FMGE 2023 — Surgery

Q: A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

Esophagoscopy. ***Esophagoscopy*** - The X-ray shows a circular radiopaque object, the classic **"coin sign"** on an anteroposterior view, which is characteristic of a foreign body lodged in the **esophagus**. - **Esophagoscopy** is the definitive procedure for both visualizing and safely removing the foreign object, especially important if it is a button battery which can cause rapid mucosal injury. *Bronchoscopy* - This procedure is indicated for the removal of foreign bodies from the **airways** (trachea or bronchi), not the esophagus. - A tracheal foreign body would typically present with **respiratory distress** (stridor, wheezing) and would appear as a thin line on an AP X-ray because it would be oriented in the sagittal plane. *Tracheostomy* - A tracheostomy is a surgical procedure to create an alternative airway and is reserved for severe **upper airway obstruction** or the need for long-term mechanical ventilation. - This patient's primary problem is **dysphagia** (difficulty swallowing) due to an esophageal obstruction, not an airway emergency requiring a surgical airway. *Heimlich's manoeuvre* - This is an emergency first-aid procedure used for acute **choking** caused by a foreign body obstructing the airway, leading to an inability to breathe or speak. - The patient is not described as actively choking and has a stable airway; therefore, this maneuver is inappropriate and could cause harm. [Practice more Surgery PYQs on OnCourse]

Q: Which of the following is associated with CSF otorrhea?

Battle sign. ***Battle sign***- **Battle sign** (ecchymosis over the mastoid process) is highly indicative of a **basilar skull fracture**, specifically involving the **temporal bone**.- Fractures of the petrous portion of the temporal bone often breach the **dura mater** and middle ear cavity, leading directly to leakage of cerebrospinal fluid (**CSF otorrhea**).*Traumatic rupture of the tympanic membrane*- While rupture of the **tympanic membrane (TM)** is often present, it is usually a consequence of the underlying **temporal bone fracture**, not the primary source of the CSF leak.- CSF otorrhea fundamentally requires a fracture allowing communication between the **subarachnoid space** and the middle ear; TM rupture solely allows fluid egress.*Penetrating injury to the eye*- These injuries involve the orbit and structures of the eye, typically causing orbital trauma, globe rupture, or associated **facial fractures**.- They are not the usual mechanism for basilar skull fractures involving the **middle cranial fossa** or temporal bone, which are necessary for CSF otorrhea.*Fracture of the roof of the nose*- Fractures of the skull base involving the anterior cranial fossa, such as the **cribriform plate** (roof of the nose), classically cause **CSF rhinorrhea** (CSF leakage through the nose).- This anatomical location is functionally separate from the temporal bone pathology required to produce **CSF otorrhea**. [Practice more Surgery PYQs on OnCourse]

Q: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Partial nephrectomy. ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**. [Practice more Surgery PYQs on OnCourse]

Q: Which of the following will have unilateral hydronephrosis?

Retrocaval ureter. ***Retrocaval ureter*** - This is a rare congenital anomaly where the **right ureter** passes behind the inferior vena cava (IVC), causing extrinsic compression and obstruction. - Since only the right ureter is involved in this pathway abnormality, it inherently results in **unilateral hydronephrosis** of the right kidney. *Phimosis* - Phimosis is the inability to retract the foreskin; severe cases can cause distal urinary outflow obstruction. - If obstruction is severe enough to cause hydronephrosis, the resulting high intravesical pressure would be transmitted equally to both kidneys, usually causing **bilateral hydronephrosis**. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are congenital folds in the posterior urethra, causing obstruction distal to the bladder neck. - This obstruction leads to high intravesical pressure, which impairs drainage from both kidneys, inevitably resulting in **bilateral hydronephrosis**. *Urethral strictures* - Urethral strictures are narrowings of the urethra, usually acquired, which obstruct urine flow distal to the bladder. - Significant obstruction at this level causes increased back pressure in the bladder and ureters, usually leading to pressure effects and subsequent **bilateral hydronephrosis**. [Practice more Surgery PYQs on OnCourse]

Q: A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

Radical cystectomy. ***Radical cystectomy***- Because this tumor involves the **muscle layer**, it is classified as **muscle-invasive bladder cancer (MIBC)** (T2 stage or higher), for which radical cystectomy is the gold standard treatment for patients who are surgical candidates.- This procedure involves complete removal of the bladder and adjacent pelvic lymph nodes, followed by urinary diversion, offering the best survival and curative rates for localized MIBC.*Intravesical administration of BCG*- This immunotherapy is used primarily for **high-risk non-muscle-invasive bladder cancer (NMIBC)**, particularly carcinoma in situ (CIS) or high-grade T1 tumors, to reduce recurrence.- It cannot achieve adequate penetration or tumor clearance in tumors that have already invaded the **detrusor muscle**.*Radiotherapy*- Radiotherapy is typically used as part of a **bladder-preserving trimodality therapy** (TMT) when the patient is unable or unwilling to undergo surgery.- For fit patients with MIBC, **radical cystectomy** generally provides superior long-term survival rates compared to radiotherapy alone.*Neoadjuvant chemotherapy with Mitomycin C*- **Mitomycin C** is an agent used *intravesically* for NMIBC, similar to BCG, to prevent recurrence after TURBT.- Standard **neoadjuvant chemotherapy** for MIBC (given before cystectomy) consists of **systemic platinum-based regimens** (like Gemcitabine/Cisplatin) and not local Mitomycin C. [Practice more Surgery PYQs on OnCourse]

22 Previous Year Questions with Answers & Explanations

Questions

A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

Which of the following is associated with CSF otorrhea?

A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

Which of the following will have unilateral hydronephrosis?

A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

All of the following are superior mediastinal tumors except:

A 50-year-old woman after thyroidectomy comes to you for a 2nd opinion for further treatment of papillary thyroid cancer. What would you recommend for this patient?

A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

Which of the following procedures has the highest risk of causing the recurrence of duodenal ulcers?

Q10

Elective splenectomy is preferred in which of the following conditions?

FMGE 2023 - Surgery FMGE Practice Questions and MCQs

Question 1: A 2-year-old was brought to the emergency department with difficulty swallowing for the last few hours. The X-ray is given below. Which is the next best step to manage this patient?

A. Bronchoscopy
B. Esophagoscopy (Correct Answer)
C. Heimlich's manoeuvre
D. Tracheostomy

Explanation: ***Esophagoscopy*** - The X-ray shows a circular radiopaque object, the classic **"coin sign"** on an anteroposterior view, which is characteristic of a foreign body lodged in the **esophagus**. - **Esophagoscopy** is the definitive procedure for both visualizing and safely removing the foreign object, especially important if it is a button battery which can cause rapid mucosal injury. *Bronchoscopy* - This procedure is indicated for the removal of foreign bodies from the **airways** (trachea or bronchi), not the esophagus. - A tracheal foreign body would typically present with **respiratory distress** (stridor, wheezing) and would appear as a thin line on an AP X-ray because it would be oriented in the sagittal plane. *Tracheostomy* - A tracheostomy is a surgical procedure to create an alternative airway and is reserved for severe **upper airway obstruction** or the need for long-term mechanical ventilation. - This patient's primary problem is **dysphagia** (difficulty swallowing) due to an esophageal obstruction, not an airway emergency requiring a surgical airway. *Heimlich's manoeuvre* - This is an emergency first-aid procedure used for acute **choking** caused by a foreign body obstructing the airway, leading to an inability to breathe or speak. - The patient is not described as actively choking and has a stable airway; therefore, this maneuver is inappropriate and could cause harm.

Question 2: Which of the following is associated with CSF otorrhea?

A. Battle sign (Correct Answer)
B. Traumatic rupture of the tympanic membrane
C. Penetrating injury to the eye
D. Fracture of the roof of the nose

Explanation: ***Battle sign***- **Battle sign** (ecchymosis over the mastoid process) is highly indicative of a **basilar skull fracture**, specifically involving the **temporal bone**.- Fractures of the petrous portion of the temporal bone often breach the **dura mater** and middle ear cavity, leading directly to leakage of cerebrospinal fluid (**CSF otorrhea**).*Traumatic rupture of the tympanic membrane*- While rupture of the **tympanic membrane (TM)** is often present, it is usually a consequence of the underlying **temporal bone fracture**, not the primary source of the CSF leak.- CSF otorrhea fundamentally requires a fracture allowing communication between the **subarachnoid space** and the middle ear; TM rupture solely allows fluid egress.*Penetrating injury to the eye*- These injuries involve the orbit and structures of the eye, typically causing orbital trauma, globe rupture, or associated **facial fractures**.- They are not the usual mechanism for basilar skull fractures involving the **middle cranial fossa** or temporal bone, which are necessary for CSF otorrhea.*Fracture of the roof of the nose*- Fractures of the skull base involving the anterior cranial fossa, such as the **cribriform plate** (roof of the nose), classically cause **CSF rhinorrhea** (CSF leakage through the nose).- This anatomical location is functionally separate from the temporal bone pathology required to produce **CSF otorrhea**.

Question 3: A 44-year-old lady presents to the hospital with a ballotable flank mass. On CT imaging, the mass measures 4cm. Urine examination shows malignant cells. What is the most appropriate management for her condition?

A. Partial nephrectomy (Correct Answer)
B. Partial nephrectomy + neoadjuvant chemotherapy
C. Radical nephrectomy + postoperative radiotherapy
D. Radical nephrectomy

Explanation: ***Partial nephrectomy*** - For localized renal tumors measuring **≤ 4 cm (T1a)**, such as the one described, partial nephrectomy is the gold standard treatment, aiming to preserve renal function. - This approach, also known as **nephron-sparing surgery**, offers equivalent cancer control to radical nephrectomy for small tumors but with a lower risk of long-term **chronic kidney disease (CKD)** and associated cardiovascular morbidity. *Partial nephrectomy + neoadjuvant chemotherapy* - **Renal cell carcinoma (RCC)**, the most common type of kidney cancer, is notoriously resistant to conventional chemotherapy, so neoadjuvant chemotherapy is not a standard treatment for localized disease. - Neoadjuvant approaches for RCC, when used, typically involve **targeted therapy** or **immunotherapy** in the context of clinical trials for larger or more advanced tumors, not for a small 4cm mass. *Radical nephrectomy* - **Radical nephrectomy**, the removal of the entire kidney, is considered overtreatment for a small 4cm mass and is generally reserved for larger tumors (**>7 cm**) or when a partial nephrectomy is not technically feasible. - Performing a radical nephrectomy when a partial is possible unnecessarily sacrifices nephrons, increasing the patient's risk of developing **CKD** in the future. *Radical nephrectomy + postoperative radiotherapy* - RCC is largely **radioresistant**, and adjuvant radiotherapy after surgery has not been shown to improve survival or prevent recurrence for non-metastatic disease. - Radiotherapy is typically reserved for palliative care in cases of metastatic RCC, for example, to control symptoms from **bone** or **brain metastases**.

Question 4: Which of the following will have unilateral hydronephrosis?

A. Phimosis
B. Posterior urethral valves
C. Urethral strictures
D. Retrocaval ureter (Correct Answer)

Explanation: ***Retrocaval ureter*** - This is a rare congenital anomaly where the **right ureter** passes behind the inferior vena cava (IVC), causing extrinsic compression and obstruction. - Since only the right ureter is involved in this pathway abnormality, it inherently results in **unilateral hydronephrosis** of the right kidney. *Phimosis* - Phimosis is the inability to retract the foreskin; severe cases can cause distal urinary outflow obstruction. - If obstruction is severe enough to cause hydronephrosis, the resulting high intravesical pressure would be transmitted equally to both kidneys, usually causing **bilateral hydronephrosis**. *Posterior urethral valves* - **Posterior urethral valves (PUV)** are congenital folds in the posterior urethra, causing obstruction distal to the bladder neck. - This obstruction leads to high intravesical pressure, which impairs drainage from both kidneys, inevitably resulting in **bilateral hydronephrosis**. *Urethral strictures* - Urethral strictures are narrowings of the urethra, usually acquired, which obstruct urine flow distal to the bladder. - Significant obstruction at this level causes increased back pressure in the bladder and ureters, usually leading to pressure effects and subsequent **bilateral hydronephrosis**.

Question 5: A 60-year-old patient presents with painless hematuria. He is diagnosed with bladder cancer involving the muscle layer. What is the next best step in the treatment of this patient?

A. Radiotherapy
B. Neoadjuvant chemotherapy with Mitomycin C
C. Radical cystectomy (Correct Answer)
D. Intravesical administration of BCG

Explanation: ***Radical cystectomy***- Because this tumor involves the **muscle layer**, it is classified as **muscle-invasive bladder cancer (MIBC)** (T2 stage or higher), for which radical cystectomy is the gold standard treatment for patients who are surgical candidates.- This procedure involves complete removal of the bladder and adjacent pelvic lymph nodes, followed by urinary diversion, offering the best survival and curative rates for localized MIBC.*Intravesical administration of BCG*- This immunotherapy is used primarily for **high-risk non-muscle-invasive bladder cancer (NMIBC)**, particularly carcinoma in situ (CIS) or high-grade T1 tumors, to reduce recurrence.- It cannot achieve adequate penetration or tumor clearance in tumors that have already invaded the **detrusor muscle**.*Radiotherapy*- Radiotherapy is typically used as part of a **bladder-preserving trimodality therapy** (TMT) when the patient is unable or unwilling to undergo surgery.- For fit patients with MIBC, **radical cystectomy** generally provides superior long-term survival rates compared to radiotherapy alone.*Neoadjuvant chemotherapy with Mitomycin C*- **Mitomycin C** is an agent used *intravesically* for NMIBC, similar to BCG, to prevent recurrence after TURBT.- Standard **neoadjuvant chemotherapy** for MIBC (given before cystectomy) consists of **systemic platinum-based regimens** (like Gemcitabine/Cisplatin) and not local Mitomycin C.

Question 6: All of the following are superior mediastinal tumors except:

A. Thyroid
B. Thymus
C. Lymphoma
D. Parathyroid (Correct Answer)

Explanation: ***Parathyroid*** - Parathyroid tumors are **not classic superior mediastinal tumors** - Ectopic parathyroid adenomas, when mediastinal, are typically located in the **anterior-inferior mediastinum**, not the superior mediastinum - They descend embryologically with the thymus from the 3rd pharyngeal pouch and are found in the **thymic tongue** or anterior mediastinum at lower levels - **Not part of the classic anterior/superior mediastinal mass differential** (the "4 Ts") *Thymus* - The thymus is the **primary organ** of the anterior and superior mediastinum - **Thymoma, thymic hyperplasia, and thymic carcinoma** are classic superior/anterior mediastinal tumors - Part of the "4 Ts" mnemonic: **Thymus**, Thyroid, Teratoma, Terrible lymphoma *Thyroid* - **Retrosternal (substernal) goiter** represents extension of cervical thyroid into the superior mediastinum - Common cause of superior mediastinal masses, especially in older patients - Can cause tracheal compression and superior vena cava syndrome - Part of the "4 Ts" of anterior mediastinal masses *Lymphoma* - **Lymphoma (especially Hodgkin lymphoma and T-cell lymphoblastic lymphoma)** is one of the most common anterior/superior mediastinal masses - Part of the "4 Ts": Thymus, Thyroid, Teratoma, and **"Terrible lymphoma"** - Typically presents as a large anterior mediastinal mass in young adults - May cause B symptoms (fever, night sweats, weight loss) and superior vena cava syndrome

Question 7: A 50-year-old woman after thyroidectomy comes to you for a 2nd opinion for further treatment of papillary thyroid cancer. What would you recommend for this patient?

A. Wait and watch.
B. Radiotherapy
C. Chemotherapy
D. Radioactive iodine (RAI) ablation (Correct Answer)

Explanation: ***Radioactive iodine (RAI) ablation*** - After total thyroidectomy for papillary thyroid cancer, **radioactive iodine (I-131) ablation** is the standard next step for most patients - **Indications for RAI ablation:** tumor >1 cm, lymph node metastases, extrathyroidal extension, vascular invasion, or unfavorable histology - RAI ablation serves dual purpose: destroys residual thyroid tissue and micro-metastases, and enables follow-up with thyroglobulin levels - A **post-therapy whole body scan** is typically performed 5-7 days after RAI ablation to assess uptake - TSH stimulation (either by thyroid hormone withdrawal or recombinant TSH) is required before RAI therapy *Wait and watch* - Only appropriate for **very low-risk papillary microcarcinomas** (<1 cm, no extrathyroidal extension, no nodal metastases) in carefully selected patients - Not the standard recommendation after thyroidectomy for papillary cancer without risk stratification details *Radiotherapy (External beam)* - **Not first-line** post-operative treatment for differentiated thyroid cancer - Reserved for: RAI-refractory disease, tumors that don't take up iodine, gross residual disease not amenable to surgery, or palliative care - May be considered in elderly patients with aggressive local disease *Chemotherapy* - **No role** in the routine management of differentiated thyroid cancer (papillary or follicular) - Only considered in advanced, progressive, RAI-refractory disease with targeted agents (lenvatinib, sorafenib) - Conventional cytotoxic chemotherapy is ineffective in thyroid cancer

Question 8: A 51-year-old lady presents with complaints of a mass in the right breast. On examination, the mass was larger than 5 cm and ipsilateral mobile axillary lymph nodes were present. What is the staging, considering the mass is malignant?

A. pT4N1M0
B. cT4N1M0
C. pT3N1M0
D. cT3N1M0 (Correct Answer)

Explanation: ***cT3N1M0*** **Correct answer based on TNM staging for breast cancer:** **T (Tumor) - T3:** - Tumor **>5 cm** in greatest dimension = T3 - The patient has a mass **larger than 5 cm**, meeting T3 criteria **N (Nodes) - N1:** - **Ipsilateral mobile axillary lymph nodes** = N1 - Mobile nodes without fixation to surrounding structures **M (Metastasis) - M0:** - **No mention of distant metastasis** = M0 **Clinical vs Pathological Staging:** - **"c" prefix** = clinical staging (based on physical examination, imaging) - **"p" prefix** = pathological staging (after surgery, histopathological examination) - This case uses **clinical examination findings**, so "c" prefix is appropriate *pT4N1M0* - Incorrect because: - Uses pathological prefix "p" without surgical specimen - T4 indicates chest wall/skin involvement, not present here *cT4N1M0* - Incorrect because: - T4 requires tumor extension to chest wall or skin ulceration/nodules - This tumor is only >5 cm without local extension *pT3N1M0* - Incorrect because: - Uses pathological staging prefix "p" when only clinical examination performed - Correct T and N staging but wrong staging type

Question 9: Which of the following procedures has the highest risk of causing the recurrence of duodenal ulcers?

A. Highly selective vagotomy (Correct Answer)
B. Gastro-jejunostomy
C. Gastrectomy
D. Truncal vagotomy

Explanation: ***Highly selective vagotomy***- ***Highly selective vagotomy*** (or parietal cell vagotomy) denervates only the acid-producing parietal cell mass, reducing basal and maximal acid output less intensely than other procedures. This procedure preserves the innervation of the **gastric antrum** and **pylorus**, maintaining physiological motility but resulting in the highest reported **ulcer recurrence rate** (historically 10-20%).*Gastrectomy*- A subtotal **gastrectomy** involves physically removing the portion of the stomach (body and/or antrum) responsible for acid or gastrin production, leading to a drastic reduction in acid load and a very low recurrence rate. This procedure is generally associated with the highest rates of **post-gastrectomy syndromes** (e.g., afferent loop syndrome, dumping syndrome) compared to vagotomy alone.*Truncal vagotomy*- **Truncal vagotomy** divides the main vagus trunks, causing near-maximal reduction of cephalic-phase acid secretion but requires mandatory **drainage procedures** (**pyloroplasty** or gastrojejunostomy) due to resulting gastric atony. The profound reduction in acid output achieved by this method gives it a significantly lower recurrence rate than highly selective vagotomy.*Gastro-jejunostomy*- **Gastro-jejunostomy** (often referring to the creation of a stoma between the stomach and jejunum) is typically performed as the **drainage procedure** necessary after truncal vagotomy, allowing food egress when the pylorus is dysfunctional. While effective in preventing stasis, a gastro-jejunostomy carries a specific risk of **marginal ulceration** (anastomotic ulceration) but the overall rate of recurrence for the combined operation is low.

Question 10: Elective splenectomy is preferred in which of the following conditions?

A. Hereditary spherocytosis (Correct Answer)
B. Hairy cell leukemia
C. Paroxysmal nocturnal hemoglobinuria
D. G6PD deficiency

Explanation: ***Hereditary spherocytosis***- It is the preferred elective treatment because the inherited structural defect in the red blood cell membrane leads to the sequestration and destruction of the rigid **spherocytes** primarily by the **spleen**. - Splenectomy significantly reduces hemolysis and corrects chronic anemia, but it is typically delayed until the child is over 5 years old to reduce the risk of **post-splenectomy sepsis**.*G6PD deficiency-Glucose-6-phosphate dehydrogenase deficiency*- This condition causes episodic hemolysis (typically **intravascular**) triggered by **oxidative stress** (drugs, fava beans, infection), not continuous extravascular hemolysis reliant on the spleen.- The mainstay of management is identifying and **avoiding oxidant triggers**; splenectomy is not indicated as it does not address the underlying enzymatic deficiency or the mechanism of hemolysis.*Paroxysmal nocturnal hemoglobinuria*- PNH is characterized by complement-mediated cytotoxicity due to lack of **GPI-anchored proteins** (CD55, CD59) on RBCs, leading to **intravascular hemolysis**.- Treatment involves targeted therapies like **complement inhibitors** (e.g., **eculizumab**) or **hematopoietic stem cell transplant**; splenectomy is usually ineffective and potentially harmful.*Hairy cell leukemia*- This is a **B-cell malignancy** effectively treated with chemotherapy using **purine analogs** (e.g., **cladribine**), which is the standard first-line approach for symptomatic disease.- Splenectomy may be considered for massive symptomatic **splenomegaly** or severe **refractory cytopenias**, but it is a secondary intervention and not the preferred elective treatment for the condition itself.