colorectal questions and answers for surgery residents

Colo Rectal disease

1. A 55-year-old man has laparoscopic appendectomy for acute appendicitis. During the operation, a contained rupture of the tip of the appendix is found. Gelatinous ascites fluid is evacuated from the abdomen and pelvis. Pathologic evaluation of the appendix indicates a 3-cm low-grade mucinous neoplasm obstructing the lumen at the base of the appendix, with perforation of the tip. No invasion of the mesoappendix is identified, and all margins of resection are negative. Cytologic analysis of the gelatinous ascites fluid demonstrates extensive acellular mucin with scant low-grade mucinous cells. Which one of the following statements about this type of neoplasm is correct? A . Epithelial neoplasms of the appendix are found incidentally in 1% to 5% of appendectomy specimens. B . A right hemicolectomy optimally should have been performed at the time of surgery. C . Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) should be considered for this patient. D . Median 5-year survival rate would be expected to be 30% to 50%. E . Cytoreductive surgery and HIPEC are associated with morbidity rates of less than 10% in this setting.

2. A 40-year-old otherwise healthy man has a symptomatic right inguinal hernia. He has a history of increased abdominal girth and early satiety over the past 12 months. The patient's weight is stable and he demonstrates excellent exercise tolerance. Upper and lower endoscopy are normal. Computed tomography (CT) of the abdomen and pelvis is performed (Figure 1). Percutaneous biopsy indicates abundant mucin and scant cellularity.  Which of the following is the most appropriate next step? A . Open peritoneal biopsy with mesh repair B . Percutaneous drainage of ascites and right colectomy C . Repair of the inguinal hernia with mesh and repeat CT in 6 months D . Exploration with histologic confirmation followed by cytoreduction and intraperitoneal chemotherapy E . Six months of systemic chemotherapy with folic acid, fluorouracil, and oxaliplatin (FOLFOX) and a biologic agent and repeat CT

3. A 75-year-old woman with stage IV rectal cancer with intra-abdominal, subcutaneous, and brain metastases has nausea/emesis and abdominal distension. Progressive disease was recently found during third-line chemotherapy. Computed tomography (CT) demonstrates multiple intra-abdominal metastases and small-bowel obstruction at multiple sites throughout the abdomen with ascites (Figure). Which of the following treatments is most likely to improve the patient's symptoms and allow for discharge home? A . Percutaneous placement of a gastrostomy tube B . Placement of a jejunostomy tube C . Small-bowel bypass, resection, or ileostomy as intraoperative findings indicate D . Cytoreduction and hyperthermic intraperitoneal perfusion E . Insertion of indwelling catheter for total parenteral nutrition

4. A 60-year-old woman has cytoreduction of all macroscopic tumor from a mucinous adenocarcinoma with extensive involvement of the peritoneal surfaces, and hyperthermic intraperitoneal chemotherapy (HIPEC) with mitomycin C (30 mg/m 2 ) administered by open technique. Which one of the following represents the most common postoperative complication(s) associated with this surgery? A . Prolonged ileus with or without evidence of pancreatitis B . Renal insufficiency that could be prevented with sodium thiosulfate administration C . Renal insufficiency due to hyperthermia that is self-limited and reverses on its own over 24-36 hours D . Intraoperative hyperglycemia and severe electrolyte imbalances due to mitomycin C diluent E . Temporarily decreased WBC from chemotherapy-induced bone marrow suppression

5. A 60-year-old man is diagnosed with goblet-cell carcinoid (GCC) of the appendix after routine appendectomy for uncomplicated appendicitis. Biopsy indicates a T3 tumor of 0.75 cm, with a negative proximal margin. Which of the following is the most appropriate recommendation? A . No active treatment, as the prognosis is excellent B . Adjuvant hyperthermic intraperitoneal chemotherapy (HIPEC) without additional colon resection required. C . Adjuvant long-acting somatostatin analogue without additional surgery. D . Right colectomy and adjuvant chemotherapy with a colon cancer regimen if disease is node-positive E . Right colectomy and adjuvant therapy with somatostatin if disease is node-positive

6. A 50-year-old woman has surgical exploration for presumed ovarian cancer. Findings include tumor arising from the cecum and involving the right ovary, right pelvic sidewall, uterus, subdiaphragmatic peritoneal surfaces, and extensive small-bowel serosa surfaces. There is no evidence of obstruction or bleeding. Evaluation of a frozen section specimen from a peritoneal implant indicates high-grade adenocarcinoma with signet ring features. The patient has an excellent performance status and noted before the surgery that she wants aggressive treatment. Which of the following is the most appropriate recommendation? A . Administer hyperthermic intraperitoneal chemotherapy (HIPEC) with limited cytoreduction to minimize morbidity B . Administer HIPEC with complete/near complete cytoreduction C . Perform cecectomy D . Stop the operation and refer the patient for whole-abdomen radiation therapy E . Stop the operation and refer the patient for systemic chemotherapy

7. A 40-year-old otherwise healthy man had a laparoscopic appendectomy 4 weeks ago. His recovery was uneventful, and he has no symptoms. Mucin was seen in the pelvis during the operation, and biopsy specimens were obtained from several omental mucinous implants. Biopsy indicates a ruptured appendiceal well-differentiated mucinous adenocarcinoma with a negative proximal margin. Examination of the mucinous implants confirms adenocarcinoma without signet ring cells. Computed tomography (CT) of the chest, abdomen, and pelvis is normal. Which of the following is the most appropriate recommendation? A . Observation and treatment at the onset of symptoms or evidence of progression B . Systemic fluorouracil (5-FU)-based chemotherapy, with surgery considered for palliation if symptoms develop such as bowel obstruction C . Right colectomy with excision of associated mesentery and omentum followed by systemic 5-FU-based chemotherapy D . Right colectomy with excision of associated mesentery; cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) E . Placement of a peritoneal catheter for combined systemic and intraperitoneal administration of chemotherapy

8. A 60-year-old woman undergoes cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis from colorectal cancer.  She had colon and small-bowel resections with anastomosis, peritoneal stripping of right diaphragm, omentectomy , splenectomy and bilateral salpingo -oophorectomy. Which complication is least likely? A . Pleural effusion B . Post-operative bleeding requiring reoperation C . Prolonged ileus D . Pancreatic fistula E . Anastomotic leak, fistula, or abscess

9. A 60-year-old female with low-grade mucinous appendiceal neoplasm is offered cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC). She states that she has read about early postoperative intraperitoneal chemotherapy (EPIC). Which of the following statements is true when comparing HIPEC to EPIC? A . Both therapies utilize heat. B . Both therapies are administered in the operating room. C . Both therapies can result in neutropenia. D . Both therapies have level 1 data to show a benefit for their use. E . Both therapies take the same amount of time for administration and completion of treatment.

10. A cytoreduction and hyperthermic intraperitoneal chemotherapy perfusion has just been performed for a woman with an appendiceal mucinous neoplasm and pseudomyxoma peritoneii . Despite a considerable disease burden, a resection is performed with a complete cytoreduction score of 0 (CC-0) (Figure). The final pathologic evaluation indicates a low-grade mucinous neoplasm, with 20 negative lymph nodes in the right hemicolectomy specimen. The patient recovers well after the operation. Which of the following is the most appropriate follow-up care for this patient? A . Surveillance imaging B . Adjuvant intraperitoneal chemotherapy C . Adjuvant systemic chemotherapy D . Planned repeat HIPEC E . Second-look exploratory laparotomy

11. A 66-year-old man is seen because of a 6-month history of vague abdominal pain associated with diarrhea, a 9-pound (4.1-kg) weight loss, and fatigue. Examination of the abdomen is unremarkable. No abnormalities are found on upper and lower endoscopies. Computed tomography (CT) of the abdomen and pelvis demonstrates a mesenteric mass with surrounding mesenteric stranding. A gastrointestinal neuroendocrine tumor is suspected. At the time of surgical exploration, a jejunal lesion with mesenteric lymphadenopathy along with two liver lesions are identified. Which of the following should be the next step in the treatment of this patient? A . Stop the surgical procedure and pursue medical management. B . Perform jejunal resection with regional lymphadenectomy only. C . Perform jejunal resection with regional lymphadenectomy and prophylactic cholecystectomy. D . Carry out careful exploration of all the small intestine, perform jejunal resection with regional lymphadenectomy and resection of the liver tumors. E . Perform resection of the liver tumors only.