Archived polls and related articles
03/07/15
If I were to have appendicitis: I would like to have
10/07/15
Would you use ICG/fluorescein before deciding limits of bowel resection?
The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery.
Surg Endosc (2015) 29:2046–2055
Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery
16/07/15
Would you refer to thoracics to surgically fix >3 rib fractures if the patient has no obvious respiratory compromise from his/her injuries?
24/07/15
Which option has been proven to reduce post-operative adhesions?
2. Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014 Oct;57(10):1228–40.
30/07/15
Which of the following are considered as superficial surgical site infection according to the CDC classification
06/08/15
What is the risk of rebleeding in Forrest 1 ulcer?
What is the risk of rebleeding in Forrest 2 ulcer?
What is the risk of rebleeding in Forrest 3 ulcer?
ACG Ulcer Bleeding Guidelines
14/08/15
Which of the following is FALSE with regards to management of enterocutaneous fistula?
20/08/15
80yo man /w AF and COPD presents with severe abdo pain, Cr 350 & pH 6.9. He was intubated and started on triple inotropes. What is the best diagnostic mode?
Check out this review article. Will you be able to do this independently?
Is there still a role for this modality in critically-ill patients? Check this out
27/08/15
40yo male with recalcitrant hypertension was referred by GP for palpitations and weight loss for investigation. Full blood count, thyroid function test, gastroscopy and colonoscopy were normal and a CTAP was arranged. It showed bilateral normal adrenal glands but a mass was noted at the inferior mesenteric ganglia and the organ of Zuckerkandl.
What is the next appropriate investigation?
For the above-mentioned pathology, which statement is true?
02/09/15
40yo male chronic smoker with T2DM but normal cardiac 2DEcho presents with rest pain and chronic Rt foot dorsum ulcer with punch-out edges. Rt ABPI was 1.2 with Rt toe pressure (PPG) at 10mmHg. Right lower limb US arterial duplex shows 11cm mid-SFA total occlusion with good reconstituted flow to popliteal, ATA, PTA and peroneal artery.
A nice review article to read, AFTER you have attempted at the question.
What is an appropriate surgical re-vascularisation intervention?
No surgical intervention.
09/09/15
65yo female with PMHx of GB stones for which she had previously refused operation, presents with a 2-day history of epigastric pain. On examination, she looks dehydrated, jaundiced and is febrile at 40 degrees with tachycardic at 120 beats per minute. Her serum amylase returned as 1100 U/L. Subsequently, the patient developed Ty1 respiratory failure and hypotension and hence was intubated, started on inotropic support and admitted to SICU. Bedside ultrasound shows GB stones with CBD at 6mm.
Despite best supportive care, patient is still cholangitic, intubated and requires high inotropic support on her 3rd day of SICU stay.
A nice case to read, AFTER you have attempted at the question.
What is the next appropriate management?
18/09/15
87yo female with previous laparoscopic distal gastrectomy and Bilroth 2 reconstruction presents with chest pain and vomiting.
If I were to have appendicitis: I would like to have
- open appendicectomy (0/18)
- laparoscopic appendicectomy ( 18/18)
- Junior resident and above ( 2/16= 12.5%)
- Senior resident and above ( 14/16= 87.5%)
10/07/15
Would you use ICG/fluorescein before deciding limits of bowel resection?
- Yes ( 4/7= 57%)
- No (3/7 = 43%)
The use of indocyanine green fluorescence to assess anastomotic perfusion during robotic assisted laparoscopic rectal surgery.
Surg Endosc (2015) 29:2046–2055
Clinical applications of indocyanine green (ICG) enhanced fluorescence in laparoscopic surgery
16/07/15
Would you refer to thoracics to surgically fix >3 rib fractures if the patient has no obvious respiratory compromise from his/her injuries?
- Yes (Fix it) = 16.7% (1/6)
- No (conservative) = 83.33% (5/6)
24/07/15
Which option has been proven to reduce post-operative adhesions?
- Seprafilm = 50% (3/6)
- None of the above = 33.3% (2/6)
- Laparoscopic Surgery = 16.7% (1/6)
- Washout before closure =0
2. Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014 Oct;57(10):1228–40.
30/07/15
Which of the following are considered as superficial surgical site infection according to the CDC classification
- Stitch Abscess = 36.4% (4/11)
- Infected episiotomy wound =36.4 (4/11)
- Wound erythema =27.3 (3/11)
- Infected Burns wound =0
- Pelvic Abscess =0
06/08/15
What is the risk of rebleeding in Forrest 1 ulcer?
- 5%
- 20%
- 50% = 57.1% (4/7)
- 80% = 42.9% (3/7)
What is the risk of rebleeding in Forrest 2 ulcer?
- 5%
- 20% =42.9% (3/7)
- 40% =28.6 % (2/7)
- 60% = 28.6% (2/7)
What is the risk of rebleeding in Forrest 3 ulcer?
- 0%
- 5% =85.7%(6/7)
- 20%
- 30% = 14.3% (1/7)
ACG Ulcer Bleeding Guidelines
14/08/15
Which of the following is FALSE with regards to management of enterocutaneous fistula?
- A gastrograffin meal and follow through is sufficient for ECF evaluation
- Many ECF occur as postoperative complications
- 1 Litre per day is consider as a high output fistula
- Anatomy Delineation is an essential step in management
- Skin integrity and sepsis control is important in treatment
20/08/15
80yo man /w AF and COPD presents with severe abdo pain, Cr 350 & pH 6.9. He was intubated and started on triple inotropes. What is the best diagnostic mode?
- CTAP
- Diagnostic peritoneal lavage
- Diagnostic laparoscopy
- Laparotomy
Check out this review article. Will you be able to do this independently?
Is there still a role for this modality in critically-ill patients? Check this out
27/08/15
40yo male with recalcitrant hypertension was referred by GP for palpitations and weight loss for investigation. Full blood count, thyroid function test, gastroscopy and colonoscopy were normal and a CTAP was arranged. It showed bilateral normal adrenal glands but a mass was noted at the inferior mesenteric ganglia and the organ of Zuckerkandl.
What is the next appropriate investigation?
- 24hr urinary metanaphrines
- CT-guided biopsy of mass
- Diagnostic laparoscopy for tissue biopsy
- Serum calcitonin levels
For the above-mentioned pathology, which statement is true?
- 20% are malignant
- Intra-op serum catecholamines monitoring is mandatory
- Beta-blockers are started before Alpha-blockers for BP control pre-op
- Organ of Zukerkandl is located along thoracic aorta
- Genetic testing is routinely recommended for functional para-ganglioma
02/09/15
40yo male chronic smoker with T2DM but normal cardiac 2DEcho presents with rest pain and chronic Rt foot dorsum ulcer with punch-out edges. Rt ABPI was 1.2 with Rt toe pressure (PPG) at 10mmHg. Right lower limb US arterial duplex shows 11cm mid-SFA total occlusion with good reconstituted flow to popliteal, ATA, PTA and peroneal artery.
A nice review article to read, AFTER you have attempted at the question.
What is an appropriate surgical re-vascularisation intervention?
No surgical intervention.
- For medical optimisation with anti-platelets and statin
- Lower limb angioplasty KIV stent
- Lower limb fem-pop vein graft bypass
- Lower limb fem-pop prosthetic graft bypass
09/09/15
65yo female with PMHx of GB stones for which she had previously refused operation, presents with a 2-day history of epigastric pain. On examination, she looks dehydrated, jaundiced and is febrile at 40 degrees with tachycardic at 120 beats per minute. Her serum amylase returned as 1100 U/L. Subsequently, the patient developed Ty1 respiratory failure and hypotension and hence was intubated, started on inotropic support and admitted to SICU. Bedside ultrasound shows GB stones with CBD at 6mm.
Despite best supportive care, patient is still cholangitic, intubated and requires high inotropic support on her 3rd day of SICU stay.
A nice case to read, AFTER you have attempted at the question.
What is the next appropriate management?
- Continue supportive care
- ERCP with sphincterotomy
- Open pancreatic necrosectomy
- PTC drainage
18/09/15
87yo female with previous laparoscopic distal gastrectomy and Bilroth 2 reconstruction presents with chest pain and vomiting.
- Type 4 Hernia (6/8=75%)
- Bochdalek Hernia (1/8= 12.5%)
- Morgagni Hernia (1/8= 12.5%)
- Answer: Type 4 Hernia
23/09/15
A 40yo lady with SLE on long term steriods was admitted with abdominal distension. She had severe lactic acidosis and acute renal failure. DPL performed and revealed hemoserous fluid.
What's the most appropriate next step?
- Antibiotics
- CT scan
- Fluid amylase
- Fluid FEME and C/S
- Laparotomy
02/10/15
36 year-old gentleman who is a chronic alcoholic is brought to ED resus for massive haemetemesis. eOGD picture is as below.
A link to 2 brief teaching slides, AFTER you have attempted the question.
What is this pathology's grade?
- Grade 1
- Grade 2
- Grade 3
(Answer: Grade 3)
9/10/15
56 year-old gentleman who has CRF with baseline Cr at 250 requires a CT aortogram for investigation of AAA.
(a link for your reading pleasure and a local paper from our institution)
Which of the following is NOT a modality for RCIN prevention?
- IV hydration
- IV bicarbonate
- Oral hydration
- Oral N-acetylcysteine
(Answer: Oral hydration, in terms of evidence of efficacy, it ranks as IV hydration, IV bicarbonate, PO N-acetylcysteine)
16/10/15:
70yo gentle
European SVS AAA guidelines
What is the most common complication post-TEVAR/EVAR?
- Contrast nephropathy
- Endoleak
- Ischaemic bowel
- Spinal ischaemia
- Trash feet
(Answer: Endoleak)
23/10/15:
70yo gentleman with PMHx of IHD presents with an acute onset of severe abdominal pain. Bloods investigations showed an amylase level of 80U/L, with arterial blood gas pH 7.2 and bicarbonate of 16mmol/L. CT abdomen/pelvis showed pneumotosis coli.
A nice review article.
Which of the following has the highest incidence?
- Arterial embolus
- Arterial thrombus
- Non-occlusive mesenteric ischaemia
- Venous thrombosis
(Answer: arterial embolus)
30/11/15
Your consultant is performing a low anterior resection and during the posterior rectal dissection, he encountered torrential bleeding.
A nice review article
Incorrect mobilisation of the rectum outside of which fascia resulted in this?
- Buck's fascia
- Cooper's fascia
- Spiegelian's fascia
- Waldeyer's fascia
(Answer: Waldeyer's fascia)
6/11/15
65-year-old male presents with fever, chills and rigors. DRE showed a palpable rectal mass. His TW was raised at 20 and CTTAP did not show any metastasis. MRI rectum showed a T3 lesion without a small collection adjacent to the tumour.
The most appropriate treatment is:
- Antibiotics-only
- Short course neoadj RT
- Long course neoadj chemoRT
- Surgical intervention (drainage/diversion vs curative)
(Answer: D)
11/11/15
After a total pancreatectomy for pancreatic cancer, which of the following is the most appropriate answer:
- An oral elemental diet is often well tolerated
- CREON can be used to treat the endocrine insufficiency
- Islet cell autotransplantation is an option
- Oral hypoglycaemics are sufficient for glycemic control
A review article on total pancreatectomy.
(Answer: A)
20/11/15
A 50yo gentleman with Child's A Hepatitis B liver cirrhosis underwent extended right hemi-hepatectomy for HCC. On POD1, his BP is persistently 80/40 with SpO2 at 90% on 100% NRM and a sluggish PU output at 0.3ml/kg/hr. Serum urea levels are above normal at 12 mmol/L and INR is 2.5.
A nice review article, AFTER you have attempted the question.
What is your main consideration?
- AMI
- Dehydration
- Hepato-renal syndrome
- Post-hepatectomy liver failure
- Pulmonary embolus
(Answer: Post-hepatectomy liver failure)
26/11/15
Forrest Classification is used to describe peptic ulcers and helps us stratify to predict risk of rebleed.
Please label the following ulcers.
(Answer: Left-Forrest 1b, Middle-Forrest 2c, Right-Forrest 2a
3/12/15
A pre-endoscopy Rockall score of 5 in a patient with a suspected upper GI bleed, indicates to you that:
- the patient has a very high probability of mortality.
- the patient needs an early (6-12 hrs) upper GI endoscopy.
- the patient has a probability of re-bleed.
- the patient can be discharged with an output OGD.
(Answer: B)
11/12/15
A 30yo construction worker was admitted after a fall from 5m. BP was 80/60 with HR 110 on arrival at ED. GCS 13 and FAST negative. XR pelvis showed a right pubic rami and acetabulum fracture. CT head, neck, TAP showed a right pelvic arterial blush.
A nice review paper for your reading pleasure.
What is the most appropriate treatment treatment at this point?
- Pelvic binder application
- C-clamp pelvic stabilization
- Pelvic ORIF
- Arterial angiogram and embolisation of Rt IIA
- Open surgery and ligation of Rt IIA
(Answer: D)
18/12/15
A 80yo gentleman with large right hepatic flexure colonic tumour with no CTAP metastasis was found to have locally advanced disease with local invasion into the head of pancreas intra-operatively and failed trial of dissection after 200 minutes, with an intra-operative blood loss of 200ml. Pre-operatively, his Hb was 9 with Alb of 25.
Some helpful resources.
What is the next best surgical step?
- Colo-colic bypass
- Ileo-colic bypass
- Ileostomy creation
- Radical en-bloc resection
- Terminate operation and palliate
(Answer: C)
24/12/15
A 40yo gentleman with nil PMHx was found to have pan-diverticulosis on screening colonoscopy. How would you counsel him in clinic?
A nice review article.
What would NOT be part of your clinic counselling?
- Encourage high fibre diet
- Will require colectomy
- Return if bleeding
- Return if pain/fever
(Answer: B)
31/12/15
A 50yo lady was admitted for LOW of 10kg over past 6 months and vague abdominal pain. O/E, there was a palpable rectal mass. Blood tests showed hypercalcaemia and raised LDH. CT TAP showed multiple enlarged mesorectal, retrocaval and peri-aortic lymph nodes with multiple lung nodules and enlarged supra-clavicular lymph nodes. OGD showed diffuse gastric thickening and colonoscopy showed a rectal mass 3cm from anal verge.
A nice review article.
Which is NOT an underlying risk factor for this pathology?
- Celiac disease
- Colonic polyps
- Epstein-Barr virus
- H Pylori infection
- Hep B virus
(Answer: B)
15/1/16:
A 60yo lady presented with a left lower cheek lump which is anterior to the angle of the mandible. It is painful, rapidly enlarging and on examination, hard and irregular. There is no facial nerve involvement on examination and the patient subsequently underwent total parotidectomy (nerve-sparing), neck dissection and post-op RT.
A summary slide
Which histology represents a high-grade malignancy?
- Acinic
- Adenoid Cystic
- Mucoepidermoid
- Sarcoma
(Answer: C)
22/1/16:
A 60yo destitute with unknown PMHx is seen by ED for acute abdomen. Bloods investigation showed metabolic lactic acidosis with no free air under the diaphragm. CTAP showed portal vein gas.
A review paper.
Which is NOT a possible aetiology?
- Diverticulitis
- Inflammatory bowel disease
- Ischaemic bowel
- Pancreatitis
- Previous liver transplant
(Answer: E)
28/1/16:
A 65yo nursing home gentleman with nil significant past medical history presented with a 2-month history of constipation. These are his scans.
A nice review.
What is NOT part of your initial management?
- Colectomy
- Colonoscopy KIV washout
- Colonic transit and anorectal physiology Ix
- Ix for electrolyte abnormalities, hyperCa and thyroid dysfunction
- Upper GI evaluation
(Answer: A)
5/2/16:
A 65yo nursing home gentleman with poorly controlled T2DM presented with fever and foul-smelling perineal region. He subsequently underwent extensive debridement, which included a penile amputation due to extensive infection (see picture below).
A nice review article to read AFTER you've attempted the question.
Which is NOT true of this condition?
(Answer: B)
19/2/16:
Well done to all residents who completed the ABSITE exam last week.
A paper correlating ABSITE and board exams.
Was this year's ABSITE _______
What would be your predicted percentile?
26/2/16:
An 81yo gentleman suffered flash burns whilst burning logs on his farm. He suffered the following burns over his thighs (see below).
A review article, American burns guidelines and WHO burns guidelines for reading
- Eventual skin cover may be achieved with STSG
- Mortality rate is around 20%
- Multiple debridements are necessary
- Urinary / faecal diversion may be necessary
- VAC dressings enable granulation
(Answer: B)
19/2/16:
Well done to all residents who completed the ABSITE exam last week.
A paper correlating ABSITE and board exams.
Was this year's ABSITE _______
- less difficult as expected
- expected difficulty
- more difficult than expected
What would be your predicted percentile?
- 0-24th centile
- 25-49th centile
- 50-75th centile
- 76-100th centile
26/2/16:
An 81yo gentleman suffered flash burns whilst burning logs on his farm. He suffered the following burns over his thighs (see below).
A review article, American burns guidelines and WHO burns guidelines for reading
Which of the following is NOT true?
- Fluid resuscitation is guided by Parkland's formula (2 x weight x TBSA), with 1/2 given over 8H and 1/2 over next 16H
- Management principles include ABCDE, fluid resuscitation, antiobiotics prophylaxis, local wound care, nutritional supplementation and tissue cover
- Risk factors for poor prognosis include age, TBSA and inhalation injury
- First degree burns are clinically erythematous, secondary burns are clinically mottled, third degree burns are clinically leathery and dry
- Wallace Rule of 9s states that anterior LL is 9% TBSA and posterior LL is 9% TBSA
(Answer: A)
3/3/16:
A 50yo lady is referred by Endocrine for hypercalcaemia and right lower pole 3cm nodule on US thyroid. She subsequently underwent parathyroidectomy.
A link to UK guidelines on surgical management of endocrine diseases.
Which of the following is NOT correct?
- BMD will show osteopenia
- DDx includes familial hyperparthyroidism, MEN syndromes or familial hypercalcaemic hypocalciuria
- Hungry bone syndrome refers to post-op profound and prolonged hypocalcaemiaIntra-op
- FS may distinguish between hyperplasia and adenoma
- Pre-op Sestamibi is helpful in parathyroid localisation
(Answer: D)
11/3/16:
A 30yo domestic helper was admitted for LBP after a fall. She c/o left LL stiffness for 2/52 and also had LOW of 5kg over the past year. On examination, her left LL has power 2/5. MRI of brain and spine were normal. Subsequent EMG/NCS was suggestive of stiff person syndrome. and CTTAP showed a 12.7cm large solid-cystic mass in the left cardiophrenic angle.
NCCN guidelines for your reading pleasure
Which of the following is NOT correct?
- 30% to 50% of patients with thymomas have myasthenia gravis
- Neoplastic mediastinal masses include thymomas, thymic CA, germ cell tumours or lung mets
- Thymic CAs are rare aggressive tumors that often metastasize to regional lymph nodes and distant sites
- There is no role for pre-op biopsy
- Mx of thymic CA include resection and chemoRT
(Answer: D)
15/4/16
A 60yo alcoholic complains of epigastric pain after x3 episodes of vomiting last night. On examination, he is febrile, tachycardic, dehydrated and has epigastric guarding. CTAP showed pneumo-mediastinum on the lower cuts with left pleural effusion.
A nice UpToDate review.
Which of the following is NOT correct?
- Keep patient NBM with IV fluids resuscitation
- Broad spectrum antibiotics
- Surgical approach depends on the site of oesophageal perforation (cervical, thoracic or abdominal)
- Oesophageal stenting may be considered for patients who are poor surgical candidates
- Oesophageal repair consists of a single-layer closure of the serosa layer
(Answer: E)
22/4/16
65yo lady with previous history of gallstones presented with epigastric pain. On examination, she is febrile, tachycardic, dehydrated and epigastric tenderness. Serological investigation showed a grossly elevated serum amylase
Atalanta classification for your reading pleasure
Which of the following is NOT true?
- The onset of acute pancreatitis is defined as the time of onset of abdominal pain (not the time of admission to the hospital).
- The definition of the severity of acute pancreatitis (during the first week) is based on clinical rather than morphologic parameters.
- The definition of severe acute pancreatitis is the persistence of organ failure that exceeds 48 hours duration
- Pseudocysts develop from an acute pancreatic fluid collection (APFC) that persists for >4 weeks after onset of pancreatitis. Prior to 3 weeks, these collections are categorized as APFC
(Answer: D)
6/5/16
70yo gentleman presents with FOBT +ve and underwent colonoscopy. An ascending colon 1cm pedunculated polyp was snared and a sigmoid colon 1cm sessile polyp was snared. Ascending colon polyp histology returned as Haggitt 1 adenoCA whilst sigmoid colon polyp histology returned as Kudo Sm1 adenoCA. Staging CT TAP did not reveal any metastasis and no enlarged lymph nodes
Paper 1 and paper 2 for your reading pleasure
Which is an appropriate management?
- Surveillence colonoscopy in 3 months
- Both lesions are suitable for ESD
- Rt hemicolectomy and anterior resection
- ESD for ascending colon polyp and anterior resection
- Rt hemicolectomy and ESD for sigmoid polyp
- Total colectomy
(Answer: B)
20/5/16
50yo ESRF, Hep B gentleman presents with haemetemesis and underwent OGD for which torrential oesophageal variceal bleed was not able to be haemostased endoscopically. Subsequently, a Minnesota tube was inserted.
Practical info regarding Minnesota tube here and here
Review article on oesophgeal grading.
Which is INCORRECT regarding Minnesota tube?
- Gastric balloon may be inflated with 200cc of air to allow for better visualisation on CXR
- Oesophageal balloon may be inflated to 15-20mmHg
- Oesophageal and gastric drainage ports may be left to passive
- Minnesota tube contains 3 ports
- Traction should be released q8H
(Answer: D)
3/6/16
40yo gentleman presents with 6/12 history of bloody diarrhoea. CTAP showed transverse colon thickening and colonoscopy showed multiple ulcers which histology returned as chronic inflammation with distorted crypt architecture.
American guidelines and excellent summary slides by junior resident
Which is NOT a diagnostic criteria for toxic megacolon?
- Bloody diarrhoea
- Fever, tachycardia, dehydration
- Leukocytosis
- Transverse colon diameter > 6cm on AXR
(Answer: A)