Miscellaneous Topics in Pancreas

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MCQ - Criteria for Borderline Resectable Pancreatic Cancer

Answer: B

Explanation:

According to the NCCN Pancreatic Adenocarcinoma Guidelines:

Solid tumor contact with variant arterial anatomy in pancreatic head adenocarcinoma is considered a criterion for borderline resectable cancer.
Solid tumor contact with the celiac axis more than 180 degrees in pancreatic head adenocarcinoma is considered a criterion for locally advanced cancer, not borderline resectable.
Solid tumor contact with IVC is a criterion for borderline resectable cancer.
Solid tumor contact with SMV more than 180 degrees is a criterion for borderline resectable cancer, provided there is a suitable vessel proximal and distal to allow for complete resection with vein reconstruction.

This information is detailed in the table provided from the NCCN guidelines, which specifies the criteria for resectable, borderline resectable, and locally advanced pancreatic adenocarcinoma based on tumor contact with various vascular structures.

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MCQ - Olaparib

Answer: D

Explanation:

Olaparib is a poly-ADP ribose polymerase (PARP) inhibitor.
It is useful in metastatic pancreatic cancer with a germline mutation in BRCA1/2.
Approximately 5% to 7% of patients with pancreatic cancer have a germline BRCA1/2 mutation.
The incidence of KRAS wild-type pancreatic cancer is 6% to 8%, not 20%.
Up to 16% to 18% of KRAS wild-type patients are younger than 50 at diagnosis.
Pembrolizumab : indication in MMR deficient pancreatic cancer

MCQ - Sump Syndrome

Answer: A

Explanation:

Sump syndrome:
- The defunctionalized distal common bile duct reservoir accumulates bile debris and sludge, potentially causing cholangitis and hepatic abscess.
- Sump syndrome often occurs 5 to 6 years after the biliary-enteric bypass, not as an early complication.
- Treatment of sump syndrome may necessitate revision of the bypass with Roux-en-Y hepaticojejunostomy.

MCQ - Posteroinferior Pancreaticoduodenal Artery

Answer: D

Explanation:

Anterosuperior pancreaticoduodenal artery is a branch of the gastroduodenal artery.
Posterosuperior pancreaticoduodenal artery is also a branch of the gastroduodenal artery.
Anteroinferior pancreaticoduodenal artery is a branch of the superior mesenteric artery (SMA).
Posteroinferior pancreaticoduodenal artery is a branch of the superior mesenteric artery (SMA).

MCQ - Best Phase to Assess Blunt Trauma to the Pancreas

Answer: C

Explanation:

The portal venous phase is the best contrast phase to assess the pancreas in the setting of blunt trauma due to the optimal enhancement of the pancreatic parenchyma and surrounding structures, allowing for better visualization of injuries.

MCQ - Pancreatic Injury Scale

Answer: D

Explanation:

Based on the pancreatic injury scale provided:

Grade I: Hematoma (minor contusion without duct injury) or Laceration (superficial laceration without duct injury).
Grade II: Hematoma (major contusion without duct injury or tissue loss) or Laceration (major laceration without duct injury or tissue loss).
Grade III: Laceration (distal transection or parenchymal injury with duct injury).
Grade IV: Laceration (proximal transection or parenchymal injury involving ampulla).
Grade V: Laceration (massive disruption of pancreatic head).

There is no Grade VI in the pancreatic injury scale, making the statement "massive disruption of pancreatic head is grade 6" false.

MCQ - Duodenal Injury Scale

Answer: D

Explanation:

According to the duodenal injury scale provided:

Grade I:
- Hematoma: Involving a single portion of the duodenum
- Laceration: Partial thickness, no perforation
Grade II:
- Hematoma: Involving more than one portion
- Laceration: Disruption <50% of the circumference
Grade III:
- Laceration: Disruption 50-75% of the circumference of D2
- Disruption 50-100% of the circumference of D1, D3, D4
Grade IV:
- Laceration: Disruption >75% of the circumference of D2
- Involving ampulla or distal common bile duct
Grade V:
- Laceration: Massive disruption of the duodenopancreatic complex
- Vascular: Devascularization of the duodenum

Therefore, the statement "Disruption of 50-100% of circumference of D1, D3, D4 is grade 3" is true. The other statements are false based on the definitions provided in the scale:

Devascularization of the duodenum is Grade V, not Grade IV.
Laceration involving ampulla is Grade IV, not Grade V.
Disruption of 50-75% circumference of D2 is Grade III, not Grade IV.

MCQ - Surgical Maneuvers

Answer: D

Explanation:

Cattell-Braasch maneuver: Right-sided medial visceral rotation.
Mattox maneuver: Left-sided medial visceral rotation.
Aird maneuver: Mobilization of splenic flexure and splenic ligaments to rotate the spleen and pancreas from lateral to medial to visualize the posterior aspects of the body and tail of the pancreas.

MCQ - Incidence of Pancreatic Pseudocyst Formation

Answer: A

Explanation:

The incidence of pancreatic pseudocyst formation after non-operative management of pancreatic trauma is 20%.
The incidence of pancreatic pseudocyst formation after operative management of pancreatic trauma is 5%.

MCQ - Pylorus Reopening after Closure

Answer: C

Explanation:

The pylorus will spontaneously reopen in approximately 6 weeks after closure with a stapler or suturing, regardless of the approach used.

MCQ - Re-evaluation of Duodenal Hematoma

Answer: D

Explanation:

In the case of duodenal hematomas, if obstructive symptoms have not improved after 14 days, a repeat CT scan should be done to re-evaluate the obstructive process.

MCQ - Site of Pancreatic Arteriovenous Malformation

Answer: A

Explanation:

The most common location for pancreatic arteriovenous malformations (AVMs) is the head of the pancreas (40%-50%) followed by the body and tail (>30%) and entire gland (>14%)

MCQ - Pancreatic Arteriovenous Malformations (AVMs)

Answer: C

Explanation:

Pancreatic AVMs represent 1% to 5% of GI tract AVMs, not 15%.
AVMs may occur in any portion of the pancreatic gland and can be associated with extra-pancreatic AVMs.
Radiation therapy has been used for extensive lesions affecting the entire gland.
Embolization has been recommended before surgical resection to reduce bleeding
The recurrence rate after any therapy for pancreatic AV malformation can approach 30%.

MCQ - Node of Importance in Pancreatic Surgery

Answer: A

Explanation:

The common hepatic artery lymph node is referred to as the node of importance in pancreatic cancer surgery.

MCQ - Lymphadenectomy in Pancreatic Cancer

Answer: A

Explanation:

Extended lymphadenectomy is associated with increased morbidity but not improved survival.
The extended lymphadenectomy includes removing lymph nodes from along the aorta, the inferior and superior mesenteric arteries, and the celiac trunk.
Diarrhea and delayed gastric emptying are more frequent complications with extended lymphadenectomy.
The current standard for pancreatic head tumors remains pancreaticoduodenectomy (PD) without extended lymphadenectomy.

MCQ - Pancreatic Surgery

Answer: B

Explanation:

The ideal splenic artery stump should be long enough to facilitate coil embolization in the event of postoperative hemorrhage.
Leaving a long splenic vein stump without flow (such as an intact inferior mesenteric vein) may increase the likelihood of developing thrombus within the stump that can propagate into the SMV and PV.
Letton and Wilson were the first to describe the technique of segmental, or central, pancreatectomy.
During islet cell transplantation, portal pressures should not exceed 25 cm H2O.

MCQ - DaGradi Serio Iacono Operation

Answer: C

Explanation:

The DaGradi Serio Iacono operation is a central pancreatectomy.

MCQ - Warsaw Technique

Answer: B

Explanation:

The Warsaw technique is a spleen preserving distal pancreatectomy with splenic vessels ligation.

Additional Notes:

The ideal splenic artery stump is long enough to facilitate coil embolization in the event of postoperative hemorrhage.
Leaving a long splenic vein stump without flow (such as an intact inferior mesenteric vein) may increase the likelihood of developing thrombus within the stump that can propagate into the SMV and PV.
Letton and Wilson were the first to describe the technique of segmental, or central, pancreatectomy.

Lacono prerequisites for segmental pancreatectomy:

Small lesions (<5 cm in diameter)
Benign or low-grade malignant tumors
Located in the neck or its contiguous portion
A distal pancreas stump of at least 5 cm in length