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  1. 1. Hepatobiliary & pancreatic surgery 1. Which of the following statements about the segmental anatomy of the liver are not true? A. Segments are subdivisions in both the French and American systems. B. Segments are determined primarily by the hepatic venous drainage. C. The French anatomic system is more applicable than the American system to clinical hepatic resection. D. Segments are important to the understanding of the topographic anatomy of the liver. Answer: D DISCUSSION: Segments are the major subdivision of the right and left lobes of the liver. In either the classic lobar (American) or the segmental (French) system, the most variable aspect is the biliary system. Therefore the hepatic venous or portal system defines most segments. The French system depicts eight segments, with the caudate lobe as segment I and the other seven segments defined primarily by the hepatic venous system. Segments are not well-depicted by topography. 2. Which of the following anatomic features of the biliary system are important considerations in operative cholangiography? A. The left hepatic duct comes off farther anterior than the right one. B. At the confluence there may be more than just a right and a left hepatic duct. C. Dissection of the triangle of Calot is more important than cholangiography in preventing bile duct injury. D. Segments V, VII, or VIII sometimes join the biliary system below the confluence. Answer: ABCD DISCUSSION: All of these features are important. The angle of takeoff of the left hepatic duct may make operative visualization difficult with the patient in the supine position. Because there may be more than two major hepatic ducts, visualization of two large ducts does not ensure that the system is normal. Ducts from any of the right-side segments can join below the confluence. Dissecting one superior edge of the gallbladder before it joins the cystic duct is particularly important in preventing injury. 3. The hepatic artery: A. Supplies the same amount of blood to the liver as the portal vein. B. Provides more blood to the bile ducts than the portal vein. C. Is autoregulated just as the portal vein is. D. Supplies most of the blood to hepatic metastases. Answer: BD DISCUSSION: The portal vein provides two thirds to three quarters of the total hepatic blood flow. The portal vein is incapable of direct autoregulation. The hepatic artery after transplantation classically infarcts portions of the biliary system, whereas hepatic metastases often arrive there via the portal vein. Most of their blood supply comes from the hepatic artery. 4. Bile formation is: A. An active secretory process. B. Determined at two sites principally. C. Regulated physiologically by hormones. D. Largely determined by the intactness of the enterohepatic circulation (EHC). Answer: ABCD DISCUSSION: Bile formation is an active process at both the canalicular and ductular sites. The paracellular pathway probably plays a minor physiologic role. Secretin and glucagon are likely physiologic regulators of biliary secretion. Bile salts are extremely important and are probably the most important agent in the changes that occur when enterohepatic circulation is interrupted. 5. Generally, the two most important hepatic functions to consider after hepatic resection are: A. Hepatic synthetic function. B. Glucose metabolism. C. The liver's role in lipid metabolism. D. The liver's role in vitamin metabolism. Answer: AB Asir Surgery MCQs Bank. 1422H-2002- first impression This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).247
  2. 2. Hepatobiliary & pancreatic surgery DISCUSSION: While other functions undoubtedly may be important postoperatively, the most common abnormalities occurring after a major hepatic resection are related to loss of protein synthesis and consequences of glucose metabolism. Therefore, it is usually advisable to administer supplemental amounts of protein and sugar postoperatively. 6. Which of the following statements about pyogenic abscess of the liver are true? A. The right lobe is more commonly involved than the left lobe. B. Appendicitis with perforation and abscess is the most common underlying cause of hepatic abscess. C. Mortality is largely determined by the underlying disease. D. Mortality from hepatic abscess is currently greater than 40%. Answer: AC DISCUSSION: Involvement of the right lobe with abscess formation approximates 70% of pyogenic abscesses. This is thought to be due to the streaming effect of superior mesenteric venous inflow to the right lobe. In addition, the greater volume of the right lobe predisposes more tissue to seeding by bacterial organisms. While appendicitis comprised 25% to 40% of cases in early series, early recognition and operative therapy for appendicitis have reduced its importance significantly. In current series, malignant or benign biliary obstruction is the underlying cause of 35% to 50% of cases. Recent studies have shown that the underlying disease or an immunocompromised host is more important prognostically than solitary versus multiple abscesses. 7. Which of the following statements most accurately describes the current therapy for pyogenic hepatic abscess? A. Antibiotics alone are adequate for the treatment of most cases. B. All patients require open surgical drainage for optimal management. C. Optimal treatment involves treatment of not only the abscess but the underlying source as well. D. Percutaneous drainage is more successful for multiple lesions than for solitary ones. Answer: C DISCUSSION: The development of ultrasonography and computed tomography (CT) in the past two decades has enabled earlier diagnosis and advances in treatment of hepatic abscess. Formerly, open surgical drainage was considered necessary in essentially all cases of pyogenic abscess. Numerous recent series, however, have reported high success rates and low mortality from the percutaneous catheter drainage of abscesses under CT or ultrasonographic guidance. Optimal management of pyogenic abscess, however, involves not only treatment of the abscess, whether by percutaneous or surgical methods, but correction of the underlying source as well. All modes of therapy are more successful in treating solitary lesions than multiple ones. 8. Which of the following statements characterize amebic abscess? A. Mortality is higher than that for similarly located pyogenic abscesses. B. The diagnosis of amebic abscess may be based on serologic tests and resolution of symptoms. C. In contrast to pyogenic abscess, the treatment of amebic abscess is primarily medical. D. Patients with amebic abscess tend to be older than those with pyogenic abscess. BC DISCUSSION: Mortality for uncomplicated amebic abscess should be less than 5%, in contrast to the 15% to 20% rate for pyogenic abscess. After the demonstration by radiologic examination of an abscess, appropriate serologic tests and resolution of symptoms after a course of treatment with an antiamebic agent such as metronidazole constitute presumptive diagnosis of amebic abscess. Aspiration of abscess contents rarely yields amebic organisms. In contrast to pyogenic abscess, amebic abscess rarely requires surgical or percutaneous drainage, except in the case of an extremely large abscess or bacterial superinfection. Amebic abscess affects males in a 9:1 to 10:1 ratio and generally affects a younger population than pyogenic abscess. Additionally, in the United States the populations most affected are immigrants from endemic areas such as Mexico or Latin America and American tourists to those regions. 9. Which of the following statement(s) is/are true about benign lesions of the liver? A. Adenomas are true neoplasms with a predisposition for complications and should usually be resected. B. Focal nodular hyperplasia (FNH) is a neoplasm related to birth control pills (BCPs) and usually requires resection. C. Hemangiomas are the most common benign lesions of the liver that come to the surgeon's attention. D. Nodular regenerative hyperplasia does not usually accompany cirrhosis. Answer: A DISCUSSION: Adenomas typically enlarge and cause symptoms, may rupture, and have a definite malignant potential. Therefore they should generally be resected when found. FNH is not a true neoplasm and generally has an uneventful Asir Surgery MCQs Bank. 1422H-2002- first impression This project was raised after an idia by Dr. Gharama Al-Shehri (consultant surgeon). Developed and typed by Dr. Ghazi Al-Shumrani (intern).248
  3. 3. Hepatobiliary & pancreatic surgery course. Both are related to BCPs, although the relationship of adenoma is more firmly established. While small bile duct hamartomas are much more common, hemangiomas are the most common lesion to come to the attention of surgeons. They should not generally be biopsied because of possible hemorrhage. By definition, nodular regenerative hyperplasia occurs in the absence of cirrhosis. 10. Which of the following statement(s) about malignant neoplasms of the liver is/are true? A. Hepatocellular carcinoma is probably the number 1 cause of death from cancers worldwide. B. The most common resectable hepatic malignant neoplasm in the United States is colorectal metastasis. C. Hepatoma has at least one variant that has a much more benign course than hepatomas in general. D. Hepatomas are generally slower growing than was formerly believed. Answer: ABCD DISCUSSION: Although exact comparisons are impossible, hepatoma seems to be the most common cause of cancer death worldwide, despite its relative infrequency in the United States. Colorectal metastasis is a more common indication for surgical treatment in the United States. The fibrolamellar variant and possibly the very well-differentiated tumor probably have a better prognosis than hepatomas in general. Previous studies from Africa in which there was a high incidenc