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Regarding pancreatic anatomy, which of the following is correct?
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A. The uncinate process is located anterior to the superior mesenteric artery
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B. The blood supply of the pancreas is partly derived from the inferior mesenteric artery
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C. The body of the pancreas lies to the right of the SMA
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D. In 60% of cases, the ducts of Wirsung and Santorini empty into the duodenum independently
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E. The splenic artery usually runs posterior to the pancreatic body
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The uncinate process is posterior to the superior mesenteric vessels. The pancreas is part of the midgut, which is supplied by the SMA and its branches. The SMA/SMV delineates the separation of the head and neck of the pancreas from the pancreatic body, which lay to the left of these blood vessels. The splenic vein is posterior to the body of the pancreas, while the artery usually runs along the superior edge.
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Regarding insulinomas, which of the following is correct?
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A. Usually occur in the head of the pancreas, measure >4 cm, malignant, and single
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B. Usually occur in the tail of the pancreas, measure >4 cm, malignant, and single
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C. Usually occur in the body of the pancreas, measure <2 cm, benign, and multiple
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D. Uniformly distributed throughout the pancreas (head, body, and tail), measure <2 cm, benign, and single
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E. Usually occur in the body of the pancreas, measure <2 cm, malignant, and multiple
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Insulinoma are usually benign tumors, measuring less than 2 cm, and uniformly distributed in pancreatic tissue.
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A-33-year-old female is involved in a motor vehicle collision and found to have a complete transaction of the pancreas at the level of the pancreatic neck:
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A. Oversewing of the proximal segment and distal pancreatectomy
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B. Drainage of the proximal and distal segments
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C. Drainage of the proximal segment and oversewing of the distal segment
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D. Oversewing of the proximal segment and drainage of the distal segment
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E. Roux-en-Y pancreaticojejunostomy of the proximal pancreas and distal pancreatectomy
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The best approach for repair in this case is distal pancreatectomy and oversewing of the proximal pancreatic remnant. Pancreatic duct injury can usually be assessed by inspection of the injury.
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In the absence of duct injury, only drainage is required. Pancreatography may be considered to evaluate the duct, although it is not essential if there is a low index of suspicion.
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Less favorable, such as distal cannulation of the pancreatic duct and transduodenal pancreaticography, should be avoided.
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Which pancreatic head adenocarcinoma is considered resectable?
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A. Tumor involves the celiac axis or the SMA
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C. Tumor extends beyond the pancreas but without involvement of the celiac axis or the SMA
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D. A 4-cm tumor limited to the pancreas with 1 peritoneal metastasis
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E. Periaortic lymph node involvement
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Extrapancreatic metastases preclude resection. Celiac axis or SMA involvement is the description of T4. A T4 tumor is unresectable, by definition.
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Which tumor suppressor gene is implicated in MEN I?
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PRAD is implicated in parathyroid tumors. RET is associated with MEN II. C-kit is seen with gastrointestinal stromal tumors. Mutations in p53 tumor suppressor gene occur in various malignancies: breast, colorectal, liver, lung, and ovarian cancer to name a few.
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The earliest manifestation of pancreas transplant graft thrombosis is:
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D. Elevated urinary amylase
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The most immediate and frequent complication is pancreatic graft thrombosis. Unexplained early hyperglycemia is usually the first manifestation.
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The most common pancreatic tumor in MEN I is:
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About 33% of gastrinomas are associated with the MEN-I syndrome. The other tumors occur with far less frequency.
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A patient with acute pancreatitis deteriorates clinically and is reimaged. CT scan shows findings of a fluid collection consistent with infected pancreatic necrosis that is adherent to the posterior gastric wall and close to the pancreatic head. What is the best management?
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C. Roux-en-Y cystojejunostomy
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Infected pseudocysts are essentially pancreatic abscesses. Along with necrotizing pancreatic collections, these are treated with external drainage. Internal drainage is reserved for sterile collections such as uncomplicated large, refractory pseudocysts and encompasses surgical enteric drainage or endoscopic drainage. External drainage is usually inappropriate as this may seed and cause contamination.
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Options for palliative chemotherapy for unresectable adenocarcinoma of the pancreas include which agent?
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Chemotherapy significantly reduced the 1-year mortality when compared to best supportive care in patients with inoperable pancreatic cancer as outlined in a 2006 Cochrane Review. Also, chemoradiation improved 1 year when compared to best supportive care. There was no significant difference in 1-year mortality for 5-FU alone versus 5-FU combinations (odds ratio [OR] 0.90, 95% confidence interval [CI] 0.62–1.30); single-agent chemotherapy versus gemcitabine (OR 1.34, 95% CI 0.88–2.02, P = 0.17); or gemcitabine alone versus gemcitabine combinations (OR 0.88, 95% CI 0.74–1.05). However, subgroup analysis showed that platinum-gemcitabine combinations reduced 6-month mortality compared to gemcitabine alone (OR 0.59, 95% CI 0.43–0.81, P value 0.001). A qualitative overview suggested that chemoradiation produced better survivals than either best supportive care or radiotherapy. Chemoradiation treatment was associated with more toxicity.
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The authors concluded that chemotherapy appears to prolong survival in people with advanced pancreatic cancer and can confer clinical benefits and improve quality of life. Combination chemotherapy did not improve overall survival compared to single-agent chemotherapy. Gemcitabine is an acceptable control arm for future trials investigating scheduling and combinations with novel agents. There is insufficient evidence to recommend chemoradiation in patients with locally advanced inoperable pancreatic cancer as a superior alternative to chemotherapy alone.
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The preferred treatment for annular pancreas is:
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A. Lateral pancreaticojejunostomy (Puestow procedure)
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D. Pylorus preserving pancreaticoduodenectomy
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E. Duodenoduodenostomy or duodenojejunostomy
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Annular pancreas is a congenital anomaly, which consists of a ring of pancreatic tissue partially or completely encircling the descending portion of the duodenum. It was first described by Tiedemann in 1818 and named “annular pancreas” by Ecker in 1862. The first surgical treatment of obstructive annular pancreas was performed on a neonate by Vidal et al in 1905. In the past, the diagnosis of this anomaly was usually made by surgery or autopsy. With the widespread use of ERCP and magnetic resonance cholangiopancreatography, more cases are diagnosed preoperatively. The surgical treatment is bypassing the obstructed duodenal segment, with either a duodenoduodenostomy or duodenojejunostomy.