Technique of CME

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Q) All are true regarding complete mesorectal excision except

a) Introduced by Hobeninger

b) It is based on ligation of central artery

c) Increases yield of lymph nodes and has decreased recurrence

d) Line of resection is below Toldt's fasica

Radiation proctitis

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Q) In radiation proctitis surgery is needed in all except 

a) Pain Abdomen

b) Rectal stricture

c) Haemorrhage

d) Vesical Fistula

Free Question on management of raiation proctiitis 

Ans a, 

In radiation proctitis, surgery is typically indicated for complications that are severe or unmanageable through conservative measures. The options can be considered as follows:

  • A) Pain Abdomen: While abdominal pain can be a symptom associated with radiation proctitis, it is not an indication for surgery on its own. Pain management and other conservative treatments can be employed first.
  • B) Rectal stricture: This can cause significant obstruction and may require surgical intervention to restore normal bowel function.
  • C) Haemorrhage: Severe bleeding due to radiation proctitis may necessitate surgical intervention if it is not controlled by endoscopic or conservative measures.
  • D) Vesical Fistula: The formation of a fistula between the bladder and rectum (vesical fistula) is a serious complication that often requires surgical repair.

Acute Radiation proctitis - Occurs within 6 mths of starting the treatment

Chronic - After 6 mths, Most patients develop symptoms at a median of 8 to 12 months after completion of radiotherapy

Modified Radiation Therapy Oncology Group rectal toxicity scale

Grade 1 Mild and self-limiting Minimal, infrequent bleeding or clear mucus discharge, rectal discomfort not requiring analgesics, loose stools not requiring medications
Grade 2 Managed conservatively, lifestyle (performance status) not affected Intermittent rectal bleeding not requiring regular use of pads, erythema of rectal lining on proctoscopy, diarrhea requiring medications
Grade 3 Severe, alters patient lifestyle Rectal bleeding requiring regular use of pads and minor surgical intervention, rectal pain requiring narcotics, rectal ulceration
Grade 4 Life threatening and disabling Bowel obstruction, fistula formation, bleeding requiring hospitalization, surgical intervention required

Prevention

  1. Use of newer conformal radiation therapy techniques.
  2. Amifostine is a prodrug that is metabolized to a thiol metabolite that is thought to scavenge reactive oxygen species
  3. Placebo-controlled phase III trials have detected no benefit from either topical or oral sucralfate.

Treatment  of radiation proctitis 

Medical

  1. Butyrates
  2. ASA
  3. Sucralfate
  4. Metronidazole
  5. Short chain FA
  6. Topical formalin
  7. Hyperbaric o2

Endoscopic

  1. dilatation
  2. Heater and bipolar cautrey
  3. ND YAG
  4. APC
  5. RFA

Surgery

Diverting ostomies for severe stricture - Better for incontinence, stricture and limited benefit  for bleed

Reconstruction with Flaps -  rectourethral or rectovaginal fistula with a pedunculated gracilis or a Martius flap to facilitate healing by introducing well-vascularized healthy tissue,

Proctectomy  complicated fistulous disease, especially when accompanied by significant pain and incontinence, or in cases of severe and intractable bleeding

Blood supply of CBD

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Q) Supraduodenal  CBD is supplied by all except (AIIMS NOV 18)
a Cystic art
b RHA
c LHA
d Anterosuperior pancreaticoduodenal artery

Ans c

The blood supply to the right and left hepatic ducts and upper portion of the CHD is from the CA and the right and left hepatic arteries.

The supraduodenal bile duct is supplied by arterial branches from the right hepatic, cystic, posterior superior pancreaticoduodenal, and retroduodenal arteries.

arteries to the supraduodenal bile duct run parallel to the duct at the 3 and 9 o’clock positions.

Approximately 60% of the blood supply to the supraduodenal bile duct originates
inferiorly from the pancreaticoduodenal and retroduodenal arteries

whereas 38% of the blood supply originates superiorly from the right hepatic artery and CD artery

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GI bleed

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Q) Which of the following statement is incorrect for  GI bleeding?

a) Clear nasogastric aspirate rules out Upper gi bleed

b) RBC scan detects bleed upto 0.1-0.5 ml/min

c) Angio detects 0.5-1 ml/min

d) UGI bleed is responsible for 15% of haematochezia

Answer

Complications of Meckel’s diverticulum

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Q. Least common complication of Meckel's diverticulum is 

a) Bleeding

b) Obstruction

c) Neoplasm

d) Obstruction

While many individuals remain asymptomatic, complications of Meckel's diverticulum can lead to significant clinical issues requiring medical intervention.

Answer is free 

Ans ) c Neoplasm

The most common clinical presentation of Meckel’s diverticulum is gastrointestinal bleeding, which occurs in 25% to 50% of patients who present with complications.

Bleeding is  often due to ulceration of the diverticulum. This bleeding can manifest as painless rectal bleeding

Another potential complication is intestinal obstruction, which can occur if the diverticulum becomes incarcerated or twisted. This situation may lead to bowel ischemia and perforation if not managed quickly.

Intestinal obstruction occur as a result of a volvulus of the small bowel around a diverticulum associated with a fibrotic band attached to the abdominal wall, intussusception, or, rarely, incarceration of the diverticulum in an inguinal hernia (Littre hernia)

Diverticulitis accounts for 10% to 20% of symptomatic presentations.

Neoplasms can also occur in a Meckel’s diverticulum, with NET as the most common malignant neoplasm (77%). Other histologic types include adenocarcinoma (11%), which generally originates from the gastric mucosa, and GIST (10%) and lymphoma (1%).

Complications of Meckel's diverticulum can be recognised and managed early if there is high index of suspicion

Complications of Meckels diverticulum

Choledochal cyst and malignancy

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Q) Choledochal cyst  and malignancy false statement is  (AIIMS 2018 nov)

a) Highest risk of malignancy in Type 3

b) Malignancy can occur even after removal of choledochal cyst

c) Malignancy can occur anywhere in the biliary tract

d) It can take upto 15 years for malignancy to develop after excision of choledochal cyst

Answer