Colorectal Surgery Practice Questions

Q: Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:

T2, N1, M0. ***T2, N1, M0*** - The tumor invades the **muscularis propria** but not through it, which is classified as **T2** in the AJCC staging for colorectal cancer. - The presence of **2 positive regional lymph nodes** (out of 16 harvested) is classified as **N1** disease. **M0** indicates no distant metastasis. *T2, N1, M1* - While the **T2** and **N1** classifications are correct for this case, **M1** signifies the presence of **distant metastasis**, which is not indicated in the provided information. - The staging is based on the **available pathological findings only**, which do not mention any distant spread. *T1, N1, M0* - **T1** classification indicates that the tumor invades the **submucosa** but not the muscularis propria, which contradicts the information that the tumor invaded the **muscularis propria**. - Although **N1** and **M0** are consistent with the provided information regarding lymph nodes and distant metastasis, the **T-stage is incorrect**. *T1, N0, M0* - **T1** is incorrect as the tumor invaded the **muscularis propria**. - **N0** is incorrect as there were **2 positive regional lymph nodes** which indicates nodal involvement.

Q: A 25-year-old woman with inflammatory bowel disease requires total colectomy with ileostomy. She is getting married in 6 months and wants to know about conversion to J-pouch. She has mild perianal disease and takes anti-TNF therapy. Evaluate the timing and appropriateness of J-pouch reconstruction.

Staged J-pouch after 3-6 months with temporary ileostomy. ***Staged J-pouch after 3-6 months with temporary ileostomy*** - This approach allows for **bowel recovery** after the initial colectomy and addresses the presence of **mild perianal disease**, which can worsen with immediate J-pouch construction. - The 3-6 month window aligns with the patient's desire for reconstruction before her wedding, providing sufficient time for healing and assessment. - **Anti-TNF therapy** increases perioperative complications, making staged reconstruction safer. *Alternative continent ileostomy procedure* - This procedure, like a **Kock pouch**, is complex and carries its own set of complications, making it a less favored primary option compared to a J-pouch. - It might be considered in cases where a J-pouch is contraindicated or fails, but not as a first-line alternative in this scenario. *Immediate J-pouch construction during colectomy* - This is generally not recommended in patients with **active inflammatory bowel disease** (even if mild) or those on **anti-TNF therapy**, as it significantly increases the risk of **anastomotic leaks** and pouch-related complications. - The presence of **perianal disease** further contraindicates an immediate approach due to increased infection risk. *Delay J-pouch until after marriage and pregnancy* - While pregnancy can influence J-pouch function, current evidence supports that a well-established J-pouch does not significantly impact fertility or pregnancy outcomes. - Delaying unnecessarily can cause the patient to endure a permanent ileostomy longer than desired, impacting her quality of life and wedding plans.

Q: A 28-year-old woman with ulcerative colitis requires emergency colectomy for toxic megacolon. She is 20 weeks pregnant with her first child. The obstetric team is concerned about fetal risks, while the surgical team emphasizes maternal life-threatening condition. The patient wants to prioritize fetal safety. Evaluate the management approach.

Immediate colectomy with fetal monitoring. ***Immediate colectomy with fetal monitoring*** - **Toxic megacolon** is a life-threatening complication that requires urgent surgical intervention to prevent **bowel perforation** and **sepsis**, which would be devastating for both mother and fetus. - While fetal stability is important, the mother's life must be prioritized, as fetal viability is impossible without a living mother; continuous **fetal monitoring** during and after surgery is crucial to assess fetal well-being. *Immediate delivery followed by colectomy* - At **20 weeks gestation**, the fetus is **non-viable**, meaning it cannot survive outside the womb. - Attempting immediate delivery would expose the mother to urgent surgery after a failed obstetric procedure, increasing her morbidity without improving fetal outcome. *Transfer to tertiary care center* - This patient has an **emergency condition** (**toxic megacolon**) that requires immediate intervention; delaying definitive treatment for transfer could lead to **bowel perforation** and **sepsis**, increasing mortality for both mother and fetus. - The necessary surgical expertise and resources for such an emergency are typically available at most acute care hospitals. *Delayed surgery with maximum medical management* - **Toxic megacolon** is a surgical emergency; delaying surgery and relying solely on medical management significantly increases the risk of **perforation**, **sepsis**, and maternal and fetal mortality. - Medical management is typically reserved for less severe forms of colitis or as a temporizing measure before surgery, and it has already failed as the patient developed toxic megacolon.

Q: A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?

Wide surgical excision with histopathological examination. ***Wide surgical excision with histopathological examination*** - This is the most appropriate management due to the **extensive, treatment-resistant perianal condyloma acuminata** in an **HIV-positive patient with HPV type 16**, which carries a higher risk of **malignant transformation**. - **Surgical excision** allows for complete removal of the lesions and provides tissue for **histopathological examination** to rule out **dysplasia or squamous cell carcinoma**. *HPV vaccination* - While important for prevention, **HPV vaccination** is generally less effective as a primary treatment for **established, extensive lesions**, especially with existing infection. - It primarily aims to prevent new infections and may have some benefit in preventing recurrence, but it won't resolve the current burden of disease. *Interferon therapy* - **Interferon therapy** can be used for severe, recurrent, or difficult-to-treat warts, but its efficacy is variable and generally considered a **second-line or adjunctive treatment**. - Given the patient's **immunosuppressed status** and **resistance to conventional treatments**, a more definitive approach is needed. *Continue conservative management with topical imiquimod* - The patient has already demonstrated **resistance to conventional treatments**, suggesting that continued topical therapy with **imiquimod** is unlikely to be effective. - In an HIV-positive individual with **extensive lesions and high-risk HPV type 16**, waiting for a response to conservative therapy could delay definitive management and potentially increase the **risk of malignant progression**.

Q: A jeep driver presents with pain in the gluteal region along with swelling and pus discharge for the past 6 months. What is the most likely diagnosis?

Pilonidal sinus. ***Pilonidal sinus*** - This is the classic presentation of **pilonidal sinus disease**, historically known as **"Jeep disease"** due to its high incidence in military personnel during WWII who sat for prolonged periods in jeeps - The **occupational clue "jeep driver"** is pathognomonic for pilonidal sinus, as prolonged sitting causes friction and pressure in the **sacrococcygeal/natal cleft region** - Presents with **chronic pain, swelling, and intermittent pus discharge** in the gluteal region, typically over weeks to months - Risk factors include: prolonged sitting, friction, deep natal cleft, obesity, and excessive body hair - The **chronic 6-month duration** with ongoing discharge is characteristic of pilonidal sinus with secondary infection, not an acute abscess *Gluteal abscess* - While this can cause pain, swelling, and pus discharge, it typically presents **acutely** (days to weeks, not 6 months) - Does not have the specific **occupational association with prolonged sitting** (jeep driver) - Would be expected to either resolve with drainage/antibiotics or progress to sepsis, not persist chronically for 6 months - Lacks the classic "Jeep disease" eponym *Fistula in ano* - This involves an abnormal tract between the **anal canal and perianal skin** - Discharge would be localized **perianally**, close to the anus, not in the broader gluteal/sacrococcygeal region - Does not have the jeep driver occupational association *Fissure in ano* - A **tear in the anal canal lining** causing severe pain during defecation with **bright red bleeding** - Does not present with swelling or chronic pus discharge - Pain is characteristically related to bowel movements, not constant

Q: What surgery is shown here in the image?

Thiersch wiring. ***Thiersch wiring*** - The image clearly depicts a **suture or wire** placed circumferentially around the anus to reduce its caliber, which is the hallmark of a **Thiersch procedure**. - This technique is used to treat **anal incontinence** by constricting the anal opening and improving sphincter function. *Hemorrhoidectomy* - This procedure involves the **surgical removal of hemorrhoids** and the images do not show any identifiable hemorrhoidal tissue being excised. - While bleeding and prolapse can be associated with hemorrhoids, the depicted technique with circumferential wiring is not used for their removal. *Altemeier operation* - The Altemeier operation is a type of **perineal rectosigmoidectomy** for rectal prolapse that involves resecting the prolapsed segment of the rectum. - The image does not illustrate resection of rectal tissue; instead, it shows a constricting device around the anus. *Wells procedure* - The Wells procedure, or **rectopexy**, involves anchoring the rectum to the sacrum to correct rectal prolapse. - This procedure typically involves an abdominal approach and fixation techniques, which are not represented in the illustration.

Q: Which of the following is not a perineal approach for the condition shown in the image?

Ripstein's procedure. ***Ripstein's procedure*** - The Ripstein procedure is an **abdominal approach** used for performing a rectopexy to treat rectal prolapse, which is clearly visible in the image. - It involves **fixing the rectum to the sacrum** through an abdominal incision using a synthetic mesh sling. - This is the **only non-perineal approach** among the options listed. *Delorme's procedure* - This is a **perineal approach** for rectal prolapse. - Involves **mucosal stripping** and plication of the rectal muscle wall through the anus. - Suitable for patients unfit for abdominal surgery or with short segment prolapse. *Altemeier's procedure* - This is a **perineal rectosigmoidectomy** (perineal approach). - Involves **resection of the prolapsed rectum and sigmoid colon** through the perineum. - Often combined with levatoroplasty for better results. *Thiersch's procedure* - This is a **perineal encirclement procedure**. - Involves placing a **wire, suture, or synthetic material** around the anus to narrow the anal opening. - Simple perineal approach but has high recurrence rates; rarely used as definitive treatment.

Q: A 53-year-old patient presents with per rectal bleeding. Which is the most appropriate investigation to evaluate for colorectal pathology?

Colonoscopy. ***Colonoscopy*** - **Gold standard investigation** for per rectal bleeding and suspected colorectal pathology - Allows **direct visualization** of the entire colon and rectum - Enables **biopsy** of any suspicious lesions for histopathological diagnosis - Can identify various causes: **polyps, diverticula, inflammatory bowel disease, and colorectal cancer** - Therapeutic potential for polypectomy during the same procedure *CECT (Contrast-enhanced CT scan)* - Can detect large masses and assess for metastasis but not the primary diagnostic tool - Does not allow direct visualization of the mucosa or biopsy capability - Not suitable for identifying subtle mucosal lesions or early pathology - May be used as an adjunct for staging after diagnosis *CA-19-9 levels* - Tumor marker primarily associated with **pancreatic cancer** - Not routinely used for diagnosis or screening of colorectal malignancies - Lacks sensitivity and specificity for colorectal pathology - Not appropriate as initial investigation for per rectal bleeding *CEA levels (Carcinoembryonic antigen)* - Tumor marker that can be elevated in colorectal cancer - Primarily used for **monitoring treatment response** and **detecting recurrence** - Not sensitive or specific enough for initial diagnosis - Cannot replace endoscopic evaluation for per rectal bleeding

Q: A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?

CT-guided percutaneous abscess drainage. ***CT-guided percutaneous abscess drainage*** - The imaging finding of a **5.5-cm, low-attenuating pelvic fluid collection** in a patient with diverticulitis strongly indicates a **diverticular abscess**. - **Abscesses greater than 3 cm** associated with diverticulitis typically require **percutaneous drainage** in addition to antibiotics and bowel rest, as spontaneous resolution is unlikely. *Observation and serial CT scans* - While observation is appropriate for **uncomplicated diverticulitis** or small abscesses (<3 cm), a **5.5-cm abscess** warrants more aggressive intervention. - Simply observing without draining a large abscess can lead to **sepsis** or abscess rupture. *Segmental colonic resection* - **Surgical resection** is usually reserved for cases of **perforated diverticulitis** with diffuse peritonitis, recurrent diverticulitis, or complicated diverticulitis that fails conservative management including drainage. - It is not the immediate next step for a drainable abscess without signs of diffuse peritonitis. *Colonoscopy* - **Colonoscopy** is generally contraindicated during an acute episode of diverticulitis due to the **risk of perforation**. - It is typically performed several weeks after resolution of the acute inflammation to rule out malignancy or other colonic pathology.

Q: Best treatment strategy for carcinoma of the anal canal:

Chemoradiation. ***Chemoradiation*** - Carcinoma of the anal canal is primarily treated with **chemoradiation** (combinations of chemotherapy and radiation therapy) as the standard of care to achieve **organ preservation**. - This combined approach improves local control and survival rates compared to either modality alone, making it the **primary curative strategy** for most localized anal canal cancers. *Radiation* - While radiation therapy is a crucial component of anal canal cancer treatment, using it alone (**monotherapy**) is generally less effective than chemoradiation. - **Local recurrence rates** are higher with radiation alone compared to combined modality treatment. *Surgery* - Surgery, specifically **abdominoperineal resection (APR)**, is typically reserved for **recurrent disease** or cases where chemoradiation fails. - Initial radical surgery for anal canal cancer leads to significant morbidity (e.g., permanent colostomy) and is generally avoided as a primary treatment due to the success of chemoradiation. *Chemotherapy* - Chemotherapy alone is **not curative** for localized anal canal carcinoma. - It is primarily used in combination with radiation (chemoradiation) to sensitize the tumor to radiation and improve local control, or as treatment for **metastatic disease**.

Question 1

Gentleman of 56 years underwent laparoscopic left hemicolectomy for diagnosed left colonic carcinoma. Histopathology revealed the tumour to be invading submucosa and muscularis propria. Among the 16 regional lymph nodes harvested, 2 were positive for malignant deposits. His staging as per AJCC will be:

Accepted Answer

T2, N1, M0

Answer

T2, N1, M1

Answer

T1, N1, M0

Answer

T1, N0, M0

Question 2

A 25-year-old woman with inflammatory bowel disease requires total colectomy with ileostomy. She is getting married in 6 months and wants to know about conversion to J-pouch. She has mild perianal disease and takes anti-TNF therapy. Evaluate the timing and appropriateness of J-pouch reconstruction.

Accepted Answer

Staged J-pouch after 3-6 months with temporary ileostomy

Answer

Alternative continent ileostomy procedure

Answer

Immediate J-pouch construction during colectomy

Answer

Delay J-pouch until after marriage and pregnancy

Question 3

A 28-year-old woman with ulcerative colitis requires emergency colectomy for toxic megacolon. She is 20 weeks pregnant with her first child. The obstetric team is concerned about fetal risks, while the surgical team emphasizes maternal life-threatening condition. The patient wants to prioritize fetal safety. Evaluate the management approach.

Accepted Answer

Immediate colectomy with fetal monitoring

Answer

Immediate delivery followed by colectomy

Answer

Transfer to tertiary care center

Answer

Delayed surgery with maximum medical management

Question 4

A 35-year-old HIV-positive woman (CD4 count 180/μL, on HAART) develops extensive perianal condyloma acuminata resistant to conventional treatments. HPV typing shows type 16. What is the most appropriate management approach?

Accepted Answer

Wide surgical excision with histopathological examination

Answer

HPV vaccination

Answer

Interferon therapy

Answer

Continue conservative management with topical imiquimod

Question 5

A jeep driver presents with pain in the gluteal region along with swelling and pus discharge for the past 6 months. What is the most likely diagnosis?

Accepted Answer

Pilonidal sinus

Answer

Fistula in ano

Answer

Fissure in ano

Answer

Gluteal abscess

Question 6

What surgery is shown here in the image?

Accepted Answer

Thiersch wiring

Answer

Hemorrhoidectomy

Answer

Altemeier operation

Answer

Wells procedure

Question 7

Which of the following is not a perineal approach for the condition shown in the image?

Accepted Answer

Ripstein's procedure

Answer

Delorme's procedure

Answer

Altemeier's procedure

Answer

Thiersch's procedure

Question 8

A 53-year-old patient presents with per rectal bleeding. Which is the most appropriate investigation to evaluate for colorectal pathology?

Accepted Answer

Colonoscopy

Answer

CECT (Contrast-enhanced CT scan)

Answer

CA-19-9 levels

Answer

CEA levels

Question 9

A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

CT-guided percutaneous abscess drainage

Answer

Observation and serial CT scans

Answer

Segmental colonic resection

Answer

Colonoscopy

Question 10

Best treatment strategy for carcinoma of the anal canal:

Accepted Answer

Chemoradiation

Answer

Radiation

Answer

Surgery

Answer

Chemotherapy

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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