AOCNP Surgical Oncology and Perioperative Care 4 — Questions and Answers
Question 1: A patient undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) develops hypotension and tachycardia intraoperatively. Which factor is MOST likely contributing to hemodynamic instability during HIPEC?
- Hypervolemia from excessive IV fluids
- Vasodilation from hyperthermia and cytokine release (Correct answer)
- Anaphylaxis to the chemotherapy agent
- Tension pneumothorax from surgical positioning
Correct answer: Vasodilation from hyperthermia and cytokine release
HIPEC causes significant vasodilation and third-spacing due to hyperthermia and systemic cytokine release, leading to hemodynamic instability requiring aggressive fluid management.
Question 2: A patient with locally advanced rectal cancer is scheduled for abdominoperineal resection (APR). Which preoperative bowel preparation practice is currently supported by enhanced recovery after surgery (ERAS) protocols?
- Mandatory mechanical bowel preparation plus oral antibiotics (Correct answer)
- Mechanical bowel preparation alone without oral antibiotics
- Oral antibiotics alone without mechanical bowel preparation
- Neither mechanical prep nor oral antibiotics are recommended
Correct answer: Mandatory mechanical bowel preparation plus oral antibiotics
Current ERAS evidence for colorectal surgery supports combined mechanical bowel preparation with oral antibiotics to reduce surgical site infection rates.
Question 3: Which sentinel lymph node biopsy technique uses a combination of radioisotope and blue dye to achieve the highest identification rate in breast cancer surgery?
- Blue dye alone injected subdermally
- Radioisotope alone injected peritumorally
- Dual-agent technique combining radioisotope and blue dye (Correct answer)
- Indocyanine green fluorescence alone
Correct answer: Dual-agent technique combining radioisotope and blue dye
The dual-agent technique combining radiolabeled colloid and blue dye achieves sentinel node identification rates exceeding 95%, superior to either agent used alone.
Question 4: A patient 48 hours post-esophagectomy develops fever, tachycardia, and increased chest tube output with turbid fluid. Which complication is MOST likely?
- Pulmonary embolism
- Anastomotic leak (Correct answer)
- Chylothorax
- Empyema from pre-existing infection
Correct answer: Anastomotic leak
Anastomotic leak post-esophagectomy typically presents 48–72 hours postoperatively with fever, tachycardia, and chest tube drainage changes, representing the most feared early complication.
Question 5: When performing intraoperative frozen section analysis of surgical margins in a patient with oral cavity squamous cell carcinoma, a finding of 'close margin' (<1mm) should prompt the surgeon to:
- Proceed with closure and plan adjuvant radiation
- Take additional tissue to achieve clear margins intraoperatively (Correct answer)
- Abort the procedure and plan re-excision at a later date
- Accept the margin and increase chemotherapy dosing postoperatively
Correct answer: Take additional tissue to achieve clear margins intraoperatively
Intraoperative frozen section provides real-time guidance, and close or positive margins should be addressed immediately by re-excision to optimize local control.
Question 6: A post-thyroidectomy patient in the PACU develops stridor, neck swelling, and respiratory distress 2 hours after surgery. The FIRST priority intervention is:
- Administer IV calcium gluconate for hypocalcemia
- Obtain stat neck CT to assess hematoma extent
- Open the wound at bedside to relieve airway compression (Correct answer)
- Request emergent bronchoscopy
Correct answer: Open the wound at bedside to relieve airway compression
Post-thyroidectomy neck hematoma causing airway obstruction requires immediate bedside wound opening to decompress the hematoma before definitive airway management.
Question 7: In a patient undergoing Whipple procedure (pancreaticoduodenectomy), which postoperative complication is defined by the International Study Group on Pancreatic Fistula (ISGPF) as amylase-rich drain fluid output >3x the upper limit of serum amylase on or after postoperative day 3?
- Delayed gastric emptying
- Postoperative pancreatic fistula (POPF) (Correct answer)
- Bile leak
- Chylous ascites
Correct answer: Postoperative pancreatic fistula (POPF)
The ISGPF defines postoperative pancreatic fistula as drain fluid amylase >3x upper limit of normal serum amylase after POD3, graded A through C by clinical impact.
AOCNP Surgical Oncology and Perioperative Care 4
A patient undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) develops hypotension and tachycardia intraoperatively.
Which factor is MOST likely contributing to hemodynamic instability during HIPEC?