In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
Pringle's manoeuvre is done to stop bleeding at:
Vocal cord palsy after thyroid surgery is due to injury to:
UPSC-CMS 2017 - Surgery UPSC-CMS Practice Questions and MCQs
Question 21: In a 65 year old, double contrast barium enema shows cancer of colon with an apple core appearance. Colonoscopic biopsy shows adenocarcinoma. What will be the next step of management?
- A. Surgery
- B. Radiotherapy
- C. Chemotherapy
- D. CECT to stage disease (Correct Answer)
Explanation: ***CECT to stage disease*** - **CECT (Contrast-Enhanced CT) of chest, abdomen, and pelvis is the essential next step** after histological confirmation of colon adenocarcinoma. - **Staging is mandatory** before any treatment decision to determine: - **Local extent** of tumor (T stage) - **Lymph node involvement** (N stage) - **Distant metastases** (M stage - liver, lungs, peritoneum) - **Resectability** and surgical planning - Even with the "apple core" appearance indicating an advanced primary tumor, **treatment decisions cannot be made without knowing the overall disease burden**. - **CEA (Carcinoembryonic Antigen) levels** are also typically obtained during staging. *Surgery* - **Surgical resection is the definitive treatment** for localized, resectable colon cancer and would be performed **after staging**, not before. - Surgery involves removing the tumor with adequate margins and regional lymphadenectomy. - However, **staging must precede surgery** to: - Determine if the disease is metastatic (which would change surgical approach) - Plan the extent of resection - Counsel the patient appropriately - Decide on neoadjuvant therapy if indicated - The "apple core" appearance suggests an advanced primary but does not indicate acute obstruction requiring emergency surgery in this stable patient who has already undergone barium enema and colonoscopy. *Chemotherapy* - **Chemotherapy** is typically given as: - **Adjuvant therapy** after surgery for stage III (node-positive) or high-risk stage II disease - **Palliative therapy** for metastatic (stage IV) disease - **Neoadjuvant therapy** is not standard for colon cancer (unlike rectal cancer) - Chemotherapy is not the immediate next step; staging and then surgery (if resectable) come first. *Radiotherapy* - **Radiotherapy has limited role in colon cancer** (unlike rectal cancer where it is commonly used). - It may be used for: - **Palliation** of symptoms (pain, bleeding) in advanced disease - Rare cases of **locally advanced unresectable disease** - It is not a primary treatment modality and is not the next step in this case.
Question 22: Pringle's manoeuvre is done to stop bleeding at:
- A. Hepatoduodenal ligament (Correct Answer)
- B. Splenic artery
- C. Renal artery
- D. Left gastric artery
Explanation: ***Hepatoduodenal ligament*** - **Pringle's manoeuvre** involves clamping the **hepatoduodenal ligament** to temporarily occlude the hepatic artery and portal vein, which are the main blood supply to the liver. - This maneuver is used during **liver surgery** to control or prevent bleeding from the liver parenchyma. *Splenic artery* - The **splenic artery** supplies the spleen and is not directly occluded by Pringle's manoeuvre. - Bleeding from the splenic artery would require direct clamping or **ligation** of that vessel, not compression of the hepatoduodenal ligament. *Renal artery* - The **renal artery** supplies the kidney and is located in the retroperitoneum, far from the liver and the hepatoduodenal ligament. - Pringle's manoeuvre has no effect on blood flow to the kidneys. *Left gastric artery* - The **left gastric artery** supplies the stomach and is a branch of the celiac trunk, which is proximal to the points of compression in Pringle's manoeuvre. - While it is part of the systemic circulation, Pringle's manoeuvre is specific to the blood supply entering the liver via the hepatoduodenal ligament, not individual gastric vessels.
Question 23: Vocal cord palsy after thyroid surgery is due to injury to:
- A. Vagus nerve
- B. Superior laryngeal nerve
- C. Recurrent laryngeal nerve (Correct Answer)
- D. Ansa cervicalis
Explanation: ***Recurrent laryngeal nerve*** - The **recurrent laryngeal nerves** innervate all intrinsic muscles of the larynx except the cricothyroid muscle, which are responsible for vocal cord movement. - Injury to this nerve during thyroid surgery leads to **vocal cord palsy**, causing hoarseness or aphonia. *Vagus nerve* - The **vagus nerve** is the main trunk from which the recurrent laryngeal nerve branches, but direct injury to the vagus itself is less common in thyroid surgery and would cause widespread symptoms beyond just vocal cord palsy. - Vagus nerve injury would also affect other structures in the neck, thorax, and abdomen, reflecting its broad autonomic and motor functions. *Superior laryngeal nerve* - The **superior laryngeal nerve** innervates the **cricothyroid muscle** (external branch) and provides sensation to the supraglottic larynx (internal branch). - Damage to this nerve causes changes in vocal pitch (due to paralysis of the cricothyroid muscle, which tenses the vocal cords) and problems with voice modulation, but not complete vocal cord paralysis. *Ansa cervicalis* - The **ansa cervicalis** innervates the infrahyoid muscles (strap muscles), which depress the hyoid bone and larynx. - Injury to the ansa cervicalis would affect neck movement and swallowing, but not directly cause vocal cord palsy.