Test yourself: MCQ and single best answer

  • Adrian Ben Cresswell
    Affiliations
    Adrian Ben Cresswell MD(Res) FRCS (Gen) Consultant HPB & General Surgeon, Hampshire Hospitals NHS Foundation Trust, Basingstoke, Hampshire, UK; Professor of Clinical Surgery, St George's University International Medical School; Clinical Editor, SURGERY
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Published:December 19, 2019DOI:https://doi.org/10.1016/j.mpsur.2019.11.001
      For questions 1–4, select the statements which are true and which are false. The correct answers are given below.

      1. Intestinal stomas

      Regarding intestinal stomas
      • A
        Closure of a loop colostomy requires a full relaparotomy or laparoscopy
      • B
        Loop colostomies require the use of a plastic “colostomy bridge” to prevent retraction, which is changed regularly and should be maintained until the point of closure
      • C
        Ileostomies are formed from the most distal section of available healthy ileum in order to optimize the blood supply to the bowel for future closure
      • D
        Formation of an end-colostomy with an adjacent mucous fistula is an example of a double-barrelled stoma
      • E
        High fat diets can be useful in managing high output stomas

      2. Anatomy of the rectum and anal canal

      Regarding the anatomy of the rectum and anal canal
      • A
        The rectum contains two curves to the right and one to the left
      • B
        At sigmoidoscopy, the rectosigmoid junction is typically 14–18 cm from the anus
      • C
        The entire length of the rectum lies beneath the level of the peritoneal reflection
      • D
        The superior rectal artery is a continuation of the inferior mesenteric artery
      • E
        The lymphatic drainage of the anal canal is to both the inguinal and the internal iliac lymph nodes

      3. Pathology of colorectal neoplasia

      Regarding the pathology of colorectal neoplasia
      • A
        Metaplastic rectal polyps carry a high risk of progression to malignancy
      • B
        Around 50% of colorectal cancers have mutations of the K-Ras gene
      • C
        Serrated polyps and their associated cancers tend to be right-sided
      • D
        The presence (or absence) of venous invasion is reported in the TNM classification of colorectal cancer staging, though not in Duke's classification
      • E
        A Kikuchi sm3 polyp cancer that has been completely excised endoscopically requires no further therapy

      4. Bowel cancer screening

      Regarding bowel cancer screening
      • A
        Around 40% more patients with screen-detected colorectal cancers are treated with curative intent compared with those presenting as an emergency
      • B
        The time taken from development of an adenoma to late stage cancer is 8–15 years
      • C
        Faecal immunochemical testing is more sensitive and more acceptable for screening than Guaiac-faecal occult blood testing
      • D
        The National Bowel Scope Programme offers a one-off invitation to persons aged 55 years to attend for a colonoscopy
      • E
        The National Bowel Cancer Audit Report in 2018 found that 25% of all new colorectal cancers were diagnosed through screening

      5. Intestinal obstruction

      Regarding intestinal obstruction
      • You have been asked to see a patient on the orthopaedic ward who underwent an emergency hip replacement 5 days ago, following a fall resulting in a fractured neck of femur. The patient was frail and has developed a postoperative chest infection and, for the last 48 hours, a distended abdomen with constipation. The plain abdominal radiograph shows a dilated colon, a relative paucity of gas in the rectum and an unremarkable small bowel gas pattern.
      • What is the most likely underlying diagnosis?

      Single best answer – select one answer only

      • A
        Diverticular stricture
      • B
        Rectal cancer
      • C
        Paralytic ileus
      • D
        Colonic pseudo-obstruction
      • E
        Colonic volvulus

      6. Surgery for colorectal cancer

      Regarding surgery for colorectal cancer
      • You have presented a new patient at the colorectal MDT with a CT1N0 2.5 cm mid-rectal cancer. The patient is a 56-year-old male, who is otherwise fit and well and no further adverse features have been identified on the colonoscopic biopsy. Staging investigations are clear.
      • Your consultant has asked which procedure you would recommend?

      Single best answer – select one answer only

      • A
        Neo-adjuvant chemoradiotherapy and total mesorectal excision
      • B
        Total mesorectal excision
      • C
        Transanal endoscopic microsurgery
      • D
        Endoscopic submucosal dissection
      • E
        Abdominoperineal excision

      Correct answers

      • 1.
        D
      • 2.
        A, B, D, E
      • 3.
        B, C
      • 4.
        A, B, C
      • 5.
        D
      • 6.
        C

      Answers to incorrect statements

       Question 1

      • A
        A loop stoma may be closed by mobilisation and re-anastomosis of the two ends, performed via the stomal incision
      • B
        A plastic colostomy bridge is often used as a temporary aid to prevent retraction of loop stomas, but is usually removed by 5 days postoperatively
      • C
        Ileostomies are fashioned from the most distal section of available healthy ileum in order to maximize length for fluid and nutrient absorption
      • E
        Useful dietary modifications for high output stomas include low fat diets, fluid restriction and the use of proton pump inhibitors to reduce gastric secretions

       Question 2

      • C
        Only the lower third of the rectum lies entirely below the level of the peritoneal reflection. The upper third of the rectum is covered by peritoneum on its anterior and lateral side and the middle third covered on its anterior surface

       Question 3

      • A
        Metaplastic rectal polyps are typically small (5–6 mm), have no evidence of true epithelial dysplasia and an extremely low risk of progression to malignancy. They are also known as hyperplastic polyps
      • D
        Venous invasion is an important prognostic indicator but is mentioned in neither the TNM, nor Duke's classifications
      • E
        A Kikuchi sm3 polyp cancer carries a 20% risk of lymph node metastases and is an indication for further therapy

       Question 4

      • D
        The National Bowel Scope Programme offers a one-off invitation to persons aged 55 years to attend for a flexible sigmoidoscopy
      • E
        The National Bowel Cancer Audit Report in 2018 found that 9.9% of all new colorectal cancers were diagnosed through screening