Flaps in Plastic Surgery

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Q. Z plasty is an example of 

a) Advancement flap

b) Delayed flap

c) Transposition flap

d) Rotation flap


Answer for all 

Flaps in plastic surgery are the cornerstone of management of skin and wound defects. Advancement flaps are used to cover skin defects in face, scalp and neck. Examples of advancement flaps are monopedicled flaps, bipedicled and V Y advancement flap.

Delay of flap is a surgical preconditioning, in which the blood supply  is partially blocked prior to actual procedure. It increases the length of the flap as well as its uptake rate.

Transposition flap - used in head and neck surgery, a rectangular flap is rotated.

 

Beger Procedure for Chronic Pancreatitis

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Q) True about Beger procedure for chronic pancreatitis

a) Posterior branch of gastro duodenal artery is preserved.

b) Beger procedure is  a pancreatic head mass resection that can be done for small pancreatic tumors.

c) Intra pancreatic, choledochal and ampullary structures are removed.

d) Neck of the pancreas is not  transected


Answer a) Posterior branch of GDA is preserved

Beger procedure for chronic pancreatitis is mostly done in Europe. Hans Beger in 1972 in Germany introduced this  for chronic pancreatitis with inflammatory head mass. This is a complex procedure which removes head of the pancreas but leaves duodenum, a thin rim of pancreas around the medial aspect of duodenum and intrapancreatic bile duct intact.

The difference from  similar Frey's procedure is that in Beger procedure neck of the pancreas is transacted where as in Frey, neck of the pancreas is not cut.

This procedure is not recommended if there is suspicion of carcinoma  head of pancreas and Whipple is the procedure for that For Small tumors it can be used

Posterior branch of GDA is preserved in Beger Procedure.

Reconstruction is at two places: Distal pancreas and rim of the pancreas at medial side of duodenum.

Free Questions on Pancreas

Traction diverticula

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Q) What is true about traction diverticula of the esophagus?

a) It is a common diverticulum at the lower end of esophagus

b) Most  of these diverticula are symptomatic and require surgery

c) Mediastinal fibrosis is a common etiologial factor

d) They are most common on the left side

c) Mediastinal fibrosis Traction diverticula  are formed from  pull from granulomatous inflamation from  surrounding , most commonly lymph nodes.

Mid esophagus on the right side 4-5 cm either side of carina. 

Etiology

Mediastinal infections, tuberculosis, mediastinal fibrosis and histoplasmosis.

 True traction diverticula and have all the walls of esophagus.

Clinical Features

Asymptomatic but can present with dysphagia, chest pain and regurgitation.

Complications include bleeding or fistula formation with airway.

Surgical option - right  thoracotomy followed by excision of fistula and repair of esophagus in layers with correction of distal obstruction if present.

SKF

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Roux en Y gastric bypass Surgery

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Q) Which  of the following statement about Roux en Y gastric bypass Surgery is not true?

a) After weight loss it resolves symptoms of venous ulcers due to stasis

b) Symptoms of pseudo tumor cerebri are resolved

c) Heartburn is alleviated immediately

d) Protein malnutrition is a very common problem


d ) Protein malnutrition is common in Biliopancreatic division and duodenal switch not in gastric bypass

Essential components of successful Roux en Y gastric bypass are 

  1. Small Gastric pouch (15-20ml). In Roux en Y gastric bypass surgery, gastric pouch is constructed from cardia of the stomach to prevent gastric dilatation and minimize acid production
  2. roux limb length 65-75 cm

After RYGB 90% of patients immediately start to have relief from heartburn and other symptoms mentioned in the question

Saby ref 

Hormonal Response (Very Imp from MCQ point of view) 

  1. Increase Glucagon like peptide (GLP)
  2. Increase Peptide YY
  3. Low Ghrelin

Early complications, within 30 days after surgery 4 % of patients and include bleeding, perforation or leakage,

Late complications such as significant abdominal pain, small bowel obstruction, anastomotic stenosis or marginal ulceration can occur in 15–20 % of patients after 30 days from surgery to over 10 years 

Results

20–30 % long term, over 2 years of weight loss and maintenance 

remission of hypertension, type 2 diabetes mellitus, obstructive sleep apnoea and musculoskeletal pain.

Approximately 40 % of obese patients with type 2 diabetes go into remission within days or weeks after RYGB

REf 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4709370/

For In depth bariatric surgery knowledge, try this book Bariatric Surgery Complications and Emergencies

 

Also important points  from bailey, weight loss and diabetic control is highest after BPD and DS, Table 64.5 bailey