INI CET GI Surgery April 24

Q) Indication of surgery  in case of primary hyperparathyroidism?
a) Sr calcium > 0.5
b) Ser calcium  >1.0
c) Urinary ca >200
One other option


Asymptomatic primary hyperparathyroidism

Serum calcium - Measurement of 0.25 mmol/L (1.0 mg/dL) above the upper limit
serum calcium of normal
Skeletal - ● BMD by DEXA; T score –2.5 at lumbar
spine, total hip, femoral neck or distal onethird
of radius
● Vertebral fracture

Renal ● Creatinine clearance <60 mL/min

24-hour urinary calcium >10 mmol/dL
(>400 mL/day) or increased risk of stone
formation by risk analysis
Age <50 years
TAble 56.2 Bailey

Q) Parathyroid  adenoma for localization
a) USG
b) MRI
c) Tc99 sestamibi
d) ⁠Spect sestamibi

Ans d

The use of sestamibi (2-methoxy-2-methylpropylisonitrile
[MIBI]) for parathyroid localization  is now regarded as the most accurate and reliable method
for imaging the parathyroid glands. It is safe and reproducible
and, while it has a sensitivity and specifcity similar to ultrasonography,
it may image glands in ectopic positions better

Invasive imaging is largely reserved for re operative surgery and
includes ultrasound or CT-guided fine-needle aspiration

Bailey page 877


Q) Most common invasive malignancy which develops from Lobular carcinoma in situ?

a) Invasive ductal ca

b) Invasive lobular ca

c) Undifferentiated carcinoma


Q) 2 X 3 lump outer  quadrant of breast. Mammogram shows adjacent calcification. What is the  next step ?

a) MRI 
b) Ultrasound 
C) CT 

d) Contrast enhanced mammogram

Ans a  This question talks about multicentricity

MRI of the breast - useful in

  1. women with dense breasts or discordant or equivocal findings on mammogram/ultrasonography;
  2. to distinguish scar from recurrence in women who have had previous breast conservation therapy for cancer
  3. to assess multifocality and multicentricity and, in lobular cancer, high-grade ductal carcinoma in situ (DCIS);
  4. women with breast cancer (BRCA) gene or other genetic changes

Bailey 917

Q) Gene for BRCA 

Important points 

5–10% of all breast cancers are hereditary; BRCA1 and BRCA2 mutations account for
up to 70% of hereditary breast cancers

BRCA1 (17q21) is associated with a 50–85% lifetime risk of developing breast cancer and up to a 40% risk of ovarian cancer. The breast cancers in BRCA1 are mostly TNBC.
BRCA2 (13q12.3) is associated with an up to 50–60% lifetime risk of breast cancer and a 20% risk of ovarian cancer. It is also associated with cancer of the prostate, colon, gallbladder, bile
duct, stomach and pancreas. BRCA mutation is more common
in males with breast cancer.

Q) After Ivor Lewis esophagectomy, on POD 5 , bile is seen in chest tube. Patient's heart rate is 120,  temp is 101 degree F, BP is 100/70. What will be the next step

a) Stenting

b) Colonic replacement of gastric conduit

c) IV antibiotics 

d) Conduit excision and  Esophageal diversion


Patients with a completely necrotic conduit are most often septic and brought to the operating room for emergent exploration.

If conduit necrosis is confirmed,   then the conduit must be resected and the patient
should be diverted with an end esophagostomy, venting gastrostomy, and feeding jejunostomy. Care should be
taken to maintain the longest possible length of remaining
esophagus to facilitate future reconstruction

Schakelford page 477

Q) Question on Ipilimumab

Monoclonal antibodies that block CTLA-4 in humans have been developed: ipilimumab, now FDA approved (afully human IgG1k monoclonal antibody), and tremelimumab (a
fully human IgG2 monoclonal antibody).

CTLA-4 blockade has
demonstrated a significant survival advantage and long-term benefit
in a minority of melanoma patients (approximately 10%).

Sabiston page 694