Healing by Primary Intention

Q)What is the false regarding the healing by  primary intention?

A)Wound edges opposed.

B)Normal healing.

C)Usually done for dirty wounds

D)Minimal scar.

Answer-C(bailey-25)

Primary intention,

Healing by primary intention is also known as healing by the first intention this occurs when there is an opposition of the wound edges

Secondary Intention

Healing occurs when the wound edges are not opposed immediately, which may be necessary for contaminated or untidy wounds.

Primary intention,

  • Would edges opposed
  • Normal healing.
  • Minimal scar.

Secondary intention,

  • Would leave open.
  • Heals by granulation, contraction and epithelialisation.
  • Increased inflammation and proliferation.
  • Poor scar.

Intestinal TB

Q) False about intestinal TB
1. Hyperplastic variety has colonic strictures
2. Raised markers,anaemia,positive sputum culture point towards diagnosis
3. BMFT shows pulled up cecum
4. IFN gamma assay

Ans A) STRICTURES ARE OF SMALL BOWEL

There are two types Of Intestinal TB

Ulcerative type - Transverse ulcers with undermined edges, Serosa of bowel is studded with tubercles. It is a severe form of disease

Hyperplastic - Hyperplasia and thickening of terminal ileum. Narrowing of lumen., Stricture and fibrosis occues of terminal ileum

There are raised inflamatory markers and anemia

Interferon gamma is for subclinical infection

BMFT shows subhepatic caecum

Bailey page 80

INactive hydatid cyst

Q According to WHO-IWGE ultrasonographic classification for Hydatid cyst, inactive cysts belong to which group
a) Group I
b)  Group 2
c) Group 3
d) Group 4

More question at www.mcqsurgery.com/hydatid

Answer: C
Reference Bailey and love 27th edition page number 64

WHO Informal Working Group on Echinococcosis (WHO-IWGE) classification
Group 1: Active group – cysts larger than 2 cm and often fertile.
Group 2: Transition group – cysts starting to degenerate and entering a transitional stage because of host resistance or treatment, but may contain viable protoscolices.
Group 3: Inactive group – degenerated, partially or totally calcified cysts; unlikely to contain viable protoscolices.

Primary Hyperparathyroidism

Q) Which is not a feature of primary hyperthyroidism?

a) Increase Parathormone

b) Increase Calcium

c) Decreased phosphate

d) Dystrophic calcification

Ans d 

Clinical features of Hyperparathyroidism are

  1. Subperiosteal bone erosions
  2. Primary Hyperthyroidism  is defined as hypercalcaemia in the presence of an unsuppressed and therefore relatively, or absolutely, elevated PTH level. Elevated calcium and elevated PTH are important  in diagnosis of PTH
  3. The presence of kidney stones remains the most common clinical manifestation of symptomatic PHPT.
  4. It is associated with a low serum phosphate in the setting of normal creatinine and vitamin D levels

Ref Bailey and Love Page 826

 Some useful questions can be bought here  MCQs and EMQs in Surgery: A Bailey & Love Revision Guide, Second Edition 

Some uncommon disorders associated with hyperparathyroidism include

peptic ulcers, pancreatitis, and bone disease

central nervous system symptoms 


Causes of Primary Hyperparathyroidism are

  1. Parathyroid Adenoma -75% (can be localised by Sestamibi scanning)

Management of primary hyperparathyroidism

Patients with symptomatic primary hyperparathyroidism as manifested by kidney stones, renal dysfunction, or osteoporosis should undergo parathyroidectomy.

If the patient is asymptomatic and detected to have high parathyroid levels then surgery is done only if

  1. age is less than 50
  2. very high excretion of calcium in urine
  3. low creatinine clearance
  4. kidney stones
  5. high serum calcium

 

Paraneoplastic syndrome in HCC

Q) Paraneoplastic Syndrome in HCC which also occurs in End stage liver disease

a) Hypercholesteremia

b) Hypoglycemia

c) Hypercalcemia

d) Carcinoid

Ans -  b

Hypoglycemia (also seen in end stage liver disease) 

Erythrocytosis

Hypercalcemia

Dysfibrogenimea

Carcinoid Syndrome

Thyroxin binding globulinincreases

Porphyria cutanea tarda

Gynecomastia, testicular atrophy, early puberty

Timing of cholecystectomy in biliary pancreatitis

Q) What is true regarding timing of cholecystectomy in biliary pancreatitis

a) Cholecystectomy should be done before discharge in severe pancreatitis to prevent recurrent attacks

b) Cholecystectomy should be done in same admission as pancreatitis when severe disease is excluded

c) Early cholecystectomy has been shown to have more complications than interval choelcystectomy

d) Early cholecystectomy increases technical complications

 Ans b

"Poncho trial " answers this question

Early  cholecystectomy (just before discharge, when the patient has recovered and severe disease excluded), compared to interval cholecystectomy, effectively reduces

  1. The rate of recurrent gallstone-related complications in patients with mild biliary pancreatitis,
  2. low added risk of complications.

Evidence on the timing of cholecystectomy in severe pancreatitis is scarce. Cholecystectomy is recommended after all signs of pancreatic necrosis have been resolved or if they persist more than 6 weeks

SKF page 1079

Skin grafting

Q)In preop evaluation before placing skin graft over wounded area…bacterial colony count must be less than
a) 10000
b) 100000
c) 1000000
d) 10000000

ans b)  10 raise to the power 5

Prerequisites for skin grafting:
The recipient site should be assessed for potential bacterial load, blood supply,
presence of devitalized tissue, and exposed vital structures.
Donor site availability
Perform recipient site tissue culture if history or concern for infection (counts <105
CFU/g tissue for most pathogens required before grafting).
Presence of group a beta heamolytic streptococci is absolute contraindication for
skin grafting
[/bg_collapse]

 

Highly selective vagotomy

Q) False about highly selective vagotomy
a) Highly selective vagotomy divides the vagus nerves supplying the acid-producing portion of the stomach
b) Incidence of postoperative complications is lower.
c) The criminal nerve of Grassi should be severed
d) Crow's feet nerves are severed till below the GE junction

 

 Ans -d

HSV only divides the last part of the nerves which supply the part of stomach which produces acid
Acnt and post nerves of Latarjet are found and their terminal branches are severed from 7 cm proximal to the pylorus to 5 cm above the GE junction
Motor function of the stomach is not affected
Criminal nerve of grassi is branch of posterior vagus. It should be sought and cut
Ref sab 2oth page 1206

Post Whipple’s Bleeding

Q) Post whipples on pod4 patient presented with fever, tachycardia and pain, usg showed collection, which was drained percutaneously. on pod 10 there is frank blood of 100ml in drain, next line of management

a. Ct angiography

b. Emergency laparotomy

c. flush the drain with noradrenaline
d. Observe

Ans a 

This is extraluminal bleed on 10th POD following most likely a pancreatic fistula. Clinical condition is mentioned for day 4 which is  because of pancreatic leak.  A pancreatic fistula can cause vascular pseudo aneurysm so answer is A CT angiography

Early extraluminal PPH requires reexploration.

Intraluminal bleeding may manifest as extraluminal if there is associated anastomotic breakdown,and this may be amenable to angiographic intervention when involving the pancreaticojejunostomy.

Patients present with septic complications and/or a sentinel  bleed. Radiographic embolization has become a more successful modality, with up to 80% success,13 but is limited by the initially intermittent nature of the bleeding

Exploration - if patient is not stable
Ref SKF  page 1241

 

Tumor lysis syndrome

Q)Tumor lysis  syndrome which is not seen

a. hyperkalemia

b hypocalcemia

c. hypophosphatemia

d. hyperuricemia

Ans is c

Tumor lysis syndrome releases, various intracellular  metabolites such as uric acid, potassium and phosphorous which overwhelm the excretory capacities of the kidney.

The metabolic anomalies are

Hyperuricemia

Hyperkalemia

Hyperphosphatemeia

Hypocalcemia

It mostly occurs in poorly differentiated leukemias and lymphomas