Colorectal Surgery Practice Questions

Q: What surgery is shown here in the image?

Thiersch wiring. ***Thiersch wiring*** - The image clearly depicts a **suture or wire** placed circumferentially around the anus to reduce its caliber, which is the hallmark of a **Thiersch procedure**. - This technique is used to treat **anal incontinence** by constricting the anal opening and improving sphincter function. *Hemorrhoidectomy* - This procedure involves the **surgical removal of hemorrhoids** and the images do not show any identifiable hemorrhoidal tissue being excised. - While bleeding and prolapse can be associated with hemorrhoids, the depicted technique with circumferential wiring is not used for their removal. *Altemeier operation* - The Altemeier operation is a type of **perineal rectosigmoidectomy** for rectal prolapse that involves resecting the prolapsed segment of the rectum. - The image does not illustrate resection of rectal tissue; instead, it shows a constricting device around the anus. *Wells procedure* - The Wells procedure, or **rectopexy**, involves anchoring the rectum to the sacrum to correct rectal prolapse. - This procedure typically involves an abdominal approach and fixation techniques, which are not represented in the illustration.

Q: Which of the following is not a perineal approach for the condition shown in the image?

Ripstein's procedure. ***Ripstein's procedure*** - The Ripstein procedure is an **abdominal approach** used for performing a rectopexy to treat rectal prolapse, which is clearly visible in the image. - It involves **fixing the rectum to the sacrum** through an abdominal incision using a synthetic mesh sling. - This is the **only non-perineal approach** among the options listed. *Delorme's procedure* - This is a **perineal approach** for rectal prolapse. - Involves **mucosal stripping** and plication of the rectal muscle wall through the anus. - Suitable for patients unfit for abdominal surgery or with short segment prolapse. *Altemeier's procedure* - This is a **perineal rectosigmoidectomy** (perineal approach). - Involves **resection of the prolapsed rectum and sigmoid colon** through the perineum. - Often combined with levatoroplasty for better results. *Thiersch's procedure* - This is a **perineal encirclement procedure**. - Involves placing a **wire, suture, or synthetic material** around the anus to narrow the anal opening. - Simple perineal approach but has high recurrence rates; rarely used as definitive treatment.

Q: A 53-year-old patient presents with per rectal bleeding. Which is the most appropriate investigation to evaluate for colorectal pathology?

Colonoscopy. ***Colonoscopy*** - **Gold standard investigation** for per rectal bleeding and suspected colorectal pathology - Allows **direct visualization** of the entire colon and rectum - Enables **biopsy** of any suspicious lesions for histopathological diagnosis - Can identify various causes: **polyps, diverticula, inflammatory bowel disease, and colorectal cancer** - Therapeutic potential for polypectomy during the same procedure *CECT (Contrast-enhanced CT scan)* - Can detect large masses and assess for metastasis but not the primary diagnostic tool - Does not allow direct visualization of the mucosa or biopsy capability - Not suitable for identifying subtle mucosal lesions or early pathology - May be used as an adjunct for staging after diagnosis *CA-19-9 levels* - Tumor marker primarily associated with **pancreatic cancer** - Not routinely used for diagnosis or screening of colorectal malignancies - Lacks sensitivity and specificity for colorectal pathology - Not appropriate as initial investigation for per rectal bleeding *CEA levels (Carcinoembryonic antigen)* - Tumor marker that can be elevated in colorectal cancer - Primarily used for **monitoring treatment response** and **detecting recurrence** - Not sensitive or specific enough for initial diagnosis - Cannot replace endoscopic evaluation for per rectal bleeding

Q: A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?

CT-guided percutaneous abscess drainage. ***CT-guided percutaneous abscess drainage*** - The imaging finding of a **5.5-cm, low-attenuating pelvic fluid collection** in a patient with diverticulitis strongly indicates a **diverticular abscess**. - **Abscesses greater than 3 cm** associated with diverticulitis typically require **percutaneous drainage** in addition to antibiotics and bowel rest, as spontaneous resolution is unlikely. *Observation and serial CT scans* - While observation is appropriate for **uncomplicated diverticulitis** or small abscesses (<3 cm), a **5.5-cm abscess** warrants more aggressive intervention. - Simply observing without draining a large abscess can lead to **sepsis** or abscess rupture. *Segmental colonic resection* - **Surgical resection** is usually reserved for cases of **perforated diverticulitis** with diffuse peritonitis, recurrent diverticulitis, or complicated diverticulitis that fails conservative management including drainage. - It is not the immediate next step for a drainable abscess without signs of diffuse peritonitis. *Colonoscopy* - **Colonoscopy** is generally contraindicated during an acute episode of diverticulitis due to the **risk of perforation**. - It is typically performed several weeks after resolution of the acute inflammation to rule out malignancy or other colonic pathology.

Q: Best treatment strategy for carcinoma of the anal canal:

Chemoradiation. ***Chemoradiation*** - Carcinoma of the anal canal is primarily treated with **chemoradiation** (combinations of chemotherapy and radiation therapy) as the standard of care to achieve **organ preservation**. - This combined approach improves local control and survival rates compared to either modality alone, making it the **primary curative strategy** for most localized anal canal cancers. *Radiation* - While radiation therapy is a crucial component of anal canal cancer treatment, using it alone (**monotherapy**) is generally less effective than chemoradiation. - **Local recurrence rates** are higher with radiation alone compared to combined modality treatment. *Surgery* - Surgery, specifically **abdominoperineal resection (APR)**, is typically reserved for **recurrent disease** or cases where chemoradiation fails. - Initial radical surgery for anal canal cancer leads to significant morbidity (e.g., permanent colostomy) and is generally avoided as a primary treatment due to the success of chemoradiation. *Chemotherapy* - Chemotherapy alone is **not curative** for localized anal canal carcinoma. - It is primarily used in combination with radiation (chemoradiation) to sensitize the tumor to radiation and improve local control, or as treatment for **metastatic disease**.

Q: Bleeding vessel in hemorrhoids is

Superior rectal artery. Superior rectal artery - Hemorrhoidal bleeding primarily originates from the **terminal branches of the superior rectal artery** within the hemorrhoidal plexus. - The hemorrhoidal cushions contain **arteriovenous anastomoses**, and bleeding occurs from rupture or erosion of the **arterial component**. - This explains why hemorrhoidal bleeding is typically **bright red** (oxygenated arterial blood) and can be brisk. - Modern surgical treatments like **hemorrhoidal artery ligation (HAL)** specifically target these arterial branches, confirming the arterial source of bleeding. Superior rectal vein - While the superior rectal vein drains the hemorrhoidal plexus and is dilated in hemorrhoids, it is **not the primary source of bleeding**. - The venous component contributes to the cushion engorgement but the **actual bleeding is arterial** in nature. - This is an older, outdated concept that has been revised with modern understanding of hemorrhoidal pathophysiology. Middle rectal vein - The middle rectal vein drains the **muscular wall of the rectum** and has minimal involvement in the hemorrhoidal venous plexus. - It is not a significant contributor to hemorrhoidal bleeding. Middle rectal artery - The middle rectal artery provides collateral blood supply to the rectum but plays a **minor role** compared to the superior rectal artery. - The **superior rectal artery** is the dominant arterial supply to the internal hemorrhoidal plexus and is the primary bleeding source.

Q: Comment on the diagnosis of a film shown of a 65-year-old man with acute abdomen:

Colocolic intussusception. ***Colocolic intussusception*** - This is a rare form of intussusception where a **proximal segment of the colon telescopes into a distal segment** within the colon itself. - In adults, it is often associated with a **lead point**, such as a tumor, polyp, or lipoma, which can be visualized on imaging. *Sigmoid volvulus* - Characterized by the **twisting of the sigmoid colon** around its mesentery, often presenting with a characteristic "coffee bean" sign on abdominal X-ray. - While it causes acute abdomen, it is distinguishable from intussusception by its specific radiological appearance and underlying mechanism of obstruction. *Ileocolic intussusception* - This involves the **terminal ileum telescoping into the cecum**, and it is the most common type of intussusception in children. - In adults, it is also typically associated with a lead point but the segment of bowel involved is different from colocolic intussusception. *Toxic megacolon* - This is a severe complication of inflammatory bowel disease or infectious colitis, characterized by **non-obstructive colonic dilation** and signs of systemic toxicity. - Imaging would reveal a dilated colon, often with loss of haustra, but without the specific "target sign" or "pseudokidney sign" indicative of intussusception.

Q: A patient with a complex rectovaginal fistula (secondary to obstetric trauma with tissue loss) should be initially treated with

Colostomy. ***Colostomy*** * Initial treatment involves **fecal diversion** via a colostomy to allow for inflammation reduction and tissue healing around the fistula. * This step is crucial for optimising conditions for a more successful definitive repair later. *Immediate primary repair* * **Immediate primary repair** is generally not recommended due to high risk of failure in the presence of acute inflammation, infection, or poor tissue quality. * These factors can lead to **dehiscence** and recurrence of the fistula. *Vaginal repair (Colporrhaphy)* * **Vaginal repair** is a definitive surgical approach but should only be performed after proper preparation, which includes fecal diversion and allowing inflammation to subside. * Attempting this as an initial step without prior **diversion** significantly increases the risk of breakdown and failure. *Rectal resection (Anterior resection)* * **Rectal resection** is a more extensive surgical procedure usually reserved for complex fistulas, higher fistulas, or those associated with severe local tissue destruction, not typically for initial management. * It is a reconstructive procedure that may follow diversion, once the tissue is healthy enough for repair.

Q: Which is the most common site for colorectal cancer metastasis?

Liver. ***Liver*** - The liver is the **most common site** for colorectal cancer metastasis due to its direct vascular connection via the **portal venous system**. - Blood from the colon and rectum drains into the **portal vein**, which then carries cancer cells directly to the liver. *Brain* - While brain metastases can occur, they are **relatively rare** and typically late manifestations in the course of colorectal cancer. - The brain is **not the primary organ** for initial metastatic spread from colorectal cancer. *Peritoneum* - **Peritoneal carcinomatosis** is a significant mode of spread, especially in advanced colorectal cancer, but it is **less common** than liver metastasis. - This type of spread involves the **lining of the abdominal cavity**, often leading to ascites and bowel obstruction. *Lungs* - **Pulmonary metastasis** is the **second most common** site for colorectal cancer after the liver. - Cancer cells reaching the lungs usually do so via the **systemic circulation** after passing through or bypassing the liver.

Q: Which statement about pilonidal sinus is false?

Usually occurs after 40. ***Usually occurs after 40*** - This statement is **false** because pilonidal sinus typically affects younger individuals, particularly those between **15 and 30 years of age**. - Its incidence significantly **decreases after the age of 40**, making late onset uncommon. *More common in males* - This statement is **true** as pilonidal sinus has a **higher prevalence in males** than females, with a male-to-female ratio of about 3:1 to 4:1. - This increased prevalence is often attributed to **hairiness** and certain occupational or lifestyle factors more common in men. *Mostly occurs in midline* - This statement is **true** as pilonidal sinuses primarily develop in the **natal cleft**, specifically in the **midline** between the buttocks. - They often begin as small pits or tracts at the top of the gluteal fold, allowing **hair and debris to collect**. *Associated with obesity* - This statement is **true** because **obesity** is a recognized risk factor for the development of pilonidal sinus. - Increased weight can lead to **deeper natal clefts** and increased skin friction, which can trap more hair and promote the formation of cysts and sinus tracts.

Question 1

What surgery is shown here in the image?

Accepted Answer

Thiersch wiring

Answer

Hemorrhoidectomy

Answer

Altemeier operation

Answer

Wells procedure

Question 2

Which of the following is not a perineal approach for the condition shown in the image?

Accepted Answer

Ripstein's procedure

Answer

Delorme's procedure

Answer

Altemeier's procedure

Answer

Thiersch's procedure

Question 3

A 53-year-old patient presents with per rectal bleeding. Which is the most appropriate investigation to evaluate for colorectal pathology?

Accepted Answer

Colonoscopy

Answer

CECT (Contrast-enhanced CT scan)

Answer

CA-19-9 levels

Answer

CEA levels

Question 4

A 56-year-old man is brought to the emergency department for the evaluation of a 3-day history of left lower abdominal pain. During this period, the patient has also had a low-grade fever and has not had a bowel movement. He has a history of constipation. He underwent a cholecystectomy at the age of 53 years. He has smoked one pack of cigarettes daily for the last 30 years. His temperature is 38.8°C (101.8°F), pulse is 80/min, respirations are 18/min, and blood pressure is 130/84 mm Hg. Cardiopulmonary examination shows no abnormalities. Abdominal examination shows left lower quadrant tenderness with no guarding or rebound. There is no edema of his lower extremities. CT of the abdomen with contrast shows segmental wall thickening of the descending colon with multiple diverticula, surrounding fat stranding, and a 5.5-cm, low-attenuating pelvic fluid collection. Intravenous fluids and bowel rest are started. Treatment with intravenous morphine, ciprofloxacin, and metronidazole is begun. Which of the following is the most appropriate next step in the management of this patient?

Accepted Answer

CT-guided percutaneous abscess drainage

Answer

Observation and serial CT scans

Answer

Segmental colonic resection

Answer

Colonoscopy

Question 5

Best treatment strategy for carcinoma of the anal canal:

Accepted Answer

Chemoradiation

Answer

Radiation

Answer

Surgery

Answer

Chemotherapy

Question 6

Bleeding vessel in hemorrhoids is

Accepted Answer

Superior rectal artery

Answer

Superior rectal vein

Answer

Middle rectal vein

Answer

Middle rectal artery

Question 7

Comment on the diagnosis of a film shown of a 65-year-old man with acute abdomen:

Accepted Answer

Colocolic intussusception

Answer

Sigmoid volvulus

Answer

Toxic megacolon

Answer

Ileocolic intussusception

Question 8

A patient with a complex rectovaginal fistula (secondary to obstetric trauma with tissue loss) should be initially treated with

Accepted Answer

Colostomy

Answer

Immediate primary repair

Answer

Vaginal repair (Colporrhaphy)

Answer

Rectal resection (Anterior resection)

Question 9

Which is the most common site for colorectal cancer metastasis?

Accepted Answer

Liver

Answer

Brain

Answer

Peritoneum

Answer

Lungs

Question 10

Which statement about pilonidal sinus is false?

Accepted Answer

Usually occurs after 40

Answer

More common in males

Answer

Mostly occurs in midline

Answer

Associated with obesity

Colorectal Surgery — MCQs

Colorectal Surgery — MCQs

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