Pancreatic Surgery Practice Questions

Q: Patients with chronic pancreatitis often exhibit a "chain of lakes" appearance in ERCP examinations. Management is?

Side to side pancreaticojejunostomy. ***Side to side pancreaticojejunostomy*** - This procedure, specifically a **Puestow procedure**, is the gold standard for managing painful chronic pancreatitis with a dilated main pancreatic duct (≥6-7 mm) and multiple strictures, presenting as a "chain of lakes" on ERCP. - It involves dividing the small bowel, closing one end, and connecting the other to a longitudinal incision made along the dilated pancreatic duct, thereby allowing drainage of pancreatic secretions into the jejunum and alleviating pain. *Total pancreatectomy* - This is a highly morbid procedure reserved for very severe cases of chronic pancreatitis that are refractory to other treatments, often associated with unmanageable pain and severe exocrine and endocrine insufficiency. - It would necessitate lifelong **enzyme replacement therapy** and **insulin for diabetes**, indicating its use as a last resort. *Sphincteroplasty* - This procedure involves widening the sphincter of Oddi and is primarily used for **biliary obstruction** or **pancreatitis secondary to sphincter dysfunction**, not for the widespread strictures and dilated ducts typical of chronic pancreatitis with a "chain of lakes" appearance. - While it can improve drainage, it does not address the extensive ductal pathology seen in many cases of chronic pancreatitis with multiple strictures. *Resecting the tail of pancreas and performing a pancreaticojejunostomy* - This describes a **distal pancreatectomy with pancreaticojejunostomy**, which is suitable for lesions or pathologies primarily confined to the **body or tail of the pancreas**, such as certain tumors or cysts. - It would not effectively address the diffuse ductal changes and multiple strictures throughout the entire pancreas that cause the "chain of lakes" appearance in chronic pancreatitis, which usually requires decompression of the entire duct system.

Q: Most common site for carcinoma of the pancreas is?

Head. ***Head*** - The **head of the pancreas** is the most common site for carcinoma, accounting for approximately **60-70%** of cases [1]. - This location is often associated with **biliary obstruction** and **Courvoisier's sign** (enlarged gallbladder) due to its proximity to the bile ducts. *Body* - Carcinomas in the **body** of the pancreas are less common, typically representing about **15-20%** of cases [1]. - They may present with **unspecific symptoms** and are often diagnosed at a later stage due to vague presentation. *Tail* - The **tail** of the pancreas is the least common site for carcinoma, contributing to about **5-10%** of cases [1]. - Tumors in this location often remain asymptomatic until advanced, leading to delayed diagnosis. *Ampulla* - Carcinomas at the **ampulla of Vater** are rare, generally accounting for only about **1-2%** of pancreatic tumors. - While they can cause biliary obstruction, they are distinct from **pancreatic ductal adenocarcinoma** typically found in the head. **References:** [1] Kumar V, Abbas AK, et al.. Robbins and Cotran Pathologic Basis of Disease. 9th ed. The Pancreas, pp. 898-899.

Q: After pancreaticoduodenectomy (PD surgery), when should the first postoperative follow-up visit be scheduled to assess the patient's recovery?

2 weeks. ***2 weeks*** - A 2-week recall after **pancreaticoduodenectomy (PD surgery)** allows sufficient time for early postoperative complications to manifest while still being within a window for timely intervention. - This timeframe enables assessment of **wound healing**, resolution of ileus, nutritional status, and early recognition of issues like **pancreatic fistula** or **delayed gastric emptying**. *1 week* - A 1-week recall might be too early to identify some significant complications that typically present slightly later, such as **pancreatic fistula**. - At this stage, patients are often still in the acute recovery phase, making comprehensive outpatient assessment less informative. *3 weeks* - Delaying recall until 3 weeks might be too late for optimal management of certain **postoperative complications**, potentially leading to more severe outcomes. - Early symptoms of complications could be missed, increasing the risk of re-admission or prolonged recovery. *4 weeks* - By 4 weeks, many **early complications** that require timely intervention may have become more advanced or difficult to manage. - This recall period is often used for a more routine follow-up rather than immediate assessment of acute recovery.

Q: Most common complication of a pseudocyst of the pancreas is

Infection. ***Infection*** - **Infection** is the most common and clinically significant complication of a pancreatic pseudocyst, often leading to sepsis and increased mortality. - While other complications can occur, **secondary infection** transforms a sterile pseudocyst into an abscess, requiring urgent intervention. *Rupture into peritoneum* - While possible, **rupture into the peritoneum** (free rupture) is a less frequent complication compared to infection. - This leads to acute peritonitis and is a highly morbid event, but statistically less common than infection. *Haemorrhage* - **Hemorrhage** (bleeding) into a pseudocyst is a serious and potentially life-threatening complication, but it is less common than infection. - It usually results from erosion into adjacent blood vessels, such as the splenic or gastroduodenal arteries. *Rupture into colon* - **Rupture into the colon** or other adjacent organs (like the stomach or duodenum) can occur, but these are less frequent compared to infection. - Such ruptures can lead to internal fistula formation, but infection remains the predominant complication.

Q: The treatment of an annular pancreas is

Duodeno-duodenostomy. ***Duodeno-duodenostomy*** - **Duodeno-duodenostomy** is the preferred bypass procedure for **annular pancreas**, connecting the dilated **proximal duodenum** to the **distal duodenum** beyond the obstruction point. - The **annular pancreatic tissue must never be divided** as the **main pancreatic duct** traverses through it, making this bypass approach the safest option. *Duodenojejunostomy* - While **duodenojejunostomy** can be used as an alternative bypass, it is **not the first-line treatment** for annular pancreas compared to duodeno-duodenostomy. - This procedure bypasses the obstruction by connecting duodenum to jejunum but is considered a **secondary option** when duodeno-duodenostomy is not feasible. *Gastrojejunostomy* - **Gastrojejunostomy** connects the stomach to jejunum and does **not address the duodenal obstruction** caused by the annular pancreas. - This procedure can lead to complications like **bile reflux gastritis** and **marginal ulcers** without resolving the underlying duodenal obstruction. *Gastro-duodenostomy* - **Gastro-duodenostomy** connects the stomach to duodenum and would **not bypass the obstruction** caused by the annular pancreatic tissue. - This procedure is typically used after **gastrectomy** (Billroth I reconstruction) and is inappropriate for treating duodenal obstruction from annular pancreas.

Q: Cullen's sign is associated with which of the following?

Bluish discolouration in the umbilicus. ***Bluish discolouration in the umbilicus*** - **Cullen's sign** is characterized by **periumbilical ecchymosis** or bluish discoloration around the umbilicus. - It is a sign of **retroperitoneal hemorrhage**, often associated with **acute pancreatitis** [1], but also can be caused by ruptured ectopic pregnancy [2] or aortic rupture. *Subcutaneous fat necrosis* - This condition involves the death of fat cells under the skin, often presenting as firm, red nodules or plaques. - While it can occur in various contexts, it is not specifically known as Cullen's sign and does not inherently involve umbilical discoloration. *Bluish discolouration of the flanks* - This description refers to **Grey Turner's sign**, which is ecchymosis or discoloration of the flanks. - **Grey Turner's sign** is also indicative of retroperitoneal hemorrhage, often seen in severe acute pancreatitis, but it is distinct from Cullen's sign which is periumbilical. *Migratory thrombophlebitis* - This condition involves recurrent inflammation and thrombosis of superficial veins in different locations over time. - It is also known as **Trousseau's sign of malignancy** and is associated with visceral cancers, particularly pancreatic adenocarcinoma, but it is unrelated to Cullen's sign.

Q: All are true about pseudopancreatic cyst of pancreas except:

Most common site is in head of pancreas. ***Most common site is in head of pancreas*** - The **body and tail of the pancreas** are the most common sites for pseudocysts due to the typical location of pancreatic inflammation and fluid accumulation. - While pseudocysts can theoretically occur anywhere, the head is less frequently affected as the primary site. *Common after acute pancreatitis* - **Pancreatic pseudocysts** are a frequent complication, occurring in about 10-20% of patients following an episode of **acute pancreatitis** [1]. - They form when pancreatic fluid, rich in enzymes, leaks and becomes walled off by granulation tissue. *Presents as an abdominal mass* - Depending on its size and location, a **pseudocyst** can present as a palpable and sometimes painful **abdominal mass**. - Larger pseudocysts can cause symptoms by compressing adjacent organs [1]. *Serum amylase is increased* - Although the acute phase of pancreatitis has resolved, some **leakage of pancreatic enzymes** into the peritoneum or bloodstream can persist, leading to elevated **serum amylase** levels. - This elevation reflects the ongoing enzymatic activity within the pseudocyst.

Q: Middle segment pancreatectomy is avoided in which of the following conditions?

Tumors of tail of pancreas. ***Tumors of tail of pancreas*** - Middle segment pancreatectomy involves resection of the central portion of the pancreas, usually sparing the head and tail. Therefore, it is not suitable for **tumors located in the pancreatic tail**. - For tail tumors, a **distal pancreatectomy** is the standard surgical approach, as it allows for complete resection of the tumor with appropriate margins. *Cystadenoma* - These are often located in the body or tail but can occur in the middle segment. If a **cystadenoma** is located in the middle segment, a middle segment pancreatectomy may be an appropriate treatment. - The decision to perform a middle segment pancreatectomy versus another procedure depends on the exact location and size of the cystadenoma, as well as its malignant potential. *Tumors of head of pancreas* - Tumors in the **head of the pancreas** typically involve crucial structures like the bile duct and duodenum. - For these tumors, a **pancreaticoduodenectomy (Whipple procedure)** is the standard and often only curative surgical option. *Tumor of neck of pancreas* - The **neck of the pancreas** is part of the middle segment of the pancreas. - Tumors in this location are amenable to **middle segment pancreatectomy**, as this procedure specifically targets resecting the central portion while preserving surrounding healthy tissue.

Q: A 60-year-old chronic smoker presented with progressive jaundice, pruritus, and clay-colored stools for 2 months, with a history of waxing and waning of jaundice. A CT scan revealed dilated main pancreatic duct and common bile duct. What is the likely diagnosis?

Periampullary carcinoma. ***Periampullary carcinoma*** - The key feature here is **waxing and waning jaundice**, which is a classic presentation of periampullary carcinoma due to the tumor's location at the ampulla of Vater. - **Mechanism**: The friable tumor tissue can undergo necrosis and sloughing, temporarily relieving the obstruction and causing fluctuating jaundice. - Both **dilated common bile duct and pancreatic duct (double duct sign)** are seen because the tumor involves the ampulla where both ducts converge. - **Chronic smoker** is a risk factor for pancreaticobiliary malignancies. - **Painless obstructive jaundice** with pruritus and clay-colored stools indicates extrahepatic biliary obstruction. *Carcinoma head of pancreas* - While this can also cause the **double duct sign** and obstructive jaundice, it typically presents with **steadily progressive jaundice** rather than waxing and waning. - Pancreatic head tumors cause persistent compression of the CBD, leading to continuous obstruction. - The fluctuating pattern is NOT characteristic of pancreatic head carcinoma. *Chronic pancreatitis* - Can cause dilated ducts and obstructive jaundice due to **fibrotic strictures**, but typically presents with **recurrent abdominal pain** and a history of repeated inflammatory episodes. - Pain is a predominant feature, which is absent in this case. - The clinical picture of painless progressive jaundice favors malignancy over inflammatory disease. *Hilar cholangiocarcinoma* - **Klatskin tumor** affects the confluence of hepatic ducts, causing **intrahepatic bile duct dilation** with normal or minimally dilated distal CBD. - **Pancreatic duct dilation would NOT occur** with hilar cholangiocarcinoma. - The presence of both dilated CBD and pancreatic duct rules this out.

Q: Most common cause of pseudocyst of the pancreas?

Acute pancreatitis. ***Acute pancreatitis*** - **Acute pancreatitis** is the most common cause of pancreatic pseudocysts due to the inflammatory process and enzyme leakage [1]. - The inflammatory exudate and necrotic debris can wall off, forming a fluid-filled cavity [1]. *Chronic pancreatitis* - While **chronic pancreatitis** can lead to pseudocysts, it is less common than acute pancreatitis as the primary etiology. - Pseudocysts in chronic pancreatitis often result from obstruction of the pancreatic ductal system. *Trauma to the pancreas* - **Pancreatic trauma** (e.g., blunt abdominal injury) can cause a pseudocyst, but it is a relatively rare cause compared to pancreatitis. - Trauma leads to disruption of the ductal system and leakage of pancreatic fluid. *Pancreatic tumors* - **Pancreatic tumors**, especially cystic neoplasms, can mimic pseudocysts but are distinct neoplastic lesions, not inflammatory collections. - True pseudocysts lack an epithelial lining, which distinguishes them from cystic tumors.

Question 1

Patients with chronic pancreatitis often exhibit a "chain of lakes" appearance in ERCP examinations. Management is?

Accepted Answer

Side to side pancreaticojejunostomy

Answer

Total pancreatectomy

Answer

Resecting the tail of pancreas and performing a pancreaticojejunostomy

Answer

Sphincteroplasty

Question 2

Most common site for carcinoma of the pancreas is?

Accepted Answer

Head

Answer

Neck

Answer

Body

Answer

Tail

Question 3

After pancreaticoduodenectomy (PD surgery), when should the first postoperative follow-up visit be scheduled to assess the patient's recovery?

Accepted Answer

2 weeks

Answer

3 weeks

Answer

4 weeks

Answer

1 week

Question 4

Most common complication of a pseudocyst of the pancreas is

Accepted Answer

Infection

Answer

Rupture into peritoneum

Answer

Haemorrhage

Answer

Rupture into colon

Question 5

The treatment of an annular pancreas is

Accepted Answer

Duodeno-duodenostomy

Answer

Duodenojejunostomy

Answer

Gastrojejunostomy

Answer

Gastro-duodenostomy

Question 6

Cullen's sign is associated with which of the following?

Accepted Answer

Bluish discolouration in the umbilicus

Answer

Subcutaneous fat necrosis

Answer

Bluish discolouration of the flanks

Answer

Migratory thrombophlebitis

Question 7

All are true about pseudopancreatic cyst of pancreas except:

Accepted Answer

Most common site is in head of pancreas

Answer

Common after acute pancreatitis

Answer

Serum amylase is increased

Answer

Presents as an abdominal mass

Question 8

Middle segment pancreatectomy is avoided in which of the following conditions?

Accepted Answer

Tumors of tail of pancreas

Answer

Tumors of head of pancreas

Answer

Cystadenoma

Answer

Tumor of neck of pancreas

Question 9

A 60-year-old chronic smoker presented with progressive jaundice, pruritus, and clay-colored stools for 2 months, with a history of waxing and waning of jaundice. A CT scan revealed dilated main pancreatic duct and common bile duct. What is the likely diagnosis?

Accepted Answer

Periampullary carcinoma

Answer

Chronic pancreatitis

Answer

Carcinoma head of pancreas

Answer

Hilar cholangiocarcinoma

Question 10

Most common cause of pseudocyst of the pancreas?

Accepted Answer

Acute pancreatitis

Answer

Chronic pancreatitis

Answer

Trauma to the pancreas

Answer

Pancreatic tumors

Pancreatic Surgery — MCQs

Pancreatic Surgery — MCQs

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