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.

ALPSS

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

Q) What does not decrease post op pulmonary complications?

  a) Smoking cessation

b) Epidural Anesthesia

c) Nasogastric tube

d) Preop and post op Spirometry

Free Questions

 Questions on Gen Surgery Peri op care

 

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

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

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

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

a) Pleomorphic sarcoma
b) MFH
c) Angiosarcoma

d) All of the above

Ans c)

Pleomorphic and MFH do not have lymph node spread

 

In Sarcoma lymph node metastasis is rare i(<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

 

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