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Squamous cell cancer of upper esophagus

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Q) A 65-year-old male presents with grade IV dysphagia and is diagnosed with squamous cell carcinoma of the upper third of the esophagus. What is the most appropriate next step in management?

a) Definitive chemoradiotherapy
b) Neoadjuvant chemotherapy followed by transhiatal esophagectomy
c) Systemic chemotherapy alone
d) Neoadjuvant chemoradiotherapy followed by three-field esophagectomy

✅ Correct answer: a) Definitive chemoradiotherapy

💡 Explanation:

  • Upper third esophageal squamous cell carcinoma poses a challenge for surgical resection due to its proximity to the pharynx and larynx.

  • In resectable upper esophageal SCC, especially in older patients or when the tumor is very proximal, definitive chemoradiotherapy (CRT) is often the preferred treatment to avoid morbid surgery like laryngopharyngoesophagectomy.

  • Multiple guidelines, including NCCN and ESMO, recommend definitive CRT for upper esophageal SCC unless there’s a compelling reason for surgery.

❌ Why other options are incorrect:

  • b) Neoadjuvant chemo + THE:
      THE (transhiatal esophagectomy) is not suitable for upper esophageal tumors. It doesn't provide good access to cervical/upper thoracic esophagus.

  • c) Chemotherapy alone:
      Not standard. Chemotherapy without radiation is inadequate for curative intent in localized esophageal cancer.

  • d) Neoadjuvant CRT + three-field esophagectomy:
      Though this is an option for mid/lower third esophageal cancers, especially in younger patients, it's more morbid and rarely used for upper third SCC in older patients.

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Blood transfusion

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Surgery MCQ | mcqsurgery.com
Q81) In trauma what is the ratio of PRBC: FFP to be transfused?
a) 1:1
b) 1:2
c) 1:3
d) 1:4
Correct Answer: a) 1:1

When there is requirement of more than 6 units of PRBC, FFP and other blood products are required. FFP and platelets should be transfused first and then PRBC. For every 7–12 Units of PRBC, ideally 6 units of FFP and one unit of platelets should be given.
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Pouchitis after IPAA in ulcerative colitis

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NEET SS - Pouchitis Question

Free Question: NEET SS Surgery

Q: Which of the following is NOT a risk factor for pouchitis post-IPAA in ulcerative colitis?

Explanation Ans A :
Pouchitis is a common complication of Ileal Pouch Anal Anastomosis (IPAA) for Ulcerative Colitis, with an incidence up to 50%.

✅ Smoking is protective against pouchitis.

Risk factors include: - Extra-intestinal manifestations (e.g. arthritis) - ANCA positivity - NOD2insC mutation - NSAIDs and PPI use post-op - Extent of colitis and thrombocytosis

🔗 Ref: Wiley Journal Article

lymphatics of colon

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Q ) Which of the following group of lymph nodes  lymphatics of the colon first drain to?

a) Paracolic

b) Epicolic

c) Nodes along SMA/IMA

d) Para aortic

Ans ) b

Lymphatics first drain to epicolic group along the bowel wall

Then it goes to  paracolic group along the marginal artery

Intermediate group along the named vessels SMA/IMA

Finally to para aortic 

Colon and upper 2/5 of rectum --- Para aortic

Lower 1/5 of rectum and anal canal - Superficial inguinal lymph nodes

Ref Sabiston-1317

Abdominal Compartment Syndrome

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Q) What is not a management option in Abdominal compartment syndrome?

a) Drainage of Intra abdominal collections

b) Muscle relaxation

c) Mesh closure

d) High PEEP

Ans d)  

Intra Abdominal Hypertension leads to Abdominal Compartment syndrome.

The decision to intervene surgically is not based on IAH alone but rather on the presence of organ dysfunction in association with IAH. Few patients with a pressure of 12 mm Hg have any organ dysfunction, whereas IAP greater than 15 to 20 mm Hg is significant in every patient

With grade III IAH, decompression may be considered when the abdomen is tense and signs of extreme ventilatory dysfunction and oliguria develop. In grade IV IAH, with signs of ventilator and renal failure, decompression is indicated

Measures to lower IAH are implemented are 

• Drainage of intra-abdominal fluid collections

• Muscle relaxation Avoid primary closure of the incision—laparotomy or mesh, Bogota bag, biologic mesh, or vacuum-assisted closure.

FNH _ Focal Nodular hyperplasia

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Q) Which of the following statements about focal nodular hyperplasia (FNH) of the liver is true?

a) A central scar is present in all cases
b) Fine-needle aspiration cytology (FNAC) is usually diagnostic in doubtful cases
c) Resection is recommended due to risk of malignant transformation
d) Asymptomatic patients with typical radiologic features usually do not require treatment

d) Asymptomatic patients with typical radiologic features usually do not require treatment

  • Focal Nodular Hyperplasia (FNH) is a benign liver lesion, often found incidentally.

  • a) Central scar is present in all cases – Incorrect. While a central stellate scar is characteristic of FNH, it is not present in all cases (seen in ~50-70% on imaging).

  • b) FNAC is usually diagnostic – Incorrect. FNAC often provides inconclusive results in FNH. Histological diagnosis requires tissue architecture, which FNAC can't reliably provide.

  • c) Resection is recommended due to risk of malignant transformation – Incorrect. FNH has no malignant potential and rarely causes complications. Surgery is not routinely recommended unless symptomatic or diagnosis is uncertain.

  • d) Asymptomatic patients with typical radiologic features usually do not require treatment – Correct. FNH with typical imaging features (especially on MRI with hepatobiliary contrast agents) does not require biopsy or surgical intervention.

Bariatric Surgery

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Q) Which of the following statements regarding bariatric surgery is false?

a) Vertical banded gastroplasty (VBG) produces less weight loss compared to Roux-en-Y gastric bypass (RYGB)
b) Jejunoileal bypass is no longer commonly performed
c) Dumping syndrome occurs primarily due to non-compliance with dietary advice
d) Laparoscopic adjustable gastric banding (LAGB) requires follow-up only once every 4–6 weeks

c
Dumping is due to the surgery and unrelated to diet
Calorie restriction is responsible for long term weight loss and its beneficial effects such as control of diabetes, dyslipidemia, hypertension and other metabolic abnormalities.
Restrictive procedures are LSG and  LAGB  which decrease the appetite and induce early satiety.           
The RYGB (ROUX en Y  gastric bypass ) is  a malabsorptive procedure  with long term sustained weight loss.
Mechanism of weight loss after bariatric surgery
Ghrelin is orexigenic gut hormone, which increases appetite. After food intake ghrelin levels fall and appetite decreases.

After restrictive surgery such as LYGB and LSG, ghrelin levels fall and appetite decreases.

Vertical Banded Gastroplasty (VBG)
 This procedure has been abandoned in favor of other operations because of poor long-term weight loss, a high rate of late stenosis of the gastric outlet, and a tendency for patients to adopt a highcalorie liquid diet, thereby leading to regain of weight. Choice a is correct

Jejuno ileal bypass has many side effects because of malabsorbtion and liver cirrhosis ( See above)  Choice b is true

Visit -  evaluate oral intake, food tolerance, and wound healing and to determine whether appropriate restriction has resulted from placement of the non inflated band.
Subsequent visits, usually scheduled monthly to bimonthly in the beginning and then less frequently, involve counseling with a nutritionist and evaluation of weight loss and the need for band adjustment.
A goal of 1 to 2 lb/wk is ideal
d is correct
Dumping is both late and early and unrelated to dietary advise

Annular pancreas

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Management of annular pancreas

Q) All are true about annular pancreas except ( AIIMS GI Surgery Question bank)

a) They are mostly asymptomatic

b) It has equal incidence in children and adults

c) Treatment of choice is duodenojejunostomy

d) Associated with Down's syndrome

Answer c

Annular pancreas is a congenital malformation but manifestations can appear in the adult life.

Annulus means a ring of pancreatic tissue around the duodenum. For annular pancreas to be diagnosed, this ring can be complete or incomplete.

Embryological basis

Normally the ventral buds of pancreas and  dorsal bud fuses together. Non rotation and fusion of these two leads to the formation of annular pancreas. It envelops the  2nd part of duodenum.

Age of presentation

Incidence is equal in both adults and children

Presentation in children is congenital anomalies and duodenal obstruction

Presents in adults as pancreatitis usually in 3rd or 4th decade

Association with other pancreatic conditions

1. Pancreas  divisum 35- 40%

2. Chronic pancreatitis 45- 50%

Other GI conditions

Annular pancreas is a possible etiology of congenital duodenal obstruction and is associated with other congenital anomalies such as Down syndrome, duodenal atresia, and imperforate anus.

Clinical Fetaures

Of those seen as adults, 75%were seen with pain

22% were diagnosed with pancreatitis

24%) had gastrointestinal (GI) symptoms that included vomiting,

11%had obstructive jaundice and/or abnormal liver function test results.

Treatment

It is duodenal bypass and not resection of duodenum as duodenum excision can lead to pancreatitis

in children its duodeno - duodenostomy

in adults duodenoduodenostomy which has now replaced duodenojejunostomy

Sabiston

Questions on Pancreas 

Pancreas annulare in radiology refers to the imaging findings of a rare congenital anomaly where a ring of pancreatic tissue encircles the duodenum. On imaging, such as CT, MRI, or endoscopic ultrasound, it may present as a characteristic encircling or constricting mass around the duodenum, often associated with symptoms like duodenal obstruction.

Splenectomy

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Q) Which of the following is not an indication for splenectomy in Non Hodgkin Lymphoma?
 
a)  Massive splenomegaly
b) Signs of hypersplenism
c) Diagnosing and staging of isolated splenic disease

d) All are indications for splenectomy

The correct answer is: d) All are indications for splenectomy

Explanation:

In Non-Hodgkin Lymphoma (NHL), splenectomy may be considered in the following scenarios:

  • Massive splenomegaly causing symptoms or complications like infarction, pain, or risk of rupture.

  • Hypersplenism, which leads to cytopenias (low counts of blood cells) that are not responsive to medical therapy.

  • Diagnostic and staging purposes, especially in isolated splenic disease where biopsy is inconclusive or not feasible.

 

BISAP Score In Pancreatitis

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Q) All are components in BISAP score except?

a) Age more than 60 years

b) WBC more than 16000

c) GCS <15

d) BUN > 25 mg/dl

Ans )b

Correct Answer: b) WBC more than 16000

The BISAP score (Bedside Index for Severity in Acute Pancreatitis) is used to predict the severity of acute pancreatitis. It includes 5 components, one point each:

  1. Blood urea nitrogen (BUN) > 25 mg/dL

  2. Impaired mental status (GCS < 15)

  3. Systemic Inflammatory Response Syndrome (SIRS)

  4. Age > 60 years

  5. Pleural effusion on imaging

✅ WBC >16,000 is not directly part of the BISAP score, although it is a criterion within SIRS, which is part of BISAP.