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Guide for Answering Theory Questions in MS Surgery

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Guide for Answering Theory Questions in MS Surgery WBUHS (2011-2015) MS- PAPER – I -IV Guide for Answering theory questions in MS Surgery Dr. Arkaprovo Roy ASSOCIATE PROFESSOR DEPARTMENT OF GENERAL SURGERY Dr. Arkaprovo Roy ASSOCIATE PROFESSOR DEPARTMENT OF GENERAL SURGERY MEDICAL COLLEGE AND HOSPITAL, KOLKATA THE WEST BENGAL UNIVERSITY OF HEALTH SCIENCES MS (General Surgery) Examination, 2015 PAPER I Time Allowed: 3 Hours Full Marks: 100 Attempt all questions 1. How will you assess the nutritional status of a surgical patient? Define and classify artificial nutritional support (ANS). Give an account of enteral nutrition and its advantages and drawbacks. 4+4+8+4 2. Describe the lymph node status in relation to spread of carcinoma stomach. Discuss in detail the different types of gastric carcinoma and prognosis in respect to lymph node harvest. 5+10+5 3. Write short notes of the following: 5x6 a) Pharmacological therapy in patients awaiting surgery for pheochromocytoma. b) Retroperitoneal fibrosis. c) Ethics and law in surgical practice. d) Pathophysiology of short bowel syndrome. e) Metabolic response to trauma. 4. Answer briefly on the following. 4x71/2 a) Laparoscopic versus conventional surgery in pregnancy. b) Component separation and role of blood components in surgery. c) Graft rejection in transplants. d) Immunohistochemistry. THE WEST BENGAL UNIVERSITY OF HEALTH SCIENCES MS (General Surgery) Examination, 2015 April 2015 PAPER I Time Allowed: 3 Hours Full Marks: 100 Attempt all questions 1. How will you assess the nutritional status of a surgical patient? Define and classify artificial nutritional support (ANS). Give an account of enteral nutrition and its advantages and drawbacks. 4+4+8+4 Answer. The first task when considering perioperative nutritional recommendations is to assess whether or not the patient has malnutrition. The basic principle of dietary and nutritional assessment in the general population is discussed elsewhere. Important aspects of nutritional assessment that pertain to surgical patients are reviewed below. Based upon expert consensus, a diagnosis of malnutrition requires that the patient exhibit two or more of the following: ●Insufficient energy intake ●Weight loss ●Loss of muscle mass ●Loss of subcutaneous fat ●Localized or generalized fluid accumulation that may sometimes mask weight loss ●Diminished functional status as measured by handgrip strength History and physical Several aspects of the past medical history are of particular importance, including chronic disease (particularly diabetes), infection, recent hospitalization, and prior surgery (particularly gastrointestinal— surgery). On review of systems, a history of weight loss or gain is important. Any recent losses or gains (and whether they were purposeful or not) prior to the hospital stay should be assessed. The details of the current hospitalization also play a central role. Newly admitted trauma patients who are otherwise well have drastically different needs from patients who have had surgery several weeks in the past but have remained hospitalized due to complications. In addition to collecting information on current medications, nonprescription medicines and other supplements should be noted. The use of dietary supplements, such as protein shakes, should also be determined. Lastly, any allergies or food intolerances should also be noted. A diet history should be collected from the patient, family, or care facility. Although there are several methods of dietary assessment, the most useful and straightforward may be to assess the usual intake on an average day before hospitalization or before the onset of the current illness. In addition to vital signs and a general physical examination, the following should be noted: ●Height and weight (calculate body mass index [BMI] using weight in kg divided by height in meters squared, or using a nomogram) ●General: Loss of subcutaneous fat, any generalized fluid accumulation ●Head and neck exam: Hair loss, bitemporal wasting, conjunctival pallor, xerosis, glossitis, bleeding or sores on the gums and oral mucosa, angular cheilosis or stomatitis, dentition ●Cardiovascular: Evidence of heart failure or high-output state ●Neck: Thyromegaly ●Extremities: Edema, loss of muscle mass ●Neurologic: Evidence of peripheral neuropathy, reflexes, tetany, mental status, handgrip strength ●Skin: Ecchymoses, petechiae, pallor, pressure ulcers, assessment of surgical wound healing and signs of surgical site infection (if postoperative). Signs of specific nutritional deficiencies should also be sought. Appropriate micronutrient levels should be investigated depending on clinical exam findings. Several clinical tools are available to quickly assess and score nutrition status. The Subjective Global Assessment of Nutritional Status is a brief tool that includes history and physical examination findings, and allows standardized assessment. The Nutritional Risk Screening tool (NRS 2002) can be applied rapidly and used to screen for poor baseline nutritional status. A study that assessed the ability of the NRS 2002 score to predict the incidence and severity of postoperative complications found the overall incidence of nutritional risk was 14 percent among 608 patients undergoing gastrointestinal surgery. A significantly higher overall complication rate was found in patients at nutritional risk compared with those with a normal NRS 2002 risk score (40 versus 15 percent). Severe complications were also significantly higher in patients at nutritional risk (54 versus 15 percent). Assessing protein status Assessing protein status is particularly important in the surgical patient because of the close relationship between protein status and wound healing, and because protein- calorie malnutrition can be— treated with supplementation as discussed below. Protein status is affected by previous intake, muscle mass, duration of current illness, blood loss, wound healing, infections, and gastrointestinal absorption. Three serum measures of protein status have differing half-lives. These serum components do not directly indicate nutritional status, but rather reflect the severity of illness and must be used in conjunction with other clinical data such as the duration of the current surgical illness to be useful in determining therapy. Although decreased levels for these protein markers correlate with adverse outcomes, improvements in these markers with nutritional supplementation are not reliably associated with a clinical benefit. ●Serum albumin has the longest half-life at 18 to 20 days and is the most extensively used parameter. Low serum albumin (<2.2 g/dL) is a marker of a negative catabolic state, and a predictor of poor outcome.Surgical stress, other acute stresses, hepatic disease, and renal disease decrease serum albumin levels. ●Serum transferrin has an intermediate half-life of eight to nine days, reflecting protein status over the past two to four weeks. Transferrin also reflects iron status, and low transferrin should be considered an indicator of protein status only in the setting of normal serum iron. ●Serum prealbumin (transthyretin) has the shortest half-life at two to three days. Although prealbumin responds quickly to the onset of malnutrition and rises rapidly with adequate protein intake, the level can be altered in the acute phase response due to acute or chronic inflammation. In general, inflammatory cytokines reduce the level of prealbumin synthesis by the liver, and it can also be reduced with renal and hepatic disease. Therefore, serum prealbumin is the least helpful of the three for assessing overall nutritional status. Other laboratory studies In addition to assessing protein status, a few other laboratory studies may be helpful. Electrolytes, glucose, and BUN/creatinine help assess overall clinical and fluid volume status and need to— be obtained if parenteral (intravenous) nutrition will be instituted. Iron levels should be measured in the setting of unexplained anemia, as should specific vitamin levels if clinically indicated (eg, B12/folate in macrocytic anemias, others based upon specific physical signs). Serum calcium, magnesium, and phosphorous should also be assessed periodically, particularly in the setting of poor oral intake or diarrhea. Artificial nutrition support: refers to the administration of nutrient solutions by the enteral or intravenous (parenteral) routes. o Enteral feeding includes the use of oral supplements and tube feeding. The method of tube feeding may be by nasogastric, nasojejunal, percutaneous endoscopic gastrostomy (PEG), percutaneous endoscopic jejunostomy (PEJ), or fine needle jejunostomy. o Parenteral nutrition may be administered by peripheral or central veins. Enteral nutrition - See the answer of question 3.d of Paper – I of 2010. 2. Describe the lymph node status in relation to spread of carcinoma stomach. Discuss in detail the different types of gastric carcinoma and prognosis in respect to lymph node harvest. 5+10+5 Answer. See the answer of question 2 of Paper – II of 2006. See the answer of question 2 of Paper – III of 2007. See the answer of question 1 of Paper – III of 2010. 3. Write short notes of the following: 5x6 a) Pharmacological therapy in patients awaiting surgery for pheochromocytoma. b) Retroperitoneal fibrosis. c) Ethics and law in surgical practice. d) Pathophysiology of short bowel syndrome. e) Metabolic response to trauma. Answer. a) Pharmacological therapy in patients awaiting surgery for pheochromocytoma. Answer. Medical therapy is used for preoperative preparation prior to surgical
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