.

Greg Knapp  45:26

Excellent. You see the patient back every four weeks with ongoing response. At six months, he’s had a complete clinical response. The lymph node exam is also normal. Repeat staging confirms that the PET shows no FDG uptake at the previously avid sites, what is the next step in management?

Ameer Farooq  45:47

So I would, I would see this patient every six months for the next two years, followed by every year until we get out to five years with a full physical examination as well as peri-anal exam and repeat endoscopy. I would also get a colonoscopy.

Greg Knapp  46:12

You follow the patient with exam and DRE every three to six months out for five years, as well as regular endoscopy. It’s been CT chest abdo pelvis. At 15 months, you notice a new palpable right inguinal lymph node. Your peri-anal and anal canal exam is free of disease. What is the management?

Ameer Farooq  46:39

I would obtain an FNA of this right inguinal lymph node as well as a PET scan.

Greg Knapp  46:49

So the biopsy shows poorly differentiated squamous cell. Additional investigations as you mentioned, CT chest abdo pelvis, no additional disease PET scan is congruent. What is the next step in your management?

Ameer Farooq  47:07

I would discuss this patient at a multidisciplinary tumor board meeting and consider this patient for a lymph node dissection on the right side.

Greg Knapp  47:22

And what are the key components of the consent process for this procedure?

Ameer Farooq  47:27

So I already explained the risks of the procedure. So the key steps is explaining the procedure itself as well as the alternatives which is in this case would likely be to just watch it. For the procedure, I would explain that this patient this risk, the usual risks and with any surgeries, it’s bleeding infection. General anesthetic complications, specifically, here there would be a risk for lymph leak and an infection.

Greg Knapp  48:08

Okay.

Ameer Farooq  48:12

Yeah, and nerve injury. Yes.

Greg Knapp  48:19

Okay, so that was a that was a bit longer. Sorry, that that. Sorry, that I didn’t behave for us. Even at the end there, you got a bit of a freebie. So just in terms of feedback, I think you, you definitely hit again. There were no there are no red flags, like from a from a surgical management from a progression through the station. From a management point of view, two quick things one, it is the lesion was four centimeter, so it would be a T-two. T-four would be, you know, invading adjacent structures. So, you know, bladder bowel involvement of the external sphincter doesn’t count. So, but that that was kind of like a bonus point. Otherwise, you know, really, the only thing would be in the workup for anything greater than two centimeters, you mentioned getting a PET scan because they’re super PET avid would be the only kind of additional piece of the workup. And then again, a bonus point was just, you know, risk factors for anal canal, screen, you know, HIV, right. So he I kind of gave you, you know, some risk factors. And so just make sure that for everyone, you’re mentioning that HIV status because if you optimize their HIV status, they have improved outcomes. And so that that was it, though. That in terms of feedback, I thought your examine ship, you know, was, was spot on, right? I think as you’re going through these questions today, you’re, you’re you are getting tighter and tighter. And I think that that, for me anyways was something I struggled with during the exam is that when I started, I had to really practice on not being overly wordy. I think that’s kind of like my tendency, and then you just get yourself A you waste time and then B you’re gonna say something that, you know, isn’t relevant, or potentially throws you off or the examiner off. So just, you know, you’re already doing that, you know, stay tight, stay kind of concise, and just get through the station. And so, and I think that just came with practice. And that is less about kind of how, you know, it’s less about your knowledge base, and how you are or how your decision, you know, is less about your decision-making process. And more, unfortunately, just about examined ship, which is, you know, probably not the intended outcome of the oral exam, but, you know, ends up becoming a big part of, of, you know, performing well on it.

Ameer Farooq  51:10

Absolutely, I did want to ask one thing about the PET scan, because that wasn’t something that I had come across in studying is that something in the NCCN in terms of if you have a big if you have a big over four centimeters? Is that part of NCCN to actually get a PET scan?

Greg Knapp  51:32

Yeah, yeah. So that yeah, and again, your that that was not the plus or minus PET scan was definitely not going to be like a like a fail not fail, right. Like, because there’s going to be some institutional variability. But for sure, you know, given how PET avid it is, and the fact that you felt kind of regional disease on your exam, you know, NCCN would, I think, you know, that would still there would still be quite standard.

Ameer Farooq  52:00

Thanks again, Caitlin, and, Greg, for, for coming on and doing this. I think people are gonna find it really helpful and beneficial. You’ve been listening to Cold steel, the official podcast of the Canadian Journal of Surgery. If you’ve liked what you’ve been listening to, please leave us a review on iTunes. We’d love to hear your comments and feedback. So feel free to email us at podcast.cjs@gmail.com or connect with us on Twitter @CanJSurg. Thanks again.