- Published on
Surgery - Sterilization, disinfection, and antiseptic
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
Definitions • Sterilization involves removing all living germs, vegetative organisms, and spores.
• Disinfection removes dividing vegetative germs.
• Antisepsis reduces the danger of medical cross-infection from germs. Sterilization
Heat: • Dry heat (e.g. incineration, blazing, red hot) is effective but rarely useful. Dry heat necessitates temperatures of 160°C for at least 60 minutes. • Moist heat, such as autoclave heating with pressurized steam at 121°C and 15lb/in2 for 15 minutes, is effective and useful for operating theaters.
Irradiation involves gamma radiation. Effective with inorganic materials. Ultrafine membrane filters can disinfect air and fluids, although they are not commonly used in hospitals.
Disinfection methods include using acids or alkalis, such as bleach. Effective for non-human contact applications. Examples of alcohols and phenols include ethyl alcohol for skin swabs, alcohol solutions for hand disinfection, carbolic chloroxylenols, and phenol (Clearsol®). • Oxidizers include povidone-iodine for skin disinfection and surgical washing, hydrogen peroxide (H2O2) for superficial wound cleansing, and aldehydes for surgical tools like endoscopes. •
Cationic solutions, such as chlorhexidine, can be used for antiseptic wash. • Organic dyes, such as Proflavine.
Antisepsis
Antisepsis concepts include: • Remove gross contamination first with plain soap. • Use high-potency acid/alkali disinfectants on inert surfaces. • Apply less corrosive oxidizers to fragile inert materials. • Use weak alcohols and oxidizers to cleanse the skin.
- Published on
Surgery - Preoperative management of anemia
Definition: Hb <13g />L for both sexes.
Classification Traditionally, MCV and MCH are used to determine potential causes. Current guidelines for diagnosis Iron and haematinic deficiency, as well as blood loss, are common and treatable issues that require proper investigation.
Postpone major elective surgery (with estimated blood loss >500mL) until correctable causes of anaemia are identified and addressed. Current guidelines Serum ferritin levels below 30 micrograms/L are the most sensitive and specific test for determining absolute iron deficient anaemia. In cases of inflammation (CRP >5 and TSAT <20%), a serum ferritin level of <100 micrograms /> indicates iron deficiency anemia. The prevalence and effects of perioperative anemia Large multicenter studies and worldwide registry databases show that perioperative anemia is widespread in surgical patients (30-35% prevalence) and related with morbidity and mortality, regardless of severity. When paired with additional perioperative risk factors, results worsen by a ratio of 3.5–7.
Assessment and management of anemia
Patients should expect to wait up to 2 months for elective surgery, giving them enough time to check and rectify anemia. If there is a >10% chance of transfusion or >500mL of blood loss, lab tests should be performed immediately to check haematinics. • If Hb is <13g />L, identify possible causes and correctable factors. Examine both visible and hidden indications of blood loss. Some patients may require additional testing, such as radiographic imaging or endoscopic evaluation. • If ferritin is <20 micrograms /> and there is no inflammation (CRP/TSAT normal), or if ferritin is <100 micrograms /> with CRP >5 and/or TSAT <20%, start preoperative iron replacement treatment.< />pan>
• If iron replacement therapy is started, non-urgent surgeries should be postponed until the goal Hb is reached.
Treatment Options for Correcting Anaemia
Preoperative anemia. • B12 and folate deficiencies can be rectified with IM or PO supplements for 2-3 weeks in 712% of patients undergoing surgery. • Iron deficiency anaemia can frequently coexist. The severity, expected malabsorption, and convenience of administration will determine whether to use PO or IM supplements for each patient. 2 To treat iron deficiency anaemia, administer 400-600mg/day of PO ferrous sulfate for 6-8 weeks.
• IV iron therapy is highly effective for urgent surgery and has no ill effects when compared to PO therapy or placebo. Administering 1000- 1500mg IV over an hour can result in a peak rise in Hb over 1-3 weeks. • Patients with iron deficiency (ferritin >100 micrograms/L) who are still anaemic can get subcutaneous (SC) erythropoietin (EPO) at a dose of 300-600mg once weekly for 4 weeks. 2 Many hospitals have perioperative clinics administered by surgical, anesthetic, and critical care teams. Local perioperative anaemia routes are a helpful resource. Post-operative anemia • Check patients' post-operative hemoglobin levels with HemoCue® during recovery or upon return to the ward. Formal FBC can typically be performed on the first day following surgery. • If a patient experiences moderate to substantial blood loss during surgery and is predicted to bleed post-operatively due to coagulopathy or surgical causes, they should be observed in a suitable setting by a senior clinician. Early detection of clinical deterioration by the National Early Warning Score (NEWS) is crucial for effective patient care.
• According to NICE guidelines, most patients should have a transfusion threshold of <7g />L for post-operative anemia, with a Hb target of 7-9g/dL after transfusion, except for extensive hemorrhage and acute coronary syndrome (target 8-10g/dL). • Regular transfusions are required due to chronic anemia. Patients having persistent post-operative blood loss should be evaluated periodically and promptly. The senior surgeon should be informed. Critical care outreach teams can provide crucial assistance.
Mean Cell Volume -Microcytic
Causes - iron deficiency anemia,Thalassemia, chronic Disease
Mean Cell Hemoglobin – Hypochromic
Mean Cell Volume – Normocytic
Causes - Acute blood loss and chronic Disease
Mean Cell Hemoglobin – Normochromic
Mean Cell Volume – Macrocytic
Causes – alcohol dependence, B12/folate deficiency, hypothyroidism, pregnancy, hemolysis
Mean Cell Hemoglobin - Normochromic
Definition: Hb <13g />L for both sexes.
Classification Traditionally, MCV and MCH are used to determine potential causes. Current guidelines for diagnosis Iron and haematinic deficiency, as well as blood loss, are common and treatable issues that require proper investigation.
Postpone major elective surgery (with estimated blood loss >500mL) until correctable causes of anaemia are identified and addressed. Current guidelines Serum ferritin levels below 30 micrograms/L are the most sensitive and specific test for determining absolute iron deficient anaemia. In cases of inflammation (CRP >5 and TSAT <20%), a serum ferritin level of <100 micrograms /> indicates iron deficiency anemia. The prevalence and effects of perioperative anemia Large multicenter studies and worldwide registry databases show that perioperative anemia is widespread in surgical patients (30-35% prevalence) and related with morbidity and mortality, regardless of severity. When paired with additional perioperative risk factors, results worsen by a ratio of 3.5–7.
Assessment and management of anemia
Patients should expect to wait up to 2 months for elective surgery, giving them enough time to check and rectify anemia. If there is a >10% chance of transfusion or >500mL of blood loss, lab tests should be performed immediately to check haematinics. • If Hb is <13g />L, identify possible causes and correctable factors. Examine both visible and hidden indications of blood loss. Some patients may require additional testing, such as radiographic imaging or endoscopic evaluation. • If ferritin is <20 micrograms /> and there is no inflammation (CRP/TSAT normal), or if ferritin is <100 micrograms /> with CRP >5 and/or TSAT <20%, start preoperative iron replacement treatment.< />pan>
• If iron replacement therapy is started, non-urgent surgeries should be postponed until the goal Hb is reached.
Treatment Options for Correcting Anaemia
Preoperative anemia. • B12 and folate deficiencies can be rectified with IM or PO supplements for 2-3 weeks in 712% of patients undergoing surgery. • Iron deficiency anaemia can frequently coexist. The severity, expected malabsorption, and convenience of administration will determine whether to use PO or IM supplements for each patient. 2 To treat iron deficiency anaemia, administer 400-600mg/day of PO ferrous sulfate for 6-8 weeks.
• IV iron therapy is highly effective for urgent surgery and has no ill effects when compared to PO therapy or placebo. Administering 1000- 1500mg IV over an hour can result in a peak rise in Hb over 1-3 weeks. • Patients with iron deficiency (ferritin >100 micrograms/L) who are still anaemic can get subcutaneous (SC) erythropoietin (EPO) at a dose of 300-600mg once weekly for 4 weeks. 2 Many hospitals have perioperative clinics administered by surgical, anesthetic, and critical care teams. Local perioperative anaemia routes are a helpful resource. Post-operative anemia • Check patients' post-operative hemoglobin levels with HemoCue® during recovery or upon return to the ward. Formal FBC can typically be performed on the first day following surgery. • If a patient experiences moderate to substantial blood loss during surgery and is predicted to bleed post-operatively due to coagulopathy or surgical causes, they should be observed in a suitable setting by a senior clinician. Early detection of clinical deterioration by the National Early Warning Score (NEWS) is crucial for effective patient care.
• According to NICE guidelines, most patients should have a transfusion threshold of <7g />L for post-operative anemia, with a Hb target of 7-9g/dL after transfusion, except for extensive hemorrhage and acute coronary syndrome (target 8-10g/dL). • Regular transfusions are required due to chronic anemia. Patients having persistent post-operative blood loss should be evaluated periodically and promptly. The senior surgeon should be informed. Critical care outreach teams can provide crucial assistance.
Mean Cell Volume -Microcytic
Causes - iron deficiency anemia,Thalassemia, chronic Disease
Mean Cell Hemoglobin – Hypochromic
Mean Cell Volume – Normocytic
Causes - Acute blood loss and chronic Disease
Mean Cell Hemoglobin – Normochromic
Mean Cell Volume – Macrocytic
Causes – alcohol dependence, B12/folate deficiency, hypothyroidism, pregnancy, hemolysis
Mean Cell Hemoglobin - Normochromic
- Published on
Surgery - Nutrition for surgery patients
Nutrition is crucial to the health of surgery patients. Providing timely nutritional support can minimize acute catabolism and skeletal muscle weakness caused by metabolic loads. This is a prevalent element that impacts the outcome of surgery patients. The incidence of pre-existing malnutrition is high and increases with age. Patients with high nutritional needs, such as those with severe burns, sepsis, intestinal fistulae, advanced cancer, or immunosuppression, may require additional support to prevent excessive acute catabolism due to metabolic demands. Assessment of nutritional status.
All patients should be evaluated for nutritional status. Various methods can be used: • BMI (weight/height in kg/m²). Relatively insensitive to all but major malnutrition. A BMI of 18-25 is considered normal, while <18 indicates underweight and>30 indicates obesity.
• Thickness of the triceps skinfolds. This test is simple and effective for measuring body fat, which can indicate chronic nutritional condition. • Strong grip. Simple, repeatable index of lean skeletal muscle. Serum albumin. Poor predictor of acute nutritional status. Responds slowly to dietary supplementation and is influenced by several circumstances.
• Serum transferrin. A reliable indicator of acute state and response to treatment. Not widely used. Effects of protein-calorie deficiency.
Decreased neutrophil and lymphocyte function. Albumin production is impaired. Impaired wound healing and collagen deposition. Skeletal muscle weakness, known as 'critical illness myopathy,' can lead to respiratory and gastrointestinal problems.
• Micronutrient deficits can cause particular clinical symptoms.
Types of Nutritional Support
• Oral supplements. Examples of high-calorie, high-protein supplements are Fortisip®, Calshakes®, and Ensures®/Enlives®. For nutritional supplementation, oral administration is always the preferable method. It promotes healthy GI flora and reduces the chance of problems following surgery. • Nasogastric (NG) or nasojejunal feeding. Often used in conjunction with oral supplements. Sometimes administered overnight to reduce appetite suppression during the day.
• Surgically implanted feeding tube (gastrostomy or jejunostomy). Not commonly used. This is reserved for people who have a functioning GI tract but cannot take via the oropharyngeal route.
• \tParenteral nutrition. It may be central or peripheral.
Nutrition is crucial to the health of surgery patients. Providing timely nutritional support can minimize acute catabolism and skeletal muscle weakness caused by metabolic loads. This is a prevalent element that impacts the outcome of surgery patients. The incidence of pre-existing malnutrition is high and increases with age. Patients with high nutritional needs, such as those with severe burns, sepsis, intestinal fistulae, advanced cancer, or immunosuppression, may require additional support to prevent excessive acute catabolism due to metabolic demands. Assessment of nutritional status.
All patients should be evaluated for nutritional status. Various methods can be used: • BMI (weight/height in kg/m²). Relatively insensitive to all but major malnutrition. A BMI of 18-25 is considered normal, while <18 indicates underweight and>30 indicates obesity.
• Thickness of the triceps skinfolds. This test is simple and effective for measuring body fat, which can indicate chronic nutritional condition. • Strong grip. Simple, repeatable index of lean skeletal muscle. Serum albumin. Poor predictor of acute nutritional status. Responds slowly to dietary supplementation and is influenced by several circumstances.
• Serum transferrin. A reliable indicator of acute state and response to treatment. Not widely used. Effects of protein-calorie deficiency.
Decreased neutrophil and lymphocyte function. Albumin production is impaired. Impaired wound healing and collagen deposition. Skeletal muscle weakness, known as 'critical illness myopathy,' can lead to respiratory and gastrointestinal problems.
• Micronutrient deficits can cause particular clinical symptoms.
Types of Nutritional Support
• Oral supplements. Examples of high-calorie, high-protein supplements are Fortisip®, Calshakes®, and Ensures®/Enlives®. For nutritional supplementation, oral administration is always the preferable method. It promotes healthy GI flora and reduces the chance of problems following surgery. • Nasogastric (NG) or nasojejunal feeding. Often used in conjunction with oral supplements. Sometimes administered overnight to reduce appetite suppression during the day.
• Surgically implanted feeding tube (gastrostomy or jejunostomy). Not commonly used. This is reserved for people who have a functioning GI tract but cannot take via the oropharyngeal route.
• \tParenteral nutrition. It may be central or peripheral.
- Published on
Surgery - Improved recuperation after surgery
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
Enhanced recovery after surgery (ERAS) aims to minimize perioperative physiological and stress responses, optimize recovery pace, and limit complications. It is typically used for healthy patients who do not require specific preoperative corrections.
The following are the important areas to consider.
Nutrition • Oral carbohydrate loading 24 hours before surgery, including up to 4 hours before anesthesia, is believed to minimize the early catabolic reaction to major surgery.
• Early reintroduction of full nutrition, including carbohydrate-rich drinks from 6 hours post-surgery, nutritional supplements, and a light food from 48 hours post-surgery, to promote immediate GI tract function. Anaesthetic Technique • Avoiding opiate use, such as morphine in PCA and epidurals, to minimize nausea and reduced GI motility.
• Avoiding epidurals to facilitate early mobilization and minimize the effects of autonomic spinal blocking on the heart, lungs, and gastrointestinal system. • Using regional LA-based treatments, such as transversus abdominis plane (TAP) block, regional LA infiltration, or infusional catheters, can reduce central nociceptor input and improve systemic stress response during surgery.
Surgical method
• Minimally invasive procedures, such as laparoscopic surgery, aim to lessen metabolic reaction, improve early mobilization, and minimize GI tract exposure during abdominal surgery. Avoiding bowel preparation during abdominal surgery minimizes the risk of fluid and electrolyte imbalances, disrupts GI tract flora, and leads to fewer GI problems (e.g., anastomotic leaks). Physiotherapy involves early mobilization with particular exercises, sitting out within 12 hours, and walking within 48 hours of surgery.
Perioperative respiratory exercises. Nursing:
• Intensive patient preparation, including preoperative teaching on expected outcomes. Intensive perioperative and post-operative nursing include promoting early re-establishment of food, movement, and self-care. Although intense and demanding, ERAS-type treatments are equally successful in the elderly and young. They are not recommended for insulin-dependent diabetics, people with pre-existing nutritional issues, or those with cognitive impairment.
- Published on
Pathology - Prophylaxis: antibiotics and thromboprophylaxis.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
- Published on
Surgery - Getting the patient to theatre
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
Organizing and following a routine are crucial when preparing patients for surgical procedures. Inadequate preparedness can lead to serious implications for patients. Background papers Prepare the theatre or endoscopic list ahead of time to ensure accuracy. The list should include the patient's name, hospital number, location, surgery information, surgeon, and anesthesiologist. Patient paperwork
• Ensure current medical notes are available for this admission, including a complete history and examination.
• \tMonitor blood results for specific conditions, such as K+ in renal failure, clotting function in anticoagulated patients, and calcium (Ca2+) in parathyroidectomy patients.
• Ensure patients have access to blood and blood products from the transfusion department. (Most hospitals have protocols for determining the appropriate quantity of units of blood.)
• Ensure necessary imaging results are available. Ensure the consent form is completed and included in the medical notes.
• Complete the medication chart.
Patient preparation • Ensure the patient's procedure side/site is clearly indicated (if applicable). This should be done with the patient awake and validated by nursing staff. Check if the patient has been marked by any relevant professionals, such as a stoma care provider or a prosthetist for amputees.
• Determine any necessary preparations, such as bowel preparation, ahead of time. Bowel preparation This device is used to empty the big bowel prior to surgery. Preparation options include a stimulant mechanical bowel preparation, such as sodium picosulfate, which should be given with plenty of drink at least 8 hours before surgery. Avoid any potential obstructions.
• Use an osmotic mechanical bowel preparation, such as magnesium citrate or Klean Prep®, with 2-4 sachets diluted in water up to 8 hours before operation. Suitable for bowel preparation during colonic surgeries, including colonoscopy and CT colonography.
• Stimulant left colon preparation, such as phosphate enema. Suitable for rectum/anus surgery or flexible sigmoidoscopy procedures.
• Mechanical bowel preparation is now less common than it was previously. Bowel surgery may increase the risk of septic complications and has known adverse effects such as electrolyte imbalances, hypovolaemia in the elderly, and nausea and vomiting (especially with large-volume osmotic preparations). Getting The Patient to Theatre 97 Anaesthetic premedication. Reduces anxiety during anaesthesia preparation and reduces the need for anesthetic agents during induction. Benzodiazepines, such as diazepam (PO) or midazolam (5mg IV), are commonly utilized as preoperative agents. Hyoscine butylbromide is occasionally used to reduce upper aerodigestive tract secretions.
- Published on
Surgery - Positioning the Patient
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
Getting the patient to the surgical table • The surgical team plays a role in ensuring patient safety during and after surgery. Ensure compliance with basic safety guidelines.
• The anaesthetist is responsible for maintaining the patient's airway by coordinating all movements. • Avoid dislodging IV cannulae, epidural sites, or existing drains. • Use approved manual handling techniques, such as a 'Patslide' or comparable device, instead of lifting patients. • Take special precautions with prosthetic joints that may dislocate during relaxation, unstable fractures, Rheumatoid arthritis related instability, ulcers, or skin sores.
Once in position. • Prevent diathermy exit point burns by ensuring no patient points come into contact with the operating table's metal surface. • Properly pad bony prominences and thin skin areas, such as the neck of the fibula in leg stirrups. • Ensure diathermy pads are properly applied and not impacted by skin preparations. • Provide adequate patient support, especially if the table is likely to shift, tilt, or rotate throughout the procedure (e.g., arm, thoracic, and abdominal supports for lateral positions, shoulder bolsters for head down positions). • When doing procedures that need access to the perineum, ensure sufficient pelvic support while exposing the perineum over the end of the operating table.
• Plan the placement of ancillary equipment. For instance, where will video stacks be located? Is more than one energy source needed, and where will the generators be located? Is there access to mobile imaging equipment or on-table radiography? Position all equipment to offer the surgical team enough access to the patient.
- Published on
Pathology - Prophylaxis: antibiotics and thromboprophylaxis.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
Preventive antibiotics
• Prophylactic antibiotics lower the incidence of SSI and are often administered in a short term (1- 3 doses). • Antibiotic treatment for existing infections following surgery may last 5 days or more. • Prophylaxis is typically used to avoid infection of surgical wounds or to prevent the spread of organisms from colonized organs like the gut after opening.
Thromboprophylaxis VTE is a widespread, preventable cause of mortality. Patients, like the general population, are 'at risk' of getting DVT. Evaluating the risk of venous thromboembolism To meet national VTE prophylaxis criteria, all patients must be screened for risk factors upon admission and again after 24 hours in the hospital.
Risk is assessed based on:
• Procedure considerations. Prolonged anaesthesia for lower limb or pelvic surgery.
• Patient factors. Immobility, malignancy, aging, and inflammatory diseases Balanced against potential bleeding concerns. Active bleeding, stroke, invasive operations, and bleeding disorders (e.g. liver disease, thrombocytopenia, hereditary illnesses).
Record the risks on the patient's drug chart or VTE documentation. Consider using mechanical (e.g., TEDS) or chemical (e.g., LMWH) thromboprophylaxis as per local guidelines. Patients who are fully anticoagulated do not require VTE prophylaxis. Extended VTE prophylaxis is required for some patient groups following surgery, such as lower limb joint replacement or pelvic surgery.
Surgical and trauma patients are at risk of VTE if they meet any of the following criteria: • A surgical procedure lasting more than 90 minutes, or 60 minutes for pelvic or lower limb surgery.
• Acute surgical admission for inflammatory or intra-abdominal conditions. • Expected reduced mobility.
• One or more of the risk factors listed below.
Treatment with mechanical instruments.
• TEDS. Continuous direct compression helps reduce stasis in infrapopliteal veins. Not suited for those with PVD or cracked skin.
• Pneumatic compression boots. Intermittent compression of the foot and lower leg veins promotes venous flow and reduces infrapopliteal vein stasis
Risk factors for VTE include active or ongoing cancer therapy.
• Over 60 years old (DVT tends to increase with age).
• Admission for critical care.
• Dehydration.
• Known thrombophilias and polycythemia.
• Obesity (BMI over 30 kg/m2).
• Significant medical comorbidities, such as heart disease, diabetes, metabolic, endocrine, or respiratory pathologies, as well as acute infectious infections and inflammatory disorders.
• A personal or first-degree relative with a history of VTE.
• Use of hormone replacement therapy.
• Use of estrogen-containing contraception.
• Varicose veins with phlebitis.
Women who are pregnant or have given birth within the last 6 weeks should seek guidance from specialists.
Treatment:
pharmaceutical • LMWH stimulates antithrombin III. • Given SC. Longer half-life than unfractionated heparin (UFH). • Examples are enoxaparin, dalteparin, and tinzaparin
. • For renal failure, lower the dose or use UFH. Alternatively, titrate doses with anti-Xa monitoring. • UFH activates antithrombin III. • Given SC. Short half-life; reversible with protamine.
• Fondaparinux inhibits factor Xa via antithrombin III
. • Low risk of heparin-induced thrombocytopenia (HIT). There may be a lesser risk of bleeding compared to LMWH. Caution in cases of renal insufficiency.
• Non-vitamin K antagonist oral anticoagulants (NOACs). • Advantages of daily PO dosage. • Examples: dabigatran, rivaroxaban, and apixaban. • Conventional clotting assays may not accurately evaluate the effect. • Most lack a direct antidote.
Surgery - In-theater preparation
Poor preparation and checking in the operating room can lead to risks for patients, such as wrong side surgery (e.g., removing a healthy kidney), incorrect site surgery (e.g., inguinal, not femoral, hernia repaired), allergic reactions to medication, insufficient vital materials (e.g., blood), insufficient equipment (e.g., image intensifier, specialist joint replacement jig), and retained swabs or instruments. Strict adherence to a checklist can reduce the probability of 'never occurrences' in high-risk industries, such as aviation. The WHO suggests a standardized checklist approach.
WHO Checklist
The WHO checklist is a customizable form with four essential checkpoints that can be tailored to specific organizations.
Before the start of the operational list.
• Ensure surgical, anaesthetic, and nursing teams are present and identifiable. • Confirm patient list, procedure order, and address any unique issues
. • Verify that anesthetic equipment, medicine, and monitoring are in working order
. • Confirm imaging and equipment requirements for the list. Before inducing anesthesia, ensure patient identity and permission are valid. Check the site and side markers, if applicable. Check that the anesthetic needs are correct and functional. Check for allergies and predicted blood loss. Before skin incision, ensure all team members are present and known. Check the procedure that will be conducted. Confirm any surgical, anesthetic, or nursing concerns. Confirm that critical imaging/equipment are available. Before leaving the theatre, ensure the correct name for the procedure conducted is known and recorded.
• Verify the swab and instrument counts are accurate. Confirm that any surgical specimens were properly collected and labeled. Confirm any specific postoperative instructions.
- Published on
Pathology - Pancreatic cystic tumors
Intraductal papillary mucinous neoplasm is a visible, mucin-producing tumor that develops within the pancreatic duct system.
• In men, the majority develop in the head of the pancreas. • Mucin-filled cysts communicate with the pancreatic duct system.
• Mucin-secreting columnar epithelial cells line the cysts, forming papillary projections. Epithelial cells can exhibit varying degrees of atypia. This lesion can give birth to invasive cancer.
Mucinous cystic neoplasms. • A variety of lesions, the majority of which are benign. • Symptoms of an abdominal mass are common among women. • Cystic tumors are well-defined and feature massive mucoid locules. The cysts don't communicate with the pancreatic ductal system. • The cysts are bordered by mucus-secreting columnar epithelial cells and have a dense, ovarian-like stroma beneath. The epithelial component can exhibit mild to severe atypia. Invasive carcinomas can develop within these lesions.
Serous cystic neoplasms. • Most benign lesions are found in women and cause abdominal mass symptoms. • The most frequent kind is serous microcystic adenoma, which causes a well-defined pancreatic mass with multiple tiny cysts and a central scar. The small cysts are bordered by cuboidal cells with a spherical nucleus and transparent cytoplasm, indicating glycogen buildup.
Small pseudopapillary neoplasm. • Pancreatic neoplasm with cystic change. • Commonly found in young women with abdominal mass symptoms. Tumors in the pancreas can form a solid mass with cysts and hemorrhage.
Histologically, the tumor is made up of homogeneous spherical cells that form sheets and cables. Pseudopapillary and cystic areas are caused by poorly cohesive cells. Tumors are typically low-grade, with most patients staying tumor-free for years after resection.
Intraductal papillary mucinous neoplasm is a visible, mucin-producing tumor that develops within the pancreatic duct system.
• In men, the majority develop in the head of the pancreas. • Mucin-filled cysts communicate with the pancreatic duct system.
• Mucin-secreting columnar epithelial cells line the cysts, forming papillary projections. Epithelial cells can exhibit varying degrees of atypia. This lesion can give birth to invasive cancer.
Mucinous cystic neoplasms. • A variety of lesions, the majority of which are benign. • Symptoms of an abdominal mass are common among women. • Cystic tumors are well-defined and feature massive mucoid locules. The cysts don't communicate with the pancreatic ductal system. • The cysts are bordered by mucus-secreting columnar epithelial cells and have a dense, ovarian-like stroma beneath. The epithelial component can exhibit mild to severe atypia. Invasive carcinomas can develop within these lesions.
Serous cystic neoplasms. • Most benign lesions are found in women and cause abdominal mass symptoms. • The most frequent kind is serous microcystic adenoma, which causes a well-defined pancreatic mass with multiple tiny cysts and a central scar. The small cysts are bordered by cuboidal cells with a spherical nucleus and transparent cytoplasm, indicating glycogen buildup.
Small pseudopapillary neoplasm. • Pancreatic neoplasm with cystic change. • Commonly found in young women with abdominal mass symptoms. Tumors in the pancreas can form a solid mass with cysts and hemorrhage.
Histologically, the tumor is made up of homogeneous spherical cells that form sheets and cables. Pseudopapillary and cystic areas are caused by poorly cohesive cells. Tumors are typically low-grade, with most patients staying tumor-free for years after resection.
- Published on
Pathology – Pancreatic Endocrine Tumors
Pancreatic endocrine tumors are epithelial tumors of the pancreas that exhibit endocrine differentiation. Tumors can be active or inactive based on the presence of an abnormal hormone secretion syndrome.
Epidemiology: Rare tumors account for around 2% of all pancreatic tumors. • Peak incidence occurs between 30 and 60 years
• Unknown in infrequent occurrences. • Approximately 15% are linked to multiple endocrine neoplasia (MEN)-1. • Early genetic events include losses at chromosomes 1 and 11q and gains at 9q. • Increased changes can lead to malignant behaviors. Tumors that produce excess hormones may exhibit symptoms such as hypoglycemia (insulin-producing tumors), recurrent duodenal ulcers (gastrin-producing tumors), and necrolytic migratory erythema (glucagon-producing tumors). • Non-functioning tumors are detected by imaging or when they become large enough to cause symptoms or metastases. Macroscopy reveals well-defined tumors in the pancreas.
Cytopathology: • Fine needle aspiration (FNA) smears are cellular, with a monotonous population of cells present singly, in loose clusters, or in pseudorosettes. • The nuclei typically exhibit a distinct granular chromatin pattern ('salt-and-pepper').
Histopathology: • Tumor cells have granular cytoplasm and form solid nests, trabeculae, glands, or rosettes. • Immunostaining confirms the endocrine origin of the cells through reactivity for markers CD56, chromogranin, and synaptophysin.
Prognosis: • Often difficult to anticipate with confidence.
Long-term follow-up is necessary for all potentially malignant tumors, as metastases can form years after the main lesion is removed.
Clinicopathological classification of pancreatic endocrine tumors.
Well-differentiated endocrine tumor. Benign pancreatic tumors are non-angioinvasive, <2cm in size, with ≤ 2 mitoses />0hpf and ≤ 2% Ki-67 positive cells. Uncertain behavior is associated with the pancreas and one or more of the following features: ≥ 2cm size, 2-10 mitoses/10hpf, > 2% Ki-67 positive cells/10hpf, angioinvasion, or perineural invasion.
Well-differentiated endocrine carcinoma. Histologically low-grade, but with significant local invasion and/or metastasis.
poorly differentiated endocrine carcinoma. Histologically high-grade, having more than 10 mitoses/10 hpf
Pancreatic endocrine tumors are epithelial tumors of the pancreas that exhibit endocrine differentiation. Tumors can be active or inactive based on the presence of an abnormal hormone secretion syndrome.
Epidemiology: Rare tumors account for around 2% of all pancreatic tumors. • Peak incidence occurs between 30 and 60 years
• Unknown in infrequent occurrences. • Approximately 15% are linked to multiple endocrine neoplasia (MEN)-1. • Early genetic events include losses at chromosomes 1 and 11q and gains at 9q. • Increased changes can lead to malignant behaviors. Tumors that produce excess hormones may exhibit symptoms such as hypoglycemia (insulin-producing tumors), recurrent duodenal ulcers (gastrin-producing tumors), and necrolytic migratory erythema (glucagon-producing tumors). • Non-functioning tumors are detected by imaging or when they become large enough to cause symptoms or metastases. Macroscopy reveals well-defined tumors in the pancreas.
Cytopathology: • Fine needle aspiration (FNA) smears are cellular, with a monotonous population of cells present singly, in loose clusters, or in pseudorosettes. • The nuclei typically exhibit a distinct granular chromatin pattern ('salt-and-pepper').
Histopathology: • Tumor cells have granular cytoplasm and form solid nests, trabeculae, glands, or rosettes. • Immunostaining confirms the endocrine origin of the cells through reactivity for markers CD56, chromogranin, and synaptophysin.
Prognosis: • Often difficult to anticipate with confidence.
Long-term follow-up is necessary for all potentially malignant tumors, as metastases can form years after the main lesion is removed.
Clinicopathological classification of pancreatic endocrine tumors.
Well-differentiated endocrine tumor. Benign pancreatic tumors are non-angioinvasive, <2cm in size, with ≤ 2 mitoses />0hpf and ≤ 2% Ki-67 positive cells. Uncertain behavior is associated with the pancreas and one or more of the following features: ≥ 2cm size, 2-10 mitoses/10hpf, > 2% Ki-67 positive cells/10hpf, angioinvasion, or perineural invasion.
Well-differentiated endocrine carcinoma. Histologically low-grade, but with significant local invasion and/or metastasis.
poorly differentiated endocrine carcinoma. Histologically high-grade, having more than 10 mitoses/10 hpf
