Pseudo achalasia

Q) Most common cause of  pseudo achalasia is ?

(a) Benign tumors of esophagus
(b) Chagas disease
(c) Caustic injury
(d) Adenocarcinoma of cardia

Answer free for all 

d

Pseudoachalasia is an achalasia-like disorder that is usually produced by adenocarcinoma of the cardia
Other uncommon causes are
 1.benign tumours at this level.
2, Tumors of bronchus, pancreas
Ref Bailey page 1097

Marjolin Ulcer

Q) True about Marjolin's ulcer

a) lymphatic spread is common

b) They are painful

c) Aggressive and fast growing tumors

d) Squamous cell carcinoma is the most common type


d. squamous cell carcinoma

When a SCC or BCC occurs in a long standing scar, it is called marjolin's ulcer.

Marjolin's type of ulcer is a malignant change that can occur in any long standing ulcer (ie venous ulcer)

Scar tissue is devoid of lymphatics, so no lymphatic spread. Lymphatic spread can still occur when it invades normal tissue. also nerve endings are not in scar tissue, so pain is a late feature

They are slow growing tumors, and squamous cell carcinoma is the most common type. Slow growth is again due to avascular characterstic

Pouchitis after IPAA in ulcerative colitis

Q) Which of the following is Not a risk factor for pouchitis post IPAA in ULcerative colitis

A) Smoking
B ) NSAIDs use post op
C) Elderly patients
D) UC with extra intestinal manifestation


Ans a

Pouchitis is the complication of Ileal Pouch Anal Anastomosis (IPAA) for Ulcerative colitis. The incidence of pochitis for the same proedure for familial Adenomatous polyposis is less than 10% but for ulcerative colitis can go as high as 50%.

Risk factors for development of pouchitis are

  1. Previous extra intestinal manifestations of IBD especially arthritis
  2. ANCA positive cases of UC
  3. NOD2insC  positive patients
  4. Smoking prevents the development of puchitis after IPAA in ulcerative colitis.

5. Other reported factors that may associate with pouchitis include extent of UC, thrombocytosis,and PPI use with  NSAId

Ref - https://onlinelibrary.wiley.com/doi/full/10.1111/den.12744

lymphatics of colon

Q ) Which of the following group of lymph nodes do lymphatics of the colon first drain to?

a) Paracolic

b) Epicolic

c) Nodes along SMA/IMA

d) Para aortic
Answer to 37


37) b

Lymphatics first drain to epicolic group along the bowel wall

Then paracolic group along the marginal artery

Intermediate group along the named vessels SMA/IMA

Finally to par aortic 

Colon and upper 2/5 of rectum --- Para aortic

Lower 1/5 of rectum and anal canal - Superficial inguinal lymph nodes

Ref Sabiston-1317

Bariatric Surgery

Q)  False regarding Bariatric surgery

a) VBG produces less weight loss when compared to RYGB

b) Jejuno-ileal by-pass not done nowadays.

c) Dumping is due to non- compliance of dietary advice

d) LAGB requires once a 4-6wk follow up

Answer (free)

c
Calorie restriction is responsible for long term weight loss and its beneficial effects such as control of diabetes, dyslipidemia, hypertension and other metabolic abnormalities.
Restrictive procedures are LSG and  LAGB  which decrease the appetite and induce early satiety.           
The RYGB (ROUX en Y  gastric bypass ) is  a malabsorptive procedure  with long term sustained weight loss.
Mechanism of weight loss after bariatric surgery
Ghrelin is orexigenic gut hormone, which increases appetite. After food intake ghrelin levels fall and appetite decreases.
After restrictive surgery such as LYGB and LSG, ghrelin levels fall and appetite decreases.
Vertical Banded Gastroplasty (VBG) This procedure has been abandoned in favor of other operations because of poor long-term weight loss, a high rate of late stenosis of the gastric outlet, and a tendency for patients to adopt a highcalorie liquid diet, thereby leading to regain of weight. Choice a is correct

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Suturing in vascular anastomosis

Q) True about suturing technique in vascular anastomosis

a) Anastomosis may not be completely water tight

b) To prevent intimal injury needle should be moved from with in to out

c) 4-0 suture is preferred for aorta

d) Any bio degradable suture which is monofilament can be used


Answer

b

Vessels should always be sewn with the needle moving from within to without on the downstream edge of the vessel to avoid creating an intimal flap and to fix any atherosclerotic plaque.

Tip of the needle should be at right angle to the intima and curve of the needle should be followed

Distal clamp is released first

Non absorbable sutures should be used

2-0 should be used for aorta 4-0 for femoral and 6-0 for popliteal

Only non absorbable monofilament sutures are used in vascular anastomosis

Bailey 27 page 99