A 55-year-old man is undergoing a planned Beger operation for chronic pancreatitis. After the anterior pancreas is exposed, dissection under the pancreatic neck is impossible secondary to dense fibrotic inflammation. What is the operative strategy?
B. Distal Panc
D. Total Panc
A 55-year-old man is currently hospital day 4, recovering from acute gallstone pancreatitis. His laboratory findings have normalized, he is asymptomatic, and he is tolerating his diet. What would you recommend to this man regarding the timing of cholecystectomy?
A. Cholecystectomy is not indicated.
B. Cholecystectomy should be performed prior to discharge.
C. Percutaneous cholecystostomy should be performed before discharge.
D. Cholecystectomy should be performed 6 weeks after discharge.
E. Cholecystectomy should be performed 6 months after discharge.
A male patient presents 8 weeks after an episode of acute pancreatitis. He reports vague abdominal pain and difficulty eating. His vital signs and laboratory values are normal, but his examination is notable for epigastric tenderness. A computed tomography scan shows a 10-cm pancreatic pseudocyst adjacent to the stomach. Which is the next best step?
A. Discharge to home with antibiotics
B. Percutaneous aspiration
C. Percutaneous drainage
D. Endoscopic drainage
E. Operative drainage
A 38-year-old woman has chronic pancreatitis that requires surgical intervention because of chronic pain interfering with her quality of life. She undergoes an intraoperative ultrasound to help guide surgical management. Her main pancreatic duct is 8 mm in diameter, with multiple strictures seen in the duct, but more than 2 cm away from the papilla. Which procedure is most appropriate for this patient?
B. Modified Puestow procedure
C. Frey procedure
E. Beger procedure
Workup of a 45-year-old woman reveals a lesion in the body of the pancreas that is believed to be an insulinoma. Which of the following findings favors enucleation of the lesion over resection?
A. Concern for metastatic disease
B. A 4-cm insulinoma located in the tail of the pancreas
C. Multiple, small lesions (largest < 2 cm) noted throughout the pancreas D. A 1.2-cm insulinoma located 3 mm from the main pancreatic duct E. A 0.8-cm insulinoma in the head of the pancreas, 1.5 mm from the duct of Wirsung
A 70-year-old man with chronic obstructive pulmonary disease on home oxygen, congestive heart failure, and multiple prior complex abdominal operations presents to the general surgery clinic having experienced recurrent, severe acute pancreatitis episodes in the setting of known pancreas divisum. His gastroenterologist has performed a complete workup, and there are no other inciting factors. What treatment option would you offer this patient?
A. Serial imaging every 6 months
B. Observation alone
C. Endoscopic minor papilla sphincterotomy
D. Open surgical minor papilla sphincteroplasty
E. Total pancreatectomy and denervation
A 56-year-old woman presents 6 months after an episode of acute pancreatitis complicated by pseudocyst, which was treated with percutaneous drainage and subsequent drain removal. She now reports abdominal pain and early satiety. Computed tomography shows a 5-cm pancreatic pseudocyst near the pancreatic tail, in a similar location as her initial pseudocyst. Magnetic resonance cholangiopancreatography demonstrates a communication between the pseudocyst and pancreatic duct. What is the most appropriate initial management?
A. Repeat percutaneous drainage
B. Endoscopic pancreatic stent placement
C. Endoscopic transgastric drainage
D. Minimally invasive pseudocyst drainage and cystogastrostomy
E. Open pseudocyst drainage and pancreatojejunostomy
The head of the pancreas is supplied by the pancreaticoduodenal artery. The inferior portion of this artery comes off of which vessel?
C. Branches off Aorta
D. Splenic Artery
E. Gastroepiploic Artery
A 65-year-old man is in the surgical intensive care unit with acute alcohol-induced pancreatitis with acute fluid collections and necrosis. He subsequently develops fever and leukocytosis, and repeat computed tomography confirms infected pancreatic necrosis with air pockets in the pancreatic bed. He is managed with nasojejunal enteral nutrition, antibiotics, and percutaneous drainage. What is the ideal timing of debridement to optimize this man’s outcome?
A. At the time of diagnosis of infected pancreatic necrosis
B. Prior to percutaneous drainage
C. 7 days after diagnosis
D. 14 days after diagnosis
E. More than 30 days after diagnosis
A 75-year-old man undergoes a pancreaticoduodenectomy. The transection plane at the neck of the pancreas is created by developing a tunnel anterior to which of the following vessels?
B. Splenic Vein
E. Portal Vein
A 55-year-old man is diagnosed with acute pancreatitis. He is clinically worsening and undergoes a repeat CT scan. What feature found on imaging most suggests infected pancreatitis?
A. Air bubbles within the area of necrosis
B. Walled off necrosis
C. Peripancreatic stranding
D. A solid cystic collection with peripancreatic fat stranding
A 52-year-old woman has had acute pancreatitis due to gallstones. Six weeks later, she has persistent nausea and is unable to eat. A CT scan shows that the inflammation have resolved, but there is a 10 cm pancreatic pseudocyst posterior to the stomach which is displacing it anteriorly. MRCP shows communication between the pancreatic duct and the pseudocyst. The most appropriate management is
A. pseudocyst-gastrostomy with cholecystectomy
B. percutaneous aspiration
C. continue total parenteral nutrition for 3 more weeks
D. administer somatostatin analogue
E. perform pancreatic duct stenting
A 40-year-old man undergoes open debridement of extensive pancreatic necrosis involving the body and tail of the pancreas. What is the likelihood of his developing diabetes?
D. <10% E. There is no risk of developing diabetes mellitus.
A 49-year-old male presents with chronic abdominal pain. The patient has a history of chronic alcoholic pancreatitis with constant abdominal pain. He has abstained from alcohol for the past 2 years, and has made a sincere effort to be free of narcotic analgesics. His BMI is 23 kg/m2, and his fasting blood glucose is normal. CT scan shows an enlarged pancreatic head, and the distal pancreatic duct is small. The patient is requesting an operative procedure because he cannot tolerate the chronic pain any longer. Which of the following procedures is most appropriate for this patient?
A. Celiac block
A 60-year-old woman with a long history of chronic pancreatitis is referred for surgical evaluation. She has daily debilitating abdominal pain. A computed tomography scan of the abdomen and pelvis demonstrates an inflammatory pancreatic head mass with a dilated pancreatic duct. Endoscopic ultrasound with biopsy of the pancreatic head shows rare atypical cells but no definitive malignant cells. What operative approach is indicated?
C. Distal pancreatectomy
D. Longitudinal pancreatojejunostomy
A 65-year-old man who is 5 days status post–pancreaticoduodenectomy has ongoing clear output from his surgical drain—a volume of 500 mL over 24 hours and is otherwise recovering uneventfully. Drain amylase is 8000 U/L and serum amylase is 75 U/L. The most appropriate next step in management of this pancreatic fistula is which of the following?
A. Computed tomography scan of the abdomen and pelvis
B. Observation, maintenance of the surgical drain, nothing by mouth (NPO; nil per os), and total parenteral nutrition
C. Broad-spectrum antibiotics
D. Return to the operating room for revision of the pancreaticojejunostomy
E. Observation and maintenance of the drain
A 36-year-old woman presents complaining of pelvic pain. A computed tomography scan of the abdomen and pelvis demonstrates a 5-cm pseudocyst in the body of the pancreas and a right ovarian hemorrhagic cyst. The woman had an episode of acute pancreatitis 5 weeks ago. She denies upper abdominal or back pain and has been eating normally without nausea or vomiting. What is the treatment for the pseudocyst?
A. Operative cystogastrostomy
B. Endoscopic drainage
C. Percutaneous drainage
E. Distal pancreatectomy and splenectomy
A 32-year-old man who was discharged 5 weeks ago after hospitalization for acute pancreatitis returns to the ED complaining of epigastric abdominal pain and early satiety. An abdominal ultrasound is obtained with a substantial fluid collection noted, and a CT scan is recommended for further classification. Which of the following CT findings would be more consistent with a walled-off necrosis versus a pseudocyst?
A. Well-circumscribed fluid collection that is round
B. Heterogenous fluid collection with liquid and nonliquid density, with varying degrees of loculation
C. Absence of internal septae within the cyst cavity
D. A well-defined wall that completely encapsulates the fluid collection
E. A fluid collection that is extrapancreatic
A 44-year-old man has a pancreatic fistula that has persisted for 30 days following necrosectomy. The output is 60 mL/day, and there is skin excoriation at the drain exit site. He has been receiving total parenteral nutrition. White blood cell count and C-reactive protein are normal. What should be your treatment plan?
A. Administer somatostatin analogue.
B. Reassure the patient and begin oral intake.
C. Back out the existing drain over 5-7 days.
D. Perform a distal pancreatectomy.
E. Perform endoscopic retrograde cholangiopancreatography (ERCP) with stent placement.
A 15-year-old boy is admitted to the hospital for his fourth episode of pancreatitis. Two years ago, he had a cholecystectomy. His mother reports that she struggles with pancreatitis. Hereditary pancreatitis is associated with inappropriate activation of pancreatic enzymes. What is the most common gene mutation associated with autosomal dominant hereditary pancreatitis?
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