FRCS Pre/Postoperative Care & Surgical Oncology — Questions and Answers
Question 1: Which ASA classification describes a patient with a known systemic disease that causes moderate functional limitation (e.g., COPD requiring bronchodilators, controlled DM, mild heart failure)?
- ASA I
- ASA II
- ASA III (Correct answer)
- ASA IV
Correct answer: ASA III
ASA III describes a patient with a severe systemic disease causing substantial functional limitation but that is not immediately life-threatening. Examples include COPD, poorly controlled DM or hypertension, morbid obesity (BMI >40), active hepatitis, or alcohol dependence. ASA II is mild systemic disease with no functional limitation.
Question 2: What is the most common electrolyte abnormality following prolonged nasogastric suction?
- Hyperkalaemia
- Hypocalcaemia
- Hypokalaemia with metabolic alkalosis (Correct answer)
- Hypernatraemia
Correct answer: Hypokalaemia with metabolic alkalosis
Prolonged nasogastric suction removes gastric fluid rich in HCl and KCl. This causes hypochloraemic, hypokalaemic metabolic alkalosis. Potassium is lost both directly in gastric juice and via secondary renal wasting (increased aldosterone secretion in response to hypovolaemia further promotes K+ loss).
Question 3: What is the risk of venous thromboembolism prophylaxis failure, and which method significantly reduces it when combined with LMWHs?
- Aspirin alone adequately replaces LMWH
- Graduated compression stockings combined with LMWH reduce VTE risk more than LMWH alone (Correct answer)
- Only mechanical devices are needed — LMWH adds little
- Warfarin is preferred over LMWH in surgical patients
Correct answer: Graduated compression stockings combined with LMWH reduce VTE risk more than LMWH alone
The combination of mechanical prophylaxis (TED stockings and/or intermittent pneumatic compression) with pharmacological prophylaxis (LMWH) is more effective than either alone in reducing post-operative VTE. NICE guidelines recommend combined prophylaxis for moderate-to-high risk surgical patients.
Question 4: A patient develops a swinging fever, right upper quadrant pain, and an elevated alkaline phosphatase on day 7 post-cholecystectomy. What is the most likely diagnosis?
- Anastomotic leak
- Bile duct injury with bile leak
- Subphrenic abscess or intra-abdominal abscess (Correct answer)
- Wound infection
Correct answer: Subphrenic abscess or intra-abdominal abscess
Swinging fever (characteristic of abscess), RUQ pain, and elevated ALP developing 5–10 days post-operatively suggests an intra-abdominal abscess (subhepatic or subphrenic). CT abdomen confirms the diagnosis and guides drainage. A bile duct injury typically presents with jaundice and/or peritonism.
Question 5: Which scoring system is used to predict the severity of acute pancreatitis at 48 hours?
- Glasgow-Blatchford score
- Glasgow (Imrie) criteria (Correct answer)
- Child-Pugh score
- Alvarado score
Correct answer: Glasgow (Imrie) criteria
The Glasgow (Imrie) criteria use 8 parameters at 48 hours (PO2 <8 kPa, age >55, WBC >15, calcium <2 mmol/L, urea >16, LDH >600, albumin <32, glucose >10). A score of ≥3 indicates severe pancreatitis. The Ranson criteria are similar but use 5 admission and 5 at-48-hour factors.
Question 6: What is the most important preoperative investigation before major elective surgery in a patient with known ischaemic heart disease?
- Chest X-ray
- Resting 12-lead ECG and cardiology review with functional assessment (Correct answer)
- Routine blood tests only
- Exercise tolerance test regardless of functional capacity
Correct answer: Resting 12-lead ECG and cardiology review with functional assessment
Perioperative cardiac assessment requires determining the patient's functional capacity (METs), current cardiac status, and any reversible ischaemia. ACC/AHA and UK guidelines recommend cardiology review, resting ECG, and if intermediate or high risk, further evaluation with stress testing or cardiac imaging to guide optimisation and anaesthetic planning.
FRCS Pre/Postoperative Care & Surgical Oncology
Which ASA classification describes a patient with a known systemic disease that causes moderate functional limitation (e.g., COPD requiring bronchodilators, controlled DM, mild heart failure)?