MCQ’s on Ca Pancreas & Surgery
High-Yield MCQs on Pancreatic Ductal Adenocarcinoma (PDAC)
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Most common mutation in pancreatic ductal adenocarcinoma (PDAC)?
- A: KRAS (Correct answer)
- B: SMAD4
- C: p53
- D: MMR
Explanation: The KRAS mutation is the most common mutation found in PDAC, seen in over 90% of cases.
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Which of the following mutation is not present in PDAC?
- A: SMAD4
- B: DPC-1 (Correct answer)
- C: MMR
- D: ATM
Explanation: DPC-1 is not associated with PDAC. Mutations in SMAD4, MMR, and ATM are implicated in PDAC.
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Which of the following mutation is present in both familial and sporadic pancreatic cancer?
- A: BRCA1
- B: BRCA2 (Correct answer)
- C: MMR
- D: p16
Explanation: BRCA2 mutations are found in both familial and sporadic pancreatic cancers, making it a key mutation in pancreatic cancer genetics.
- BRCA-2 mutation is found in 6-19% of familial pancreatic cancer patients
- PALB2 gene -3% of familial pancreatic cancer
- Precursor lesion of PDAC?
- A: PanIN-1A
- B: Pancreatic adenoma
- C: PanIN-3 (Correct answer)
- D: All of the above
Explanation: PanIN-3 is a high-grade precursor lesion of PDAC and represents carcinoma in situ, which can progress to invasive pancreatic cancer. PanIN-1A and PanIN-2 are low-grade lesions that are more often incidental findings.
Pancreatic Intraepithelial Neoplasia (PanIN) Notes:
- PanIN represents precursor lesions to pancreatic ductal adenocarcinoma, with varying degrees of dysplasia.
- Replacement of cuboidal non-mucinous epithelium:
- In PanIN, cuboidal non-mucinous cells are replaced by columnar, mucin-secreting cells.
- Low-grade PanIN:
- These are common incidental findings and usually do not require further clinical attention.
- High-grade PanIN (PanIN-3):
- This is the precursor to invasive pancreatic cancer, marking carcinoma in situ.
- Colloid carcinoma:
- Associated with intraductal papillary mucinous neoplasm (IPMN).
- Better prognosis compared to typical PDAC.
- Medullary carcinoma:
- Associated with microsatellite instability (MSI).
- Often found in the ampulla and duodenum.
- Has a better prognosis.
- Risk factors for PDAC are all except:Explanation:
- A: Diabetes
- B: O blood group (Correct answer)
- C: H. pylori infection
- D: Cholecystectomy
Explanation:
- Non-O blood groups are associated with an increased risk of pancreatic ductal adenocarcinoma (PDAC), while O blood group is protective.
- Other factors like diabetes, H. pylori infection, and cholecystectomy are considered risk factors for PDAC.
- Highest risk of PDA in genetic syndrome:
- A: Peutz-Jeghers syndrome (Correct answer)
- B: Hereditary pancreatitis
- C: FAMMM syndrome
- D: Ataxia telangiectasia
Explanation:
- Peutz-Jeghers syndrome (PJS), associated with STK11 gene mutations, confers the highest risk of developing pancreatic ductal adenocarcinoma (PDAC) with a 100-fold increased risk.
- Hereditary pancreatitis (cationic PRSS1 mutation) confers a 50-80 fold increased risk.
- FAMMM syndrome (p16 mutation) increases the risk by 20-34 fold.
- Ataxia telangiectasia is less well established as a PDAC risk factor.
- Hereditary breast and ovarian cancer associated with BRCA2 and BRCA1 mutations carry a 10-fold and 3-fold increased risk of pancreatic cancer, respectively.
- HNPCC [SKF] and FAP [Sabiston] are least associated with PDAC
- Triple phase Pancreatic protocol CT involves:
- A: Arterial phase, portal venous phase, delayed phase
- B: Early arterial, late arterial, portal venous phase
- C: Unenhanced phase, pancreatic phase, portal venous phase (Correct answer)
- D: None of the above
Explanation:
- Triple-phase CT for pancreatic evaluation includes the following phases:
- Unenhanced phase: Provides a baseline image without contrast.
- Pancreatic phase: Optimally highlights the pancreas.
- Portal venous phase: Provides enhanced imaging of the veins for metastasis or vascular involvement.
- Pancreatic phase in pancreatic protocol triple-phase CT scan corresponds to:
- A: 10-15 seconds
- B: 40-60 seconds (Correct answer)
- C: 30-45 seconds
- D: 60-90 seconds
Explanation:
-
The pancreatic phase typically occurs 40-60 seconds after contrast injection, which optimally enhances the pancreas and highlights pancreatic lesions.
Key Points:
- The MDCT protocol uses thin-slice scanning for high-resolution imaging.
- Iodinated contrast is injected intravenously at a rate of 3-5 mL/s to enhance visualization.
- The pancreatic phase is timed to 40-50 seconds after contrast injection for optimal imaging of the pancreas.
- The portal venous phase is captured between 65-70 seconds for assessing venous structures and possible metastatic involvement.
MDCT Protocol Parameters CT Scanner Multi-detector CT (at least 64-slice preferred) Acquisition and Section Thickness Thinnest collimation used (preferably submillimeter 0.5-1 mm if available) Interval Same as section thickness (without gap) Oral Contrast Agent Neutral agent such as water Intravenous Contrast - 125 ml iodinated contrast agents (preferably high concentration >300 mg I/L) - Injection rate of 3-5 mL/s - Lower concentration contrast may be used if low kV technique is applied Contrast-Enhanced Phases - Pancreatic phase: 40-50 seconds - Portal venous phase: 65-70 seconds (following the beginning of contrast injection) 9. Clinical staging for a hypovascular mass in the head of the pancreas abutting SMV (180 degrees), with SMA and CA free, and no lymphadenopathy: - A: T1cN1M0 - B: T2N0M0 (Correct answer) - C: T4N1M0 - D: T1bN2M0
Explanation:
- T2N0M0 is the correct staging as per the AJCC 8th edition.
- T2: Tumor size is greater than 2 cm but ≤ 4 cm.
- N0: No lymph node involvement (N0).
- M0: No distant metastasis (M0).
- Abutting the SMV (≤180 degrees) does not qualify as T4; only arterial involvement (SMA or CA) is classified as T4. Since the SMA and CA are free, this remains a T2 tumor.
- True statement:
- A: EUS has higher sensitivity to detect arterial invasion than venous invasion in PDAC
- B: Preoperative biopsy is always required in PDAC
- C: RCC & Melanoma metastasize to periampullary region (Correct answer)
- D: FDG PET helps in differentiating malignant and benign pancreatic lesions
Explanation:
- C: RCC (Renal Cell Carcinoma) and melanoma can metastasize to the periampullary region, which is a true statement.
- A: EUS:
- is actually better at detecting venous rather than arterial invasion in PDAC.
- Indicated when there is No mass, But Dilated PD & Bile duct.
- B: A preoperative biopsy is not mandatory in all cases of PDAC.
- D: FDG PET cannot reliably differentiate between inflammatory masses and cancer, as both can show uptake.
- Indications for staging laparoscopy in PDAC are all except:
- A: Tumor > 3 cm
- B: CA19-9 > 100
- C: Severe weight loss
- D: Venous abutment (Correct answer)
Explanation:
- D: Venous abutment is not an indication for staging laparoscopy in PDAC.
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Indications for staging laparoscopy include:
- Tumor size > 4 cm.
- CA19-9 > 100.
- Small, indeterminate liver or peritoneal disease.
- Ascites.
- Severe weight loss may also indicate advanced disease, necessitating staging laparoscopy.
JSAP-05 Randomized Trial - Revision Notes
- Trial Objective: Evaluate neoadjuvant gemcitabine + S-1 (2 cycles) vs. upfront surgery in 364 patients.
- Adjuvant Treatment: All patients received S-1 for 6 months post-surgery.
- Overall Survival (OS):
- Neoadjuvant group: Median OS (mOS) = 36.7 months.
- Upfront surgery group: mOS = 26.6 months.
- Final publication pending.
SWOG S1505 Trial
- Design: Randomized phase II trial with 102 patients.
- Perioperative Chemotherapy: Compared FOLFIRINOX vs. gemcitabine-nab-paclitaxel (GN).
- Outcome: No arm showed a statistically significant 2-year OS above the 40% threshold.
- CT features that represent unresectability in PDAC of the head of the pancreas include all except:
- A: SMA contact >180 degrees
- B: Celiac artery >180 degrees contact
- C: Involvement of the first jejunal branch of SMV
- D: Short segment HA encasement (Correct answer)
Explanation:
- A and B: Contact >180 degrees with the SMA or celiac artery indicates unresectability.
- C: Involvement of the first jejunal branch of the SMV is now considered potentially resectable, but reconstruction is challenging.
- D: Short segment encasement of the hepatic artery (HA) is not considered unresectable, as it may still allow for surgical resection depending on the location and extent of the encasement.
- 60-year-old patient with a 3 cm hypodense lesion in the body of the pancreas, contact with CA >180 degrees, but aorta and GDA are free. True statement:
- A: Unresectable tumor, palliative chemo
- B: Resectable tumor, upfront surgery
- C: Borderline resectable tumor, neoadjuvant chemotherapy (Correct answer)
- D: Borderline resectable, upfront surgery
Explanation:
- C: This tumor is borderline resectable due to >180-degree contact with the celiac artery. For borderline resectable tumors, the standard approach is neoadjuvant chemotherapy to downstage the tumor before considering surgery.
- An Appleby procedure (distal pancreatectomy with en bloc celiac axis resection) may be performed later after NACT.
- A: The tumor is not unresectable since it does not involve the aorta or major vessels that would preclude surgery.
- B and D: Upfront surgery is not recommended for borderline resectable tumors. Neoadjuvant chemotherapy is first given to improve surgical outcomes.
NCCN guidelines Resectability Status Based on 6th Edition Blumgart
Resectable
- Arterial Involvement:
- No arterial tumor contact with the Celiac Axis (CA), Superior Mesenteric Artery (SMA), or Common Hepatic Artery (CHA).
- Venous Involvement:
- No tumor contact with the Superior Mesenteric Vein (SMV) or Portal Vein (PV).
- ≤ 180-degree contact without vein contour irregularity.
Borderline Resectable
Head/Uncinate Process:
- Arterial Involvement:
- Solid tumor contact with the SMA ≤180 degrees.
- Solid tumor contact with the CA ≤180 degrees without extension to the aorta or bifurcation of the hepatic artery.
- Presence of variant arterial anatomy (e.g., replaced right hepatic artery, replaced CHA, and the accessory artery). The degree of tumor contact should be noted as it may affect surgical planning.
- Venous Involvement:
- Solid tumor contact with the SMV or PV >180 degrees, contact ≤180 degrees with contour irregularity of the vein, or thrombosis of the vein but with suitable vessel proximal and distal to the site of involvement allowing safe and complete resection with reconstruction.
- Solid tumor contact with the Inferior Vena Cava (IVC).
Body/Tail:
- Arterial Involvement:
- Solid tumor contact with the CA ≤180 degrees.
- Solid tumor contact with the CA >180 degrees without involvement of the aorta and with intact and uninvolved gastrocolic trunk.
Unresectable
- Distant metastasis (including non-regional lymph node metastasis).
Head/Uncinate Process:
- Arterial Involvement:
- Solid tumor contact with the SMA >180 degrees.
- Solid tumor contact with the CA >180 degrees.
- Solid tumor contact with the first jejunal SMA branch.
- Venous Involvement:
- Unreconstructible SMV/PV due to tumor involvement or occlusion.
- Contact with the most proximal draining jejunal branch into the SMV.
Body/Tail:
- Arterial Involvement:
- Solid tumor contact of >180 degrees with the SMA or CA with aortic involvement.
- Venous Involvement:
- Unreconstructible SMV/PV due to tumor involvement or occlusion.
MD Anderson Criteria for Borderline Resectable Pancreatic Cancer (BRPC)
Type A - Anatomic Criteria
- Refers to tumor-vessel involvement that makes resection technically challenging but still potentially feasible with vascular reconstruction.
- Includes tumor contact with the following vessels:
- Superior Mesenteric Artery (SMA): Involvement ≤ 180 degrees.
- Celiac Axis (CA): Involvement ≤ 180 degrees.
- Superior Mesenteric Vein (SMV) or Portal Vein (PV): Tumor contact with distortion, narrowing, or occlusion that can still be reconstructed.
Type B - Findings Suggestive of Metastatic Disease
- Clinical or radiographic findings that indicate the possibility of metastasis, but not confirmed.
- Includes:
- Indeterminate hepatic lesions.
- Peritoneal thickening or nodules.
- Enlarged regional lymph nodes that raise suspicion for metastatic disease but are not definitive.
Type C - Comorbidity Criteria
- Refers to patient comorbidities that increase the risk of morbidity or mortality with surgery.
- Includes conditions such as:
- Cardiovascular disease.
- Pulmonary disease.
- Any other significant comorbid conditions that would impact surgical outcomes, making the patient a high-risk candidate for resection.
NCCN Pancreatic Adenocarcinoma Guidelines (Version 1.2013) Defining Resectability based 6th Edition BLG:
Resectability Status
Localized and Resectable
- No distant metastasis.
- No radiographic evidence of SMV (Superior Mesenteric Vein) or HPV (Hepatic Portal Vein) distortion.
- Clear fat planes around Celiac Axis (CA), Hepatic Artery (HA), and Superior Mesenteric Artery (SMA).
- No tumor abutment of SMA.
Borderline Resectable
- No distant metastasis.
- Venous involvement of SMV or HPV with distortion or narrowing of the vein or occlusion of the vein, with suitable vessel proximal and distal for resection and replacement.
- GA (Gastroduodenal Artery) encasement up to the HA with either short-segment encasement or direct abutment of the HA without extension to the CA.
- Tumor abutment of SMA less than 180 degrees.
Unresectable
- Distant metastasis present.
- Arterial involvement:
- >180 degrees SMA encasement.
- Any celiac abutment.
- Aortic encasement or invasion.
- Venous involvement:
- IVC (Inferior Vena Cava) involvement.
- SMV/HPV unconstructible due to involvement or occlusion.
- 40-year-old male with abdominal pain, jaundice, and a mass in the head of the pancreas encasing the portal vein, SMA and CA free. LFT shows Bilirubin 10.5/8.5, further management:
- A: Start FOLFIRINOX and monitor response
- B: Whipple’s with portal vein resection
- C: ERCP and EUS guided biopsy (Correct answer)
- D: Refer to palliative chemotherapy
Explanation:
- C: This is a borderline resectable pancreatic cancer (BRPC). In this case, a preoperative biopsy is mandatory before considering neoadjuvant chemotherapy (NACT). Additionally, the bilirubin level should be reduced (<2 mg/dL), which can be achieved by ERCP to relieve the biliary obstruction and allow safe administration of NACT.
- A: FOLFIRINOX is appropriate after biopsy confirmation and biliary decompression.
- B: Whipple’s surgery is not recommended without preoperative NACT for BRPC.
- D: This is not a palliative case since it is borderline resectable. Palliative chemotherapy is indicated for unresectable or metastatic disease.
- In the above patient, After 4 cycles of FOLFIRINOX, the patient's repeat CT scan shows similar findings. Further management?
- A: Give 2 more cycles
- B: Start immunotherapy
- C: Proceed for surgery (Correct answer)
- D: PET CT
Explanation:
- C: The CT scan is primarily used to assess disease progression rather than downsizing or resectability. If there is no progression after chemotherapy, surgery can be considered, and a Whipple procedure with portal vein resection can be performed in this case.
- A: Extending chemotherapy is unnecessary as the tumor remains operable.
- B: Immunotherapy is not the standard treatment for PDAC.
- D: PET CT is not required at this stage if no distant metastases are suspected.
- Which of the following regarding adjuvant therapy in pancreatic cancer is not true?
- A: CONKO trial - adjuvant gemcitabine is superior to 5-FU (Correct answer)
- B: ESPAC-1 - adjuvant CRT alone is deleterious
- C: ESPAC-3 - Gemcitabine is superior to 5-FU-LV as adjuvant therapy
- D: ESPAC-4 - Gem-Cap is superior to Gem alone as adjuvant therapy
Explanation:
- A: This statement is incorrect because the CONKO trial compared gemcitabine with observation, not 5-FU. The trial showed that adjuvant gemcitabine improved disease-free survival compared to observation.
- B: In the ESPAC-1 trial, adjuvant chemoradiotherapy (CRT) alone was found to be deleterious, making this statement true.
- C: The ESPAC-3 trial demonstrated that gemcitabine was not inferior to 5-FU with respect to overall survival but had fewer side effects.
- D: In the ESPAC-4 trial, gemcitabine plus capecitabine (Gem-Cap) was shown to be superior to gemcitabine alone as adjuvant therapy.
Study Comparisons in Pancreatic Cancer Trials
PRODIGE 24 (2018)
- Intervention: FOLFIRINOX vs. gemcitabine.
- Best Median Overall Survival (OS): 54.4 months.
APACT (2019)
- Intervention: Gemcitabine and nab-paclitaxel vs. gemcitabine.
- Best Median OS: 40.6 months.
- Which of the following trials compared the role of NACRT for BRPC?
- A: PREOPANC (Correct answer)
- B: NEOPA
- C: PRODIGE 24
- D: APACT
Explanation:
- A: The PREOPANC trial specifically studied the role of neoadjuvant chemoradiotherapy (NACRT) for borderline resectable pancreatic cancer (BRPC), comparing it to upfront surgery.
- B: NEOPA focused on neoadjuvant therapy for resectable pancreatic cancer.
- C: PRODIGE 24 compared FOLFIRINOX vs. gemcitabine in the adjuvant setting for pancreatic cancer.
- D: APACT investigated the role of adjuvant gemcitabine plus nab-paclitaxel in pancreatic cancer.
- A 50-year-old male underwent Whipple's for Ca HOP. Post-op histopathology showed a 1 cm well-differentiated adenocarcinoma in the head of the pancreas. All margins were free of tumor, 6 lymph nodes were free of tumor, and no perineural or lymphovascular invasion was seen. Most appropriate treatment?
- A: Adjuvant chemotherapy (Correct answer)
- B: Adjuvant CRT
- C: Both A and B
- D: Observation
Explanation:
- A: Even in stage 1 pancreatic cancer, adjuvant chemotherapy is recommended to reduce the risk of recurrence, unless the cancer is periampullary, where observation may be an option.
- B and C: CRT is typically used when there are positive margins, nodal involvement, or other risk factors, which are absent in this case.
- D: Observation alone is not recommended in pancreatic ductal adenocarcinoma (PDAC), as adjuvant chemotherapy has been shown to improve survival outcomes.
- Which of the following is false regarding neoadjuvant therapy in pancreatic cancer?
- A: Neoadjuvant therapy increases OS in BRPC
- B: Neoadjuvant therapy is only used in BRPC (False, correct answer)
- C: CECT is the investigation of choice to assess resectability post-NACT in BRPC (False, correct answer)
- D: Both B and C
Explanation:
- B: Neoadjuvant therapy is not limited to BRPC; it is also being explored in resectable pancreatic cancer to improve outcomes (e.g., NEOPA trial).
- C: CECT is the preferred modality for assessing progression post-NACT, but it is not reliable in determining tumor downsizing or resectability alone. Surgery is considered if there is no progression.
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FOLFIRINOX includes all except:
- A: 5-FU
- B: Oxaliplatin
- C: Docetaxel (Correct answer)
- D: Irinotecan
Explanation:
- C: FOLFIRINOX includes 5-FU, oxaliplatin, and irinotecan, but docetaxel is not part of the regimen.
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Regimen used as palliative chemotherapy in metastatic pancreatic cancer?
- A: Nab-paclitaxel + gemcitabine
- B: Gemcitabine + capecitabine
- C: FOLFIRINOX
- D: All of the above (Correct answer)
Explanation:
- All of the listed regimens (Nab-paclitaxel + gemcitabine, gemcitabine + capecitabine, and FOLFIRINOX) are used as palliative chemotherapy options in metastatic pancreatic cancer.
Trial Summaries:
- ESPAC-5 trial: Studied the role of neoadjuvant therapy in BRPC with various regimens like surgery, GEMCAP, FOLFIRINOX, and CRT with capecitabine.
- NEOPAC trial: Focused on the role of NACT in resectable pancreatic cancer.
- NEOPA trial: Compared neoadjuvant CRT vs. surgery.
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One-stage Whipple's procedure involving resection of the gall bladder, antrum, duodenum, and head of the pancreas was first done by:
- A: Waugh and Clagett (Correct answer)
- B: Kaush
- C: Allen Whipple
- D: Codavilli
Explanation:
- A: Waugh and Clagett performed the first modern one-stage Whipple's procedure.
- B: Kaush (1912) performed a two-stage operation.
- C: Allen Whipple is credited with the two-stage and later the one-stage procedure in 1935 by waugh and clagget.
- D: Codivilla in Italy performed the first pancreaticoduodenectomy (PD) in 1890.
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Not a part of standard Whipple's procedure:
- A: Cholecystectomy
- B: Feeding jejunostomy (Correct answer)
- C: Gastrojejunostomy
- D: None of the above
Explanation:
- B: Feeding jejunostomy is not a standard part of the Whipple's procedure. It may be added as an adjunct in cases where postoperative nutritional support is anticipated, but it is not routine.
- A: Cholecystectomy is part of the standard Whipple's procedure as the gallbladder is removed.
- C: Gastrojejunostomy is performed as part of the standard reconstruction following resection of the stomach and duodenum.
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Most common cause of PPH (postpancreatectomy hemorrhage) post-Whipple's is:
- A: GDA pseudoaneurysm (Correct answer)
- B: GJ site bleed
- C: SMA pseudoaneurysm
- D: CHA pseudoaneurysm
Explanation:
- GDA (gastroduodenal artery) pseudoaneurysm is the most common cause of PPH post-Whipple's procedure, particularly in delayed hemorrhage due to pseudoaneurysm formation related to pancreatic fistulas.
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Most common cause of late PPH:
- A: Pancreatic fistula (Correct answer)
- B: Anastomotic ulceration
- C: Technical failure
- D: None of the above
Explanation:
- Late PPH is most commonly caused by pseudoaneurysms resulting from pancreatic fistulas. These pseudoaneurysms can erode into surrounding vasculature, leading to bleeding.
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Most common cause of early PPH (within 24 hours):
- A: GDA pseudoaneurysm
- B: Anastomotic ulceration
- C: Technical failure (Correct answer)
- D: Pancreatic fistula
Explanation:
- Technical failure during surgery, such as incomplete hemostasis, is the most common cause of early PPH within 24 hours postoperatively.
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50-year-old male post-Whipple's on day 4 has blood-tinged discharge from abdominal drain. Drain fluid amylase on day 3 was 10,000. Next line of management?
- A: Wait and watch
- B: CT angio (Correct answer)
- C: UGI endoscopy
- D: DSA
Explanation:
- The patient presents with a sentinel bleed (blood-tinged discharge) and a high amylase level, which indicates the possibility of a pseudoaneurysm secondary to a pancreatic fistula. The next step is to perform a CT angiography to evaluate the source of bleeding.
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45-year-old female post-laparoscopic Whipple's has 500 mL of blood in the drain, HR 120, BP 90/70, pallor. Next line of management?
- A: Urgent CT angio
- B: Urgent DSA and embolization
- C: Relaparotomy (Correct answer)
- D: FFP, blood transfusion, wait and watch with serial Hb
Explanation:
- This patient has an early, unstable bleed (hemodynamically unstable with tachycardia and hypotension), indicating immediate surgical exploration via relaparotomy to control the source of bleeding. This is classified as Grade B hemorrhage and requires surgical intervention.
- Grade of hemorrhage:
- B- early, severe = Relaparotomy
- A- early mild = Observation
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50-year-old male post-Whipple's for periampullary cancer. Day 3 drain amylase is 500. He is taking orally, afebrile, and hemodynamically stable. Correct statement?
- A: Grade A POPF
- B: Grade B POPF
- C: Grade C POPF
- D: Biochemical leak (Correct answer)
Explanation:
- D: A biochemical leak is defined as elevated drain amylase (>3x serum amylase) on or after postoperative day 3 without clinical impact (i.e., no need for additional treatment). Since the patient is stable and there are no complications, it is classified as a biochemical leak, not a clinically relevant fistula.
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65-year-old female post-Whipple's for periampullary carcinoma on day 5 presents with fever. TLC count is 25,000, USG shows a 5 cm peripancreatic collection. USG-guided PCD was done. Fluid amylase was 12,000.
- A: Grade A fistula
- B: Grade B fistula (Correct answer)
- C: Grade C fistula
- D: None of these
Explanation:
- B: This is classified as a Grade B fistula because the patient required an intervention (percutaneous drainage) and had elevated amylase in the drain fluid. Grade B requires active treatment such as drainage or somatostatin analogs, while Grade A does not require such interventions.
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Which of the following anastomoses has the lowest leak rate?
- A: Duct to mucosa
- B: Blumgart
- C: Dunking
- D: PG
- E: None of the above (Correct answer)
Explanation:
- E: No particular anastomosis (duct-to-mucosa, Blumgart, dunking, or pancreatogastrostomy) has consistently been proven to have the lowest leak rate. All techniques can be successful depending on patient factors such as pancreatic texture and duct size.
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Not true about PG (pancreatogastrostomy) in pancreaticoenteric anastomosis:
- A: Similar leak rate to PJ
- B: Used in soft pancreas
- C: Decreased incidence of upper GI bleed (Correct answer)
- D: All of the above
Explanation:
- C: There is evidence that pancreatogastrostomy (PG) Increases the incidence of upper GI bleeding compared to pancreatojejunostomy (PJ). Both PG and PJ have similar leak rates, and PG is often preferred in cases of a soft pancreas due to ease of anastomosis.
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Risk factors for POPF (Postoperative Pancreatic Fistula) include all except:
- A: Soft gland
- B: Blood loss > 1000 mL
- C: Neoadjuvant therapy (Correct answer)
- D: Non-dilated duct
Explanation:
- C: Neoadjuvant therapy is actually protective against POPF, and patients with Ca head of the pancreas tend to have a lower leak rate due to the associated fibrosis. Soft gland, non-dilated duct, and significant blood loss (>1000 mL) are well-established risk factors for POPF.
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Fistula risk score includes all except:
- A: Texture of pancreas
- B: Duct diameter
- C: Blood loss
- D: Age (Correct answer)
Explanation:
- D: Age is not part of the Fistula Risk Score (FRS). Factors included are pancreatic texture, duct diameter, blood loss, and male sex. Age is not considered a direct risk factor for pancreatic fistula formation.
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Most common complication after Whipple's procedure:
- A: Primary DGE
- B: Secondary DGE (Correct answer)
- C: POPF
- D: PPH
Explanation:
- B: Delayed gastric emptying (DGE), especially secondary DGE, is the most common complication after Whipple's surgery. It usually occurs due to factors like sepsis or other postoperative complications rather than as a primary issue.
-
Factors that decrease the incidence of DGE:
- A: Pylorus preservation
- B: Antecolic GJ (Correct answer)
- C: Retrocolic GJ
- D: Classical Whipple's
Explanation:
- B: Performing an antecolic gastrojejunostomy (GJ) significantly reduces the incidence of DGE compared to the retrocolic approach. Pylorus-preserving and classical Whipple's procedures do not necessarily reduce the risk of DGE.
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Definition of DGE according to ISGPS (International Study Group of Pancreatic Surgery):
- A: Inability to take oral solids by day 7 (Correct answer)
- B: NG requirement or insertion after day 1
- C: Inability to take oral liquids by day 5
- D: Inability to remove NG by day 2
Explanation:
- A: According to ISGPS, delayed gastric emptying (DGE) is defined as the inability to take oral solids by day 7 post-surgery. Other criteria like NG tube requirement may suggest a complication but are not the definitive markers for DGE.
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Lymph node removed in standard PD (Pancreaticoduodenectomy):
- A: Station 7
- B: Station 9
- C: Station 14 (Correct answer)
- D: Station 11
Explanation:
- C: Station 14 nodes (along the superior mesenteric vessels) are typically removed in a standard pancreaticoduodenectomy (Whipple procedure). Other stations may be included in extended lymphadenectomy.
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Branch which is divided first in the artery-first approach in Whipple's:
- A: IPDA (Inferior Pancreaticoduodenal Artery) (Correct answer)
- B: SPDA
- C: First jejunal artery
- D: First jejunal vein
Explanation:
- A: In the artery-first approach for Whipple's procedure, the IPDA is the first artery to be divided. This approach helps to assess resectability and improve visualization of critical structures early in the operation.
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Indications for the artery-first approach include all except:
- A: Borderline resectable cancer
- B: Venous resection
- C: Improve lymph node yield (Correct answer)
- D: Identification of aberrant anatomy
Explanation:
- C: Improving lymph node yield is not an indication for the artery-first approach. This approach is typically used in borderline resectable cancers, to facilitate venous resection, and for identifying aberrant anatomy early in the operation.
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True about RAMPS (Radical Antegrade Modular Pancreatosplenectomy):
- A: Proceeds from left to right
- B: Plane of dissection is always above Gerota's fascia
- C: Increases overall survival compared to standard distal pancreatectomy
- D: Posterior RAMPS - left renal vein forms posterior plane of dissection (Correct answer)
Explanation:
- D: In posterior RAMPS, the left renal vein forms the posterior plane of dissection. This approach provides better clearance for tumors involving the posterior region and facilitates en bloc resection. RAMPS typically proceeds from right to left and the plane of dissection can be above or below Gerota's fascia, depending on tumor involvement. There is no conclusive evidence that RAMPS significantly improves overall survival compared to standard distal pancreatectomy.
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Appleby procedure involves:
- A: Distal pancreatectomy with celiac artery resection (Correct answer)
- B: Central pancreatectomy
- C: Distal pancreatectomy with SMA resection
- D: None of these
Explanation:
- A: The Appleby procedure involves a distal pancreatectomy with en bloc resection of the celiac axis. The hepatic blood supply is maintained via the gastroduodenal artery (GDA). This procedure is also known as DIPCAR (Distal Pancreatectomy with Celiac Artery Resection) and was initially described for the treatment of gastric cancer. It is now also used for locally advanced pancreatic cancers.
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Not an indication for spleen-preserving distal pancreatectomy:
- A: 3 cm adenocarcinoma of the tail of the pancreas (Correct answer)
- B: 3 cm BD-IPMN in the body of the pancreas
- C: 3 cm neuroendocrine tumor in the body of the pancreas
- D: Traumatic transection of the neck of the pancreas
Explanation:
- A: Adenocarcinoma of the pancreas (PDAC) is generally not an indication for spleen-preserving distal pancreatectomy because of the need for an oncologically complete resection, which includes the spleen for better lymph node clearance.
- B and C: Spleen-preserving distal pancreatectomy is often performed for benign or low-grade malignant lesions like BD-IPMN and neuroendocrine tumors.
- D: In trauma cases, while spleen preservation may not always be prioritized, especially if there is significant damage, it can be attempted in selected cases depending on the extent of the injury. However, PDAC is a clear contraindication for spleen preservation.
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True about minimally invasive pancreatic surgery:
- A: DIPLOMA trial - Laparoscopic distal pancreatectomy is similar to open surgery in terms of postoperative outcome (Correct answer)
- B: LEOPARD I trial - Laparoscopic Whipple is inferior to open surgery in postoperative complications
- C: LEOPARD II trial - Laparoscopic Whipple is superior to open surgery in postoperative complications
- D: All of the above
Explanation:
- A: The DIPLOMA trial reported that laparoscopic distal pancreatectomy is not inferior to open surgery in terms of postoperative outcomes.
- B and C: The LEOPARD II trial (not LEOPARD I) was closed early due to increased mortality in the laparoscopic group compared to the open surgery group, highlighting concerns about the safety of minimally invasive Whipple procedures. The trial did not show superiority of laparoscopic Whipple's over open surgery, and it raised concerns about increased postoperative complications and mortality.
This confirms that minimally invasive distal pancreatectomy is comparable to open surgery, but minimally invasive pancreaticoduodenectomy (Whipple) remains controversial due to higher observed mortality in studies like LEOPARD II.
IDENTIFY THE STRUCTURES MARKED :
1 = CHA
2 = SMA
3 = SMV
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- = SMA
TRIANGLE OPERATION = FOR GOOD EXTENDED LN CLEARANCE
