Necrotising Infections

Q)  Least common Signs or symptoms of necrotising infections is
a) Unusual pain
b) Oedema beyond area of erythema
c) Crepitus
d) Fever

( MCQS on infections bailey and Sabiston based) 

Ans d 

Fever is unusual

Signs and symptoms of necrotising infections
● Unusual pain
● Oedema beyond area of erythema
● Crepitus
● Skin blistering
● Fever (often absent)
● Greyish drainage (‘dishwater pus’)
● Pink/orange skin staining
● Focal skin gangrene (late sign)
● Shock, coagulopathy and multiorgan failure

Ref Bailey 27th page 30

Adenoid Cystic Tumors

Q) All are true for adenoid cystic tumor of the hard palate except

a) Perineural invasion

b) Lung metastasis

c) Lymph node metastasis

d) Increased risk of local recurrence

Ans c 

Adenoid cystic carcinoma is a rare tumor arising from the minor salivary glands;, the palate being the commonest site.

Distant metastasis and perineural invasion are common in adenoid cystic carcinoma.

The lesion is uncapsulated and infiltrative; invasion of underlying bone is common.

Incidence of cervical metastasis is low.

Distant metastasis occurs through blood stream to lung and bones. Direct extension of lesion of the base of skull has been reported as a cause of death.

Ref -

MCQ on General onco

Q) WHich is not a invasive mechanism of cancer cells invasion ?

a) Rise in interstitial pressure in the tissue

b) Dissolution of extracellular matix

c) Mobility of cells to Invade

d) Extra cellular matrix dissolution is due to  physical factors

Ans d 

Cancer cells secrete collagenases and proteases that chemically dissolve any extracellular boundaries
They also express  of cell-surface molecules called integrins

Three main mechanisms of cancer cells  that  facilitate invasion are

(1) Rise in the interstitial pressure within a tissue

2. They secrete enzymes that dissolve extracellular matrix

3. Acquire mobility

bailey 141

Differential diagnosis of mass in right iliac fossa

Q) Patient with generalized ill health and pyrexia has a mass in the right iliac fossa with a history of blood-stained mucoid diarrheia? Most common etiology in this case would be ? 

a) Carcinoma

b) TB

c) Amoeboma

d) Lymphoma

More questions on general surgery tropical infections

Ans  c

Amoeboma is partially treated amoebic infection of the caecum

It mostly presents as a mass in RIF and causes confusion with malignancy.

Such a patient is highly unlikely to have a carcinoma because altered bowel habit is not a feature of right-sided colonic carcinoma.

Ref Bailey page 58

Vascular occlusion ( MCQ with free answer)

Q) False about vascular occlusion for hepatic surgery
A. Portal triad clamping along with clamping of supra hepatic and infra hepatic IVC allows adequate bleeding control
B. Prolonged intermittent clamping is usually used in longer surgeries
C. Portal triad clamping can be done for 60 minutes under normothermia
D. Liver tolerates vascular clamping well

Ans b is false, Short intermittent clamping is better

Hepatic vascular exclusion (HVE) combines total inflow and outflow vascular occlusion of the liver. Total isolation of the liver
from the systemic circulation is intended during resection of large tumors adjacent to or involving the major hepatic veins
and/or the IVC.  ( BG 1619)

Intermittent inflow occlusion (Pringle, 1908) to control blood flow to the remnant, usually maintaining inflow occlusion for
periods of 15 minutes, interspersed by 5 minute periods of relief to allow perfusion of the remnant and decompression of
the bowel.

The superiority of intermittent inflow occlusion versus continuous or total occlusion is now widely accepted

According to the Cochrane database, in elective resection, intermittent portal triad clamping seems better than continuous clamping, especially in patients with diseased parenchyma. Therefore, intermittent triad clamping could be recommended as the “gold
standard” method of clamping

Clamps are applied for up to 60 minutes in patients with normal liver ( BG 1619)

c)  is true A number of studies have

established that ≤ 90 min of complete PTC is safe in normal livers. Nonetheless, many surgeons will not clamp the inflow continuously for > 45 min because of concern about occult liver damage and most resections can be accomplished within this time frame.

d) is true Although the liver is relatively resistant to periods of warm ischaemia, it is vulnerable to anoxic conditions and may be more severely vulnerable if it has been chronically damaged by either cirrhosis or chemotherapy.


Q) ALPSS all are true except? (AIIMS 2017 Gi questions) (Liver Surgery MCQs) 

a) ALPPS should not be considered in every patient in whom PVE has failed.

b) CT scan and volumetric assessment is done after POD 7 and proceeded to stage 2 if sFLR greater than 30% (BWR > 0.5%) or 40% (BWR > 0.8%) depending on parenchymal quality

c) Indicated for Large CRLM

d) Is a relative contraindication for patients with hilar cholangiocarcinoma

Ans a)  ALPPS should be considered in every patient in whom PVE or the classic two-stage approach is not feasible or has failed

The limits for safe hepatic resections are usually considered from 20% to 40%, depending on the quality of liver parenchyma (fibrosis, steatosis,
chemotherapy-related liver injury). The lower limit for FLRV is set at 20% in patients with normal livers, 30% to 35% in patients with chemotherapy-related liver injury, and 40% in patients with chronic liver disease

Cut-off values for proceeding to stage 2, usually after 7 to 14 days, are sFLR greater than 30% (BWR > 0.5%) or 40% (BWR > 0.8%) depending on parenchymal quality. ( Ref BG page 1665) 

Currently,CRLM is the most promising indication, especially for bilobar involvement
In hilar cholangiocarcinoma its a relative contraindication as the mortality and morbidity are high


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