Pancreatic Surgery Practice Questions

Q: Which of the following is not an indication for surgical intervention in acute pancreatitis?

Acute fluid collection. ***Acute fluid collection*** - **Acute fluid collections** are common in acute pancreatitis and are often **sterile** and resolve spontaneously without intervention. - Early surgical intervention for uncomplicated acute fluid collections is generally **contraindicated** due to high morbidity and mortality. *Diagnostic dilemma* - When the diagnosis of acute pancreatitis is uncertain and other surgical emergencies, such as **perforated viscus** or **ischemic bowel**, cannot be ruled out, surgery may be necessary. - An **exploratory laparotomy** can help confirm the diagnosis and address any concurrent surgical pathology. *Pancreatic abscess* - A **pancreatic abscess** is a localized collection of pus in or near the pancreas, indicating **infected necrotic tissue**. - Surgical drainage and debridement are typically required to control the infection and prevent systemic sepsis. *Infected pancreatic necrosis* - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis with high mortality, often requiring surgical debridement (necrosectomy). - While sterile necrosis may be managed conservatively, **infected necrosis** necessitates intervention to remove the source of infection.

Q: A 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:

Endoscopic stenting of bile duct. **_Endoscopic stenting of bile duct_** - The presence of **distant liver metastases** and **vascular encasement** makes the disease inoperable and renders curative surgery impossible. - **Endoscopic stenting** offers effective palliation for **obstructive jaundice**, improving quality of life by relieving symptoms such as itching and nausea, and preventing cholangitis. *Total pancreatectomy* - This is an **extensive surgical procedure** suitable for resectable pancreatic head tumors without metastatic disease. - It is **highly morbid** and not indicated in the presence of **liver metastases** and **vascular encasement**, as it would not be curative and carries significant risks. *Biliary and gastric bypass* - This procedure aims to relieve both **biliary obstruction** and potential gastric outlet obstruction, which can occur from pancreatic head tumors. - While it addresses symptoms, it is still a **surgical intervention** with associated risks and is generally reserved for patients with a longer life expectancy or when endoscopic stenting is unsuccessful or unfeasible. It is not the most appropriate initial palliative step given the metastatic disease. *Pancreaticoduodenectomy (Whipple procedure)* - The **Whipple procedure** is the standard curative surgical treatment for **resectable pancreatic head cancers**. - However, the patient's presentation with **liver metastases** and **gastroduodenal artery encasement** indicates unresectable disease, making this procedure inappropriate and potentially harmful.

Q: The Ranson prognostic criteria used at the time of admission in acute pancreatitis include all of the following except

Serum calcium 200 mg/100 mL** is one of the five Ranson criteria assessed at the time of admission. - High glucose indicates significant physiological stress and typically a more severe illness. *WBC count more than 16,000/mm3* - An elevated **white blood cell count > 16,000/mm3** is one of the Ranson criteria assessed at admission. - This indicates a significant inflammatory response, suggesting severe pancreatitis. *Age more than 55 years* - **Age > 55 years** is one of the Ranson criteria assessed at the time of admission [1]. - Older age is a recognized risk factor for more severe outcomes in acute pancreatitis [1].

Q: In acute pancreatitis, surgery is indicated in which one of the following conditions?

Infected pancreatic necrosis. ***Infected pancreatic necrosis*** - **Infected pancreatic necrosis** is a severe complication of acute pancreatitis requiring surgical or percutaneous debridement (necrosectomy) to remove infected tissue and prevent sepsis. - The presence of infection in necrotic tissue significantly increases morbidity and mortality, making intervention crucial. *Acute pseudocyst* - An acute pseudocyst is usually managed conservatively and only requires intervention if it is **symptomatic**, rapidly expanding, or becomes infected. - Surgical drainage is typically reserved for large, symptomatic, or complicated pseudocysts that persist beyond 6 weeks. *Acute fluid collection* - **Acute fluid collections** are generally self-limiting and resolve without intervention. - They are typically asymptomatic and represent an early stage of fluid accumulation, often preceding pseudocyst formation. *Sterile pancreatic necrosis* - **Sterile pancreatic necrosis** is usually managed with supportive care, as surgical intervention in the absence of infection does not improve outcomes and may increase complications. - The key distinction is the absence of infection—surgery is indicated only when necrosis becomes infected.

Q: A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is

Pancreatic pseudocyst. **Pancreatic pseudocyst** - The presence of an **epigastric mass** in an **alcoholic male** with acute epigastric pain and vomiting for 10 days is highly suggestive of a pancreatic pseudocyst, which commonly develops after **acute pancreatitis**. - Pseudocysts are collections of **pancreatic fluid** encased by a non-epithelial inflammatory wall, often presenting as a palpable mass within days to weeks after an acute episode. - The **alcoholic history** and **acute presentation** strongly support this diagnosis. *Carcinoma of head of the pancreas* - While pancreatic carcinoma can cause epigastric pain, **vomiting** and an **acute course** over 10 days are less typical. - It is usually associated with **weight loss**, **jaundice** (if the head is involved), and a more insidious onset. *Perforated peptic ulcer with sub-hepatic abscess* - A perforated peptic ulcer presents with **sudden, severe epigastric pain** that rapidly worsens, often with signs of **peritonitis** and acute abdomen. - A sub-hepatic abscess would typically be accompanied by **fever**, **leukocytosis**, and signs of sepsis. *Hepatoma in left lobe of liver* - A hepatoma would usually present with a **liver mass**, potentially **jaundice**, weight loss, and abnormal liver function tests, rather than an acute onset of severe epigastric pain and vomiting. - The mass would typically be felt in the **right upper quadrant** or epigastrium, but the clinical picture does not align with an acute pancreatic process.

Q: A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:

Pseudocyst pancreas. Pseudocyst pancreas - The history of **acute severe upper abdominal pain** followed by a progressively enlarging, firm, smooth-surfaced upper abdominal mass points strongly towards a pancreatic pseudocyst, a common complication of **pancreatitis** [1]. - **Early satiety** can occur due to the mass effect of the pseudocyst compressing the stomach [1]. *Cancer colon* - A rapidly growing upper abdominal mass is **not a typical presentation** of colon cancer, which usually presents with changes in bowel habits, rectal bleeding, or weight loss. - Colon cancer does not typically cause a history of **acute, severe generalized abdominal pain** preceding mass formation in this manner. *Splenic cyst* - While a splenic cyst could present as an abdominal mass, it is **less likely to follow a history of acute severe abdominal pain** (unless trauma-related). - A history of acute pancreatitis is a strong indicator away from a splenic cyst as the primary diagnosis [1]. *Cancer stomach* - Gastric cancer can present with early satiety and an upper abdominal mass, but the specific history of **acute severe pain followed by a mass** is less characteristic of gastric cancer's typical insidious onset. - The "firm, smooth surfaced, not moving with respiration" description, especially in the context of prior pancreatitis, is more aligned with a **pancreatic pseudocyst** [1].

Q: A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from:

Carcinoma head of pancreas. A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from: ***Carcinoma head of pancreas*** - The classic triad of **painless progressive jaundice**, **weight loss**, and a **palpable, non-tender gallbladder** (Courvoisier's sign) strongly indicates carcinoma of the head of the pancreas due to obstruction of the common bile duct [1]. - The high serum bilirubin value further supports a severe obstructive process, typical of a pancreatic head mass compressing the bile duct [1]. *Carcinoma stomach* - Carcinoma of the stomach typically presents with upper abdominal pain, dyspepsia, early satiety, and weight loss, but **jaundice is rare** unless there is extensive metastasis to the liver or porta hepatis. - It usually does not directly lead to **obstructive jaundice** with a palpable gallbladder, as the tumor's location is remote from the common bile duct. *Choledocholithiasis* - While choledocholithiasis can cause obstructive jaundice, it is often associated with **pain** (biliary colic) and fluctuating jaundice rather than the painless, progressive pattern described. - A gallbladder obstructed by a stone would typically be **tender** if inflamed, or decompressed if the obstruction is intermittent, rather than smooth and non-tender due to chronic distal obstruction. *Klatskin tumour* - A Klatskin tumor (hilar cholangiocarcinoma) causes obstructive jaundice, but it typically obstructs the bile ducts above the cystic duct insertion, meaning the **gallbladder would usually be decompressed and non-palpable** [2]. - These tumors often present with **jaundice and itching**, but the presence of a palpable gallbladder makes a pancreatic head mass more likely [2].

Q: During Pylorus preserving pancreatico-duodenectomy (PPPD) the following organs are removed except:

Stomach. ***Stomach*** - In a **pylorus-preserving pancreaticoduodenectomy (PPPD)**, the **pylorus** and a portion of the **stomach** are deliberately preserved. - This distinguishes it from the classic Whipple procedure, where the **antrum** and pylorus of the stomach are removed. *Distal Bile Duct* - The **distal bile duct** is routinely resected in both standard and pylorus-preserving Whipple procedures to ensure adequate margins and remove potential **lymph node** metastases. - This is necessary because pancreatic head tumors often involve or compress the **distal common bile duct**. *Gall bladder* - The **gallbladder** is invariably removed during a PPPD to provide access to the **common bile duct** and facilitate the creation of a **choledochojejunostomy**. - Its removal prevents future complications like **cholecystitis** or **choledocholithiasis** secondary to altered bile flow. *Head of pancreas* - The **head of the pancreas** is the primary target for resection in a PPPD as this is typically the location of the **tumor**. - This involves removing the mass along with surrounding pancreatic tissue to achieve clear **surgical margins**.

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.

Question 1

Which of the following statements regarding annular pancreas is INCORRECT?

1. It results from failure of rotation of ventral pancreatic bud during development.
2. A ring of pancreatic tissue surrounds the second or third part of duodenum.
3. It presents with vomiting due to duodenal obstruction.
4. Duodenoduodenostomy is the preferred treatment of this condition.

Accepted Answer

4. Duodenoduodenostomy is the preferred treatment of this condition.

Answer

3. It presents with vomiting due to duodenal obstruction.

Answer

1. It results from failure of rotation of ventral pancreatic bud during development.

Answer

2. A ring of pancreatic tissue surrounds the second part of duodenum.

Question 2

Which of the following is not an indication for surgical intervention in acute pancreatitis?

Accepted Answer

Acute fluid collection

Answer

Diagnostic dilemma

Answer

Pancreatic abscess

Answer

Infected pancreatic necrosis

Question 3

A 65-year-old patient presents with obstructive jaundice and 15 kg weight loss. An ultrasound shows a 4 cm mass in the head of the pancreas with dilated bile ducts. Further work up includes a helical CT scan. The study shows several lesions consistent with metastasis in the right and left lobes of the liver and encasement of gastroduodenal artery. The most appropriate treatment would be:

Accepted Answer

Endoscopic stenting of bile duct

Answer

Total pancreatectomy

Answer

Biliary and gastric bypass

Answer

Pancreaticoduodenectomy (Whipple procedure)

Question 4

The Ranson prognostic criteria used at the time of admission in acute pancreatitis include all of the following except

Accepted Answer

Serum calcium < 2.0 mmol/L

Answer

Blood glucose more than 200 mg/100 mL

Answer

WBC count more than 16,000/mm3

Answer

Age more than 55 years

Question 5

In acute pancreatitis, surgery is indicated in which one of the following conditions?

Accepted Answer

Infected pancreatic necrosis

Answer

Acute pseudocyst

Answer

Acute fluid collection

Answer

Sterile pancreatic necrosis

Question 6

A 40-year old alcoholic male complains of acute pain in the epigastrium associated with vomiting for the last 10 days. On clinical examination, he is found to have a mass in the epigastrium. The most likely diagnosis is

Accepted Answer

Pancreatic pseudocyst

Answer

Carcinoma of head of the pancreas

Answer

Perforated peptic ulcer with sub-hepatic abscess

Answer

Hepatoma in left lobe of liver

Question 7

A 35 year old woman presented with a lump in her upper abdomen for two months which was slightly increasing. She also complained of early satiety. She gave a history of acute severe pain in upper abdomen for which she was admitted in hospital for 10 days, about three months ago. On examination, the mass was firm, smooth surfaced and not moving with respiration. She was most likely suffering from:

Accepted Answer

Pseudocyst pancreas

Answer

Cancer colon

Answer

Splenic cyst

Answer

Cancer stomach

Question 8

A 60 year old man presents with painless progressive jaundice for two months. He has a history of weight loss. On examination, his gallbladder is palpable which is smooth, non‐tender and globular. His serum bilirubin is 18.2 mg/dL. He is most likely suffering from:

Accepted Answer

Carcinoma head of pancreas

Answer

Carcinoma stomach

Answer

Choledocholithiasis

Answer

Klatskin tumour

Question 9

During Pylorus preserving pancreatico-duodenectomy (PPPD) the following organs are removed except:

Accepted Answer

Stomach

Answer

Distal Bile Duct

Answer

Gall bladder

Answer

Head of pancreas

Question 10

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

Pancreatic Surgery — MCQs

Pancreatic Surgery — MCQs

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