Transplant Surgery Practice Questions

Q: A 55-year-old woman with cirrhosis requires liver transplantation. Her MELD score is 28, and she has been on the waiting list for 8 months. She presents with confusion, asterixis, and ammonia level of 150 μg/dL (normal 15-45). What is the most important consideration for transplant candidacy at this time?

Hepatic encephalopathy suggests end-stage disease. ***Hepatic encephalopathy suggests end-stage disease*** - The presence of **hepatic encephalopathy** (confusion, asterixis, elevated ammonia) indicates severe, **end-stage liver disease**, making liver transplantation highly urgent and potentially the only definitive treatment. - While MELD score dictates initial priority, the acute presentation of encephalopathy in a patient with a high MELD score highlights the critical need for a transplant. *Presence of ascites* - While ascites is a common complication of cirrhosis, it is a **less urgent indicator** for transplant candidacy than acute hepatic encephalopathy. - Ascites can often be managed medically, unlike acute severe encephalopathy, which necessitates an immediate transplant. *Length of time on waiting list* - The length of time on the waiting list is a factor in **transplant allocation**, but it does not supersede the urgency of acute, severe complications like hepatic encephalopathy. - A patient's medical status and **likelihood of survival** are primary considerations, overriding waiting time alone. *Reversibility of hepatic encephalopathy with treatment* - Although treatment for hepatic encephalopathy (e.g., lactulose, rifaximin) can temporarily improve symptoms, it does not address the underlying **progressive liver failure**. - The goal of transplantation is to treat the **irreversible liver disease**, not just its transient complications.

Q: A 42-year-old surgeon is diagnosed with hepatitis C and requests evaluation for liver transplantation. Her viral load is high, and she has early cirrhosis. She wants to continue operating while awaiting transplant. Evaluate the ethical and medical considerations regarding her continued practice.

Defer decision to hospital ethics committee. ***Defer decision to hospital ethics committee*** - This complex scenario involves balancing the **autonomy** of the physician, patient safety, and institutional responsibility, making it suitable for a **multidisciplinary discussion**. - An ethics committee can provide a structured framework to consider **legal implications**, hospital policies, and the latest **medical guidelines** regarding infected healthcare workers. *Allow continued practice with universal precautions* - While **universal precautions** are essential, the risk of **blood-borne pathogen transmission** (HCV) still exists, particularly in invasive surgical procedures where sharps injuries can occur. - The surgeon's **high viral load** increases the risk, and relying solely on precautions may not adequately protect patients. *Restrict practice to non-invasive procedures only* - This option offers a compromise, reducing the direct exposure risk to patients from **blood-borne pathogens** during surgical procedures. - However, it significantly limits the surgeon's professional scope and may still raise ethical questions about the **physician's fitness** for any patient-facing role while actively infected with a transmissible disease. *Require immediate cessation of all surgical practice* - While this eliminates the immediate risk of **HCV transmission** to patients during surgery, it is a drastic measure with significant impact on the surgeon's career and livelihood. - Such a decision should not be made unilaterally without a thorough evaluation of all factors, including the **actual risk** and less restrictive alternatives.

Q: A 65-year-old man with cirrhosis (Child-Pugh B) and hepatocellular carcinoma presents with a 4 cm tumor. He has portal hypertension with esophageal varices and ascites. His MELD score is 18. Evaluate the optimal treatment strategy considering tumor stage, liver function, and available therapies.

Liver transplantation evaluation. ***Liver transplantation evaluation*** - The presence of a 4 cm hepatocellular carcinoma within a background of advanced cirrhosis (Child-Pugh B, MELD 18) and portal hypertension (esophageal varices, ascites) makes **liver transplantation** the optimal treatment strategy. This addresses both the tumor and the underlying liver disease. - According to the **Milan criteria**, a single tumor up to 5 cm (or up to 3 tumors, each 3 cm or less) is within transplant eligibility, offering the best chance for long-term survival for appropriate candidates. *Sorafenib chemotherapy* - **Sorafenib** is a systemic therapy typically reserved for advanced HCC that is **not amenable to locoregional or surgical therapies**, or in cases of metastatic disease. - Given the tumor size and the patient's liver function, a more definitive and potentially curative option like transplantation should be considered first. *Radiofrequency ablation of the tumor* - **Radiofrequency ablation (RFA)** is a locoregional therapy often used for small HCCs, typically **< 3 cm**, in patients with good liver function. - A 4 cm tumor might be less effectively treated by RFA, and the patient's compromised liver function and portal hypertension make even effective local control less beneficial without addressing the underlying liver disease. *Transarterial chemoembolization (TACE)* - **TACE** is a locoregional treatment for intermediate-stage HCC (often multiple tumors or larger tumors not suitable for RFA or surgery). It is **not considered curative**. - While TACE can control tumor growth, it does not treat the underlying advanced liver disease, which is a major factor in this patient's prognosis.

Q: Xenograft is transplantation of tissue:

From a different species. ***From a different species*** - A **xenograft** (or heterograft) is the transplantation of cells, tissues, or organs from **one species to another**, such as from a pig to a human. - This type of transplant faces significant immunological challenges due to the **genetic disparity** between the donor and recipient. *From same species* - This describes an **allograft** (or homograft), where tissue is transplanted between genetically distinct individuals of the **same species**. - Examples include organ transplants between unrelated humans. *From genetically identical twins* - This describes an **isograft** (or syngeneic graft), which involves transplantation between **genetically identical individuals**, such as monozygotic twins. - These grafts typically have the **highest success rate** due to minimal immune rejection. *From one part of body to another* - This describes an **autograft**, where tissue is transplanted from one site to another **within the same individual**. - Examples include a skin graft from the thigh to a burned area on the arm or a **coronary artery bypass graft** using a leg vein; these grafts are not rejected as they originate from the patient's own body.

Q: What is the documented mortality rate for healthy liver donors undergoing donor hepatectomy?

Mortality for donor is 0.2 to 0.4 %. ***Correct: Mortality for donor is 0.2 to 0.4%*** - Studies indicate that the **mortality rate** for healthy liver donors undergoing **donor hepatectomy** is very low, typically ranging from **0.2% to 0.4%**. - This rate reflects the extensive **pre-operative screening** and careful surgical techniques used to ensure donor safety. - Current data from major transplant centers worldwide support this range as the most accurate representation of donor risk. *Incorrect: Mortality for donor is 0.6 to 0.8%* - This range is **higher** than the generally accepted and documented mortality rates for healthy liver donors. - While complications can occur, fatal outcomes are rare, making this percentage an **overestimation** of actual risk. *Incorrect: Mortality for donor is 0.5%* - This mortality rate is also **higher** than the current reported rates for living liver donation in well-established centers. - Continuous advancements in surgical safety and donor selection have driven the mortality rate **below 0.5%** in most high-volume centers. *Incorrect: Mortality for donor is 1%* - A 1% mortality rate for healthy liver donors would be considered **unacceptably high** given the current standards of care. - This percentage severely **overestimates** the actual risks associated with living related liver donation and does not reflect modern surgical outcomes.

Q: All are Indications of liver transplant except

Cholangiocarcinoma. ***Cholangiocarcinoma*** - **Cholangiocarcinoma** is a **contraindication** for liver transplantation due to its aggressive nature and high recurrence rate post-transplant, except in highly selected early cases treated with neoadjuvant therapy. - The risk of **tumor recurrence** and poor long-term survival generally outweighs the benefits of transplantation for this malignancy. *Biliary atresia* - **Biliary atresia** is the most common indication for **pediatric liver transplantation**. - It involves the progressive destruction of bile ducts, leading to **cholestasis**, cirrhosis, and liver failure in infants. *Cirrhosis* - **Cirrhosis** from various etiologies (e.g., viral hepatitis, alcohol, NASH) is a primary indication for liver transplantation when it leads to **decompensated liver disease** or end-stage liver failure. - Patients with complications like **ascites**, **encephalopathy**, or recurrent variceal bleeding often require transplant. *Fulminant hepatitis* - **Fulminant hepatitis** (acute liver failure) rapidly progresses to severe liver dysfunction and encephalopathy in individuals without pre-existing liver disease. - It is an urgent indication for **emergent liver transplantation** to prevent multi-organ failure and death.

Q: An isograft indicates transfer of tissues between:

Monozygotic twins. ***Monozygotic twins*** - An **isograft**, also known as an **isogeneic graft**, refers to the transplantation of tissues or organs between two genetically identical individuals. - **Monozygotic (identical) twins** are genetically identical, making them ideal donors and recipients for isografts as there is minimal risk of immune rejection. *Related donors* - This describes **allografts** or **homografts**, where tissue is transferred between genetically non-identical individuals of the same species. - While related donors may have better histocompatibility than unrelated donors, they are typically not genetically identical, leading to a risk of immune rejection. *Unrelated donors* - This also describes **allografts**, where tissue is transferred between genetically non-identical individuals of the same species. - The greater genetic disparity between unrelated individuals increases the risk of **graft rejection** compared to related donors or identical twins. *Parts of same individual* - This describes an **autograft**, where tissue is transplanted from one part of an individual's body to another part of the *same* individual. - Autografts are immunologically ideal as there is no risk of rejection, but this is distinct from an isograft which involves two separate individuals.

Q: For transplantation, cornea can be removed from dead body up to:

24 hours. ***24 hours*** - Corneas can be harvested from a deceased donor within **24 hours** of death, provided the body is kept in a cool environment. - This time frame allows for adequate perfusion of the corneal tissue and maintains **cellular viability** for successful transplantation. *6 hours* - While some organs have a very limited window for retrieval, **corneas** generally have a longer viability compared to highly metabolic organs. - A 6-hour window is often too short and would significantly limit the availability of corneal tissue for transplantation. *18 hours* - An 18-hour window is a reasonable period but is often extended to 24 hours under proper storage conditions. - Extending to **24 hours** maximizes the opportunity for procurement and does not significantly compromise tissue quality for corneal transplantation. *12 hours* - A 12-hour window, although longer than 6 hours, is still a conservative estimate for corneal retrieval. - With advancements in preservation techniques, the **viability period** for corneas is now widely accepted to be up to 24 hours post-mortem.

Q: Most common complication after intestinal transplantation is

Sepsis. ***Sepsis*** - **Infection** is the leading cause of morbidity and mortality after intestinal transplantation, making **sepsis** the most common complication. - The immunocompromised state due to immunosuppressive therapy and the inherent bacterial load of the gastrointestinal tract contribute significantly to the high risk of severe infections. *Intestinal obstruction* - While intestinal obstruction can occur post-transplant due to adhesions or strictures, it is **less common** than infectious complications. - It typically manifests later and may require surgical intervention but doesn't have the same high frequency as sepsis. *Graft versus host disease* - **Graft-versus-host disease (GVHD)** is a significant complication in intestinal transplantation, but it is **not the most common**. - Its incidence varies, and while serious, it does not surpass the overall frequency of infectious complications and sepsis. *Intestinal necrosis* - **Intestinal necrosis** (e.g., due to infarction or severe rejection) is a severe complication but is **less frequent** than sepsis. - It is often a consequence of vascular compromise or overwhelming rejection, leading to graft failure or perforation.

Question 1

What is the correct order of anastomosis in a lung transplant?

Accepted Answer

Pulmonary vein, bronchus, pulmonary artery

Answer

Pulmonary artery, pulmonary vein, bronchus

Answer

Pulmonary vein, pulmonary artery, bronchus

Answer

Pulmonary artery, bronchus, pulmonary vein

Question 2

A 55-year-old woman with cirrhosis requires liver transplantation. Her MELD score is 28, and she has been on the waiting list for 8 months. She presents with confusion, asterixis, and ammonia level of 150 μg/dL (normal 15-45). What is the most important consideration for transplant candidacy at this time?

Accepted Answer

Hepatic encephalopathy suggests end-stage disease

Answer

Presence of ascites

Answer

Length of time on waiting list

Answer

Reversibility of hepatic encephalopathy with treatment

Question 3

A 42-year-old surgeon is diagnosed with hepatitis C and requests evaluation for liver transplantation. Her viral load is high, and she has early cirrhosis. She wants to continue operating while awaiting transplant. Evaluate the ethical and medical considerations regarding her continued practice.

Accepted Answer

Defer decision to hospital ethics committee

Answer

Allow continued practice with universal precautions

Answer

Restrict practice to non-invasive procedures only

Answer

Require immediate cessation of all surgical practice

Question 4

A 65-year-old man with cirrhosis (Child-Pugh B) and hepatocellular carcinoma presents with a 4 cm tumor. He has portal hypertension with esophageal varices and ascites. His MELD score is 18. Evaluate the optimal treatment strategy considering tumor stage, liver function, and available therapies.

Accepted Answer

Liver transplantation evaluation

Answer

Sorafenib chemotherapy

Answer

Radiofrequency ablation of the tumor

Answer

Transarterial chemoembolization (TACE)

Question 5

Xenograft is transplantation of tissue:

Accepted Answer

From a different species

Answer

From same species

Answer

From genetically identical twins

Answer

From one part of body to another

Question 6

What is the documented mortality rate for healthy liver donors undergoing donor hepatectomy?

Accepted Answer

Mortality for donor is 0.2 to 0.4 %

Answer

Mortality for donor is 0.6 to 0.8 %

Answer

Mortality for donor is 0.5 %

Answer

Mortality for donor is 1%

Question 7

All are Indications of liver transplant except

Accepted Answer

Cholangiocarcinoma

Answer

Biliary atresia

Answer

Cirrhosis

Answer

Fulminant hepatitis

Question 8

An isograft indicates transfer of tissues between:

Accepted Answer

Monozygotic twins

Answer

Related donors

Answer

Unrelated donors

Answer

Parts of same individual

Question 9

For transplantation, cornea can be removed from dead body up to:

Accepted Answer

24 hours

Answer

6 hours

Answer

18 hours

Answer

12 hours

Question 10

Most common complication after intestinal transplantation is

Accepted Answer

Sepsis

Answer

Intestinal obstruction

Answer

Graft vs host disease

Answer

Intestinal necrosis

Transplant Surgery — MCQs

Transplant Surgery — MCQs

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