General Surgery Board Review Case Studies & Practical Application 5

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?

Accepted Answer

Anatomic lobectomy

Answer

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?

Accepted Answer

Pyogenic liver abscess from portal pyemia (pylephlebitis)

Answer

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?

Accepted Answer

Acute colonic pseudo-obstruction (Ogilvie's syndrome) — neostigmine or colonoscopic decompression

Answer

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?

Accepted Answer

Alpha-blockade first, then laparoscopic adrenalectomy

Answer

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?

Accepted Answer

Radiofrequency ablation (RFA)

Answer

Endoscopic radiofrequency ablation is the first-line treatment for flat high-grade dysplasia in Barrett's esophagus without submucosal invasion.

General Surgery Board Review Practice Test

General Surgery Board Review Practice Test

General Surgery Board Review Case Studies & Practical Application 5