General Surgery Board Review General Surgery Board Review Gastrointestinal Surgery 2 — Questions and Answers
Question 1: Which factor best defines resectability of colorectal liver metastases (CRLM)?
- Three or fewer lesions present
- Ability to achieve R0 resection with adequate future liver remnant volume (Correct answer)
- No extrahepatic disease on imaging
- All lesions smaller than 5 cm in diameter
Correct answer: Ability to achieve R0 resection with adequate future liver remnant volume
Modern criteria define CRLM resectability as the ability to achieve negative margins (R0) while leaving adequate functional liver remnant (≥25–30% of total liver volume) — number and size are no longer absolute contraindications.
Question 2: A T3N1M0 colon cancer corresponds to which AJCC stage?
- Stage I
- Stage IIA
- Stage IIIB (Correct answer)
- Stage IV
Correct answer: Stage IIIB
T3N1M0 colon cancer is Stage IIIB: T3 indicates invasion through the muscularis propria into pericolorectal tissues, N1 indicates 1–3 positive regional nodes, and M0 indicates no distant metastasis.
Question 3: A patient with Crohn's disease has an ileosigmoid fistula. What is the standard surgical approach?
- Sigmoid resection alone
- Resection of the diseased terminal ileum with simple closure or repair of the sigmoid defect (Correct answer)
- Diverting loop ileostomy only
- Biologic therapy and observation indefinitely
Correct answer: Resection of the diseased terminal ileum with simple closure or repair of the sigmoid defect
The diseased bowel (terminal ileum in Crohn's) is the source of the fistula; resection of the affected ileum with closure of the 'innocent bystander' sigmoid defect is the standard surgical approach.
Question 4: Which operation is preferred for a patient with toxic megacolon from ulcerative colitis who fails 48–72 hours of maximal medical therapy?
- Total proctocolectomy with ileal pouch-anal anastomosis (IPAA)
- Subtotal colectomy with end ileostomy (Correct answer)
- Hartmann procedure (sigmoid resection with end colostomy)
- Diverting loop ileostomy alone
Correct answer: Subtotal colectomy with end ileostomy
Subtotal colectomy with end ileostomy is the preferred emergency operation — it removes the diseased colon quickly, preserves the rectum for future IPAA, and avoids pelvic dissection in a sick patient.
Question 5: The most common cause of significant lower GI bleeding in patients over 60 years of age is:
- Colorectal cancer
- Diverticulosis (Correct answer)
- Angiodysplasia
- Internal hemorrhoids
Correct answer: Diverticulosis
Diverticulosis accounts for approximately 40–55% of significant lower GI bleeding episodes in elderly patients; most bleeds stop spontaneously but can be massive.
Question 6: Peutz-Jeghers syndrome is characterized by which combination of features?
- Adenomatous polyps, desmoid tumors, and extraintestinal osteomas
- Hamartomatous GI polyps, mucocutaneous melanin pigmentation, and increased GI and extraintestinal cancer risk (Correct answer)
- Hyperplastic polyps and mismatch repair gene mutations
- Juvenile polyps and protein-losing enteropathy only
Correct answer: Hamartomatous GI polyps, mucocutaneous melanin pigmentation, and increased GI and extraintestinal cancer risk
Peutz-Jeghers syndrome (STK11/LKB1 mutation) presents with hamartomatous polyps throughout the GI tract, perioral and buccal melanin spots, and elevated lifetime risks of GI, breast, pancreatic, and gynecologic cancers.
General Surgery Board Review General Surgery Board Review Gastrointestinal Surgery 2
Which factor best defines resectability of colorectal liver metastases (CRLM)?