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SURGERY MCQS

Q1 A 75 year old male patient presents in the emergency room with 1 day history of severe pain abdomen. He is a known case of chronic bilateral knee osteoarthritis and takes dilofenac sodi um off and on. Chest X ray shows gas under both domes of diaphragm and on exploration he is found to have a small duodenal ulcer perforation. His Blood gas shows a ph of 7.29 with base deficit -12. His TLC counts are 19000 and pulse is 120/min with BP of 130/80. What would be the best surgery for him? a) Truncal Vagotomy Pyloroplasty b) Gastrectomy c) Truncal Vagotomy with gastrectomy d) Omental patch closure of the perforation Q2. A 64 year old gentleman complains of cough of 3 months duration. He undergoes an x ray Chest which shows a doubtful nodule in the Left lung base. He is advised CT scan of thorax which reveals 1 cm mediastinal node. What should be the next step in managemnent a) Keep the patient under close followup b) PET CT c) Bronchoscopy d) Radiotherapy Q3. A 60 year old female presents with features of epigastric pain. She has had recurrent and progressive episodes of pain abdomen and vomiting in the last 3 years and pain gets relieved after vomiting. She underwent Billroth II gastrectomy 25 years back for chronic duodenal ulcer. Her X ray abdomen shows dilated stomach with distended loops of duodenum and jejunum. The best treatment for this patient would be a) Symptomatic treatment and Follow up as this condition gets relieved over time b) Conversion of Billroth II to Roux en Y Gastrojejunostomy c) Endoscopy and de rotation of stomach d) Feeding Jejunostomy Q4. A 21 year old male suffers a road traffic accident with liver injury on the right side. Patient is haemodynamically stable and responds to IV fluid resuscitation. His hemoglobin is 8 mg% and INR is 2.6 CT Abdomen shows parenchymal disruption involving 75% of the right lobe with blushing fromthe Right hepatic artery What should be the next step in management? a) Observation as patient is haemodynamicaaly stable b) Immediate Exploration c) Angio Embolization of Right hepatic artery d) Transfusion of 4 Packed cells and 8 Fresh frozan plasma Q5 A 50 year old male patient undergoes Whipple's Pancreaticoduodenectomy for Carcinoma Head of the pancreas. He undergoes a s seemingly uneventful post operative recovery when on the 10 th post operative day, he complains of vomiting, abdominal distension and dizziness. Over a period of 2 hours he does not improve and starts talking incoherently. What has happened to this patient a) Bleeding from Gastro Jejunal Anastomoses b) Gastro duodenal artery stump blow out c) Pancreatic jejunal anastomoses leak d) Pulmonary Embolism

Answers
1.Ideally in a case of duodenal ulcer perforation acid reducing operation like Truncal vagotomy or highly selective vagotomy is done in 3 instances i) Patient is known to be H Pylori Negative ii) He would require chronic NSAIDs (as in this case) iii) Failed medical therapy However in emergency in a 75 year old male with acidosis the best option would be to quickly close the perforation and do a thorough peritoneal toileting. If the patient was young and stable the best option would have been truncal vagotomy and pyloroplasty Reference Book- Sabiston Surgery 19th edition 2)c

The next step would be to find the nature of disease and rule out malignancy. The patient would require a bronchoscopy and biopsy/FNAC to rule in/out a malignant disease. PET CT would be advised later to find out if there is any distant metastasis or not. 3)b The patient has typical symptoms of afferent loop obstruction. It is a chronic sometimes acute condition after Billroth II Gastrectomy (especially antecolic) in which the afferent loop is long (30-40 cm). The food in the gastric remnant and efferent loop elicits pancreatic and biliary secretions which distends the afferent loop which keeps distending (causing pain) until vomiting occurs and pain disappears. Diagnosis is by upper GI series, CT showing a distended duodenum, HIDA scanning and endoscopy. Management is always surgery and either conversion to a Billroth II to Billroth I or conversion to Roux limb can be done.

4C Angioembolization has been shown to be a good adjunctive measure in supporting patients with blunt liver trauma who are placed on conservative therapy. Blush on the CT scan means contrast leak from Right hepatic artery and is an indication for Angioembolization in haemodynamically stable patient. vascular blush is not the only indication for Angioembolization. It should be done in high grade liver injuries (IV and above ) to decrease blood loss and cause tamponade in the low pressure hepatic veins. Zealous overfilling of patients with blood and FFP should also be avoided. 5) b Gastroduodenal artery stump blow out After Whipple's surgery this normally happens in the 2nd week leading to sudden and progressive blood loss. Q1. Which coronary arterial vessels are most susceptible to ischaemia? a) Myocardial arterial vessels. b) Epicardial arterial vessels c) Pericardial arterial vessels d) All vessels are equally affected Q2. What is not true about left dominant coronary circulation? a) It is seen in 20% of the population b) Left circumflex artery supplies the Posterior descending artery c) Left circumflex artery terminates as obtuse marginal branch d) Left circumflex artery may originate from right coronary sinus. Q3. Which of the following is not an indication for Coronary artery Bypass grafting (CABG)? a) Left main coronary artery disease stenosis more than 60%. b) One, two or three vessel disease with proximal left Anterior descending artery (LAD) stenosis c) Three vessel disease with impaired ventricular function (less than 50%) d) Double vessel disease with patent left anterior descending artery (LAD) Q4. Which is not a pathological stage in mitral stenosis a) Fusion of commisures b) Commisural fusion with subvalvular shortening of chordae c) Calcification of leaflets and chorda d) Fixation of valve alone with free subvalvular system Q5. Which of the following pathological change does not occur in mitral stenosis A) Increased left atrial pressure B) Left atrium dilatation C) Ventricular hypertrophy d) Embolisation of clots Q6. Most common congenital anomaly associated with coarctation of aorta is a) Ventricular septal defect (VSD) b) Atrial septal defect ( ASD) c ) Bicuspid Aortic valve d) Patent ductus arteriosis (PDA) Q 7 which one of the following is not a clinical feature of Coarctation of Aorta a) Hypotension b) Rib notching c ) Prominent pulsation under the ribs d ) Radio femoral delay

Answers 1. b Epicardial vessels are the most susceptible to to coronary artery disease and Intramyocardial vessels are the least susceptible 2. a 90% of the people have Right dominant coronary system , that means Right coronary artery ends as Posterior descending artery. If the Left circumflex artery supplies major branches to posterior descending artery, this system is called the left dominant system. Left circumflex artery arises from Left Main coronary artery (LMCA) and gives of marginal branches, It ends as obtuse marginal artery. in 0.5% cases it arises from Right coronary sinus 3. d Main indications for coronary artery bypass grafting are LMCA (Left Main coronary Artery) stenosis more than 60% LAD or LCA stenosis more than 70% Two or three vessel disease with LVEF (Left ventricular ejection fraction) less than50% Two or three vessel disease with proximal LAD stenosis 4. d All the above three are progressive pathological stages . There is fixation of both the valve and the subvalvular system. The pathological stage predicts the suitability of balloon valvuloplasty, commisurotomy or valve replacement Also the valvular fibrosis and calcification may be related to repeated inflamation or turbulent flow. Schwartz text book surgery 8th edition page 663. 5.c Ventricular hypertrophy does not occur as the stenosed mitral valve protects left ventricle 6) c All these congenital anomalies are seen with Coatctation of Aorta but Bicuspid Aortic Valve is the most common seen in 2540% cases. 7) a In coarctation of Aorta there is narrowing of lumen of Aorta distal to the left subclavian artery. There is hypertension and not hypotension because of left ventricular obstruction. There is increased formation of collaterals particularly of intercostal and internal mammary arteries leading to rib notching and predominant precordial pulsation. Femoral pulse is of low volume and delayed.

Q1. The usual incision given for surgery of Zenker's diverticulum of esophagus is a) Left Cervical incision b) Right Cervical c) Suprahyoid d) Midline

Q2. In Transhiatal Vs Trans thoracic esophagectomy most common complication associated with THE (Trans Hiatal esophagectomy) is a) Pulmonary complications b) Anastomotic leak c) Bleeding d) Injury to recurrent laryngeal nerve Q3.Which is the most disabling complication after three field esophagectomy? a) Bronchorrhoea b) Recurrent laryngeal nerve palsy c) Tracheal stenosis d) Q4. What is the most common complication after esophagectomy a) Arrythmia b) Pulmonary Collapse and Consolidation c) Recurrent laryngeal nerve injury d) Massive bleeding Q 5.Most valuable investigation for preoperative evaluation of extensive corrosive stricture is a) Endoscopic ultrasound b) Barium study c) CT Thorax d) Pharyngoscopy

1. a Zenker's diverticulum is a pulsion diverticulum between the cricopharungeal muscle and inferior constrictor muscle in an area of weakness called Killian's dehiscence. There may be other areas of weakness as well such as Killian Jamieson area between the oblique and transverse fibres of cricopharyngeal muscle and Laimer's triangle formed between the cricopharyngeal muscle and most superior esophageal wall circular muscles. The pharyngoesophageal diverticulum (Zenkers diverticulum) (ZD) is the most common esophageal diverticulum. 1. Increased upper esophageal sphincter (UES) pressure 2. Failure of UES to relax 3.Incordination between hypophraynx and sphincter to relax Other mechanisms proposed are 1. Fibrosis of cricopharyngeal muscle 2. Spasm of Cricophayngeus due to abonormal reflux (GERD)

There is loss of ATPase and energy changes in patients with ZD. Both neurogenic and myogenic abnormalities are present. At this stage, poor UES compliance rather than cricopharyngeal incoordination appears to be the most plausible explanation Treatment can be done endoscopically or surgically. A commonly used surgical approach is cervical esophagomyotomy and resection of the diverticulum performed through an oblique left cervical incision that parallels the anterior border of the sternocleidomastoid muscle or a transverse cervical incision centered over the cricoid cartilage. Complications of Surgery for Zenker's divertculum Salivary fistula 3-25% Recurrence of Zenker's diverticulum 2.5-20% 2. d The transhiatal cervical anastomosis predisposes to a higher rate of leaks (13.6% for transhiatal vs. 7.2% for transthoracic) Transthoracic resections, which involve a posterolateral thoracotomy, have a higher incidence of pulmonary complications compared with the transhiatal approach A review of the literature with a meta-analysis,has shown that operative blood loss is significantly less during transhiatal esophagectomy compared with transthoracic esophagectomy Now Orringer the proponent of Transhiatal esophagectomy has published that the use of stapled side to side esophagogastric anastomoses in THE has reduced the anatomotic leak rate to 3% This means now recurrent laryngeal nerve injury is more in THE group than TTE group

Ref: Transhiatal versus transthoracic esophagectomy for esophageal cancer 3. a Three field esophagectomy involves lymph node dissection in the cervical, mediastinal and abdominal region. In contrast to the standard two field esophagectomy, japanese surgeons argue that three field esophagectomy leads to better prognostication and survival benefits without significantly increasing the morbidity and mortality. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1356512 Cervical lymphadenectomy included the paratracheal lymph nodes (deep internal nodes). The nodes lateral from the sternocleidomastoid muscle, ie, lateral to the internal jugular vein and supraclavicular nodes 4.b Pulmonary complications occurred in 32.8%, cardiac dysrhythmias in 10.9%, and persistent recurrent nerve problems in 2.6%. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1356512 5.a Q11. Which is not a recommended procedure for carcinoma esophagus in the thoracic cavity A) McKeown approach b) Lewis Tanner approach c) Transhiatal esophagectomy

d) single right thoracotomy incision Q12. In Achalasia cardia all are possible etiological theories except a) Trauma b) Drastic weight loss c) Emotional stress d) Epiphrenic diverticulum Q 13 Not true about the etiology of Achalasia cardia a) It is a familial disease b) Allgrove's disease is a rare condition associated with achalasia c) HSV-1, HSV-2, Polio virus d) Assciation with class II MHC antigen Q14. True about the role of medical therapy in Barrett's Esophagus a) There is direct evidence that medical treatment prevents development of Barrett's esophagus in patients with GERD b) The end point of treatment in Barrett's esophagus is control of reflux c) COX 2 inhibitors have a role in prevention of Adenocarcinoma in patients with Barrett's Esophagus d) Q15. One of the following is not a hallmark of end stage Achalasia Cardia a) Severe dysphagia or regurgitation b) Hypertensive Lower esophageal sphincter tone c) Mega esophagus or sigmoid esophagus d) Reduction of ganglion cells with fibrosis of Myenteric plexus Answers

11) d For tumors in the upper thoracic esophagus, obtaining a sufficient proximal resection margin dictates an anastomosis placed in the neck. McKeown approach--- In this procedure a right thoracotomy is first carried out to mobilize the thoracic esophagus together with lymphadenectomy, and this is followed by abdominal and neck incisions for the mobilization of the esophageal substitute placing the anastomosis in the neck. For middle 1/3rd thoracic esophageal tumors Lewis Tanner approach is used. The operation begins with an abdominal phase, in which the stomach is prepared; a right thoracotomy and resection of the tumor together with lymphadenectomy follows this. The stomach is then brought up into the chest for anastomosis with the proximal esophagus at the apex of the pleural cavity. Isolated Left Thoracotomy and not a right thoractomy maybe an option. Through a left thoracotomy and incision in the diaphragm, both the esophagus and stomach can be mobilized and resection carried out, and the stomach delivered into the chest for anastomosis, either below or above the aortic arch. A transhiatal approach, whereby the thoracic part of the esophagus is mobilized by blunt and often blind dissection through the enlarged esophageal hiatus, and the mobilized stomach is then delivered to the neck and anastomosed to the cervical esophagus, is advocated especially for distal esophageal tumor or early-stage tumors of other parts of the esophagus. Ref Maingot 11th edition

12. d Achalasia cardia is a motor disorder of the esophagus characterised by difficulty in swallowing. Manometry is the gold standard for diagnosing it. manometric findings include Hypertonic LES (lower esophageal sphincter) with pressure more than 35 mm Hg. Normal is 18-24 13. a Familial Achalasia constitues 1% of all cases of Achalasia. Allgrove's disease or the AAA syndrome includes, Achalasia, Alacrima and ACTH (Adrenocortico trophic Hormone ) resistant adrenal insufficiency. The etiology and pathogenesis of Achalasia Cardia s not known fully and various hypothesis have been put forward:Pathology includes Inflamation and selective losss of inhibitory myenteric neurons in the Auerbech's plexus. Auerbech's plexus normally secretes Nitric Oxide and VIP. As a result of this there is faiure of lower esophageal sphincter to relax leading to aperistalsis and dilatation of esophagus Although herpes simplex virus type 1 (HSV-1), HSV-2, polio, human papillomavirus, and measles have all been proposed as candidates in initiating the immune response, no infectious pathogens have been convincingly isolated from tissue samples either by electron microscopy or by polymerase chain reaction amplification.

Certain class II major histocompatibility complex (MHC) antigens such as HLA-DQw1, HLA-DQB1, and HLA-DRB1 have been also associated with achalasia Chagas disease of esophagus caused by Trypanosoma cruzi has similarities in clinical presentation, manometry and radiology to achalasia however subtle differences are there 1. Chagas disease is having denervation of both excitatory and inhibitory myenteric neurons 2. LES (Lower Esophageal Sphincter) hypotonic

14 c There is Indirect evidence that medical treatment prevents Barrett 's esophagus 1. Long duration of GERD Symptoms lead to barrett Odds ratio is 6.4 after 10 years of symptoms as compared to symptoms of less than 1 day 2. Prevalence of Barrett in general population is between 5-15% The end point of medication is control of symptoms like heartburn and regurgitation. Reflux is not controlled. Another thing which can be improved is the elevation of intraesophagel ph COX 2 inhibitors are used in chemoprevention SCHCKELFORD's Surgery Alimental CAnal 6th edition 15) b Traditionally treatment of end stage achalasia is esophageal resection. Hypertensive LES is not a end satge achalasia and is seen is 30-40% patients of achalasia All others signify end satge achalasia Q1. Ideal treatment of alkaline reflux gastritis after after Billroth I and Billroth II gastrectmy is a) Conversion of Billroth I gastrectomy to Billroth II gastrectomy b) Roux en Y gastrojejunostomy c) Total gastrectomy d) Conservative management Q2.Surgical Treatment of bleeding Type I gastric ulcer is a) Wedge resection of the gastric ulcer b) Oversewing the vessel at the ulcer base c) Distal gastrectomy d) Distal gastrectomy along with truncal vagotomy Q3.Helicobacter Pylori (H.Pylori) is a known cause of peptic ulcer disease. It was discovered in Australia in 1987. Which of the following statements is not true regarding it a) Its infectivity is highest in developed world. b) Person to person transmission is common c) It is seen in populations with low socio economic status d)H. Pylori is a gram negative microaerophilic bacteria Q4. Which of the following hormones are not released in duodenum? a) Gastrin b) Motilin c) Somatostatin d) Pancreatic YY Q5. Treatment for bleeding duodenal diverticulum is a) Diverticulectomy b) Diverticulopexy c) Diverticulization d) Subtotal diverticulectomy

1. b Once a diagnosis of alkaline reflux gastritis is made, treatment is directed at the relief of symptoms. Medical or conservative treatment is not very helpful and do not show consistent benefit.

Surgery is recommended for those who have intractable symptoms. The surgical procedure of choice is conversion of Billroth II to Roux-en Y Gastrojejunostomy in which is the Roux loop is lengthened to about 45 cm Sabiston text book of surgery 18th edition page 125

2. c Treatment of choice for a bleeding gastric ulcer Type I is distal gastrectomy followed with a Billroth I gastrojejunostomy. For type II and type III ulcers vagotomy is added. If the patient is too moribund to undergo gastrectomy then other options available are wedge excision of the ulcer or just under running of the bleeding vessel and biopsies of the ulcer. Sabiston textbook of surgery 18 page 1249 3. a H. Pylori was discovered by Warren and Marshall in 1987. It is a disease associated with poor sanitation, over crowding and under developed countries. Peptic ulcer associated with H. Pylori is rarely seen in the developed countries. Sabiston 18th page 1236 4. d Peptide YY is released from ileum. Gastrin - G cells stomach Motilin- M cells from duodenum and jejunum Somatostatin - D cells in pancreas, stomach and duodenum 5. a Treatment of choice in such cases is diverticulectomy. Subtotal diverticulectomy is done if the diverticulum is very close to ampulla of vater to safeguard the bilio- pancreatic ducts Q6. Which of the following does not appear to cause early dumping a) Serotonin b) Bradykinin c) Neurotensin d) Secretin Q7. Which is not a genetic alteration associated with Carcinoma Stomach? a) Over expression of k-sam b) Over expression of c-erbB2 c) Inactivation of c-met d) Inactivation of p53 Q8. Which does not predispose to Carcinoma stomach? a) Low fat and protein diet b) Salted meat and fish c) Low Nitrate consumption d) HIgh Complex carbohydrate consumption Q9.Which of the following is not true about gastric lymphoma? a) Stomach is the most common organ in the gi system which is involved in Lymphoma b)Peak incidence of lymphomas is seen in 6th-7th decade c)Endoscopy usually reveals gastritis like picture or gastric ulcer. d)MALT lymphoma is the commonest variety. Q10. Which is false for GIST (Gastro intestinal stromal tumor) of stomach a) It is the same as leiomyoma and leomyosarcoma as described previously. b) origin is from mucosa from the interstitial cells of Cajal c) Associated with C-Kit Mutation d) Imatinab is a new effective drug for adjuvant therapy.

6.d Serotonin, Bradykinin, Neurotensin and Enteroglucagon are associated with symptoms of early dumping. Secretin has no association with Dumping

Sabiston 17 th page 1296 7. c The over expression of met, sam and erbB2 associated with inactivation of p53 and p16 are associated with carcinoma stomach. Sabiston 17th page 1304 8. c Factors associated with increased risk of developing stomach cancer are Nutritional Environmental Social Medical Low Fat and Protein Poor food preparation Low Social class Salted meat and fish No refrigeration HIgh NItrate Consumption Poor drinking water High Complex Carbohydrates Smoking Sabiston 17th page 1303

Prior gastric surgery H.Pylori Gastric atrophy Adenomatous polyp and male gender

9. d Diffuse B cell lymphoma is the commonest variety (55%) followed by MALT The stomach is the most common site for lymphomas in the gastrointestinal system. However, primary gastric lymphoma is still relatively uncommon, accounting for less than 15% of gastric malignancies and 2% of lymphomas. Endoscopy rarely reveals a mass lesion and stomach is the most commonly involved organ 10.b Gastric sarcomas arise from mesenchymal components of the gastric wall and constitute about 3% of all gastric malignancies. GISTs were previously classified as leiomyomas or leiomyosarcomas. Histologically, they appear to arisefrom the muscularis propria & not mucosa; most likely originate from the cells of Cajal. Kit is a transmembrane tyrosine kinase receptor,The Kit protein is detected by immunohistochemistry and can reliably distinguish GISTs from true smooth muscle neoplasms. Imatinib mesylate (formerly ST1517, now Glivic/Gleevec) is a competitive inhibitor of certain tyrosine kinases, including the kinases associated with the transmembrane receptor Kit and platelet-derived growth factor receptors. Initial studies showed encouraging results, with 54% of patients exhibiting at least a partial response Q 1. Most common site of gastric ulcer is a) Incisura b) Greater curvature stomach c) Fundus of stomach d) Antrum Q2. a) b) c) d) One of the follwing is not a surgery for duodenal ulcer disease Taylor Hill Baker HSV (Highly selective vagotomy) Lewis

Q3 Which of the following is not a sign of malignant gastric ulcer on radiographic studies? a) Carmen sign b) Hampton's line c) Nodular gastric ulcer mound d) Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater. Q4. Which of the following is not a poor predictor of response of bleeding gastric ulcer to endoscopic therapy? a) Large size of ulcer b) Active bleeding at the time of endoscopy c) Stomach ulcer at the lesser curvature d) Ulcer at the anterior duodenal location

1. a Types of gastric ulcer Type I ulcer - commonest --A type I gastric ulcer is typically located along the lesser curvature of the stomach, usually at the antral-fundic junction, and is associated with acid hyposecretion. Type II ulcer - Occurs in conjunction with active or healed duodenal ulcer disease. Type III- Prepyloric ulcer Type IV ulcer - Gastro esophageal junction at the lesser curve Type V ulcer- Anywhere in the stomach associated with chronic NSAID use or aspirin use

2. d Lewis operation is not a gastric ulcer surgery .It is a radical two field esophagectomy Taylor procedure is for ulcer of the stomach and duodenum. It is a laparoscopic posterior vagotomy with anterior seromyotomy Hill Baker is laproscopic posterior vagotomy and and anterior highly selective vagotomy. 3. b The signs of malignant gastric ulcer on barium examination are.. 1.Eccentrically located ulcer within the ulcer mound. 2. Irregularly shaped ulcer crater 3. Nodular ulcer mound 4. Abrupt transition between normal and abnormal mucosa several cms away from the ulcer crater 5. Rigidity, lack of distensibility and lack of changeability 6. Associated large mass 7. Carmen meniscus sign-a relatively shallow gastric ulcerating malignancy projecting as an ulcer which is always convex inwards to the lumen and which does not project beyond the wall 8. Ulcer projects within the anticipated wall of the stomach Sigs of benign gastric ulcer are Hamptons line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa 4. d Failure of endoscopy during excessive bleeding from a gastric ulcer means that a surgical intervention will be likely. All these are predictive factors for failure of endoscopy except placement of ulcer on the posterior wall of duodenum. Ulcer on the posterior duodenal wall is difficult to be approached during endoscopy. Q1. Which of the following are not true for emphysematous cholecystitis? a) Usually it is associated with acalculus cholecystitis. b) Most common with diabetes mellitus c) Air is seen in the lumen of gall bladder d) Clostridium perfringes and other clostridia are the comomn causative organisms. Q2. Prophylactic cholecystectomy is not recommended for a) Heart transplant receipients b) Diabetes Mellitus c) Incidental gallstones on laparotomy d) Q3. Which of the following is not an ultrasonic finding in acute cholecystitis a) Absence of gallstomes b) Gallbladder wall thickness more than 6 mm c) Pericholecystic fluid d) Sonographic Murphy's sign Q4. Which of the following is not a premalignant condition of gallbladder? a) Porcelain gallbladder b) Adenomyomatosis of gallbladder c) Salmonella infection d) Phrygian cap Q5. Which of the following is not true regarding gallbladder cancer following cholecystectomy a) Subsequent treatment depends on many factors including stage of disease, surgical margins, spillage etc b) For T1 and T2 lesions cholecystectomy is sufficient c) The term extended cholecystectomy is preferred to radical cholecystectomy d) Common Bile Duct (CBD) excision is not required in all cases

1. c Emphysematous cholecytitis is seen in elderly patients with male to female ratio of 3:1. It is mostly caused by clostridia species and commonly seen in diabetics. It is usually but not always associated with aclaculus cholecystitis. CT scan is the investigation of choice and air is not seen in the lumen of gallbladder but in the wall of gallbladder. Treatment is emergency cholecystectomy. 2. b Diabetes mellitus was earlier thought to be associated with increased compications of cholelithiais and cholecystitis but recent literature suggests that Diabetes is not associated wuth increasesd complications. The indication of surgery for cholelithiasis remain the same in diabetis mellitus. Cardiac transplant patients have a high prevalence of biliary tract disease, Studies reported in the surgical literature seem to favor prophylactic cholecystectomy for patients identified with cholelithiasis preoperatively. Patients with asymptomatic cholelithiasis before transplantation commonly develop symptoms and often complications after transplantation

(Gallbladder Disease in Cardiac Transplant Patients A Survey Study Michael J. Englesbe, MD; Derek A. Dubay, MD; Audrey H. Wu, MD, MPH; Shawn J. Pelletier, MD; Jeffery D. Punch, MD; Michael G. Franz, MD Arch Surg. 2005;140:399-403.) Link
3. b Ultrasound has a sensitivity of 85% and specificity of 95% in diagnosing acute cholecystitis. If the wall thickness is more than 4 mm, it is suggestive of Acute Cholecystitis. 4. d 5. b After cholecystectomy if the histopathology report suggests malignany, many preoperative and intra operative factors have to be considered. These are duration of symptoms, previous history of jaundice,laparoscopic or open surgery, difficulty and blood loss in surgery, spillage of bile, if an endobag was used or not for gallbladder retrieval. The most important is to define the T stage in the gallbladder . For T1a and selected T1b lesions (those lesions which do not have neural, lymphatic) simple cholecystectomy suffices, however for T2 lesions, extended cholecystectomy is the procedure of choice The term extended cholecystectomy is preferred to radical these days because radical can be anything ranging from wedge excision of liver to resection, of duodenum, CBD or even a Whipple's procedure Extended cholecystectomy entails cholecystectomy + removal of lymph nodes in periportal , hepatoduodenal, right coeliac, posterior pancreaticodudenal and pericholedochal + 2 cm wedge excision of liver. CBD excision is not always necessary and required only in some select conditions Sabiston text book of surgery 19 th edition Laparoscopic Cholecystectomy in Cirrhosis Partial Contraindication 1. Hard friable brittle liver is difficult to retract 2. Limited exposure of porta, Calot's Triangle and Gall bladder 3. Portal hypertension and Colaterals bleed 4. Coagulopathy- which should be corrected Q1. Endoscopic stone extraction from Common Bile Duct (CBD) is possible only ina) Multiple bile duct stones b) Intrahepatic bile duct stones c) Multiple Gallstones d) Prior Gastrectomy Q2. Which of the following is not the functions of bile? a) Excretion of toxins and normal cellular metabolites b) Absorbtion of lipids c) Cholesterol excretion d) Absorbtion of water soluble vitamins Q3. What is the management of choledochal cyst (bile duct cyst) adherent to portal vein? a) Excision and Roux en y hepaticojejunostomy b) Internal drainage into roux en y jejunal limb c) Hepatic lobectomy d) The internal lining of the cyst can be excised, leaving the external portion of the cyst wall intact.

Q4. In the classification of cholangiocarcinoma of hepatic duct hilum (Klatskin tumor) by site, Type II is a) Confined to the common hepatic duct b) Involve the bifurcation without involvement of secondary intrahepatic ducts c) Tumors extend into either the right or left secondary intrahepatic ducts, respectively. d) Involve the secondary intrahepatic ducts on both sides. Q5. What is not true regarding laparoscopic bile duct injuries? a) As surgeon experience goes beyond twenty cases rate of bile duct injusry decreases. b) The rate of laparoscopic bile duct injury is approximately 0.8% c) Most of the injuries are due to errors of judgement and skill Q 6. Brown pigment stones, false is a)They are earthy b) stones Seen in Asian population c) Easily breakable d) All the above

Answers 1.a Approximately 7% to 15% of patients undergoing cholecystectomy have common bile duct stones 1% to 2% of patients managed with laparoscopic cholecystectomy without a cholangiogram for gallstones present after the cholecystectomy with a retained stone. Endoscopic sphincterotomy and stone extraction was introduced more than 20 years ago and permits common bile duct stones to be removed without the need for conventional surgery Endoscopic stone extraction iis difficult in multiple gallstones, intrahepatic stones, large gallstones, impacted stones, duodenal diverticula, prior gastrectomy, bile duct stricture. Sabiston 17 th page 1618

2.d Bile functions in two important ways in the human body 1st Liver is the major site of detoxification. bile transport allows excretion of toxins and normal cellular metabolites 2nd important function of the bile is to form micelles which helps in absorbtion of lipids. in the deficiency of bile there is malabsorbtion of fat soluble vitamins Bile also functions to remove excessive cholesterol Bile has no role in absorbtion of water soluble vitamins like vitamin B 3. d Total cyst excision with Roux-en-Y hepaticojejunostomy is the definitive procedure for management of types I and II choledochal cysts. In cases whereby there is significant inflammation, it may be impossible to safely dissect the entire cyst way from the anterior surface of the portal vein. In these circumstances, the internal lining of the cyst can be excised, leaving the external portion of the cyst wall intact. Type III cysts are typically approached by opening the duodenum, resecting the cyst wall with care to reconstruct and marsupialize the remnant pancreaticobiliary ducts to the duodenal mucosa. In type IV cysts, the bile duct excision is coupled with a lateral hilar dissection to perform a jejunal anastomosis to the lowermost intrahepatic cysts. If the intrahepatic cysts are confined to a single lobe or segment, hepatic resection may be indicated. The treatment of type V cysts involving both lobes is usually palliative with transhepatic or U tubes until liver transplantation can be performed. Type I cysts represent 80% to 90% of cases and are simply cystic dilations of the common bile duct. Type II cysts are represented as a diverticulum arising from the common bile duct. Type III cysts are also referred to as choledochoceles and are isolated to the intrapancreatic portion of the common bile duct and frequently involve the ampulla. Type IV cysts are second in frequency and represent dilation of both intrahepatic and extrahepatic bile ducts. In type V cysts, only the intrahepatic ducts are dilated. Type I cysts represent 80% to 90% of cases and are simply cystic dilations of the common bile duct. Type II cysts are represented as a diverticulum arising from the common bile duct. Type III cysts are also referred to as choledochoceles Type IV cysts are second in frequency and represent dilation of both intrahepatic and extrahepatic bile ducts. In type V cysts, only the intrahepatic ducts are dilated. 4. b Bismuth classification of perihilar cholangiocarcinoma by anatomical extent. Type I tumors common hepatic duct Type II tumors involve the bifurcation without involvement of secondary intrahepatic ducts. Type IIIa and IIIb tumors extend into either the right or left secondary intrahepatic ducts, respectively. Type IV tumors involve the secondary intrahepatic ducts on both sides. 5. c

All are true but most of the injuries are due to visual perceptual illusion and not error of skill. 6. d Brown pigment stones are earthy in texture and are typically found in the bile ducts, especially in Asian populations. Brown stones often contain more cholesterol and calcium palmitate and occur as primary common duct stones in Western patients with disorders of biliary motility and associated bacterial infection 5th edition of Blumgart Surgery of the liver is out. Check the link below

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Post Graduation Home Mcqsurgery.com becomes the most Popular Surgery Multiple Choice Questions Website. Mcqsurgery.com The place for doctors to try competitive surgery Questions Q1. Most common site of Colo Rectal cancer is a) Hepatic Flexure b) Sigmoid colon c) Anal canal d) Rectum

Q2. All are premalignant for carcinoma esophagus except a) Diverticulum c) Mediastinal fibrosis b) Caustic burn d) Human papillloma virus

Q3. Lipoma which undergo malignant degeneration is a) Retroperitoneal c) subfascial b) Subserosal d) Submucosal

Q4. Most important prognostic factor for carcinoma esophagus is a) cellular differentiation c) length of esophagus involvement b) Depth of esophagus involvement d) age of the patient

Q5 Contraindication to anterior resection of rectum is a) Age more than 60 c) Sigmoid lymph nodes b) poorly differentiated carcinoma d) single hepatic metastasis

Answers 1) d Rectal Cancer is a common malignany of the lower GI tract and rectal pain is relatively a late feature. Rectum is the most common site of malignany in all colo rectal tumors. Other sites in order of decreasing frequency are Rectum -38%, Sigmoid colon 21% Hepatic flexure of colon - 2%, Caecum 12%, Anal Canal 2% 2) c Risk factors for carcinoma of esophagus are Alcohol, tobacco, beverages( low), nitrosamines, polycyclic aromatic hydrocarbons, croton flaveus, trace element deficiencies Tylosis, achlasia (midesophagus), strictures due to lye ingestion, chronic esophagitis are other risk factors. Barrets esophagus, congenital rests of columnar epithelium predispose to carcinoma esophagus and particularly adeno carcinoma. Diverticula have a very small risk of carcinoma, HPV 16 and HPV 18 lead to carcinoma esophagus. schakelford 5th editionpg 316 3) c Lipoma of retroperitoneum and mediastinum are the most common to undergo malignant degeneration and change into carcinoma. 4) b Most important is depth of involvement of wall of esophgus and lymph node involvement of the surrounding esophageal tissue. Length of esophagus involvement is not that important because esophagus has extensive submucosal lymph supply and for complete cure 10 cm excision margin would mean removal of almost total esophagus. 5b

APR (Abdomino perineal resection) is done if carcinoma Rectum or Anal Canal is poorly differentiated, sphincters cannot be preserved or there is no continence Q56). Ulcerative Colitis with malignancy a) Has a better prognosis than Carcinoma Colon alone b) Is related to disease activity c) Is related to duration of ulcerative colitis d) Malignancy is more in ano rectal ulcerative colitis Q57) In ulcerative coilitis with toxic megacolon lowest recurrence is seen in a) complete proctocolectomy and brook's ileostomy b) Ileo rectal anastomosis c) koch's pouch d) Ileo anal pull through procedure

Q58) All are premalignant except a) Turcot syndrome b) cowden syndrome c) Juvenile polyposis coli d) none

Q59) Colonic polyps are seen to regress with a) Azathioprine b) streptozocin c) Sulindac Q60) All are precancerous for carcinoma colon except a. crohn's disease b. Bile acids c. Fats d. carotene Q61. Toxic Megacolon is associated with all except a) Ulcerative colitis b) Crohn's Disease c) Pseudomembranous Colitis d) Shigella

Answers 56/c Carcinoma colon in ulcerative colitis is related to the duration of the disease. More is the duration of the disease, higher the incidence of malignancy

57) a Total proctocolectomy with brooke's ileostomy removes almost all of the diseased segment. IRA and IPAA leave behind rectal mucosa which may or may not be diseased 58) d Turcot syndrome Turcot et al first described an association between colonic polyps and tumors. The colonic/rectal polyps are adenomatous, usually multiple, and 1-30 mm in diameter. Most central nervous tumors are supratentorial glioblastoma with occasional medulloblastoma. Other reported abnormalities include sebaceous cysts, papillary carcinoma of the thyroid, leukemia, and spinal cord tumors. They are definately premalignant PN Cowden syndrome is a rare disorder that is inherited in autosomal dominant manner with intra-familial and inter-familial differences in the expressivity of symptoms It is mostly not malignant and no endoscopic screening is required but risk of malignancy at extra gi sites is more. JPC is premalignant Patients with polyps should undergo endoscopic surveillance every 1-3 year. Colectomy is recommended for patients who have numerous polyps in the colon; however, surveillance of the ileal pouch should be continued because of the risk of malignant change. 59)c 60) d Carotene, Vit C and Calcium reduce the risk of colonic malignancy. 61) d In Toxic megacolon bacterial infection of the wall of colon creates dilatation of the wall which further progresses to imminent perforation. Necrotic thin walled colon in which pneumatosis can be seen radiographically Q1. Which is not a type of anal margin tumors? a) Basal cell carcinoma b) Epidermoid carcinoma c) Paget's disease d) Bowen's disease Q2. False about the pelvic floor is a) Anorectal ring is formed by Puborectalis and ext sphincter b) Anorectal ring is 3cm above anal verge. c) Pelvic Floor is supplied by S2,3,4 d) All are true Q3 True about radiation proctitis is a) Sucralfate enema is very effective. b) Laser Abalation is efective in every case. c) Local Metronidazole is effective d) Resection and Anastomoses give best results. Q4. Recurrence after resection for Ca rectum is related to all except a) Tumor Grade b) No. of lymph nodes c) Lateral Margin Involvement d) Inexperienced surgeon

e) None of the above Q5. Contraindication for resection of locally recurent rectal cancer are all except a) Extrapelvic disease b)Sciatic pain c) Bilateral ureteric obstruction d) S1 or S2 nerve inolvement e) Circumferential or extensive pelvic side wall involvement f) None

1. b Epidermoid carcinoma is a collective term used used for tumors from the epithelium of anal canal. It includes squamous,clacogenic, transitional,basaloid, mucoepidermoid and round cell carcinoma. Most Common anal margin tumor is Squamous cell carcinoma. A preinvasive form of squamous carcinoma, Anal Intraepithelial Neoplasia (AIN) was previosly known as Bowen disease. Basal Cell carcinoma occurs less frequently in anal margin than other parts of skin. A rare entity is Paget disease or Intraepithelial adenocarcinoma.

2) d Pelvic floor is formed by Levator Ani which has three parts (i) Ileococcygeus (ii) Pubococcygeus (iii) Puborectalis The fibres of puborectalis and external anal sphincter are continuous and form the Anorectal ring. Anorectal ring is 3-4 cm above the anal verge. It can be palpated during the P/R examination and this distance is known as surgical anal canal. Anatomical anal canal is from anal verge to dentate line. Ext anal sphincter is supplied by pudendal nerve S2-3 Levator Ani -- S2-3-4 Schakelford rectum pg 346.

3)b Radiation Proctitis occurs due to radiotherapy to the pelvic organs. Rectum is fixed

and in proximity to the pelvic structures so it is more liable for injury. The symptoms include tenesmus, discharge, bleeding etc. Management of Acute radiation proctitis is Stop Radiation, Fluid Rehydration, Dietary Modification, Antidiarrhoeals Management of Chronic Prcotitis (Bleeding) Oral Sucralfate (Not Enema) Nd-YAG laser and Argon Laser Multiple sessions arerequired. 4% formalin instillation has shown good results . Surgery is reserved for complications like Rectovaginal fistula and strictures Schakelford 457.

4)e It is related to all these factors. The rate of recurrence is 25-50%. It is related to the following factors. Tumor Related High Grade, mucin producing, venous or lymphatic involvement, Aneuploidy, mutant p53. Extent of disease and stage is the single most important factor that predicts relapse. Technical factors Tumors in the distal rectum, Techinque and experience of the surgeon. Q1. Which of the following is not an indication for admission in a case of burns a) Full thickness burns more than 5% of total body surface area (TBSA) b) Partial thickness burns more than 10% in adults c) Partial thickness burns more than 10% in children d) Inhalationsl burns Q2. Which is the site for escharotomies in extremities for deep burns? a) Anterior aspect b) Posterior Aspect of the limb c) Medial or lateral aspect of limb d) It can be anywhere Q3. Which of the following is not true about carbon monoxide poisoning? a) It shift the oxygen hemoglobin dissociation curve to left b) Kills cytochrome c) It increases displacemnet of oxygen from hemoglobin d) Direct action occurs on central nervous system Q4. Which is not true regarding infectious complications in a burn patient? a) The incidence of serious infections increase in proportion to the total body surface area (BSA) b) Flame, Chemical, Inhalational burn injury and full thickness burns are more prone for infection c) Catheter related sepsis is more common than local wound sepsis d) Burn wound septicemia has 80% mortality in children Answers 1.b Indications of admission for a burn patient are generally - Partial thickness burn more than 10% in age less than 10 and more than 50 years - Partial thickness burn more than 20% in adults - Partial thickness burn of face, hand, feet, perineum - Full thickness burn more than 5% TBSA

- Chemical burns, Inhalational burns, Electric burns - Burns with other medical illness - Burns with other trauma, like bony fractures Note- scalds are the most common burns in civilian practise 2c The escharotomy should be away from the main arterial and venous blood supply. Mid medial or mid lateral aspect of extremity is chosen for escharotomy. the incision is taken deep to the eschar through to the dermis into the subcutaneous fat. Notes 1st degree burns-- Involve the epidermis, Do not blister, erythematous 2nd degree superficial partial thickness involves upper dermis. It is very sensitive and forms blister 2nd degree deep partial thickness burn involves Reticular dermis 3rd degree burn all layers of dermis with contractures 4th degree burn involves the subcutaneous tissue as well. 3. c Poisoning with carbon monoxide poisoning leads to formation of carboxyhemoglobin which has 200 times more affinity for hemoglobin. Carboxyhemoglobin prevents reversible displacement of oxygen. It shifts the oxygen hemoglobin dissociation curve to the left , kills the cytochrome, direct action on CNS and direct toxicity to cardiac and skeletal muscles. 4. c Burn victims are susceptible to a wide variety of infections associated with relative immunosuppression (which occurs with burns of 30% TBSA or more) and complications of intensive care. Virtually any organ can become the target of an infection in such patients. The most common infections in burned children are those related to the burn wound and catheter-associated septicemia

Mcqsurgery.com ----Surgery MCQs

Q1 Which of the following is a contraindication for breast conserving surgery (BCT)? A) Small lump to breast ratio b) Central breast tumor mass c) Breast Tumor size less than 5 cm d) Young age Q2. Which is not true regarding BRCA mutations in breast cancer? a) BRCA 1 tumors are high grade as compared to BRCA 2 b) BRCA 1 breast cancer are hormone receptor positive c) BRCA 1 breast tumor are aneuploid d) BRCA 1 breast cancer have an incraesed S phase fraction Q3 ) Which of the following muscles do not form the posterior relation of breast? a) Pectoralis major b) Serratus Anterior c) Rectus Abdominis d) Lattismus Dorsi Q4 Minimum number of lymph nodes to be dissected in Axillary sampling in brest conservation surgery is a) 2 b) 3 c) 4 d) 5 Q5) In Breast Reconstructive surgery after mastectomy which of the following is not true regarding TRAM flap a) TRAM flap may be based on a pedicled Superior Epigastric artery b) TRAM flap can be transferred as a free flap c) It is a type of myocutaneous flap d) It uses supraumbilical fat Q6) Not a true statement regarding breast implants a) They are made of silicone shell filled with either saline or silicone gel b) Silicone gels filled implants provide a more natural shape c) Silicone gel filled implants became controversial becasue of risk of associated malignancy d) In case of rupture of implants silicone gel may get absorbed in axillary lymph nodes

1) b Breast conservation involves resection of the primary breast cancer with atleast 2 mm margin of normalappearing breast tissue, adjuvant radiation therapy, and assessment of axillary lymph node status. Breast conservation surgery is contraindicated when -- the tumor is multicentric and multifocal -- the tumor is central, the advantages of preserving the breast are lost as nipple areola complex is sacrificed -- tumor is to breast ratio is large ie the form of breast is not preserved

-- Patient is not a candidate for radiation exposure, eg pregnancy, previous history of radiation SLE etc Age is no criteria. 2) b . BRCA1- associated breast tumors have a worse prognosis than BRCA2- associated breast cancers. They are high grade, associated with negative ER- PR receptors, increased S phase fraction and aneuploid. 3. d The deep or posterior surface of the breast rests on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. Schwartz Surgery 4. c Minimum number of lymphnodes to be removed in Axillary sampling is 4 and in Sentinel Lymph node biopsy is 2 In Breast conservation surgery the axilla can be dealt in three separate ways; 1. Sentinel Lymph Node Biopsy 2. Axillary sampling 3. Axillary Dissection Sentinel Lymphnode biopsy axillary sampling is done for clinically node negative axilla. 5) d After MRM, breast mound can be created using a TRAm flap which is a myocutaneous flap. It uses infraumbilical suprapubic fat and not supraumbilical fat. It may be pedicled based on superior epigastric artery or free flap based on deep inferior epigastric or perforator veseels. Drawbacks to the TRAM flap include a longer operative time, a visible scar on the lower abdomen, and a slight weakening of the abdominal wall. Sabiston 18th edition 6) c Silicone filled implants became controversial not because of their association with malignancy but because of the associated risk of systemic diseases like autoimmune disorders, arthritis and collagen vascular disorders.
Q1. Which of the following is not true for Hashimoto thyroiditis? a) It is an autoimmune disease caused by CD4 cells with specificity to thyroid antigens b) commonly presents as hypothyroidism c) Surgery is required in almost all cases d) Hashimoto thyroiditis can progress to lymphoma of thyroid

Q 2. In which of the following conditions anti thyroid antibody may not be elevated? a) Hashimoto thyroiditis b) Grave's disease c) Multinodular goitre d) Lymphoma thyroid Q3. Regarding thyroid and parathyroid neoplasms a. Follicular carcinoma of thyroid primarily spreads through lymphatics b. Parathyroid adenoma is the most likely cause of primary hyperparathyroidism c. Hrthle cell carcinoma is a variant of papillary carcinoma of the thyroid d Phaeochromocytoma is detected by measuring urinary 5-HIAA levels e. Superior laryngeal nerve supplies cricothyroid muscle

Q4. A complication of thyroidectomy which can be prevented by prophylaxis is a) Injury to recurrent laryngeal nerve b) Hypocalcemia c) Thyroid Storm d) Q5) What is the next step in investigating a 26 year old male with solitary thyroid nodule 1 cm in size? a) Radio Isotope scan b) Thyroid functions (T3,T4, TSH) c) USG guided FNAC

d) Follow without investigations

Answers
1. c Hashimoto's thyroiditis is an autoimmune process that is thought to be initiated by the activation of CD4+T (helper) lymphocytes with specificity for thyroid antigens. Hypothyroidism is due to cytotoxic cells and autoantibodies. Primary treatment is Thyroxine and surgery is only indicated for cosmetic reasons . Hashimoto's thyroiditis more common in women (male: female ratio 1:10 to 20) between the ages of 30 and 50 years. Commony presents as moderately enlarged firm gland discovered on routine physical examn or the awareness of a painless anterior neck mass, although 20% of patients present with hypothyroidism, and 5% present with hyperthyroidism (hashitoxicosis) Chances of lymphoma are more in cases with hashimoto's thyroiditis. 2. d Antibodies include antithyroglobulin (anti-Tg), antimicrosomal or antithyroid peroxidase (anti-TPO) and thyroid-stimulating immunoglobulin (TSI). Anti-Tg and anti-TPO antibody levels they indicate the underlying disorder, usually an autoimmune thyroiditis. Approximately 80% of patients with Hashimoto's thyroiditis have elevated thyroid antibody levels, but levels may also be increased in patients with Graves' disease, multinodular goiter, and, occasionally, with thyroid neoplasms In Grave's disease antibodies are directed against (TRAbs) (thyroid hormone receptors) (TSI)

Notes Iodine Metabolism The average daily iodine requirement is 0.1 mg. Iodine is rapidly converted to iodide in stomach and jejunum. Iodide is actively transported into the thyroid follicles. Thyroid Hormone Synthesis involves four steps 1.Thyroid trapping of iodide 2. Oxidation of iodide into iodine and coupling with tyrosine to form monoiodotyrosine and diiodotyrosine. 3. Coupling to form T3 and T4 4.Hydrolisation of Thyroglobulin to release T3 and T4

In the euthyroid state, T4 is produced and released entirely by the thyroid gland, whereas only 20% of the total T3 is produced by the thyroid. Most of the T3 is produced by peripheral deiodination of T4 in the liver, muscles, kidney, and anterior pituitary, The thyroid gland is capable of autoregulation, which allows it to modify its function independent of TSH. As an adaptation to low iodide intake, the gland preferentially synthesizes T3 rather than T4, thereby increasing the efficiency of secreted hormone. In situations of iodine excess, iodide transport, peroxide generation, synthesis, and secretion of thyroid hormones are inhibited.

3.e 4. c Thyroid storm, a manifestation of severe thyrotoxicosis, is avoided by prophylactic treatment with propylthiouracil or methimazole prior to surgery. 5. B Although some or all of these tests may be required at some stage, the initial investigation would be thyroid function tests to look at whether the patient is hypothyroid or hyperthyroid. Low TSH means hyperthyroidism and is further evaluated with Radio isotope scan. It also suggests lower chance of malignancy High TSH suggests hypothyroidism most likely Hashimoto's thyroidits Q1. Which of the following is not true regarding blood supply of pancreas? a) Pancreas receives blood supply from coeliac trunk and superior mesenteric artery. b) Body and tail of pancreas is supplied by Splenic artery c) Posterior superior pancreaticoduodenal artery is a branch of Superior mesenteric artery. d) All major pancreatic arteries lie posterior to pancreatic ducts. Q2. Most Common Cause of death in early acute Pancreatitis is a) Renal Failure

b) Cardiac failure c) Respiratory Failure d) Uncontrolled Coagulopathy

Q3. All of the following have been used in management of Acute Pancreatitis except a) Interleukin-10 b) Gabexate c) Somatostatin d) Peritoneal dialysis Q4. Which of the following is not true for ectopic pancreas a) stomach and duodenum are the most common site b) Ectopic pancreas appears as a submucosal irregular nodule in the wall c) Islet tissue is present in all the organs where ectopic pancreas is present. d) Ulceration, bleeding and obstruction are the most common symptoms Q5. Nealon's classification is used for a) Acute pancreatitis b) chronic pancreatitis c) pseudocyst pancreas d) alcoholic pancreatitis

1. c Anterior and Posterior Superior Pancreaticoduodenal artery & vessels are derived from coeliac artery. Anteior and Posterior Inferior pancreaticoduodenal artery & vessels are derived from Superior Mesenteric artery. Splenic artery supplies the body and tail of pancreas. Dorsal pancreatic artery usually arises from the splenic artery, near its origin from the celiac trunk. A right branch of the dorsal pancreatic artery supplies the head of the pancreas and usually joins the posterior arcade. The gastroduodenal artery gives origin to the supraduodenal, retroduodenal, and posterior superior pancreaticoduodenal (PSPD) arteries. The gastroduodenal artery ends by dividing into the right gastroepiploic and anterior Superior pancreaticoduodenal (ASPD) arteries. PSPD (Postero Superior Pancreaticodeuocenal Artery) is a branch of gastroduodenal and not Superior mesenteric artery The anterior inferior pancreaticoduodenal artery arises from the SMA at or above the inferior margin of the pancreatic neck

Pancreas Surgery Questions from MCH Exam


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Note the Superior Pancreaticoduodenal artery coming off the coeliac artery.The Inferior Pancreaticoduodenal arteries are branches of Superior Mesenteric artery and both form an important anastomotic area in the C loop in the duodenum In Beger's Pancreatectomy posterior Superior Pancreaticodeuodenal artery has to be preserved

2. c Respiratory failure is the cause of death in the early phase (7 days). The pulmonary manifestations of pancreatitis include atelectasis and acute lung injury. where as infective complications are the cause of death in late phase. 3. a Peritoneal dialysis, Gabexate, lexipafant (Anti PAF factor) Somatostatin all have been used in management of acute pancreatitis but have been found to be of no proven value . IL 10 is raised in pancreatitis and has no role as treatment modality 4. c Ectopic pancreas is most commonly seen as a submucosal nodule in the wall of stomach, duodenum, ileum, colon, gall bladder, meckel's diverticulum and mesentary. Islet tissue is present only in the wall of stomach and duodenum not in other organs. Ulceration , bleeding and obstruction (Ectopic pancreas can form a lead point of intussusception). Sabiston Surgery 18th edition page 1592. 5.c Nealon classification describes the relationship of pseudocyst pancreas with the pancreatic duct Q6. Which of the following is not true regarding blood supply of pancreas?

a) Pancreas receives blood supply from coeliac trunk and superior mesenteric artery. b) Body and tail of pancreas is supplied by Splenic artery c) Posterior superior pancreaticoduodenal artery is a branch of Superior mesenteric artery. d) All major pancreatic arteries lie posterior to pancreatic ducts.

Q7. Which of the following is not a drawback of Ranson's score in Pancreatitis

a) It is cumbersome to use b) It takes 48 hours to complete

c) Sensitivity and specificty range from 40-90% d) HIgher score does not necessarily mean severe disease

Q8. One of the following is not a characterstic of cut surface of malignant neoplasm of pancreas

a) Rubbery b) Glistening c) Firm d) Gray

Q 9. What is not a key concept in surgery of Duodenum Preserving Pancreatic head resection (DPPHR)

a) Preserving posterior branch of gastro duodenal artery b) Identifying and preserving the Duodeno pancreatic grrove c) Common Bile duct is not opened d) Neck of pancreas is divided over the superior mesenteric vein

Q10. Which of the following is not a rationale in duodenum preserving pancreatic head resection

a) Dilated ducts in body and tail with non dilated duct in head of pancreas b) Common duct obstruction from small pseudocysts, fibrosis, or inflammation in the head of the pancreas. c) Previous longitudinal pancreaticojejunostomy who have recurrent or persistent pain associated with small strictured ducts in an enlarged fibrotic pancreatic head with or without common bile duct obstruction d) Dilated duct in head of pancreas

Answers 1. c Anterior and Posterior Superior Pancreaticoduodenal artery & vessels are derived from coeliac artery. Anteior and Posterior Inferior pancreaticoduodenal artery & vessels are derived from Superior Mesenteric artery.

Splenic artery supplies the body and tail of pancreas. Dorsal pancreatic artery usually arises from the splenic artery, near its origin from the celiac trunk. A right branch of the dorsal pancreatic artery supplies the head of the pancreas and usually joins the posterior arcade.

The gastroduodenal artery gives origin to the supraduodenal, retroduodenal, and posterior superior pancreaticoduodenal (PSPD) arteries. The gastroduodenal artery ends by dividing into the right gastroepiploic and anterior Superior pancreaticoduodenal (ASPD) arteries.

PSPD (Postero Superior Pancreaticodeuocenal Artery) is a branch of gastroduodenal and not Superior mesenteric artery The anterior inferior pancreaticoduodenal artery arises from the SMA at or above the inferior margin of the pancreatic neck

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Note the Superior Pancreaticoduodenal artery coming off the coeliac artery.The Inferior Pancreaticoduodenal arteries are branches of Superior Mesenteric artery and both form an important anastomotic area in the C loop in the duodenum In Beger's Pancreatectomy posterior Superior Pancreaticodeuodenal artery has to be preserved

Answers

7. d

The Ranson criteria have several drawbacks. First, the list is cumbersome and there are two lists to follow depending on suspected etiology . Second, an accurate Ranson's score takes 48 hours to compute and the criteria have not been validated beyond the 48-hour time limit. Third, not all laboratories measure all the parameters in routine blood tests (e.g., serum lactate dehydrogenase [LDH]). Fourth, the overall sensitivity of the Ranson criteria (using three signs as the cutoff) for diagnosing severe disease is only 40% to 88% and the specificity is only 43% to 90%.

8. a Ductal Adenocarcinoma of pancreas can have a sclerotic reaction making it difficult to distinguish from chronic pancreatitis. The characteristics that distinguish ductal adenocarcinoma are its firm, gray, and glistening cut surface, rather than the rubbery, milky white appearance of benign fibrotic lesions The difficulty in distinguishing ductal adenocarcinoma from chronic pancreatitis also occurs microscopically. Chronic pancreatitis may be associated with remarkable epithelial atypia (architectural and cytologic) in pancreatic tissue; conversely, ductal adenocarcinoma is notorious for its deceptively bland appearance

9.c Common bile duct might need to be decompressed either as choledochalpancreostomy or choledochojejunostomy

Identification and preserving the posterior branch of the gastroduodenal artery which provides blood flow to the duodenum, intrapancreatic common bile duct, and pancreaticoduodenal groove. The neck of the pancreas overlying the portal and superior mesenteric vein is divided, and all but a small amount of pancreatic tissue along the inner aspect of the duodenum is resected. The common bile duct is decompressed, if necessary, either by choledochopancreatostomy to the rim of surrounding pancreas, or by choledochojejunostomy to the Roux limb of jejunum that is used to form the pancreaticojejunostomy with the pancreatic body. Reconstruction consists of an end-to-end pancreaticojejunostomy to the distal pancreas, and end-to-side pancreaticojejunostomy to the remnant of pancreatic tissue on the inner aspect of the duodenum

10. d This section also discusses the rationale of Pancreatic head resection surgery Tissue and duct hypertension is considered as a major factor in the etiology of pain in patients with chronic pancreatitis. Duct dilatation is a consequence of duct obstruction due to scars or duct stones In about 30%50% of the patients with alcoholic pancreatitis there is an inflamatory mass in the head of the pancreas leading to a head enlargement. Besides local complications (such as stenosis of the pancreatic main duct, the common bile duct or the duodenum) the area of inflammation leads to a pancreatitis-specific neuritis which contributes to the clinical pain syndrome via local release of pain hormones, such as substance P and CGRP. Resection of this part of the head serves to relieve pain In Frey's procedure Duodenum is preserved and head coring is carried out. Beger is true DPPHR Above three are all indications and rationale for the same Q16. Which of the following regarding biliary strictures in chronic pancreatitis is not true? a) Endoscopic stenting is a primary modality of management b) Most of the patients are asymptomatic c) All patients should undergo evaluation to rule out malignancy d) Main factor for development of chronic pancreatitis is the proximity to head of pancreas Q17. True about duodenal obstruction in chronic pancreatitis a) Duodenal obstruction is caused by pancreatic pseudeocyst alone b) Endoscopy cannot diagnose this condition c) 25% of patients with common bile duct stenosis need surgery for duodenal obstruction also d) Conservative treatment should be given for a month

Q18. Which of the following is not an indication of surgery in Pancreatic ascites a) Persistent or recurrent accumulation of ascitic fluid b) Sudden deterioration of symptoms c) Failure of medical therapy d) After control of leak after pancreatic duct stenting Q 19. The most common Vein to be involved in Extrahepatic portal hypertension in chronic pancreatitis is a) Portal vein b) Splenic vein c) Superior mesenteric vein d) Inferior mesenteric vein Q20. Most common cause of nausea and vomiting in patients with carcinoma head of pancreas is a) Tumor infiltration of coeliac nerve plexus b) Direct tumor infiltration of duodenum c) Tumor infiltration around Superior Mesentary artery d) External Compression of duodenum 16. a Main factor for CBD stricture in chronic pancreatitis is the close association of CBD with the head of pancreas. A pseudocyst compressing the CBD is a rare cause Most of the patients are asymptomatic or have rise in alkaline phosphatase or bilirubin or both Surgical therapy is indicated in almost all cases Endoscopic stenting is not the primary therapy. Stents should be inserted in patients who are unfit for surgery. Stents have their own problems like infection, stent displacement and stent occlusion. Concomitant malignancy should be ruled out Schakelford 6th edition page 1311

17. c Duodenal obstruction occurs in 12% of all cases of chronic pancreatitis and 25% cases operated for CBD obstruction also have duodenal obstruction. It can occur both due to the inflamatory mass and pseudocyst. patient has history of long standing nausea and vomiting. Endoscopy shows a concave extraluminal impression without mucosal involvement. Conservative treatment should be given for 2 weeks only Schakelford 6th edition page 1311 18. d 4% of patients with chronic pancreatitis have ascites and 12% with pancreatic pseudocyst develop pancraetic ascites. After making a diagnosis, ERCP should be done for defining the site of leak and going for a therapeutic procedue such as endoscopic stenting. Simultaneous use of octreotide, diuretics and repeated paracentesis also helps. Surgery is not the primary treatment and is indicated when medical management fails, or despite adequate attempt asictes persists or recurs. Add comment 19. b EPH or extrahepatic portal hypertension is the most common vascular complication of chronic pancreatitis. Any part of splenomesentericoportal venous axis may be involved resulting in either occlusive or non occlusive portal hypertension Splenic vein is the most frequently involved Common causes of venous thrombosis are Inflamatory process causing danage to vessel wall with vasospasm, venous stasis and thrombosis Progressive fibrosis of Chronic pancreatitis Extrinsic compression by pseudocyst 20.a Nausea and vomiting occurs in upto 50% of patients in carcinoma head of pancreas. Obstructive jaundice in 90%. The most common cause of nausea and vomiting is motility disturbance of stomach and duodenum due to infiltration of coeliac nerve plexus. Rest of the choices are other causes. Small intestine motility disturbcance can occur due to tumor infiltrating the SMA ( Superior Mesentary Artery) Blumgart: Surgery of the Liver, Biliary Tract and Pancreas, 4th ed.

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