Surgery Marrow Pg 251-260 (GIT)
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Questions and Answers

Which of the following is NOT a contraindication for PAIR?

  • Deep seated
  • Dead/calcified cyst
  • Uniloculated cyst (correct)
  • Impending rupture

    • Cysto-biliary communication occurs when bile is aspirated during PAIR.

    True

    What is the surgical approach when PAIR is contraindicated due to multiple cysts in one segment of the liver?

    Liver resection

    In cases of cysto-biliary communication, a __________ agent may lead to chemical cholangitis.

    <p>scolicidal</p> Signup and view all the answers

    Match the following surgical options with their correct descriptions:

    <p>Cystopericystectomy = Removal of a cyst surrounding another cyst Capitonnage = Spiral closure of the cyst cavity Liver resection = Removal of whole sections of the liver PAIR = Percutaneous aspiration, injection, and re-aspiration</p> Signup and view all the answers

    What type of tumor is hepatoblastoma?

    <p>Tumor of fetal hepatocytes</p> Signup and view all the answers

    Hepatoblastoma is commonly associated with the APC gene mutation.

    <p>True</p> Signup and view all the answers

    What syndrome is hepatoblastoma associated with?

    <p>Familial Adenomatous Polyposis (FAP) Syndrome</p> Signup and view all the answers

    Hepatoblastoma is a tumor of ________ hepatocytes.

    <p>fetal</p> Signup and view all the answers

    Match the conditions with their related features:

    <p>Hepatoblastoma = Tumor of fetal hepatocytes Familial Adenomatous Polyposis = APC gene mutation APC gene = Associates with FAP syndrome Tumor origin = Fetal liver cells</p> Signup and view all the answers

    What is one of the criteria for liver tumor resection under the Milan criteria?

    <p>Single tumor &lt; 5cm</p> Signup and view all the answers

    The most common site of metastasis for HCC is the liver.

    <p>False</p> Signup and view all the answers

    What is one treatment option for advanced HCC with multiple tumors in one lobe?

    <p>Trans-arterial chemoembolisation (TACE)</p> Signup and view all the answers

    The ___ technique involves associating liver partition with portal vein ligation for staged hepatectomy.

    <p>ALPPS</p> Signup and view all the answers

    Match the following terms related to HCC with their descriptions:

    <p>CLIP = A scoring system for assessing liver cancer prognosis BCLC = Barcelona Clinic Liver Cancer staging system RFA = Radiofrequency Ablation used to treat tumors AFP = Alpha-fetoprotein, a tumor marker often elevated in liver cancer</p> Signup and view all the answers

    What is the primary scolicidal agent commonly used in the management of liver cysts?

    <p>Hypertonic saline</p> Signup and view all the answers

    CE4 and CE5 cysts typically require immediate treatment.

    <p>False</p> Signup and view all the answers

    What classification stage describes a solid or calcified cyst?

    <p>Inactive</p> Signup and view all the answers

    The first line treatment for liver cyst management is __________ for a minimum of 7-10 days before intervention.

    <p>Albendazole</p> Signup and view all the answers

    Match the types of liver cysts with their characteristics:

    <p>Transitional = Cyst with detached membranes; Water lily sign Inactive = Solid/calcified cyst Active = Cyst with daughter cyst in a solid matrix</p> Signup and view all the answers

    What is the most common benign tumor of the liver?

    <p>Hemangioma</p> Signup and view all the answers

    Hepatocellular Carcinoma (HCC) is the most prevalent primary malignant tumor in adults.

    <p>True</p> Signup and view all the answers

    What investigatory method is primarily used for liver tumors?

    <p>Triple phase CT</p> Signup and view all the answers

    The LI-RADS score of 100% definite HCC is classified as __________.

    <p>LR-5</p> Signup and view all the answers

    Match the following LI-RADS scores with their descriptions:

    <p>LR-1 = Probably HCC LR-2 = Intermediate probability for HCC LR-3 = 100% Benign LR-4 = Probably benign (Follow up done) LR-5 = 100% Definite HCC</p> Signup and view all the answers

    What is the recommended management for a large and symptomatic focal nodular hyperplasia (FNH)?

    <p>Angioembolisation</p> Signup and view all the answers

    Focal nodular hyperplasia is more commonly found in males than females.

    <p>False</p> Signup and view all the answers

    What is the primary investigation technique used for diagnosing focal nodular hyperplasia?

    <p>Triple Phase CT</p> Signup and view all the answers

    In hepatic adenomas, there is a strong association with __________.

    <p>oral contraceptive pills</p> Signup and view all the answers

    Match the following features or management options with their corresponding conditions:

    <p>Focal Nodular Hyperplasia (FNH) = Conservative management for asymptomatic cases Hepatic Adenoma = 10% risk of cancer Symptoms of Hepatomegaly = Usually present in hepatic adenoma Triple Phase CT = Used for diagnosing FNH</p> Signup and view all the answers

    What is the main source of bleeding during a liver resection?

    <p>Hepatic vein</p> Signup and view all the answers

    Patient operated with high central venous pressure (CVP) has a lower mortality rate than those with low CVP during liver resection.

    <p>False</p> Signup and view all the answers

    What is the principle technique used to minimize bleeding during liver resection?

    <p>Low central venous pressure (CVP)</p> Signup and view all the answers

    Most bleeding during liver resection comes from the __________.

    <p>hepatic vein</p> Signup and view all the answers

    Match the surgical practice with its outcome during liver resection:

    <p>Low CVP = Decreased mortality risk High CVP = Increased bleeding Control of hepatic veins = Successful hemostasis Improper surgical technique = Increased complication rates</p> Signup and view all the answers

    What is a characteristic feature of hepatocellular carcinoma (HCC) observed in imaging studies?

    <p>Hyperdense intratumoral hemorrhage</p> Signup and view all the answers

    The incidence of HCC increases with exposure to Thorotrast.

    <p>True</p> Signup and view all the answers

    What clinical sign may indicate advanced liver disease and is considered a late sign in HCC?

    <p>Jaundice</p> Signup and view all the answers

    HCC is more common in males, particularly in the __________ to __________ decade of life.

    <p>4th, 5th</p> Signup and view all the answers

    Which of the following symptoms is commonly associated with paraneoplastic syndromes in HCC?

    <p>Hypoglycemia</p> Signup and view all the answers

    Match the risk factors with their corresponding details:

    <p>HCV = Viral infection linked to liver cancer Alcohol = Contributing factor for liver cirrhosis Obesity = Associated with Non-Alcoholic Fatty Liver Disease (NAFLD) Aflatoxin = Carcinogenic substance found in moldy crops</p> Signup and view all the answers

    The triple-phase CT scan is primarily used to assess liver function scores in HCC patients.

    <p>False</p> Signup and view all the answers

    What is the primary tumor marker that is increased in hepatocellular carcinoma?

    <p>AFP</p> Signup and view all the answers

    A core biopsy is used when the diagnosis is __________ after a CT scan.

    <p>uncertain</p> Signup and view all the answers

    Match the tumor markers with their relevant descriptions:

    <p>AFP = Increased in HCC PIVKA-II = Protein induced in Vitamin K antagonism Glypican = Cell surface protein related to cell growth HepPar-1 = Specific marker for hepatic cells</p> Signup and view all the answers

    What prevents the downward displacement of the spleen?

    <p>Phrenicocolic ligament</p> Signup and view all the answers

    The splenic enlargement occurs laterally.

    <p>False</p> Signup and view all the answers

    What is the location of the spleen in relation to the ribs?

    <p>Along the axis of the 9-11th ribs</p> Signup and view all the answers

    The _______, which is related to the spleen, contains short gastric vessels.

    <p>Gastrosplenic ligament</p> Signup and view all the answers

    Match the following ligaments with their descriptions:

    <p>Splenophrenic = Avascular, can be cut Gastrosplenic = Contains short gastric vessels Lienorenal = Contains splenic vessels and tail of pancreas Splenicocolic = Avascular, can be cut</p> Signup and view all the answers

    Study Notes

    Contraindications of PAIR

    • PAIR (Percutaneous Aspiration and Injection) is not suitable for all liver cysts.
    • Dead or calcified cysts are unsuitable for PAIR.
    • Deep-seated cysts are not good candidates for PAIR.
    • Cysts with an impending rupture are not suitable for PAIR.
    • Multi-septate cysts are generally not suitable for PAIR, especially if multiple uniloculated cysts are present.
    • Extra hepatic cysts are unsuitable for PAIR.

    Cysto-biliary Communication

    • If bile is aspirated from a liver cyst, PAIR should be abandoned.
    • This is because scolicidal agents can cause chemical cholangitis.

    B. Surgery

    • An alternative approach is to perform surgery when PAIR is contraindicated.
    • Options include:
      • Cystopericystectomy: Removal of the cyst.
      • Liver resection: Resecting the liver segment containing the cyst.
      • Capitonnage: Closing the cyst cavity after removing cyst contents, by spiralling closure.

    Hepatoblastoma

    • Hepatoblastoma is a tumor of fetal hepatocytes, a rare but aggressive liver cancer found in children.
    • It can be associated with Familial Adenomatous Polyposis (FAP) Syndrome due to mutations in the APC gene.
    • Treatment is based on the Barcelona Clinic Liver Group (BCLC) staging system for HCC.

    Liver: Part 2

    • Localized HCC:
      • For patients with Child-Pugh B/C and inadequate FLR (Functional Liver Reserve) of 25%.
      • Liver resection is the recommended approach.
    • Milan criteria:
      • Applies to HCC with favorable prognosis.
      • Single tumor ≤ 5cm or 1-3 tumors ≤ 3cm.
      • No metastasis.
    • Non-Milan Criteria:
      • Nimura technique or ALPPS (Associating Liver Partition with Portal vein ligation for Staged hepatectomy)
      • Procedure:
        • Portal vein embolisation is used to trigger hypertrophy of the other lobe.
        • This increases the volume of functional liver tissue for eventual resection.
    • Advanced or metastatic HCC:
      • Palliative treatment options:
        • Radiofrequency Ablation (RFA) for tumors ≤ 3cm.
        • Percutaneous Ethanol Injection.
        • Multiple tumors in one lobe:
          • Trans-arterial chemoembolisation/TACE
          • Trans-arterial radioembolisation/TARE (Using Yttrium spheres)
        • Metastatic HCC: Immunotherapy with Sorafenib (Tyrosine kinase inhibitor) or Pembrolizumab/Nevolumab
    • FLR: Assessed using Fibroscan.
    • Liver resections exceeding 25% are feasible.
    • Prognostic indicators for HCC:
      • CLIP (Cancer of the Liver Italian Program)
      • Okuda stage
      • BCLC (Barcelona Clinic Score)
      • Stage of disease is the most significant prognostic factor.
      • Lung is the most common site of metastasis.
    • Fibrolamellar variant:
      • Often affects young patients.
      • Tumor markers:
        • Neurotensin B is increased.
        • AFP is not elevated.
      • Good prognosis, typically found in non-cirrhotic livers.
      • Equal prevalence in males and females.

    Liver Cyst Classification and Management

    • Liver cysts can be classified using WHO and Gharbi classifications.
    • The classifications categorise cysts based on their characteristics, including membrane detachment, presence of daughter cysts, and solid/calcified formations.
    • CE4 and CE5 cysts are considered inactive and usually do not require treatment.
    • Albendazole (minimum 7-10 days before intervention) is the first-line treatment option.
    • Interventional modalities (PAIR) are used for active cysts:
      • Percutaneous aspiration of fluid (under image guidance)
      • Injection of scolicidal agents:
        • Hypertonic saline (most common agent)
        • Ethanol
        • Absolute Alcohol
        • Cetrimide solution
        • Mebendazole solution
      • Re-aspiration
    • Hydatid fluid, if leaked into circulation, can trigger anaphylaxis.
    • Formalin is not considered a scolicidal agent due to its potential to cause chemical cholangitis.

    LIVER: PART 2

    • Triple phase CT (Contrast CT) is the investigation of choice for all liver tumors.
    • LIRADS (Liver Imaging Reporting and Data System) scoring helps classify liver lesions based on CT scan findings:
      • LR-1: 100% Benign
      • LR-2: Probably benign (Follow-up done)
      • LR-3: Intermediate probability for HCC (Follow-up/biopsy)
      • LR-4: Probably HCC
      • LR-5: 100% Definite HCC
    • Common liver tumors:
      • Most common benign tumor: Hemangioma
      • Second most common benign tumor: Focal Nodular Hyperplasia (FNH)
      • Most common malignant tumor: Metastasis/Secondaries to Liver
      • Most common primary malignant tumor: Hepatocellular Carcinoma (HCC)
      • Most common primary malignant tumor in children: Hepatoblastoma

    Benign Tumors of Liver

    • I. LIVER HEMANGIOMAS

      • Collections of blood vessels.
      • Clinical features:
        • More common in women than men.
        • Often asymptomatic, diagnosed incidentally.
        • Kassabach-Merritt Syndrome: Consumption coagulopathy in very large hemangiomas, leading to bleeding and pain.
      • Investigations:
        • Triple phase CT:
          • Non-contrast phase: Hypodense
          • Arterial phase: Peripheral nodular enhancement
          • Washout phase: Homogeneous enhancement

    Focal Nodular Hyperplasia (FNH)

    • Proposed Etiology: Vascular insult to the liver (e.g., post-trauma or intervention).
    • Clinical Features:
      • More common in women than men.
      • Asymptomatic, diagnosed incidentally.
    • Investigations:
      • Triple Phase CT: Central stellate scar, dilated arteriole + branches (Also seen in oncocytoma of the kidney).
      • Histopathology (HPE): Hepatocytes, atypical bile duct structures, Kupffer cells.
        • Usually unencapsulated, showing "hot-spot" on a sulphur colloid scan.
      • α-fetoprotein (AFP): Normal (helps differentiate FNH from HCC).
    • Management: Observation

    Hepatic Adenoma

    • Benign liver tumor.
    • 10% risk of malignant transformation.
    • Clinical Features:
      • Strongest association with oral contraceptive pills (OCPs).
      • More common in women than men.
      • Usually symptomatic: Hepatomegaly (+).
      • Spontaneous rupture can lead to hemoperitoneum (most common non-traumatic cause).

    Liver Resection

    • Principle of Liver Resection:
      • Major bleeding typically originates from the hepatic vein.
      • Low central venous pressure (CVP) during surgery (50%) is associated with decreased mortality.
    • Investigations:
      • Triple phase CT: Fat content (Hypodense), Intratumoral hemorrhage (Hyperdense), Heterogenous lesion.
      • AFP: May be raised in some patients
      • HPE: Sheets of hepatocytes, no bile duct structures, no Kupffer cells.
    • Management:

      • 2cm: Close observation.

    Hepatocellular Carcinoma (HCC)

    • Risk factors:
      • Chronic Hepatitis C infection.
      • Alcohol abuse.
      • Obesity.
      • Thorotrast exposure (Contrast medium).
      • Aflatoxin exposure.
      • Diabetes mellitus.
      • Non-alcoholic steatohepatitis (NASH) or non-alcoholic fatty liver disease (NAFLD).
    • Clinical Features:
      • More common in men.
      • Often diagnosed in the 4th-5th decade.
      • Hepatomegaly: Often hard and nodular.
      • Jaundice (Late sign, as liver has a large reserve).
    • Note: Thorotrast exposure increases the risk of:
      • HCC.
      • Cholangiocarcinoma.
      • Renal cell carcinoma.
    • Paraneoplastic Syndromes:
      • These are unexplained by direct spread or metastasis.
      • Common symptoms include:
        • Hypoglycemia.
        • Hypercholesterolemia.
        • Cushing's syndrome.
        • Gynecomastia.

    Investigations

    • Triple Phase CT: Helps differentiate HCC from metastasis. Classical and diagnostic findings:
      • HCC:
        • Non-contrast phase: Hypodense
        • Arterial phase: Hyperdense
        • Venous phase: Early washout
      • Metastasis:
        • Non-contrast phase: Hypodense
        • Arterial phase: Hyperdense
        • Venous phase: Early washout
    • Core Biopsy: Performed when diagnosis is uncertain after CT scan or metastasis is suspected.
    • Tumor Markers:
      • AFP (increased)
      • PIVKA-II (increased)
      • Glypican
      • HepPar-1
      • Neurotensin B (increased, especially in Fibrolamellar variant)
    • Liver Function Scores:
      • Child-Turcotte-Pugh score.
      • MELD score.
      • PELD score.
    • Images are mentioned, but descriptions are not available.

    SPLEEN

    • Surface Anatomy

      • Location: Along the axis of the 9th-11th ribs.
      • Border: Inferior lateral border has a notch.

    • Applied aspect

      • Splenic enlargement: Displaces the organ medially.
      • Downward displacement: Prevented by the phrenicocolic ligament.
      • Fracture of 9th-11th ribs on the left: May result in splenic trauma.

    SPLENIC LIGAMENTS

    • Splenophrenic & splenicocolic ligaments: Avascular, can be cut surgically.

    • Gastrosplenic ligament: Contains the short gastric vessels.

    • Lienorenal ligament: Contains the splenic vessels and the tail of the pancreas.

    • The diagram shows the spleen's location, highlighting its relationship to other abdominal organs.

    • Key vessels and structures are labelled, including the coeliac trunk, portal vein, hepatic artery, gastroduodenal artery, aorta, splenic artery and vein, inferior and superior mesenteric vessels.

    • The diagram also shows a section of the spleen with its vascular supply highlighting how the splenic vessels are formed by the portal and superior mesenteric veins.

    • The inferior mesenteric vein also drains into the splenic vein.

    • The Falciform ligament and the lesser omentum are also visible in the diagram.

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    Description

    This quiz explores the contraindications of Percutaneous Aspiration and Injection (PAIR) for liver cysts and discusses alternative surgical options. Understand the specific conditions that make PAIR unsuitable and learn about alternative approaches such as cystopericystectomy and liver resection for managing liver cysts.

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