General Surgery Board Review Case Studies & Practical Application 5 — Questions and Answers
Question 1: A 66-year-old male smoker presents with a 3 cm right lung nodule. PET scan shows FDG avidity. Mediastinal staging is negative. Pulmonary function tests show FEV1 of 65% predicted. What is the preferred treatment?
- Stereotactic body radiotherapy (SBRT)
- Anatomic lobectomy (Correct answer)
- Wedge resection
- Chemoradiation
Correct answer: Anatomic lobectomy
Anatomic lobectomy is the gold standard for resectable stage I NSCLC in patients with adequate pulmonary reserve (FEV1 ≥40% predicted).
Question 2: A 52-year-old male presents 8 days after laparoscopic appendectomy with fever, chills, and right upper quadrant pain. Labs show elevated alkaline phosphatase and WBC 18,000. CT reveals multiple hypodense liver lesions with peripheral rim enhancement. What is the most likely diagnosis?
- Hepatocellular carcinoma
- Pyogenic liver abscess from portal pyemia (pylephlebitis) (Correct answer)
- Amoebic liver abscess
- Cholangiocarcinoma
Correct answer: Pyogenic liver abscess from portal pyemia (pylephlebitis)
Multiple liver abscesses developing after appendectomy are classic for pylephlebitis (septic portal vein thrombosis) with seeding of the liver.
Question 3: A 75-year-old woman presents with a 4-day history of worsening abdominal distension and obstipation. She had a sigmoid colectomy 10 years ago. CT shows a massively dilated cecum (12 cm) without a transition point or mechanical obstruction. What is the diagnosis and treatment?
- Sigmoid volvulus — emergent sigmoidoscopy
- Acute colonic pseudo-obstruction (Ogilvie's syndrome) — neostigmine or colonoscopic decompression (Correct answer)
- Cecal volvulus — right hemicolectomy
- Small bowel obstruction — nasogastric decompression
Correct answer: Acute colonic pseudo-obstruction (Ogilvie's syndrome) — neostigmine or colonoscopic decompression
Acute colonic pseudo-obstruction with cecal dilation >12 cm and no mechanical cause is treated with IV neostigmine or colonoscopic decompression to prevent perforation.
Question 4: A 38-year-old male is found to have a 4 cm adrenal mass incidentally on CT. Lab workup shows elevated urinary metanephrines and normetanephrines. BP is 148/92. What is the correct sequence of management?
- Laparoscopic adrenalectomy immediately
- Alpha-blockade first, then laparoscopic adrenalectomy (Correct answer)
- Beta-blockade first, then surgery
- Biopsy of the mass, then surgery
Correct answer: Alpha-blockade first, then laparoscopic adrenalectomy
Pheochromocytoma requires alpha-adrenergic blockade (phenoxybenzamine) for at least 10-14 days preoperatively before surgical resection to prevent hypertensive crisis.
Question 5: A 60-year-old woman with a 15-year history of Barrett's esophagus undergoes surveillance endoscopy showing high-grade dysplasia in a 3 cm segment without a visible lesion. Endoscopic ultrasound shows no submucosal invasion. What is the best treatment?
- Esophagectomy
- Radiofrequency ablation (RFA) (Correct answer)
- Photodynamic therapy
- Surveillance endoscopy every 3 months
Correct answer: Radiofrequency ablation (RFA)
Endoscopic radiofrequency ablation is the first-line treatment for flat high-grade dysplasia in Barrett's esophagus without submucosal invasion.
Question 6: A 45-year-old male presents with obstructive jaundice. CT shows a 2.5 cm mass at the pancreatic head with dilation of the common bile duct and pancreatic duct (double duct sign). No distant metastases are seen. CA 19-9 is 450. What is the definitive treatment if technically resectable?
- Palliative biliary stenting only
- Pancreaticoduodenectomy (Whipple procedure) (Correct answer)
- Distal pancreatectomy
- ERCP with biopsy and gemcitabine chemotherapy
Correct answer: Pancreaticoduodenectomy (Whipple procedure)
A resectable pancreatic head adenocarcinoma is treated with pancreaticoduodenectomy, which is the only potentially curative option.
Question 7: A 34-year-old female presents with a 6-week history of dysphagia to solids and liquids. Barium swallow shows a 'bird-beak' tapering at the gastroesophageal junction. Esophageal manometry reveals absent peristalsis and failure of LES relaxation. What is the most effective long-term treatment?
- Calcium channel blockers
- Pneumatic dilation
- Heller myotomy with partial fundoplication (Correct answer)
- Botulinum toxin injection
Correct answer: Heller myotomy with partial fundoplication
Laparoscopic Heller myotomy with partial fundoplication provides the most durable long-term relief for achalasia with symptom control in 85-90% of patients.
General Surgery Board Review Case Studies & Practical Application 5
A 66-year-old male smoker presents with a 3 cm right lung nodule.
PET scan shows FDG avidity.
Mediastinal staging is negative.
Pulmonary function tests show FEV1 of 65% predicted.
What is the preferred treatment?