Revisional Bariatric Surgery — MCQs
Complications of sling procedures (TVT) for USI are all except:
In a clinical scenario where a patient is being fitted for a complete denture, the operator notes the lifting of the tray with an impression, accompanied by protrusion of the tongue. Which area should be re-adapted to ensure proper fit?
In a patient with a perforated peptic ulcer, what surgical procedure is typically indicated?
All of the following are primarily restrictive operations for morbid obesity, except which of the following?
Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.
Which of the following is not a relative contraindication for breast conservative surgery?
Deep vein thrombosis is MOST common after which of the following procedures?
Which of the following is not a risk factor for postoperative pulmonary complication?
What is the most appropriate surgical management for a patient with achalasia who has tried nonoperative therapies, including lifestyle modifications, calcium channel blockers, botulin toxin injections, and endoscopic pneumatic dilatation, but has not experienced symptom relief?
A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
Revisional Bariatric Surgery Indian Medical PG Practice Questions and MCQs
Question 1: Complications of sling procedures (TVT) for USI are all except:
- A. Obturator nerve injury is about 10% (Correct Answer)
- B. Overactive bladder in about 7% cases
- C. Injury to bladder and wound haematoma
- D. Sling erosion particularly with polytetrafluoroethylene (Goretex)
Explanation: ***Obturator nerve injury is about 10%*** ✓ **CORRECT ANSWER (NOT a complication of TVT)** - **Obturator nerve injury** is exceedingly rare during **TVT (Tension-free Vaginal Tape)** procedures, which use a retropubic approach through the space of Retzius. - This complication is primarily associated with **TOT (Trans-Obturator Tape)** procedures where the tape passes near the obturator foramen, not with standard retropubic TVT. - The incidence of obturator nerve injury in TVT is essentially negligible (<0.1%), nowhere near 10%. *Overactive bladder in about 7% cases* - **De novo overactive bladder (OAB)** symptoms or worsening of pre-existing OAB can occur in 3-15% of patients after TVT procedures, with 7% being a commonly cited figure. - This occurs due to changes in bladder neck support, urethral kinking, or irritation from the sling material. *Injury to bladder and wound haematoma* - **Bladder injury/perforation** occurs in 2-5% of TVT cases due to the retropubic passage of needles close to the bladder, which is why intraoperative cystoscopy is routinely performed. - **Wound hematoma** can occur at the vaginal or suprapubic incision sites as a common surgical complication from tissue dissection and bleeding. *Sling erosion particularly with polytetrafluoroethylene (Goretex)* - **Sling erosion** into the vagina or urethra is a documented complication of synthetic slings, with rates of 0.5-3% for modern materials. - **Polytetrafluoroethylene (Goretex)**, an older first-generation mesh material, was associated with significantly higher rates of erosion (up to 10%) and infection compared to modern monofilament polypropylene meshes, which is why it has been largely discontinued for sling procedures.
Question 2: In a clinical scenario where a patient is being fitted for a complete denture, the operator notes the lifting of the tray with an impression, accompanied by protrusion of the tongue. Which area should be re-adapted to ensure proper fit?
- A. Hamular notch
- B. Palatoglossus area (Correct Answer)
- C. Retromolar pad area
- D. Anterior labial flange reduced
Explanation: ***Palatoglossus area*** - The **palatoglossus muscle** is involved in tongue protrusion; its fibers are positioned strategically to influence the posterior border of the denture. - When the tongue protrudes, the **palatoglossus muscle contracts**, potentially displacing the impression tray if this area is overextended. *Hamular notch* - The **hamular notch** is a critical area for posterior seal and retention, but its overextension typically causes pain or discomfort, not necessarily tray lifting with tongue protrusion. - Problems here might lead to denture instability or gagging, distinct from the described scenario. *Retromolar pad area* - The **retromolar pad** provides support and stability for the mandibular denture, and issues here usually affect retention during chewing or speaking. - Overextension in this area can cause soreness or interfere with jaw movements, but it's less directly linked to tongue protrusion and tray lifting compared to the palatoglossus area. *Anterior labial flange reduced* - Reducing the **anterior labial flange** would primarily address issues related to lip support, esthetics, or overextension causing discomfort in the anterior region. - This adjustment would not directly impact the lifting of an impression tray due to tongue protrusion, which is a posterior and lateral issue.
Question 3: In a patient with a perforated peptic ulcer, what surgical procedure is typically indicated?
- A. Total gastrectomy
- B. Laparoscopic repair of the perforation (Correct Answer)
- C. Gastric bypass
- D. Pyloroplasty
Explanation: ***Laparoscopic repair of the perforation*** - For a **perforated peptic ulcer**, the immediate goal is to close the perforation and control contamination, which is typically achieved via **laparoscopic primary repair** using sutures and an omental patch (Graham patch). - This minimally invasive approach has advantages of reduced pain, shorter hospital stay, and faster recovery compared to open surgery, making it suitable for most stable patients. *Total gastrectomy* - **Total gastrectomy** involves the complete removal of the stomach and is a major, highly invasive procedure. - It is typically reserved for extensive gastric malignancies or diffuse, intractable ulcer disease, not for an acute, localized perforation. *Gastric bypass* - **Gastric bypass** surgery is primarily a **bariatric procedure** performed for severe obesity or severe, uncontrolled diabetes. - It is not indicated for the emergency management of a perforated peptic ulcer. *Pyloroplasty* - **Pyloroplasty** is a procedure to widen the pyloric channel and is performed to improve gastric emptying. - It is typically done in conjunction with a vagotomy for recurrent, complicated duodenal ulcers that cause obstruction, not as the primary treatment for an acute perforation.
Question 4: All of the following are primarily restrictive operations for morbid obesity, except which of the following?
- A. Laparoscopic adjustable gastric banding
- B. Roux-en-Y operation (Correct Answer)
- C. Vertical band gastroplasty
- D. Duodenal switch operation
Explanation: **Roux-en-Y operation** - The **Roux-en-Y gastric bypass** is considered a **malabsorptive as well as a restrictive procedure** because it creates a small gastric pouch and bypasses a significant portion of the small intestine. - This dual mechanism leads to greater weight loss compared to purely restrictive surgeries. *Vertical band gastroplasty* - **Vertical band gastroplasty** is a **purely restrictive procedure** that creates a small pouch and restricts outflow, but does not involve nutrient malabsorption. - It is less commonly performed now due to higher rates of weight regain and complications compared to other bariatric surgeries. *Laparoscopic adjustable gastric banding* - **Laparoscopic adjustable gastric banding** is a **purely restrictive procedure** where an inflatable band is placed around the upper part of the stomach to create a small pouch. - This limits the amount of food that can be consumed at one time and slows gastric emptying, but does not alter nutrient absorption. *Switch duodenal operation* - The **duodenal switch operation** (biliopancreatic diversion with duodenal switch) is primarily a **malabsorptive procedure** with a restrictive component. - While it includes creation of a small gastric pouch, its most significant effect on weight loss comes from bypassing a large portion of the small intestine, leading to **significant malabsorption**.
Question 5: Identify the procedure shown in the image, which is performed in a patient with recurrent GERD.
- A. Nissen fundoplication (Correct Answer)
- B. Partial gastrectomy
- C. Esophageal banding
- D. Toupet fundoplication
Explanation: ***Nissen fundoplication*** - The image clearly depicts the **fundus of the stomach** being wrapped completely around the lower esophagus and sutured in place, which is the hallmark of a **360-degree Nissen fundoplication**. - This procedure aims to strengthen the **lower esophageal sphincter (LES)** to prevent reflux in patients with recurrent GERD. *Partial gastrectomy* - This procedure involves the **surgical removal of a portion of the stomach** and is typically performed for conditions like gastric cancer or severe ulcers, not primarily for GERD. - The image shows the stomach intact and being wrapped, not resected. *Esophageal banding* - Esophageal banding is a procedure used to treat **esophageal varices** by placing elastic bands around dilated veins, not a surgical intervention for GERD that alters stomach anatomy. - The image shows a gastric maneuver, not banding of the esophagus. *Toupet fundoplication* - A Toupet fundoplication involves a **partial (270-degree) wrap** of the fundus around the esophagus, leaving a small portion unwrapped. - The image distinctly illustrates a **complete 360-degree wrap**, distinguishing it from a Toupet fundoplication.
Question 6: Which of the following is not a relative contraindication for breast conservative surgery?
- A. Multicentric disease
- B. Previous radiation to breast
- C. Large tumor size
- D. Small tumor size (<3cm) (Correct Answer)
Explanation: ***Small tumor size (<3cm)*** ✓ - A small tumor size is **NOT a contraindication** for breast-conserving surgery; it is actually a **favorable condition** and an indication for breast conservation. - Small tumors allow for complete tumor removal with good cosmetic outcomes and adequate margins. - This is the **correct answer** as it is the only option that is NOT a relative contraindication. *Multicentric disease* - **Multicentric disease** refers to the presence of multiple tumor foci in **different quadrants** of the breast, making complete surgical removal challenging with breast-conserving surgery. - This is a **relative contraindication** as it increases the risk of **positive margins** and local recurrence, making mastectomy often a more appropriate option. *Previous radiation to breast* - Prior radiation therapy to the breast is a **contraindication** (often considered absolute) for subsequent breast radiation, which is an essential component of breast-conserving therapy. - Re-irradiation carries a high risk of severe **skin and tissue toxicity**, making further breast conservation unfeasible. *Large tumor size* - A large tumor size is a **relative contraindication** as it can make it difficult to achieve **clear surgical margins** while maintaining an acceptable cosmetic result. - However, **neoadjuvant chemotherapy** may downstage large tumors to make them suitable for breast-conserving surgery. - Without tumor reduction, it often requires **mastectomy**.
Question 7: Deep vein thrombosis is MOST common after which of the following procedures?
- A. Neurosurgery
- B. Total hip replacement (Correct Answer)
- C. Gastrectomy
- D. Prostatic operation
Explanation: ***Total hip replacement*** - **Total hip replacement surgery** is a significant risk factor for DVT due to extensive tissue trauma, prolonged immobility, and potential damage to venous endothelium during the procedure. - The incidence of **postoperative DVT** can be as high as 40-60% without prophylaxis, earning it a classification as a **very high-risk procedure** for VTE. *Neurosurgery* - While neurosurgery carries a risk of DVT, it is generally **lower compared to major orthopedic surgeries** like total hip replacement. - The focus in neurosurgery often revolves around avoiding **intracranial bleeding**, which can limit the intensity of anticoagulant prophylaxis. *Gastrectomy* - Gastrectomy, a major abdominal surgery, does increase the risk of DVT, but typically **less profoundly than total hip replacement**. - Risk factors like **anesthesia duration** and degree of inflammation contribute to DVT risk, but not to the same extent as direct trauma to large veins in the lower extremities. *Prostatic operation* - **Prostatic operations**, such as prostatectomy, carry a moderate risk of DVT, but this risk is generally **lower than that associated with major orthopedic procedures**. - The risk is influenced by factors such as **surgical time**, patient age, and the presence of malignancy, but the extent of venous stasis and damage is typically less severe.
Question 8: Which of the following is not a risk factor for postoperative pulmonary complication?
- A. Normal BMI (18.5-24.9) (Correct Answer)
- B. Age 25-40 years
- C. Upper abdominal surgery
- D. Patient with 20 pack years of smoking
Explanation: ***Patient with 20 pack years of smoking*** - This is a significant risk factor for postoperative pulmonary complications, as **chronic smoking** impairs lung function and mucociliary clearance. - Patients with a history of **20 pack-years or more** are at a substantially increased risk of developing atelectasis, pneumonia, and respiratory failure after surgery. *Normal BMI (18.5-24.9)* - A **normal BMI** is not considered a risk factor for postoperative pulmonary complications; instead, it is associated with a lower risk compared to obesity or underweight states. - Patients with a normal BMI generally have **better respiratory mechanics** and lung volumes, reducing their susceptibility to pulmonary issues. *Age 25-40 years* - This age range is generally associated with a **lower risk** of postoperative pulmonary complications compared to very young or elderly patients. - Younger adults typically have **better physiological reserves** and healthier lungs, contributing to a reduced incidence of respiratory problems post-surgery. *Upper abdominal surgery* - **Upper abdominal surgery** is a significant risk factor for postoperative pulmonary complications due to its proximity to the diaphragm. - It often leads to **diaphragmatic dysfunction**, reduced lung volumes, and increased pain, all of which predispose patients to atelectasis and pneumonia.
Question 9: What is the most appropriate surgical management for a patient with achalasia who has tried nonoperative therapies, including lifestyle modifications, calcium channel blockers, botulin toxin injections, and endoscopic pneumatic dilatation, but has not experienced symptom relief?
- A. Repeat pneumatic dilation with higher pressures
- B. Esophagectomy
- C. Surgical esophagomyotomy proximal to the LES
- D. Modified Heller myotomy and partial fundoplication (Correct Answer)
Explanation: ***Modified Heller myotomy and partial fundoplication*** - A **Heller myotomy** involves incising the muscle fibers of the lower esophageal sphincter (LES) to relieve obstruction, which is the definitive treatment for achalasia. - A **partial fundoplication** is added to prevent **postoperative gastroesophageal reflux disease (GERD)**, a common complication of myotomy. *Esophagectomy* - **Esophagectomy** is a highly invasive procedure involving removal of the esophagus, reserved for end-stage achalasia with **megaesophagus** or **recurrent aspiration**, not typically first-line surgical management. - It carries significant morbidity and mortality risks, making it an option only as a **last resort** when other treatments have failed and the esophagus is severely diseased. *Surgical esophagomyotomy proximal to the LES* - A myotomy specifically targets the **hypertonic LES** to relieve dysphagia. Performing it significantly proximal to the LES would not address the primary pathology. - While myotomy is the correct approach, its efficacy depends on precise dissection of the muscle fibers at the **gastroesophageal junction** where the LES is located. *Repeat pneumatic dilation with higher pressures* - Although **pneumatic dilation** is an effective *nonoperative* treatment, the patient has already undergone it without relief, indicating a **refractory case**. - Repeating the procedure with higher pressures increases the risk of **esophageal perforation** without necessarily improving long-term outcomes in a patient who has already failed multiple prior treatments.
Question 10: A patient scheduled for elective inguinal hernia surgery has a history of myocardial infarction (MI) and underwent coronary artery bypass grafting (CABG). What should be included in the preoperative assessment?
- A. History + c/e + routine labs + V/Q scan
- B. History + c/e + routine labs
- C. History + c/e + routine labs + stress test (Correct Answer)
- D. History + c/e + routine labs + angiography to assess graft patency
Explanation: ***History + c/e + routine labs + stress test*** - A **stress test** is crucial in patients with a history of MI and CABG to assess **myocardial ischemia** and functional capacity, guiding perioperative management. - This evaluation helps determine the patient's **cardiac risk** for non-cardiac surgery and the need for further cardiac optimization. *History + c/e + routine labs + angiography to assess graft patency* - **Coronary angiography** is an invasive procedure and is generally not indicated as a routine preoperative assessment unless there are new, significant cardiac symptoms or signs of **graft dysfunction**. - Assessing graft patency through angiography carries risks and would only be justified if there were strong clinical indications suggesting acute or severe **cardiac ischemia**. *History + c/e + routine labs* - While critical for any preoperative assessment, **routine history, physical examination, and basic laboratory tests** are insufficient for a patient with a significant cardiac history like MI and CABG. - This approach would **underestimate the cardiac risk** and might miss undetected ischemia, leading to adverse perioperative cardiac events. *History + c/e + routine labs + V/Q scan* - A **ventilation-perfusion (V/Q) scan** is primarily used to diagnose **pulmonary embolism** or assess regional lung function. - It does not provide information about myocardial ischemia or cardiac functional capacity, making it **irrelevant** for assessing cardiac risk in this clinical scenario.
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