SURGERY PRETEST QUESTIONS I

Second Semester- General Surgery 4th year

1. A 45-year-old man was discovered to have a hepatic flexure colon cancer during a
colonoscopy for anemia requiring transfusions. Upon exploration of his abdomen in the
operating room, an unexpected discontinuous 3-cm metastasis is discovered in the edge of the
right lobe of the liver. Preoperatively, the patient was counseled of this possibility and the
surgical options. Which of the following is the most appropriate management of this patient?

a. A diverting ileostomy should be performed and further imaging obtained

b. Right hemicolectomy
c. Right hemicolectomy with local resection of the liver metastasis
d. Closure of the abdomen followed by chemotherapy
e. Right hemicolectomy with postoperative radiation therapy to the liver

2. A 42-year-old man has bouts of intermittent crampy abdominal pain and rectal bleeding.
Colonoscopy is performed and demonstrates multiple hamartomatous polyps. The patient is
successfully treated by removing as many polyps as possible with the aid of intraoperative
endoscopy and polypectomy. Which of the following is the most likely diagnosis?

a. Ulcerative colitis
b. Villous adenomas
c. Familial polyposis
d. Peutz-Jeghers syndrome
e. Crohn colitis

3. A 53-year-old man presents to the emergency room with left lower quadrant pain, fever,
and vomiting. CT scan of the abdomen and pelvis reveals a thickened sigmoid colon with
inflamed diverticula and a 7-cm by 8-cm rim-enhancing fluid collection in the pelvis. After
percutaneous drainage and treatment with antibiotics, the pain and fluid collection resolve. He
returns as an outpatient to clinic 1 month later. He undergoes a colonoscopy, which
demonstrates only diverticula in the sigmoid colon. Which of the following is the most
appropriate next step in this patient’s management?

a. Expectant management with sigmoid resection if symptoms recur

b. Cystoscopy to evaluate for a fistula
c. Sigmoid resection with end colostomy and rectal pouch (Hartmann procedure)
d. Sigmoid resection with primary anastomosis
e. Long-term suppressive antibiotic therapy

4. After complete removal of a sessile polyp of 2.0 cm by 1.5 cm found 1 finger length above
the anal mucocutaneous margin, the pathologist reports it to have been a villous adenoma that
contained carcinoma in situ. Which of the following is the most appropriate next step in
management?

a. Reexcision of the biopsy site with wider margins

b. Abdominoperineal rectosigmoid resection
c. Anterior resection of the rectum
d. External radiation therapy to the rectum
e. No further therapy

5. A 57-year-old woman sees blood on the toilet paper. Her doctor notes the presence of an
excoriated bleeding 2.8-cm mass at the anus. Biopsy confirms the clinical suspicion of anal
cancer. In planning the management of a 2.8-cm epidermoid carcinoma of the anus, which of
the following is the best initial management strategy?

a. Abdominoperineal resection
b. Wide local resection with bilateral inguinal node dissection
c. Local radiation therapy
d. Systemic chemotherapy
e. Combined radiation therapy and chemotherapy

6. An 80-year-old man is admitted to the hospital complaining of nausea, abdominal pain,

distention, and diarrhea. A cautiously performed trans anal contrast study reveals an apple-
core
configuration in the rectosigmoid area. Which of the following is the most appropriate next
step in his management?

a. Colonoscopy decompression and rectal tube placement

b. Saline enemas and digital disimpassion of fecal matter from the rectum
c. Colon resection and proximal colostomy
d. Oral administration of metronidazole and checking a Clostridium difficile titer
e. Evaluation of an electrocardiogram and obtaining an angiogram to evaluate for colonic
mesenteric ischemia

7. A 46-year-old woman who was recently diagnosed with Crohn disease asks about the need
for surgery. Which of the following findings would be an indication for an immediate
exploratory laparotomy?

a. Intestinal obstruction
b. Enterovesical fistula
c. Ileum-ascending colon fistula
d. Enterovaginal fistula
e. Free perforation

8. A septuagenarian woman undergoes an uncomplicated resection of an abdominal

aneurysm. Four days after surgery the patient presents with sudden onset of abdominal pain
and distention. An abdominal radiograph demonstrates an air-filled, kidney-bean–shaped
structure in the left upper quadrant. Which of the following is the most appropriate
management at this time?

a. Decompression of the large bowel via colonoscopy

b. Placement of the NG tube and administration of low-dose cholinergic drugs
c. Administration of a gentle saline enema and encouragement of ambulation
d. Operative decompression
e. Right hemicolectomy
9. A 30-year-old female patient who presents with diarrhea and abdominal discomfort is
found at colonoscopy to have colitis confined to the transverse and descending colon. A
biopsy is performed. Which of the following is a finding consistent with this patient’s
diagnosis?

a. The inflammatory process is confined to the mucosa and submucosa.

b. The inflammatory reaction is likely to be continuous.
c. Superficial as opposed to linear ulcerations can be expected.
d. Noncaseating granulomas can be expected in up to 50% of patients.
e. Micro abscesses within crypts are common.

10. A 24-year-old man presents to the emergency room with abdominal pain and fever. CT
scan of the abdomen reveals inflammation of the colon. He is referred to a gastroenterologist
to be evaluated for inflammatory bowel disease (Crohn disease versus ulcerative colitis).
Which of the following indications for surgery is more prevalent in patients with Crohn
disease?

a. Toxic megacolon
b. Massive bleeding
c. Fistulas between the colon and segments of intestine, bladder, vagina, urethra, and skin
d. Intractable disease
e. Dysplasia or carcinoma

11. A 32-year-old woman undergoes an uncomplicated appendectomy for acute appendicitis.

The pathology report notes the presence of a 1-cm carcinoid tumor in the tip of the appendix.
Which of the following is the most appropriate management of this patient?

a. Right hemicolectomy
b. Right hemicolectomy and chemotherapy
c. Chemotherapy only
d. Radiation only
e. No further treatment

12. A 48-year-old woman develops pain in the right lower quadrant while playing tennis. The
pain progresses and the patient presents to the emergency room later that day with a low-
grade fever, a WBC count of 13,000/mm3 and complaints of anorexia and nausea as well as
persistent, sharp pain of the right lower quadrant. On examination, she is tender in the right
lower quadrant with muscular spasm, and there is a suggestion of a mass effect. An ultrasound
is ordered and shows an apparent mass in the abdominal wall. Which of the following is the
most likely diagnosis?

a. Acute appendicitis
b. Cecal carcinoma
c. Hematoma of the rectus sheath
d. Torsion of an ovarian cyst
e. Cholecystitis

13. A 22-year-old woman presents with a painful fluctuant mass in the midline between the
gluteal folds. She denies pain on rectal examination. Which of the following is the most likely
diagnosis?
a. Pilonidal abscess
b. Perianal abscess
c. Perirectal abscess
d. Fistula-in-ano
e. Anal fissure

14. A 54-year-old man complains that his eyes are yellow. His bilirubin is elevated. His
physical examination is unremarkable. A CT of the abdomen shows a small mass in the head
of the pancreas encasing the superior mesenteric artery. Cytology from the ERCP is positive
for cancer. Which of the following is the most appropriate treatment for this patient?

a. Pancreaticoduodenectomy
b. Pancreaticoduodenectomy with reconstruction of the superior mesenteric artery
c. Total pancreatectomy
d. Total pancreatectomy with reconstruction of the superior mesenteric artery
e. Chemoradiation therapy
Surgery pretest answers I

1. The answer is c. (Townsend, pp 1406-1415.) Five-year survival rates of 25% have been
reported after synchronous resection of primary colorectal cancers and liver metastases.
Because approximately 5% of colorectal cancers are associated with resectable hepatic
metastases, appropriate preoperative discussion should include obtaining permission for
removal of synchronous peripheral hepatic lesions if they are found. Adequate local resection,
either by wedge or by limited partial hepatectomy, may be carried out whenever no
extrahepatic disease is found and the hepatic lesion is technically removable. Any option that
leaves the symptomatic colon cancer (bleeding) would be unacceptable. Radiation therapy has
little to offer in colon cancer or its hepatic metastases.

2. The answer is d. (Townsend, pp 1400-1414.) Peutz-Jeghers syndrome is characterized by

intestinal polyposis and melanin spots of the oral mucosa. Unlike the adenomatous polyps
seen in familial polyposis, the lesions in this condition are hamartomas, which have no
malignant potential. Surgery for symptomatic polyps involves polypectomy. Cancer of the
colon in patients with chronic UC is 10 times more frequent than in the general population.
Duration of disease is very important; the risk of developing cancer is low in the first 10 years
but thereafter rises about 4% per year. The average age of cancer development in patients
with chronic UC is 37 years; idiopathic carcinoma of the colon, however, develops at an
average age of 65 years. Crohn colitis is currently felt to be a precancerous condition as well.
The chance of development of carcinoma of the colon in patients with familial polyposis is
essentially 100%. Treatment of the patient with familial polyposis generally consists of total
proctocolectomy with ileoanal J-pouch.
Villous adenomas have been demonstrated to contain malignant portions in about one-third of
affected persons and invasive malignancy in another one-third of removed specimens.
Anterior resection is performed for large lesions or those containing invasive carcinomas
when the lesion is above the peritoneal reflection. Abdominal-perineal resection (APR) is
indicated for low-lying rectal villous adenomas when they have demonstrated invasive
carcinomas. Transrectal excision with regular follow-up examinations is sufficient for lesions
without invasive carcinomas.

4. The answer is d. (Townsend, pp 1365-1369.) The indications for surgical intervention for
diverticular disease include hemorrhage secondary to diverticulosis, recurrent episodes of
diverticulitis, intractability to medical therapy, and complicated diverticulitis.
The latter includes perforated diverticulitis with or without abscess and fistulous disease.
Diverticular abscesses are treated with percutaneous drainage initially followed by definitive
resection therapy.
Initial percutaneous drainage allows for a 1-stage procedure that consists of resection of the
affected colon with primary anastomosis. Perforated diverticulitis is typically treated with
either the Hartmann procedure (sigmoid resection with end colostomy and rectal stump) or
sigmoid resection, anastomosis, and diverting loop ileostomy.
5. The answer is e. (Brunicardi, p 1048.) The term carcinoma in situ refers to the presence of
malignant cells in the mucosal layer only. Endoscopic polypectomy is adequate treatment
when malignant cells are identified in a colonic polyp, even if an invasive component is
identified, if: (1) no vascular or lymphatic invasion is present; (2) there is an adequate
negative margin (2 mm), and the cancer is not poorly differentiated.

6. The answer is e. (Townsend, pp 1459-1460.) Epidermoid cancers of the anal canal

metastasize to inguinal nodes as well as to the perirectal and mesenteric nodes. The results of
local radical surgery have been disappointing. Combined external radiation with synchronous
chemotherapy (fluorouracil and mitomycin), also known as the Nigro protocol, has been used
as the standard treatment of the disease, whereas radical surgical approaches are now
generally reserved for treatment failures and recurrences.

7. The answer is c. (Townsend, pp 1371-1372.) A markedly distended colon could have many
causes in this 80-year-old man. The contrast study, however, reveals a classic apple-core
lesion appropriate prior to relief of this large-bowel obstruction. After medical preparation
(eg, hydration, normalization of electrolytes), this patient should undergo prompt surgical
management of his mechanical obstruction; conservative management by resection and
proximal colostomy would generally be preferred in this elderly patient with an obstructed,
unprepared bowel.

8. The answer is e. (Townsend, pp 1385-1387.) Perforation of bowel into the free abdominal
cavity is obviously a surgical emergency. Surgical treatment of Crohn disease is aimed at
correcting complications that are causing symptoms. Fistula formation in itself is not an
indication for surgery. An ileum-ascending colon fistula is very common yet rarely
symptomatic. Fistulas between the intestine and the bladder and the intestine and the vagina,
however, generally cause significant symptoms and warrant surgical intervention. Intestinal
obstruction is usually partial and secondary to a fixed stricture that is not responsive to anti-
inflammatory agents. When the obstruction causes symptoms that compromise nutritional
status, surgery is warranted.

9. The answer is e. (Townsend, pp 1370-1371.) The patient has a cecal volvulus and the
procedure of choice is a right hemicolectomy. A cecal volvulus involves axial rotation of the
terminal ileum, cecum, and ascending colon with concomitant twisting of the associated
mesentery. Immediate operation is required to correct the volvulus and prevent ischemia.
Colonoscopy decompression is usually unsuccessful and does not prevent recurrence of a
cecal volvulus. A transverse colostomy “decompression” would not decompress the cecum,
nor would it provide detorsion of the cecal mesentery to allow restoration of adequate blood
supply to the right colon.

10. The answer is d. (Townsend, pp 1373-1385.) The patient depicted in this question has
Crohn disease of the colon (Crohn colitis). Crohn colitis is characterized by linear mucosal
ulcerations, discontinuous (skip) lesions, a transmural inflammatory process, and
noncaseating granulomas in up to 50% of patients. Because their clinical features and
management differ, Crohn colitis must be distinguished from UC. UC is usually found in the
rectum, although in rare cases the rectum is spared involvement. The entire colon, from
cecum to rectum, may be involved (pancolitis). UC typically presents as a grossly continuous
inflammatory process (without skip lesions) that microscopically is confined to the mucosa
and submucosa of the colon. In addition, crypt abscesses and superficial ulcerations are
common in UC.
11. The answer is c. (Townsend, pp 1373-1385.) Patients with Crohn disease can develop
fistulas between the colon and other segments of intestine, the bladder, the urethra, the vagina,
the skin, or the prostate. Toxic megacolon, massive bleeding, dysplasia/carcinoma, and
intractability of symptoms are indications for surgery found in both Crohn disease and
ulcerative colitis.

12. The answer is e. (Brunicardi, p 1088.) The most appropriate treatment for a 1-cm
carcinoid tumor at the tip of the appendix is an appendectomy. Therapy for a carcinoid tumor
of the appendix is based on tumor size and location. Simple appendectomy is adequate
treatment for appendiceal carcinoid tumors less than 1 cm. Tumors larger than 2 cm should be
treated with a right hemicolectomy to decrease locoregional recurrence. Treatment for tumors
between 1 and 2 cm is based on location. Tumors located at the base of the appendix or
invading the mesentery are best treated with a right hemicolectomy. No further treatment is
needed after an appendectomy for a 1- to 2-cm tumor located at the tip of the appendix.

13. The answer is a. (Townsend, pp 1449-1450.) The patient has a pilonidal abscess which
develops from an infected pilonidal cyst. It typically presents as a painful fluctuant mass
extending from the midline and is located between the gluteal clefts. Perianal and perirectal
abscesses are usually much closer to the anus and are very painful on rectal examination. A
fistula-in-ano is a chronically draining tract in the perianal region. It may become plugged and
develop a perianal or perirectal abscess. An anal fissure is a linear ulcer along the anal canal
and is not associated with an abscess.

14. The answer is e. (Townsend, pp 1612-1619.) The patient has unresectable pancreatic
cancer and needs chemotherapy and radiation. Tumors involving critical peripancreatic
arteries are T4 lesions and are deemed unresectable. Tumors involving the portal vein or
superior mesenteric vein (T3 lesions) are technically resectable with venous resection and
reconstruction, but the long-term survival of these patients is poor. Other CT changes
suggestive of unresectability include extension beyond the pancreatic capsule and into the
retroperitoneum, involvement of neural or nodal structures surrounding the origin of the celiac
axis or superior mesenteric artery, and extension of the tumor along the hepatoduodenal
ligament.