Pancreatic Surgery Practice Questions

Q: A 45 year old female presented with a cystic lesion in the lesser sac on CT scan. Endoscopic ultrasound guided aspiration showed amylase to be 500 IU and carcinoembryonic antigen as 500ng/ml. What was she suffering from?

Mucinous neoplasm of pancreas. ***Mucinous neoplasm of pancreas*** - **Markedly elevated CEA** (500 ng/ml, well above the threshold of 192 ng/ml) is highly specific for **mucinous cystic neoplasms** (MCN or IPMN). - The presence of **elevated amylase** (500 IU) indicates communication with the pancreatic ductal system, which can occur with **intraductal papillary mucinous neoplasms (IPMN)** or MCN with ductal involvement. - **CEA >192 ng/ml has >90% specificity** for distinguishing mucinous from non-mucinous lesions. - This patient likely has either an **MCN** (mucinous cystadenoma/cystadenocarcinoma) or **IPMN** with malignant potential requiring surgical evaluation. *Pseudocyst pancreas with ductal communication* - Pseudocysts typically have **high amylase** but **low CEA (<5 ng/ml)**. - A CEA of 500 ng/ml essentially **rules out a simple pseudocyst**. - Pseudocysts lack epithelial lining and do not produce CEA. *Chronic pseudocyst* - Similar to acute pseudocyst, chronic pseudocysts have **high amylase but low CEA**. - The markedly elevated CEA (500 ng/ml) makes this diagnosis incorrect. - Would expect CEA <5 ng/ml in pseudocyst fluid. *Pancreatic adenocarcinoma* - Solid pancreatic adenocarcinoma can have elevated CEA, but typically presents as a **solid mass**, not a cystic lesion. - Cyst fluid analysis would show **malignant cells on cytology** and typically **low amylase**. - Does not present as a pure cystic lesion in the lesser sac.

Q: Treatment of choice for annular pancreas is

Duodenoduodenostomy. ***Duodenoduodenostomy*** - This procedure bypasses the **annular pancreatic constriction** by creating an anastomosis between two healthy segments of the **duodenum**, restoring normal flow. - It's preferred because it avoids manipulation or resection of the pancreatic tissue itself, which can lead to complications such as **pancreatitis** or **fistula formation**. *Resection* - Direct resection of the **annular pancreas** is generally avoided due to the high risk of **pancreatitis**, **fistulae**, and injury to the **biliary duct** or **main pancreatic duct**. - The abnormal pancreatic tissue is often intimately associated with the **duodenal wall**, making its complete removal difficult and dangerous. *Pyloromyotomy* - This procedure involves incising the muscle layer of the **pylorus** and is typically used for conditions like **pyloric stenosis**. - It does not address the obstruction caused by an annular pancreas around the **duodenum**. *Gastrojejunostomy* - This procedure involves creating a connection between the **stomach** and the **jejunum** to bypass a distal duodenal or pyloric obstruction. - While it can relieve gastric outlet obstruction, it does not directly address the obstruction in the **proximal duodenum** caused by an **annular pancreas**.

Q: The commonest major surgical complication following Whipple procedure is:

Disruption of pancreatic anastomosis. ***Disruption of pancreatic anastomosis*** - **Pancreatic fistula** resulting from the disruption of the pancreatic anastomosis is the most frequent and most serious complication, occurring in 5-20% of cases. - Leakage of pancreatic fluids can lead to severe **intra-abdominal infection**, hemorrhage, and multi-organ failure. *Disruption of gastric anastomosis* - While possible, leak from the **gastric or duodenal anastomosis** is less common than pancreatic fistula. - This complication typically leads to peritonitis or abscess formation but generally has a lower morbidity compared to pancreatic leaks. *Biliary peritonitis* - **Bile leaks** from the hepaticojejunostomy are less common than pancreatic leaks and generally have a lower risk of severe systemic complications. - They primarily cause **peritonitis** and sometimes require percutaneous drainage or re-operation. *GI bleeding* - Gastrointestinal bleeding can occur post-Whipple, either from the **anastomotic sites**, stress ulcers, or coagulation issues. - While serious, it is typically less common and often more manageable than the sequelae of a pancreatic fistula.

Q: The most common complication of pancreas divisum is:

Recurrent acute pancreatitis. ***Recurrent acute pancreatitis*** - **Pancreas divisum** is a congenital anomaly where the dorsal and ventral pancreatic ducts fail to fuse, leading to the **majority of pancreatic secretions draining through the smaller, narrower minor papilla**. - This anatomical variation can cause relative **obstruction to pancreatic exocrine flow**, particularly during periods of increased secretion, predisposing to **recurrent episodes of acute pancreatitis** [1]. *Obstructive jaundice* - **Obstructive jaundice** typically results from **biliary tract obstruction**, such as gallstones or tumors, affecting the common bile duct. - While pancreatic disease can cause jaundice, **pancreas divisum primarily affects the pancreatic duct system** and is not a common direct cause of biliary obstruction. *Peptic ulcer* - **Peptic ulcers** are lesions in the lining of the stomach or duodenum, usually caused by **_H. pylori_ infection** or **NSAID use**. - There is **no direct causal relationship** between pancreas divisum and the development of peptic ulcers. *Duodenal obstruction* - **Duodenal obstruction** can result from various causes such as **mass lesions (_e.g._, pancreatic head tumor), strictures, or malrotation**. - Pancreas divisum is an **anatomical variation of the pancreatic ducts**, and it does not directly cause mechanical obstruction of the duodenum itself.

Q: A 52-year-old man presents with an 8 cm pancreatic head mass with biliary obstruction. Biopsy shows adenocarcinoma. Staging shows no distant metastases, but the tumor encases the superior mesenteric artery. The oncologist recommends neoadjuvant therapy, the patient wants immediate surgery, and the family requests a second opinion. Evaluate the management approach.

Neoadjuvant therapy with vascular surgery consultation. ***Neoadjuvant therapy with vascular surgery consultation*** - The presence of **superior mesenteric artery encasement** classifies this tumor as **borderline resectable** pancreatic cancer, making neoadjuvant therapy crucial for downstaging and improving R0 resection rates. - A vascular surgery consultation is essential to assess the feasibility of **vascular reconstruction** after tumor shrinkage and optimize the surgical plan if the patient becomes suitable for resection. *Immediate Whipple procedure with vascular reconstruction* - An **immediate Whipple procedure** is contraindicated in this case due to the **superior mesenteric artery encasement**, which indicates a borderline resectable tumor and a high likelihood of R1 or R2 resection. - Attempting immediate surgery without downstaging would likely lead to an **incomplete resection** and poorer long-term outcomes for the patient. *Palliative bypass surgery only* - This option is inappropriate because the patient does not have distant metastases and the tumor is potentially resectable after **neoadjuvant therapy**. - **Palliative bypass surgery** would only address the biliary obstruction symptomatically, without attempting to cure the cancer or prolong survival. *Second opinion followed by patient preference* - While a second opinion is reasonable, simply following **patient preference** without proper clinical guidance can be detrimental, especially when the patient's preference for immediate surgery goes against established oncologic principles for borderline resectable tumors. - A second opinion should primarily confirm the **neoadjuvant strategy** and clarify the rationale to the patient and family.

Q: A 20-year-old football player received a hard kick in the epigastrium. A large cystic swelling appeared in the epigastrium two weeks later. The most likely diagnosis is:

Pancreatic pseudocyst. ***Pancreatic pseudocyst*** - Trauma to the epigastrium, such as a hard kick, can lead to **pancreatic injury**, causing the leakage of pancreatic enzymes. - These enzymes can create a fluid collection, often walled off by fibrous tissue, known as a **pseudocyst**, which typically presents weeks after the initial injury. - This is the classic presentation of a **traumatic pancreatic pseudocyst** developing 2-4 weeks post-injury. *Amoebic liver abscess* - This is an infectious condition usually caused by *Entamoeba histolytica* and is associated with a history of **dysentery** or travel to endemic areas, not direct trauma. - Symptoms include fever, right upper quadrant pain, and hepatomegaly, which differ from the presentation in this case. *Hydatid cyst of liver* - This is a parasitic infection caused by **Echinococcus granulosus**, typically acquired through contact with infected animals (e.g., dogs). - It grows slowly over months to years and is not triggered acutely by trauma in this manner. *Hematoma of rectus sheath* - While trauma can cause a hematoma, a rectus sheath hematoma typically presents immediately or soon after the injury with **pain and a palpable mass** within the rectus muscle. - It is unlikely to present as a large cystic swelling two weeks post-trauma in the epigastric region in this specific context.

Q: Carcinoma of pancreas attains largest size when it is sited in -

Body & tail. ***Body & tail*** - Carcinomas in the **body and tail of the pancreas** are often diagnosed at a later stage because they typically do not cause symptoms as early as those in the head of the pancreas. - This delayed diagnosis allows the tumor to grow larger before detection, resulting in a **larger tumor size** at presentation compared to other locations. *Head* - Pancreatic cancers in the **head of the pancreas** often present early with symptoms like **jaundice** (due to biliary obstruction) or weight loss. - Due to these early warning signs, they are usually detected when they are **smaller in size**. *Periampullary* - **Periampullary tumors** are located near the ampulla of Vater and often cause **biliary obstruction** early in their development. - This obstruction leads to symptoms such as **jaundice**, prompting earlier investigation and diagnosis when the tumor is still relatively small. *Ampulla* - Tumors originating directly from the **ampulla of Vater** are often diagnosed at a very early stage because they cause prominent and early symptoms, particularly **obstructive jaundice**. - This early symptomatic presentation leads to their discovery when they are generally the **smallest** among pancreatic or periampullary cancers.

Question 1

A 45 year old female presented with a cystic lesion in the lesser sac on CT scan. Endoscopic ultrasound guided aspiration showed amylase to be 500 IU and carcinoembryonic antigen as 500ng/ml. What was she suffering from?

Accepted Answer

Mucinous neoplasm of pancreas

Answer

Pancreatic adenocarcinoma

Answer

Pseudocyst pancreas with ductal communication

Answer

Chronic pseudocyst

Question 2

Which one of the following regarding Pancreatic effusion is correct?

Accepted Answer

Percutaneous drainage under image guidance is indicated for symptomatic effusions

Answer

Pancreatic stenting is to be done

Answer

Free fluid collection in Pleural cavity

Answer

Never associated with abdominal collection

Question 3

Pancreatic pseudocysts developing complications are best managed by?

Accepted Answer

Surgery

Answer

Conservative treatment

Answer

Radiologically guided interventions

Answer

External drainage

Question 4

Treatment of choice for annular pancreas is

Accepted Answer

Duodenoduodenostomy

Answer

Resection

Answer

Pyloromyotomy

Answer

Gastrojejunostomy

Question 5

The following procedures are recommended for palliation in a patient with obstructive jaundice due to unresectable carcinoma of head of pancreas except:

Accepted Answer

Choledochoduodenostomy, gastrojejunostomy with pancreaticojejunostomy

Answer

Cholecystojejunostomy with jejunojejunostomy with gastrojejunostomy

Answer

Hepaticojejunostomy with gastrojejunostomy

Answer

Choledochoduodenostomy with gastrojejunostomy

Question 6

The commonest major surgical complication following Whipple procedure is:

Accepted Answer

Disruption of pancreatic anastomosis

Answer

Disruption of gastric anastomosis

Answer

Biliary peritonitis

Answer

GI bleeding

Question 7

The most common complication of pancreas divisum is:

Accepted Answer

Recurrent acute pancreatitis

Answer

Obstructive jaundice

Answer

Peptic ulcer

Answer

Duodenal obstruction

Question 8

A 52-year-old man presents with an 8 cm pancreatic head mass with biliary obstruction. Biopsy shows adenocarcinoma. Staging shows no distant metastases, but the tumor encases the superior mesenteric artery. The oncologist recommends neoadjuvant therapy, the patient wants immediate surgery, and the family requests a second opinion. Evaluate the management approach.

Accepted Answer

Neoadjuvant therapy with vascular surgery consultation

Answer

Immediate Whipple procedure with vascular reconstruction

Answer

Palliative bypass surgery only

Answer

Second opinion followed by patient preference

Question 9

A 20-year-old football player received a hard kick in the epigastrium. A large cystic swelling appeared in the epigastrium two weeks later. The most likely diagnosis is:

Accepted Answer

Pancreatic pseudocyst

Answer

Amoebic liver abscess

Answer

Hydatid cyst of liver

Answer

Hematoma of rectus sheath

Question 10

Carcinoma of pancreas attains largest size when it is sited in -

Accepted Answer

Body & tail

Answer

Head

Answer

Periampullary

Answer

Ampulla

Pancreatic Surgery — MCQs

Pancreatic Surgery — MCQs

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