ALPSS

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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

 

Post op pulmonary complications

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Q) What does not decrease post op pulmonary complications? ( Questions on Gen Surgery Peri op care)  

a) Smoking cessation

b) Epidural Anesthesia

c) Nasogastric tube

d) Preop and post op Spirometry

Ans c) Routine Naso gastric tube placement

Postoperative pulmonary complications occur in approximately 6% of patients after major abdominal operations and

It includes pneumonia/infection, respiratory failure requiring prolonged ventilation, exacerbation of chronic obstructive pulmonary disease (COPD), and lobar/parenchymal collapse with or without associated effusion.

More recently, standard patient care protocols (e.g., iCough) have been developed to decrease the risk of pulmonary complications, which include incentive spirometry, coughing and deep breathing, oral care
(brushing teeth and using mouthwash), elevating the head of bed,
and getting out of bed three times a day.

Multimodal pain control
and judicious use of regional analgesia (e.g., thoracic epidurals) may
also help to prevent pulmonary complications in surgical patients.
Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

Ref Sabiston 21 page 247

Surgery for Gastric volvulus

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Q)   Which is not an operative approach in  in gastric volvulus? ( Click for  more Questions on Stomach) 

a) Tanner

b) Opolzsr

c) Grey Ghimmenton

d) Gavrilu

Ans  d ) Gavrilu

Gavrilu is  trans-abdominal myotomy and antireflux procedure using a flap of greater curvature of stomach to be sutured over esophageal mucosa through a left subcostal incision

Division of gastro colic ligament and gastropexy is tanner

Splitting the meso colon and doing a gastropexy is grey ghimelton

Fundo antral gastrogastrostomy - opolzsr
Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

Endocrine cells of Pancreas

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Q  Which is wrongly matched ( Free Questions) (#AIIMS 2021 GI Recall

a) Alpha cell - pancreatic poly peptide

b) Beta cell - insulin

c) Epsilon cell - ghrelin

d) Delta cell -  somatostatin

Ans a, ALpha cells

Alpha cells secrete glucagon

Pancreatic polypeptide is from F cells which form 15% of islet mass and are seen in Head and Uncinate process of Pancreas

Also alpha cells are the first cells to develop in the lineage
Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

REf Sabiston 21st edition page 943

 

Sarcoma with early lymph node spread

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Q) Soft tissue sarcoma  with  early lymph node metastasis is (#AIIMS onco 2021  # Soft tissue sarcoma)

a) Pleomorphic sarcoma
b) MFH
c) Angio sarcoma

d) all

Ans c)

In Sarcoma lymph node metastasis is rare in (<5%), except in a few histologic subtypes such as
1. epithelioid sarcoma

2. rhabdomyosarcoma

3. clear-cell sarcoma,

4.angiosarcoma

5.Undifferentiated pleomorphic sarcoma (UPS).

Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice

 

Fibrolamellar HCC

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Q) Fibrolamellar HCC is associated with ? ( #NEET onco Questions 2020) 

a) Young age

b) No lymph node metastasis

c) Poor Prognosis

d) Occurs in setting of cirrhosis

Ans a Young age

This tumor generally occurs in younger patients without a history of cirrhosis.

Well demarcated and encapsulated and may have a central fibrotic scar

Good prognosis than HCC, probably related to high resectability rates, lack of chronic liver disease, and a more indolent course. Long-term survival can be expected in approximately 50% to 75%

Lymph nodes can be involved and associated with poor outcome

 

Crohn Disease Pathology

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Q) Which of the following is not characteristic of Crohn Disease  : * (From AIIMS 2020 November GI)  

a) Granular mucosa
b) Transmural involvement
c) Skip lesions
d) Giant cell granuloma

Ans a ) Granular Mucosa- This is a feature of ulcerative colitis ( Table 49-7 Sabiston 20) 

The typical gross appearance of ulcerative colitis is hyperemic mucosa. Friable and granular mucosa is common in more severe cases, and ulceration may not be readily evident. ( Saby 1340) 

IN Crohn disease - Microscopically, there are focal areas of chronic inflammation involving all layers of the intestinal wall with lymphoid
aggregates. Non-caseating giant cell granulomas are found in 60% of patients and when present clearly allow a confident diagnosis of CD.

( Bailey 1242) 

 

Gastrinoma diagnosis

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Q) Gastrinoma false is (AIIMS GI 2020) 
a) Fasting sG 1000 g/ml
b) Duodenotomy should be done in all cases
c) Diarrhea most common symptom
d) SRS can localize 80% cases

Ans  )  c -

Duodenotomy detects 25% to 30% of tumors not seen on preoperative imaging.

Gastrin  levels higher than 1000 pg/mL are strongly suggestive of gastrinoma, provided that the patient demonstrated increased gastric acid  secretion ( gastric secretion ph should be less than 2) 

Most common is abdominal pain ( 75%) In 10% to 20% of patients, diarrhea is the only symptom ( Saby page 954) 

SRS should be performed because almost all gastrinomas express somatostatin receptors.

Meld score uses and drawbacks

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Q. All are true about Na-MELD except :

a) It corelates with cirrhosis
b)Range of sodium value  is 125-137
c)It relates to vasoconstriction
d) Used for allocation in DDLT patients

Ans c

 MELD was originally developed to predict three-month mortality following transjugular intrahepatic portosystemic shunt (TIPS) placement and was derived using data from a population of 231 patients with cirrhosis who underwent elective TIPS placement.

Range of MELD score is 6-40

MELD Score = 10 x (0.957 x Ln(serum creatinine mg/dL) + 0.378 x Ln(serum bilirubin  mg/dL) + 1.120 x Ln(INR) + 0.643 )

For candidates with an initial MELD score greater than 11, the MELD score is then re-calculated as follows:
MELDNa = MELD(i) + 1.32*(137-Na) - [0.033*MELD(i)*(137-Na)]

  • Sodium values less than 125 mmol/L will be set to 125, and values greater than 137 mmol/L will be set to 137.

It is used for allocation in DDLT to assess wait list mortality

MELD score has also proved to be an effective predictor of outcome in other situations, such as

  1. Patients with cirrhosis going for surgery and patients with fulminant hepatic failure or alcoholic hepatitis.
  2. The MELD score does have limitations in situations where the INR or creatinine may be elevated due to reasons other than liver disease, and its implementation for organ allocation purposes does not take into consideration several conditions that benefit from liver transplantation.

Smoking treatment

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Q) Smoking cessation- Not a  first line drug option ?

a) Clonidine 

b) Nicotine replacement (patches)

c) Varenicline

d)  Bupropion

Ans A) clonidine

NRT ,  varenicline (Chantix), and bupropion (Zyban) are the three principal firstline pharmacotherapies recommended for use either alone or in combination 

Clonidine and nortriptyline—as second-line pharmacotherapies for tobacco dependence typically used when a smoker cannot use first-line medications due to either contraindications or lack of effectiveness.

Ref Devita

Fong Score

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Q.Not a Poor risk factor according to Fong score
a) Node +
 b) Disease free interval more than 1 yr
c) 2 Liver Mets

d) Single metastasis 6 cm

Ans b 

Fong score is for Survival after treatment for metastatic colorectal cancer to the liver. It includes 5 variables for which score is alloted to each point

Nodal status of primary

Disease-free interval from the primary to discovery of the liver metastases of <12 months

Number of tumors >1,

Preoperative CEA level >200 ng/ml, and

Size of the largest tumor >5 cm