62 Free General Surgery Board Exam Practice Questions

This case describes a patient with acquired thrombotic thrombocytopenic purpura (TTP); HIV is a known risk factor. Decreased activity (<10%) of the ADAMTS13 enzyme along with the presence of autoantibodies against ADAMTS13 confirms the diagnosis of TTP. These autoantibodies are effectively removed by plasma exchange therapy. Therefore, the standard treatment includes therapeutic plasma exchange along with high-dose steroids. The blood product of choice for plasma exchange is fresh frozen plasma (FFP). After an initial response, if the disease recurs within 30 days of treatment, it is classified as an exacerbation (as in the given case). The next step in management is the addition of monoclonal anti-CD20 antibody, rituximab.

Bortezomib is incorrect because it is currently only FDA-approved for use in the management of multiple myeloma in combination with cyclophosphamide and dexamthasone.

Caplacizumab is incorrect as it is currently is recommended in the management of thrombotic thrombocytopenic purpura (TTP) relaspse (defined as an improvement of symptoms followed by a recurrence of symptoms (thrombocytopenia, clinical symptoms).

Salvage splenectomy is incorrect because it is reserved for more severe forms of the disease, uncontrolled by plasma therapy (plasmapheresis), steroids, and rituximab.

Vincristine is incorrect because it can be given in refractory cases; rituximab is usually preferred in acquired thrombotic thrombocytopenic purpura (TTP).

Proceed to emergent open hernia repair following administration of prothrombin complex concentrate (PCC) is correct because, in cases of strangulated hernia, urgent surgery is needed to relieve the constriction of blood supply to avoid bowel gangrene. Four-factor PCC or alternatively, fresh frozen plasma (FFP) and vitamin K should be administered preoperatively to prevent bleeding. Although recurrence rates are high without using mesh, in an emergency setting, the benefits of tissue repair (i.e., primary repair) outweigh the risks of developing an infection of the implanted mesh.

Admit the patient, administer fresh frozen plasma (FFP) and operate once the international normalised ratio (INR) has normalized is incorrect because this is a case of an incarcerated and possibly strangulated hernia. The window for successful treatment to avoid bowel resection is 4-6 hours, and waiting for the INR to normalize is not the correct choice.

Perform emergent laparoscopic hernia repair with mesh is incorrect as laparoscopic repair can be challenging in this patient, and there is also an increased risk of bleeding. Also, laparoscopic surgery usually requires a mesh which may be infected easily in this patient.

Attempt reduction of the hernia under sedation in the emergency department is incorrect because hernia reduction is no longer recommended in emergency settings. It can lead to dreadful complications of reduction en masse (i.e. reduction of the bowel contained within the hernia sac with a narrow neck) and reduction of gangrenous bowel into the abdomen.

Perform mesh herniorrhaphy using polypropylene mesh immediately is incorrect as synthetic mesh in cases of incarcerated (possibly strangulated) hernia and bowel obstruction is associated with a high infection rate and should generally be avoided.

Chronic pain is the correct response because this is the most common complication of Lichtenstein repair of the inguinal hernia. This technique is also known as an open flat mesh repair.

Recurrence of hernia is incorrect because the procedure described is Lichtenstein hernia repair, which has been shown to have lower recurrence rates than other hernia repair surgeries (i.e., tissue repairs) such as Bassini repair due to reduction in tension placed on the tissues.

Meshoma formation is incorrect because this is a common complication of open plug and patch mesh repair of an inguinal hernia, not of open flat mesh repair. A meshoma is a relatively rare complication and is defined as the shrinkage of the mesh manifesting as a round mass in the inguinal region. Increased intra-abdominal pressure and inadequate fixation of the mesh are risk factors of a meshoma formation.

Wound infection is incorrect because although it is more common after open Lichtenstein repair than laparoscopic surgery, the most common complication after Lichtenstein operation is chronic pain, not wound infection.

Testicular infarction is incorrect because it is one of the rarest complications of inguinal hernia repair surgeries. It occurs due to damage to the testicular artery per-operatively. Although rare, it is one of the most serious complications of hernia repair surgeries.

Institution of salt restriction, diuretics, and antibiotics, followed by urgent primary umbilical hernia repair is correct because this patient has developed compromise of the overlying skin overlying the umbilical hernia, which can lead to serious peritonitis. The patient should be optimized preoperatively and postoperatively using this regimen and then needs to be operated on emergently (i.e., primary repair) to avoid future complications.

Emergency hernia repair alone is incorrect because the patient needs to have adequate control of his ascites to avoid recurrence. Emergent surgery alone puts the patient at risk of recurrence and infection.

Discharge patient with the trial of salt restriction, diuretics, and an abdominal binder is incorrect because this patient cannot be discharged as he is at risk of developing peritonitis.

Paracentesis and antibiotics is incorrect as they do not offer the prospect of hernia repair. This would be appropriate in the management of spontaneous bacterial peritonitis.

Mesh hernia repair along with ventriculoperitoneal shunt is incorrect because ventriculoperitoneal (VP) shunt is not indicated for ascites. VP shunt is primarily used in the management of hydrocephalus. In addition, there is a high risk of developing a mesh infection in this case due to compromise of the overlying skin.

Obstruction due to fibrotic stricture is the correct answer. Minimally invasive surgery has an advantage over open surgery with few pulmonary complications in the post-operative period, shorter hospital stay, and improved cosmetic results. Strictureplasty, small bowel resection, partial/total colectomy, ileocolectomy, and proctectomy can be performed safely in selected patients with Crohn’s disease using minimally invasive surgery based on the extension and severity of the disease.

Severe obstruction with massively dilated intestine is incorrect as it is a contraindication to minimally invasive surgery in a patient with Crohn’s disease, as it will be difficult to safely establish pneumoperitoneum and the visualization will be poor.

Obliterative peritonitis is incorrect as it is a contraindication to minimally invasive surgery in a patient with Crohn’s disease, as it will be difficult to establish pneumoperitoneum safely.

Intraabdominal varices due to portal hypertension is incorrect, as it is a contraindication to minimally invasive surgery in a patient with Crohn’s disease due to the risk of injury to the variceal blood vessels, which can result in massive hemorrhage.

Enterocutaneous fistula is incorrect as it is a contraindication to minimally invasive surgery in a patient with Crohn’s disease as it will be difficult to establish pneumoperitoneum safely and a portion of the anterior abdominal wall will be required to be resected.

Second-generation cephalosporin is correct because second-generation cephalosporins are administered for achieving antibiotic prophylaxis before the surgery. Antibiotic prophylaxis prior to incision is only indicated in those at high-risk of developing surgical site infections (these include individuals over the age of 70, pregnant women, those with acute cholecystitis, those with nonfunctioning gallbladder, those with obstructive jaundice, those with common bile duct stones, and those on systemic immunosuppression). Recommended antibiotics are cefazolin (first-generation cephalosporin) WITH metronidazole, cefoxitin (second-generation cephalosporin), OR cefotetan (second-generation cephalosporin).

First-generation cephalosporin is incorrect because antibiotic prophylaxis for cholecystectomy is achieved by the dual administration of cefazolin and metronidazole or the administration of second-generation cephalosporins.

Third-generation cephalosporin and subcutaneous heparin is incorrect because second-generation cephalosporin (or first-generation cephalosporin and metronidazole) is the drug of choice to be used as a prophylactic antibiotic before cholecystectomy. Subcutaneous heparin is only indicated in individuals at high risk of developing deep vein thromboses. Studies have shown subcutaneous heparin increases bleeding during laparoscopic procedures.

Second-generation cephalosporin and metronidazole is incorrect because second-generation cephalosporins can be used alone for prophylaxis against surgical site infections

Third-generation cephalosporin and amoxicillin-clavulanic acid is incorrect because a second-generation cephalosporin alone is sufficient for prophylaxis against surgical site infections prior to laparoscopic cholecystectomy.

Observation and repeat CT scan after 4 weeks is correct as the collection description is consistent with acute necrotic collection (likely sterile). The patient is not showing any signs of sepsis, thus ruling out infected necrosis. The recommended treatment in such cases is observation, as most collections resolve spontaneously.

Percutaneous CT guided drainage of the collection is incorrect because CT-guided drainage is not recommended in non-infected pancreatic necrosis as it has the chance of converting it into infected necrosis.

Endoscopic ultrasound-guided drainage of the collection into the stomach is incorrect because endoscopic drainage is recommended for pancreatic pseudocyst, which fails to resolve with a conservative approach.

Insertion of wide bore drain under CT guidance is incorrect because drainage is not recommended in non-infected pancreatic necrosis as it can convert it into infected necrosis.

Open drainage and debridement of the collection is incorrect as open debridement and drainage are considered last resort in the management of infected pancreatic necrosis given its high associated morbidity.

Peripheral blood smear and bone marrow aspiration is the correct response because the patient’s blood smear will show a low platelet count of less than 60000/mm³, and the bone marrow will show plentiful supply of platelet-producing megakaryocyte, thereby confirming the diagnosis of idiopathic thrombocytopenic purpura (ITP).

Prothrombin time and bleeding time is incorrect because coagulation studies do not help in the diagnosis of idiopathic thrombocytopenic purpura.

APTT, international normalised ratio (INR), and bleeding time is incorrect because physical examination points towards idiopathic thrombocytopenic purpura (ITP), APTT, international normalised ratio (INR), and bleeding time will not confirm the diagnosis of idiopathic thrombocytopenic purpura (ITP).

Only bone marrow aspiration is incorrect because peripheral blood smear is also needed for establishing the diagnosis of idiopathic thrombocytopenic purpura (ITP).

Ultrasound of the abdomen is incorrect because spleen is enlarged in only 10% of the cases. Gross enlargement of spleen points towards other differential diagnoses.

Due to high risk of postoperative urinary retention is correct because the patient has prostatic pathology. In patients with hernia in the groin region, along with prostatic symptoms, postoperative urinary retention is common and, therefore, urologic assessment is warranted.

To rule out a urologic mass is incorrect because the patient’s history and examination point towards a working diagnosis of inguinal hernia and there is no evidence of probable urologic mass.

To rule out hernia with strangulation is incorrect because the overlying skin in the region of the lump is normal in this patient. In cases of strangulation, the overlying skin exhibits cellulitis. Moreover, the patient’s lump is painless whereas strangulated hernias are very painful.

To rule out saphena varix is incorrect because location of saphena varix is below the inguinal ligament. On the other hand, the location of inguinal hernia is above the inguinal ligament, as is seen in this patient.

For assessment of inguinal lymph nodes is incorrect because lymphadenopathy is suspected if the lump is persistent and irreducible. This patient’s lump is intermittent.

Boyce’s sign is correct. A gurgling sound can be experienced by the patient as air passes through the diverticulum; this is known as Boyce’s sign. Diagnosis is aided by barium swallow, upper gastrointestinal series (UGI) endoscopy, esophageal manometry, and 24-hour pH monitoring.

Aaron’s sign is observed in acute appendicitis. It describes referred pain felt in the epigastrium upon continuous firm pressure over McBurney’s point.

Kehr’s sign is observed in case of a ruptured spleen. It describes left shoulder pain due to irritation of the inferior surface of the diaphragm due to pleading from a splenic rupture.

Rosenstein’s sign is observed in acute appendicitis. It describes tenderness in the right lower quadrant that increases when the patient moves from a supine position to a recumbent posture on the left side.

Bancroft’s sign is incorrect because it is observed in deep vein thrombosis (DVT) of a posterior tibial vein; this is also known as Moses’ sign. It describes pain in the calf is elicited when the calf muscle is compressed forward against the tibia but not when the calf muscle is compressed from side to side.

Needle decompression followed by tube thoracostomy placement is correct. This patient has developed a tension pneumothorax as evidenced by absent breath sounds on the right side, distended neck veins, and hemodynamic instability. This is a life-threatening emergency requiring urgent decompression (via placement of an angiocath in the 5th intercostal space in the midaxillary line in adult patients). Immediate needle decompression is recommended to relieve the building intrapleural pressure. This should then be followed by a tube thoracostomy.

Order a chest radiograph is incorrect. This patient has a traumatic tension pneumothorax with hemodynamic instability, a life-threatening condition requiring emergent treatment. A strong clinical suspicion precludes the need for an x-ray before needle decompression, as this would waste valuable time.

Perform emergent thoracotomy is incorrect. Exploratory thoracotomy is indicated in patients with evidence of intra-thoracic bleeding or those who present with loss of vital signs upon presentation to resuscitate the patient.

Needle pericardiocentesis is incorrect. The patient’s findings indicate a tension pneumothorax and are not suggestive of cardiac tamponade. Needle pericardiocentesis is only recommended for selected cases of cardiac tamponade.

Intubation and mechanical ventilation is incorrect. Intubation and mechanical ventilation before chest decompression will further worsen the patient’s tension pneumothorax. It can exacerbate air leaks, leading to further air accumulating in the intrapleural space, which in turn increases intrapleural pressure and worsens mediastinal shift. This then contributes to further hemodynamic instability.

To rule out a mass or cyst is the correct response because an irreducible swelling can be hernia or a mass or cyst, which can be easily differentiated on an ultrasound. Most hernias can be diagnosed on clinical examination. However, in cases where the examination is equivocal, an ultrasound scan is a valuable tool to distinguish an irreducible hernia from a groin mass of cyst.

To rule out a hematoma or seroma is incorrect because hematoma and seroma formation occur in the postoperative period. Since the patient has not undergone any surgery recently, the formation of a hematoma or seroma is unlikely.

To determine the number of fascial defects is incorrect because a CT scan is the investigation of choice for determining the number of fascial defects of a hernia, not an ultrasound.

To determine the size of fascial defects is incorrect because a CT scan is the investigation of choice for determining the size of fascial defects in cases of a hernia.

To identify the contents of a hernia definitively is incorrect because a CT scan is helpful in the definitive identification of the contents of a hernia. CT scan shows the hernial contents better than an ultrasound scan. An ultrasound may be able to determine if bowel is contained in the hernia; however, a CT scan can definitively determine what areas of the bowel or other abdominal organs are within the hernia sac.

Paraesophageal (or hiatal) hernia is common in the elderly population. It can be diagnosed on an upright chest x-ray showing a gas bubble with or without an air-fluid level behind the cardiac shadow, as seen in this patient’s chest x-ray and marked in the image.

Peptic ulcer disease is incorrect. Although this patient has a history of dyspepsia and is taking proton pump inhibitors, peptic ulcer disease (PUD) is diagnosed on the visualization of an ulcer on endoscopy. This patient’s chest x-ray is indicative of hiatal hernia.

Lung abscess is incorrect because lung abscesses present on a chest x-ray as a well-demarcated mass in the lung parenchyma with an air-fluid level and are associated with fever.

Barrett’s esophagus is a common complication of gastroesophageal reflux disease and hiatal hernia. However, it is diagnosed on the visualization of displacement of the squamocolumnar junction and intestinal metaplasia in the esophagus on endoscopy.

Cardiac myxoma is incorrect because a cardiac myxoma will be expected to present with valvular signs and symptoms and will be detected on echocardiography.

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Stabilization using an external fixator is correct as this patient has an open fracture with a large contaminated wound, as shown in the images. Initially, the fracture is stabilized using an external fixator and management of the wound involves serial debridements followed by repair. Once adequate soft tissue coverage of the bone has been achieved definitive fixation can be done.

Fixation using a dynamic compression plate (DCP) is incorrect because this is an open fracture with a large contaminated wound. Fixation using DCP in this particular patient carries a high risk of infection.

Fixation using an intramedullary rod is incorrect. Intramedullary rods have a high risk of infection with an open fracture and large contaminated wound as seen in this patient.

Stabilization using a U slab is incorrect. A U slab or cast gives poor stabilization. In this case the patient is likely to require multiple debridements necessitating the removal and reapplication of the U slab and would not be the best management option.

Fixation using K wires is incorrect. K wires are generally used for fractures involving small bones or bony fragments such as in the hands and feet and not long bones such as the humerus where they may not provide sufficient stability.

Wide local excision is the correct option because it is the cornerstone of treatment for benign and malignant phyllodes tumors. Phyllodes tumor is a fibroepithelial breast tumor characterized by multinodular, smooth, painless lumps appearing as well-circumscribed hypoechoic masses on an ultrasound. Histologically, there will be a leaf-like (phyllodal) epithelial pattern due to an exaggerated intracanalicular pattern and increased stromal cellularity adjacent to the epithelium. Wide local excision of the mass with a 1 cm margin is the main treatment.

Bilateral mastectomy is incorrect because it is an aggressive treatment approach that is not recommended for phyllodes tumors. Even large tumors may be effectively treated with breast conservation if the excision is complete with attention to the histologic margins.

Radiation therapy is incorrect because it is not the mainstay treatment option for malignant phyllodes tumors and is clearly not the best treatment option. It is sometimes used as adjuvant therapy to decrease the risk of recurrence.

Neoadjuvant chemotherapy is incorrect because it is often prescribed when a tumor is too large to be operable or in cases when vital organs may be affected by a tumor’s growth. Some data suggest adjuvant chemotherapy for patients with high-risk or recurrent malignant tumors >5 cm.

BRCA gene testing is incorrect because it is recommended for evaluating breast cancer in patients with a family history of breast, ovarian, tubal, or in some patients after breast cancer is diagnosed (e.g., triple negative or bilateral breast cancer). However, this patient has no family history of breast disease.

Medullary carcinoma is the correct option because this patient has carcinoma with medullary features, a special type of triple-negative cancer which is a rare subtype of invasive ductal carcinoma. On physical examination, it appears as a soft mass that may imitate benign tumors. It is often seen as a round, oval, or lobulated mass on mammography, which makes it hard to distinguish from benign tumors. On histology, it is characterized by a syncytial growth pattern, with large sheets of anaplastic cells, as seen in this patient.

Comedocarcinoma is incorrect because it is a subtype of ductal carcinoma in situ (DCIS) which is characterized by extensive necrosis, aggressive behavior, and increased risk for recurrence. On histology, the lesion plugs the lactiferous ducts and shows necrosis. Transected ducts produce cheese-like necrotic tissue that extrudes when gentle pressure is applied.

Fibroadenoma is incorrect because it usually occurs in women of reproductive age < 35 years. Moreover, histologically, it is characterized by nests of proliferating ductal elements embedded in a fibrous stroma. Thus, although clinically fibroadenoma is difficult to distinguish from medullary breast cancer, the histological results, in this case, exclude this diagnosis.

Invasive ductal carcinoma is incorrect because it typically produces an extensive desmoplastic response, which is the growth of fibrous or connective tissue surrounding the tumor and replaces the normal breast tissue. Invasive ductal carcinoma is the most common type of breast cancer. However, the histological presence of lymphocytic infiltrate and soft mass on physical examination favors another diagnosis in this case.

Phyllodes tumor is incorrect because, on histology, the tumor is characterized by a “leaf like” growth pattern with bulbous nodules of proliferating stromal cell covered by epithelium. Phyllodes are typically seen in the 5th decade. This patient’s age and histological findings favor another diagnosis.

Mammography is the correct option because this patient’s presenting features of a firm, nontender, nonmobile breast mass is concerning for breast cancer. Mammography is the preferred imaging technique for the evaluation of a breast lump in women older than 35 years of age. Moreover, it is the initial step in breast cancer diagnosis and allows deciding whether there is a need for biopsy or not.

MRI scan of the breast is incorrect because it is indicated for the diagnosis of a suspicious breast lump when routine imaging tests are inconclusive or as a screening tool when the patient has an increased risk for breast cancer (e.g., a BRCA mutation carrier). However, none of these conditions apply to this patient.

Monthly self-breast exams is incorrect because it is not a recommended strategy in this patient since she has a breast lump concerning for breast cancer, which requires further workup.

BRCA gene testing is incorrect because it is recommended for evaluating breast cancer in patients with a family history of breast, ovarian, tubal, or in some patients after breast cancer is diagnosed (e.g., triple negative or bilateral breast cancer).

Ultrasonography of the breast is incorrect because it is the recommended initial imaging test for a self-palpated breast lump in women younger than 30 years of age because it offers higher sensitivity than mammogram. This patient is > 30 years of age.

Peritoneal lavage and Graham patch repair is the correct answer because the above case describes a patient with the most likely diagnosis of perforated peptic ulcer located at the anterior surface of the duodenum. The exploration of the abdomen is directed towards repairing the perforation and removing the debris from the abdominal cavity. An omental patch is used to repair small duodenal perforations in the majority of the cases with copious peritoneal lavage.

Peritoneal lavage and closure of the abdomen is incorrect because there is a perforation identified at the anterior surface of the duodenum that should be addressed by either primary closure or omental or Graham patch repair.

Distal gastrectomy with Roux-en-Y reconstruction is incorrect because this patient has a small duodenal perforation which can be repaired with a Graham patch. In patients with massive duodenal or gastric perforation where simple closure is not possible, distal gastrectomy with Roux-en-Y reconstruction is the procedure of choice.

Excise the ulcer and perform primary closure is incorrect because excision of ulcer is indicated in patients with gastric ulcer to rule out perforation secondary to a malignant ulcer. Malignancy is unlikely in patients with duodenal perforation. Hence, excision is not indicated in this case.

Omental patching with truncal vagotomy and pyloroplasty is incorrect because the above case describes a patient who is unstable. Hence, omental patching with truncal vagotomy and pyloroplasty is not indicated in this patient as it is a time-consuming procedure.

Calcific aortic stenosis is the correct answer because this patient’s brisk gastrointestinal (GI) bleeding with no identifiable source on upper or lower endoscopy suggests bleeding in the distal duodenum, jejunum, or ileum, which are not well visualized with standard endoscopy. Small bowel bleeding is often due to vascular malformations in the bowel wall, particularly angiodysplasias. Angiodysplasias is associated with aortic stenosis (this association is known as Heyde’s syndrome).

Chronic liver disease is incorrect because it is associated with portal hypertension, which can cause bleeding from gastric or esophageal varices. However, varices are generally seen on upper endoscopy. In addition, chronic liver disease is often associated with elevated international normalised ratio (INR) due to deficiency in coagulation factors; von Willebrand factor (VWF) is not typically affected because it is primarily produced by the endothelium.

Glucose intolerance is incorrect because it is associated with the development of type 2 diabetes mellitus, which is characterized by excessive elevations in blood glucose following meals due to insulin resistance and/or impaired insulin secretion.

Uncontrolled hypertension is incorrect because it may be seen in patients with obstructive sleep apnea, renal artery stenosis, and primary aldosteronism. Uncontrolled hypertension is not a common cause of low von Willebrand factor (VWF) multimers and gastrointestinal (GI) bleeding. Severe hypertension can cause anemia due to mechanical destruction of erythrocytes (forming schistocytes).

Vitamin B12 deficiency is incorrect because it is often caused by disorders of the gastrointestinal (GI) tract, such as atrophic gastritis, celiac disease, and bacterial overgrowth in the small bowel. Although vitamin B12 deficiency commonly causes megaloblastic anemia and is sometimes associated with mild thrombocytopenia, it is not tightly linked to low von Willebrand factor (VWF) multimers or gastrointestinal (GI) bleeding.

Cecal volvulus is the correct answer because this patient with progressive abdominal pain, distension, and a single, dilated loop of large bowel on x-ray most likely have a colonic volvulus. In cases of a cecal volvulus, the dilated loop of the large bowel originates in the right lower quadrant and projects towards the left upper quadrant (in cases of sigmoid volvulus, the dilated bowel would originate in the left lower quadrant and project toward the right upper quadrant). It occurs due to the torsion of the cecum around its mesentery and can lead to peritonitis or perforation. So a prompt diagnosis and early management are essential.

Gastric outlet obstruction is incorrect because it can cause abdominal distension and pain; however, an x-ray typically reveals an enlarged gastric bubble with decompressed bowel distally.

Ileocolic intussusception is incorrect because it can cause self-resolving episodes of abdominal pain and vomiting. However, because the mechanical obstruction occurs in the distal small bowel (ileum), x-ray typically reveals multiple, dilated small-bowel loops with air-fluid levels.

Paralytic ileus is incorrect because typically causes generalized distension of the large and small bowel on x-ray.

Toxic megacolon is incorrect because it can cause colonic dilation on x-ray. However, x-ray typically reveals diffuse dilation of the colon within its normal anatomic arrangement rather than a single, dilated colonic loop, as in cecal volvulus. In addition, patients typically appear toxic (i.e. fever, altered sensorium) and often have bloody diarrhea.

Upright chest radiograph is the correct answer because the above case describes a patient with the most likely diagnosis of perforated peptic ulcer based on age, medicine history, and clinical presentation. Upright chest radiograph will show gas under the diaphragm in more than 50% of the cases of the perforated peptic ulcer, which can be diagnostic.

Supine abdominal radiograph is incorrect free air is difficult to detect in the supine abdominal radiograph. Hence, an erect chest radiograph is mandatory in patients with suspected perforation of the bowel.

Esophagogastroduodenoscopy is incorrect because the patient is in shock and needs urgent laparotomy for a perforated peptic ulcer. Esophagogastroduodenoscopy (EGD) is not indicated in this case as it will be time-consuming and can increase the risk of injury to the already inflamed mucosa that may cause further deterioration of the patient.

CT scan of the abdomen with contrast is incorrect because although CT is the most accurate modality for diagnosis of perforated peptic ulcer, CT scan is not indicated in this patient who requires urgent resuscitation and definitive treatment in the form of laparotomy. CT can delay the management of the patient and may cause further deterioration in the condition of the patient.

Ultrasound of the abdomen is incorrect because ultrasound may show free fluid but will not be able to show free air in the peritoneum. Hence, ultrasound is not indicated in patients with suspected perforation as the initial diagnostic investigation.

Smoking cessation at least four weeks before surgery is correct because smoking cessation before surgery (regardless of timing) has been shown to decrease the risk of postoperative pulmonary complications. However, ideal results are seen if patients stop smoking at least 4 weeks before surgery and, ideally, 8 weeks before surgery.

Preoperative prophylactic antibiotic administration is incorrect because this aids in reducing the incidence of surgical site infections, not postoperative pulmonary complications.

Preoperative chest physiotherapy is incorrect because it is used in the postoperative period to reduce pulmonary complications.

Preoperative continuous positive airway pressure (CPAP) is incorrect because CPAP is used postoperatively to reduce the risk of pulmonary complications.

Placement of a nasogastric (NG) tube is incorrect because there is an increased risk of aspiration with the routine use of a nasogastric tube due to an open gastroesophageal junction. NG tube may be protective against aspiration and pulmonary insult in patients with nausea or vomiting.

Rapid sequence intubation is correct because this patient’s mechanism of injury and physical examination are both consistent with a cervical fracture that is complicated by altered mental status with respiratory insufficiency (respiratory rate of 7/min). Cervical fractures may lead to immediate or delayed cervical spinal cord compression and phrenic nerve paralysis and subsequent respiratory failure. Although an oxygen saturation of 96% may seem reassuring, hypercapnic respiratory failure may present with normal pulse oximetry. Rapid sequence intubation is vital to secure the patient’s airway and allow for proper management of his cervical injury. Delaying this intervention in favor of imaging could lead to respiratory arrest, seizure, and death.

Rectal tone assessment is incorrect because it is performed during the Disability or Exposure portions of the primary trauma survey. In general, it should not be performed until after the Airway, Breathing, and Circulation portions of the primary survey have been completed, especially in a patient who is unconscious and has a respiratory rate of 7/min.

Laryngeal mask airway insertion is incorrect because these insertion devices are not the recommended method of airway management in an unconscious patient with impaired respiratory status, especially in a trauma setting, where a laryngeal mask might exacerbate occult esophageal injury.

CT scan of the spine is incorrect because although it is an appropriate diagnostic test for the management of suspected cervical injuries, it should only be done after the patient has been stabilized. Favoring imaging over airway management would result in severe damage to the patient’s health.

MRI of the spine is incorrect because although it might be used for the diagnosis of traumatic spinal cord injury as well as presurgical planning, this patient’s respiratory status is compromised (he is unconscious and his respiratory rate is 7/min). Delaying airway management in favor of imaging could be devastating if the patient were to decompensate inside the MRI machine.

She should undergo a skin biopsy, aggressive wound care, and hemodialysis; the condition will likely improve after parathyroidectomy is correct. Calciphylaxis, now more commonly called calcific uremic arteriolopathy (CUA) – which is more descriptive of this process – is a rare, severe, and life-threatening complication of secondary hyperparathyroidism. Hyperparathyroidism is almost always secondary to end-stage renal disease (ESRD). CUA is characterized by medial calcification of small to medium-sized arteries, resulting in ischemic damage to dermal and epidermal structures. Ischemic changes present as livedo reticularis and are a reflection of medial arteriolar calcification and subintimal fibrosis, which leads to luminal narrowing and diminished blood flow. When the calcium-phosphate product is grossly elevated, non-specific vascular calcifications can occur. The calcification can lead to non-healing ulcers, gangrene, and sepsis.

She should undergo an arteriogram and lower extremity vascular bypass, as well as wound debridement, thyroidectomy should be performed is incorrect. Women on hemodialysis are 2 to 3 times more likely to develop the disease than men. The diagnosis of calcific uremic arteriolopathy (CUA) is usually based on clinical findings of characteristic skin lesions and can be supported by microscopic examination of skin biopsy samples.

She should immediately be started on dapsone with no debridement of wounds; parathyroidectomy should be performed is incorrect. Lesions are mottled and painful and advance to hard tender plaques that develop central ulceration and then eschar. Serum calcium and parathyroid hormone levels can be normal or slightly elevated. Parathyroidectomy is effective for many patients in slowing the progression of the disease and allowing eventual healing of the wounds, with intensive local therapy.

She should immediately be started on dapsone, and wound debridement should be performed; parathyroidectomy should be performed is incorrect. Some authors advocate urgent parathyroidectomy. Overall, calcific uremic arteriolopathy (CUA) involving the trunk, shoulder, buttock, or thigh has a poorer prognosis than in patients with distal extremity disease. Patients with CUA typically lack other signs of vasculitis and will have intact peripheral pulses in the absence of concurrent vascular disease.

She should undergo a skin biopsy, aggressive wound care, and hemodialysis; the condition will likely improve after thyroidectomy is incorrect. Arteriogram will not demonstrate a lesion amenable to bypass; in addition, this patient has palpable pulses. A vascular bypass will not help this condition. This patient does not give a history of being bitten by a spider. The brown recluse spider bite is associated with necrosis and ischemic skin changes. Surgery is rarely indicated. Patients bitten by a brown recluse spider should be immediately started on dapsone.

Endoscopy is the correct response. This patient’s presentation with diarrhea progressing from watery to bloody, abdominal pain, history of similar symptoms in the past, presence of aphthous ulcers, and perianal disease is suspicious for Crohn’s disease (CD). She also has a smoking history, which is associated with an increased risk of CD. Diagnosis of Crohn’s disease is established on endoscopy or other imaging modalities such as high-resolution ultrasound, CT scan, or MRI. Biopsy taken on endoscopy will show transmural inflammation of the intestinal wall and non-caseating granulomas.

C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) is incorrect. CRP and ESR are non-specific inflammatory markers that are raised in many inflammatory conditions. Even though CRP and ESR will be high in CD, they alone will not provide a definitive diagnosis.

Complete blood count (CBC) is incorrect. CBC is performed in patients with CD, as they are likely to be anemic. However, CBC alone will not diagnose the condition.

Stool analysis is incorrect. Stool analysis would provide the diagnosis if the patient’s symptoms were due to an infectious etiology. Her clinical picture is indicative of CD.

Enzyme immunoassay for Clostridium difficile is incorrect. This patient has no risk factors for clostridium infection.

5-Fluorouracil, mitomycin-C and 6 weeks of radiotherapy is correct. This case describes a patient with a locoregional anorectal neoplasm, with sphincter involvement and positive perirectal lymph nodes. Imaging modalities like endorectal ultrasound or pelvic MRI are helpful in evaluating the depth and extent of tumor involvement as well as lymph node involvement, thereby helps in tumor staging. Modified Nigro protocol employed today involves neoadjuvant treatment with 5-Fluorouracil and mitomycin-C along with 6 weeks of radiation therapy. The advantages of this neoadjuvant therapy include tumor downstaging, improved resectability, and high rates of anal sphincter preservation. The modified Nigro protocol has shown an initial complete response in about 90% of patients. Those with persistent disease may be subjected to salvage surgery (APR).

Wide local excision and follow-up is incorrect because it is considered in anal margin carcinoma where clear margins can be achieved.

Abdominoperineal resection (APR) is reserved as salvage therapy in residual lesions after neoadjuvant chemoradiation (Nigro protocol)

5-Fluorouracil + cisplatin is incorrect because it is employed in case of metastatic anorectal neoplasms.

Low anterior resection with colo-anal anastomosis is incorrect because it is not feasible in this patient.

Regular breast self-examinations, clinical breast examinations, and follow-up mammography is correct because the patient in the given case has fat necrosis of the breast (given the presence of foamy histocytes and fat globules on multiple core needle biopsies), most likely due to previous breast surgery. It is a benign breast condition that requires monthly breast self-examination along with annual clinical breast examinations and regular mammographic screening beginning at 40 years of age as per recommendations.

Radiation therapy of the left breast is incorrect because this patient has presented with fat necrosis of the breast, which is a non-malignant condition, and radiation therapy is reserved for malignant lesions of the breast (either after mastectomy or lumpectomy).

Simple mastectomy of the left breast is incorrect because mastectomy is an invasive procedure done for the management of aggressive cancers of the breast, while the case presented here is of fat necrosis.

MRI of the left breast is incorrect because tissue diagnosis has already been done with confirmation of fat necrosis, so further imaging is unnecessary. MRI of the breast is utilized for screening in younger (i.e., less than age 25) patients with an elevated risk of breast cancer (prior chest wall irradiation or the presence of a BRCA mutation)

Wide local excision with sentinel node biopsy is incorrect because it is the treatment option for breast cancers that are candidates for breast conservation therapy. These patients typically require adjuvant radiotherapy after resection

Perform breast ultrasonography is the correct answer. Typically women over 30 should have breast masses evaluated by mammography and ultrasound. Those under the age of 30 should have breast masses evaluated by ultrasound. Based on the findings of the imaging studies, a core needle biopsy may be warranted.

Reassure the patient and re-examine her in 6 weeks is incorrect because the patient under consideration is high risk of possible breast cancer owing to her age at presentation, the mass that is increasing in size, positive family history, and prolonged use of oral contraceptives along with nulliparity. In cases with high suspicion or high risk of having underlying breast malignancy, it is recommended to perform imaging and appropriate pathological analysis.

Perform MRI of the breast is incorrect because although MRI has high sensitivity and specificity for picking up breast lesions, mammography has already been done, suggesting a benign disorder.

Perform immediate fine needle aspiration cytology (FNAC) of the breast mass does not provide adequate information concerning the tumor architecture. FNAC is typically used to evaluate suspicious axillary lymph nodes prior to planned surgical resection.

Get an immediate core needle biopsy of the breast mass is incorrect because first imaging should be performed to evaluate for the presence of suspicious findings concerning for breast cancer.

2 cm non-ulcerated mucosal mass with no perigastric lymph nodes is the correct answer because it fulfills the common indications for endoscopic submucosal resection (ESR). The question describes the indications for ESR in patients with early gastric cancer (EGC). Recently, cases of EGC have been increasing secondary to greater use of screening endoscopy. ESR has been shown to provide similar efficacy compared to open surgery for EGC. ESR is performed by injecting epinephrine in the submucosa beneath the tumor and incising the mucosa and submucosa with an endoscopic knife. Indigo carmine can be applied to assist in identifying the edges of the tumor. Common indications for ESR including the following: well-differentiated, non-ulcerated, intramucosal tumors that are less than or equal to 2 cm and have no worrisome lymph node on ultrasound or CT imaging (i.e., lymph nodes 1 cm or greater in size).

1 cm non-ulcerated submucosal mass with 0.5 perigastric lymph nodes is incorrect because the tumor extends to the submucosa.

1 cm ulcerated mucosal mass with no perigastric lymph nodes is incorrect because the tumor is ulcerated.

3 cm ulcerated mucosal mass with 0.5 cm perigastric lymph nodes is incorrect because the tumor is greater than 2 cm and is ulcerated.

2 cm non-ulcerated mucosal mass with 1.5 cm perigastric lymph nodes is incorrect because of the presence of worrisome lymph nodes.

Bilateral cystectomy is the correct response as this patient has evidence of bilateral ovarian endometrioma. Recent evidence indicates that excision/cystectomy of ovarian endometrioma is associated with improved symptoms, low rates of recurrence, and increased pregnancy rates.

Unilateral cystectomy is not the correct answer for this patient as she has evidence of cystic mass arising from both ovaries. Bilateral cystectomy is, therefore, more appropriate for her.

Rectal shaving is not the correct response as it is appropriate for patients with endometriosis involving rectum. This patient has evidence of bilateral ovarian endometrioma and diagnostic laparoscopy shows no evidence of bowel endometriosis. This patient should undergo bilateral cystectomy.

Segmental resection of rectum is not the correct choice as this patient has no evidence of bowel endometriosis. Excision of the involved rectal segment and subsequent primary anastomosis is appropriate for patients with deep infiltrating endometrial lesions of the rectum.

Hysterectomy is not an appropriate choice for this patient as she is in her reproductive years and also desires fertility. Hysterectomy is appropriate for older women who have completed their families. Hysterectomy should always be considered as a last resort for patients with endometriosis.

Acute peripancreatic fluid collection is correct because this patient has sustained a blunt epigastric injury leading to acute pancreatitis, which was not managed properly. The development of a pseudocyst of the pancreas is common in children after a blunt abdominal injury (the most common cause of acute pancreatitis in children). Initially, this is termed an acute peripancreatic fluid collection, and if it persists beyond four weeks of the initial insult, it is called a pseudocyst.

Aortic aneurysm is incorrect because this patient presents with a smooth, firm mass in the epigastric region. An aortic aneurysm is a pulsatile mass found in the epigastric region, usually in the elderly population.

Bowel perforation is incorrect because the chest x-ray in this patient is unremarkable. Bowel perforation usually presents with gas in the diaphragm on an upright chest x-ray.

Intussusception is incorrect because this patient has a history of trauma accompanied by the progression of symptoms. Intussusception is a medical emergency where a proximal part of the intestine telescopes inside a distal portion. It usually occurs in children of younger age and presents as acute colicky pain and the passage of blood mucoid stools (i.e., ‘currant jelly’ stools).

Appendicular abscess is incorrect because this patient has a mass in the epigastrium associated with a blunt traumatic injury. An appendicular abscess occurs in the right lower quadrant. It is associated with a history of appendicitis (i.e., right lower quadrant pain, fever, anorexia), which is not present in this patient.

Ruptured spleen is correct because this patient presents with blunt trauma to the abdomen and severe left upper abdominal pain with fractures of the left lower ribs. The shoulder pain is referred pain due to diaphragmatic irritation from the blood by spleen injury.

Pancreatic cyst is incorrect because this patient has an injury to the left upper quadrant of the abdomen with a fracture of the left lower ribs. Pancreatic cyst presents with a mass in the epigastrium and radiating pain to the back.

Flail chest is incorrect because this patient has rib fractures at single sites. Flail chest is characterized by an unstable chest wall segment associated with a fracture of at least 3 ribs at 2 different positions leading to paradoxical respiratory movements.

Pneumothorax is incorrect because this patient is suffering from a ruptured spleen accompanied by blunt abdominal trauma. Pneumothorax is associated with chest x-ray findings of flattened diaphragm and loss of vascular markings, which are not present in this patient.

Liver injury is incorrect because this patient is suffering from blunt abdominal trauma with the left upper quadrant’s tenderness. Liver injury is associated with right upper quadrant tenderness.

Administration of a crystalloid bolus is correct. The standard of fluid resuscitation involves the administration of a two-liter fluid bolus, which helps provide the volume needed to sustain the circulatory process. In the hemorrhagic shock, the fluid will replace the lost blood until blood products can be given while in the hypovolemic shock, the initial fluid resuscitation will, partly, help with the dehydration of the patient.

Administration of vasopressors is incorrect because adding vasopressors may not help the case and potentially harm distant tissue with ischemia. Many patients will ultimately require vasopressors but only after they receive adequate resuscitation.

Administration of blood products is incorrect. While blood products are helpful in the setting of hemorrhagic shock, this may not be the only cause of hypovolemic shock. Blood components should also be processed before infusion and may take slightly longer to provide to the patient.

Invasive hemodynamic monitoring (not including blood pressure) is incorrect. Regular monitoring of patients with basic vital signs obtained will be sufficient to determine the condition of the patient, and it would not be the most appropriate to spend time obtaining an invasive means of monitoring. Also, there are hemodynamic monitors that do not require placing a pulmonary artery catheter. Management of the patient would not change whether invasive hemodynamic monitoring is used or not.

Administration of an albumin infusion is incorrect. Albumin resuscitation would play no real role in these patients and has been shown to increase mortality in trauma patients. Cardiogenic shock mainly involves the administration of inotropic agents rather than fluid administration – which is the rare exception to the management of states of shock.

Achalasia of cardia is the most likely diagnosis as it is characterized by the presence of long-standing dysphagia, specifically for liquids and not for solids associated with regurgitation halitosis. A barium swallow study is the investigation of choice as it will reveal a dilated esophagus with a narrowing of the distal end described as a “bird beak” on appearance.

Gastroesophageal reflux disease (GERD) is less likely as the patients usually present with the classical triad of symptoms, including retrosternal burning pain, epigastric pain occasionally radiating through to the back, and regurgitation. Endoscopy is the investigation of choice.

Pharyngeal diverticulum is less likely in this patient as it typically presents with dysphagia, regurgitation, chronic cough, aspiration, halitosis, and weight loss. A plain radiograph is not useful in the diagnosis; rather, a barium swallow is indicated. A barium swallow study will reveal a diverticulum rather than a bird beak appearance.

Rolling hiatus hernia is less likely in this patient as it is more common in elderly patients with typical symptoms of dysphagia and chest pain that resolves following a loud belch. The symptoms occur due to the twisting of the esophagus and stomach. A plain radiograph may show a gas bubble with a fluid level behind the heart. A CT scan with oral contrast is the appropriate choice of investigation as it will provide information about the anatomy of the stomach along with information about the involvement of other structures in the hernia. A barium swallow study will reveal a gastroesophageal junction above the diaphragm with the gastric fundus just along the esophagus, causing compression.

Esophageal carcinoma is less likely in this patient as most patients present with dysphagia to solids rather than liquids and less commonly present with vomiting, regurgitation, and odynophagia.

Latrogenic esophageal perforation accounts for almost 50% of the cases with endoscopic procedures being the most common cause. Diagnostic endoscopic procedures are associated with an increased risk of perforation of the cervical esophagus, while therapeutic endoscopic procedures are associated with an increased risk of perforation of the distal esophagus.

Trauma leading to esophageal perforation is rare, accounting for only 10% of the cases, and usually occurs secondary to penetrating or blunt forces. Penetrating injuries are more common than blunt injuries that may be masked by more severe injuries like cardiac contusion or aortic dissection.

Perforation due to a foreign body accounts for only 14% of the cases. The impacted foreign body will cause pressure necrosis leading to ischemia of the esophageal wall and subsequent perforation. The distal third of the esophagus is the most commonly involved site of impaction secondary to peptic stricture, achalasia, or esophagitis, while impaction in the middle third of the esophagus is usually secondary to neoplasms causing an obstruction.

Boerhaave’s syndrome accounts for only 15% of cases of esophageal perforation, which occurs due to a sudden increase in intra-esophageal pressure along with negative intrathoracic pressure.

Caustic injury can lead to perforation if it is a third-degree injury, and is very rarely seen.

Routine endoscopic ultrasound is correct. It has been observed that bleeding risks may be reduced by the routine use of endoscopic ultrasound in selecting the site for placement of a transluminal stent.

Salvage procedure for infected debris removal is incorrect. Salvage procedures are undertaken secondary to the failure of nonsurgical therapy. Salvage procedures help remove infected debris and establish complete drainage. However, this treatment regimen is associated with increased risks of complications and death, so it is an incorrect option.

Resection of a pseudocyst is an incorrect option. Resection is indicated for cysts found in the pancreatic tail. It is also recommended in cases where a disruption in the mid-pancreatic duct has given rise to a distally located pseudocyst. However, it is not associated with reduced bleeding risk.

Distal pancreatectomy can be undertaken for removal of a pseudocyst, with or without splenectomy. However, in cases of prior pancreatitis, it becomes a complex and challenging procedure. This procedure is not linked to a reduced risk of bleeding complications.

Internal drainage procedure is linked with a reduced risk for developing a pancreatic-cutaneous fistula. This procedure, however, is not associated with a notably decreased risk of bleeding.

Secretin simulation test is correct. This patient likely has gastrinoma, given the presence of multiple ulcers and thick gastric folds in addition to an elevated fasting serum gastrin level. However, when the gastrin level is less than 1000 pg/mL, a secretin stimulation test should be performed to confirm the diagnosis of a gastrinoma. In this test, a patient is administered secretin. If, after secretin administration, the patient’s gastrin levels increase by two-fold above its basal level, the diagnosis of a gastrinoma is confirmed.

Monitored fast can help confirm the diagnosis of an insulinoma, not Zollinger-Ellison syndrome (ZES), which is likely present in this patient. In this technique, blood is sampled every 4 to 6 hours for glucose and insulin levels until the patient becomes symptomatic. However, a monitored fast requires close supervision due to the inherent danger of a state of induced hypoglycemia.

Octreotide scintigraphy with computed tomography would localize gastrinomas. It combines whole-body imaging with increased sensitivity of the octreotide scan and locates nearly 85% of the gastrinomas.

Endoscopic ultrasound is useful for preoperative localization of gastrinomas, especially in the pancreatic head or duodenal wall. However, it is not a method of choice for confirmation of diagnosis.

Checking serum calcium levels helps rule out MEN1 syndrome prior to surgery. This is necessary because resection of the gastrinomas in these patients is rarely associated with prolongation of survival. However, this is a pre-operative requirement and does not precede the initial confirmation of diagnosis.

Splenectomy is correct. It is indicated in this case for several reasons. Splenectomy may be the appropriate management strategy in patients with thalassemia who have severe anemia, increase in transfusion requirements (i.e., an annual transfusion requirement of greater than one unit of packed cells per kilogram of body weight), growth retardation, hypersplenism leading to other cytopenias, symptomatic splenomegaly, and secondarily infected splenic infarcts (leading to a splenic abscess consisting of several locations). In this case, the patient has an increase in transfusion requirements. However, splenectomy still has its risks, and these must be discussed with the patients, such as thromboembolism, post-splenectomy sepsis, and pulmonary hypertension. The decision to move forward with splenectomy should be a cautious and informed one, but should be considered in this case.

Exchange transfusions is incorrect. They are indicated in patients with sickle cell anemia upon presenting with stroke or severe crisis. It is not a part of the management plan in thalassemia patients presenting with excessive transfusion requirements.

Corticosteroid therapy is incorrect. It is indicated in the management of idiopathic thrombocytopenic purpura and autoimmune hemolytic anemia. It is not a recommendation for patients suffering from thalassemia.

Intravenous immunoglobulin administration is incorrect. It is indicated in idiopathic thrombocytopenic purpura. It is recommended in cases of internal bleeding when platelet counts remain less than 5000/mm^3, when extensive purpura exists, or to preoperatively boost platelets. However, it is not involved in the treatment of thalassemia.

Initiation of rituximab is incorrect. It is a second-line treatment for idiopathic thrombocytopenic purpura. It is not indicated for the treatment of thalassemia.

Nuclear imaging is correct. The use of indium-labeled autologous platelet scanning (ILAPS) is a nuclear imaging technique that helps predict the usefulness or lack thereof of a splenectomy. This procedure identifies the location of sequestered platelets, i.e., the spleen, liver, or both. In platelet sequestration diseases, this information helps to determine the course of subsequent management.

Splenic angiography is incorrect. It is the process of invasive arterial imaging of the spleen. This procedure, in combination with therapeutic splenic embolization, can act as an adjunct to splenectomy for the management of patients with hematologic disorders. However, this procedure does not help decide upon this patient’s management course.

Magnetic resonance imaging (MRI) is incorrect. An MRI is costlier than a computerized tomography scan or ultrasound, and despite its detailed abdominal imaging, it does not help decide the mode of management in this patient.

Plain radiography is incorrect. It can only provide primary splenic imaging and identify splenic calcifications and is not a useful modality for deciding upon the treatment method in this patient.

Ultrasound is incorrect. An ultrasound is a simple, non-invasive imaging procedure to evaluate the anatomy of the spleen, but it cannot help decide the course of management in this patient.

Partial splenectomy is correct and can help treat certain lipid storage disorders, such as Gaucher’s disease. The technique is indicated to minimize the risk of post-splenectomy sepsis in children. Apart from Gaucher’s disease, some forms of traumatic splenic injury (blunt and penetrating), spherocytosis in children, and focal benign splenic lesions are also responsive to partial splenectomy.

Robotic splenectomy is incorrect. This patient has presented with massive splenomegaly and requires partial splenectomy. This complex surgical procedure is not yet recommended through the process of robotic splenectomy.

Single-incision laparoscopic splenectomy is incorrect since solid organ retraction is complicated enough through this procedure. The high body mass index of this patient makes this choice even more unlikely.

Splenorrhaphy is indicated in the setting of capsular tears. Since this patient has not undergone trauma and a capsular tear is unlikely, this option is incorrect.

Laparoscopic splenectomy is now considered the gold standard for elective splenectomy in patients who present with normal-sized spleens. The presence of splenomegaly as in this patient is reportedly associated with high rates of both complications and conversion to open splenectomy. Therefore, this option is also incorrect.

Non-Hodgkin’s lymphoma is the correct option. It has been observed that there is a higher risk of developing certain cancers in individuals who have undergone splenectomy. A higher risk of the development of leukemia, non-Hodgkin’s lymphoma, esophagus, stomach, liver, and other head and neck cancers were found in splenectomy patients. Defective immune surveillance in splenectomy patients is projected as a possible cause.

Initial drop in platelet count is incorrect. The platelet count is expected to rise initially within several days of splenectomy.

Chronic drop in hemoglobin level is incorrect. A successful splenectomy would result in a rise in hemoglobin levels. A chronic drop in hemoglobin levels is not a typical complication associated with splenectomy.

Portal hypertension is incorrect. Portal hypertension is often due to liver cirrhosis and is accompanied by splenomegaly and splenic congestion. It is not a complication occurring as a result of splenectomy.

Felty’s syndrome is incorrect. Felty’s syndrome is a triad of rheumatoid arthritis, splenomegaly, and neutropenia. Since Felty’s syndrome is not listed as a complication of splenectomy, this option is incorrect.

Magnetic resonance cholangiopancreatography (MRCP) is the correct response. MRCP provides anatomic details to confirm or eliminate the diagnosis of bile duct stones. A respective sensitivity and specificity of 95% and 89% are associated with MRCP for detecting choledocholithiasis. Since it is safe and effective, it is the most appropriate option for confirming the presence of bile duct stones in cases with low to moderate suspicion of choledocholithiasis.

Endoscopic retrograde cholangiopancreatography (ERCP) is incorrect. ERCP is highly effective at diagnosing choledocholithiasis, but due to the risks associated with the procedure, it is scarcely used as a purely diagnostic modality. ERCP is reserved for cases with a high clinical suspicion of choledocholithiasis or a confirmed diagnosis – i.e., cases in which a therapeutic intervention such as stone extraction or sphincterotomy is planned.

Endoscopic ultrasound is incorrect. While endoscopic ultrasound is as good as endoscopic retrograde cholangiopancreatography (ERCP) for detecting common bile duct stones (sensitivity of 95% and specificity of 97%), it requires endoscopic expertise, which makes it less desirable except in particular clinical scenarios.

Percutaneous transhepatic cholangiography (PTC) is incorrect. PTC drain is an incorrect option since it is rarely needed in patients with common bile duct stones. It is recommended only in patients with contraindications to endoscopic or surgical approaches.

Biliary scintigraphy is incorrect. Biliary scintigraphy is primarily used to diagnose acute cholecystitis and not choledocholithiasis. The condition appears as a nonvisualized gallbladder along with the immediate filling of the duodenum and common bile duct. This absence of gallbladder filling is due to the cystic duct’s inflammatory closure, which prevents bile backflow.

Transabdominal ultrasonography is the correct answer because it is considered the most helpful initial radiologic test for diagnosing acute cholecystitis. Ultrasonography has a sensitivity and specificity of 70% to 90%. Ultrasound documents the presence or absence of stones showing any gallbladder wall thickening and the presence of pericholecystic fluid, both of which are suggestive of acute cholecystitis. The sonographic Murphy’s sign, elicited as localized tenderness over the gallbladder upon compression by a sonographic probe, would also support the diagnosis of acute cholecystitis.

Computerized tomography (CT) scan is incorrect. A CT scan is performed in the setting of abdominal pain of unknown etiology. It helps pinpoint the cause of undifferentiated abdominal pain and excludes other pathologic processes at once. However, it is less sensitive than ultrasonography in detecting gallstones.

Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) is incorrect. MRCP outlines the anatomy of the biliary tree and the pancreatic duct. MRI, in concert with an MRCP, is a focused, non-invasive test. This test helps in the diagnosis of biliary tract and pancreatic diseases. While it has a sensitivity and specificity of 95% and 89%, respectively, for detecting choledocholithiasis, it is not indicated as an initial diagnostic modality in the management of suspected acute cholecystitis.

Endoscopic retrograde cholangiopancreatography (ERCP) is incorrect. ERCP is often reserved as a treatment modality in the presence of common bile duct stones. It is not an early diagnostic option in suspected acute cholecystitis.

Biliary scintigraphy is incorrect. It is a primary diagnostic modality for acute cholecystitis. However, since false-positive results can occur in alcoholism, this is not the best initial diagnostic tool for this patient. The condition appears as a nonvisualized gallbladder along with immediate filling of the duodenum and common bile duct. This absence of gallbladder filling is due to inflammatory closure of the cystic duct, which prevents the backflow of bile. If the biliary scintigraphy verifies the cystic duct obstruction, acute cholecystitis is confirmed.

Mesh repair at the same time is correct. There is a high rate of mortality and morbidity associated with strangulated or incarcerated obturator hernias. If an obturator hernia is found incidentally, it should be repaired by mesh hernioplasty in this patient. Mesh is fixed to the ligaments of Cooper and Gimbernat. An obturator hernia is present more commonly in females. They are a rare type of hernia, mostly seen in elderly women. The obturator hernia is at high risk of incarceration because of the rigid boundaries of the obturator foramen. If found during another procedure, it should be repaired concurrently using mesh.

Annual follow-up with an annual pelvic MRI is incorrect. Follow-up with pelvic MRI is not recommended.

Observation is incorrect. Observation alone is not recommended.

Convert to open procedure is incorrect. If an obturator hernia is incidentally found, it should be repaired by mesh hernioplasty. This can be done laparoscopically, and converting to an open technique is usually not needed. There is a high rate of mortality and morbidity associated with strangulated or incarcerated obturator hernias.

Mesh repair after 6 months is incorrect. If an obturator hernia is found incidentally, it should be repaired by mesh hernioplasty at the same time. Repair should not be delayed.

Angular cheilitis is associated with dental issues or vitamin B deficiency. It presents as ulcerations and fissures on the corners of the mouth; therefore, this option is correct.

Aphthous ulcers present on mucosal surfaces where the skin is not tightly bound to the bone. In this patient, the sores involve the skin; therefore, this option is incorrect.

Leukoplakia is a whitish patch found on mucosal surfaces of the oral cavity associated with tobacco chewing or premalignant conditions. In this patient, the ulcers are exclusively present on the corners of the mouth; therefore, this option is incorrect.

Herpes simplex virus infection presents as vesicles that typically ulcerate and are not associated with vitamin or iron deficiencies; therefore, this option is incorrect.

Glossitis is inflammation of the tongue, which can present as a shiny red surface of the tongue due to ulceration. In this case, the ulceration does not involve the tongue; therefore, this option is incorrect.

Necrotizing sialometaplasia (NS) is a benign, self-limiting inflammatory reaction of minor salivary glands usually caused by ischemia of glandular tissue. Histology shows squamous metaplasia with signs of ischemic and inflammatory necrosis; therefore, this option is correct.

Adenoid cystic carcinoma of palate appears as a pleomorphic adenoma of minor salivary glands on histology. Distant metastases and perineural invasion are common. Also, the invasion of the underlying bone is common. In this patient, no signs of metastases are seen and histology shows no signs of adenoma; therefore, this option is incorrect.

Subacute necrotizing sialadenitis is an inflammatory condition of minor salivary glands, and it presents with localized erythematous swelling with a sudden onset of pain, which is not present in this case. Histology shows the absence of squamous metaplasia with cell atrophy; therefore, this option is incorrect.

Aphthous ulcer typically presents as a recurrent round/oval ulcer inside the mouth, especially on the inside of lips and cheeks or underneath the tongue where the mucosa is not tightly bound to the underlying bone. In the present case, an ulcer is present on the palatal region, which is not a typical site of aphthous ulcers; therefore, this option is incorrect.

Mucoepidermoid carcinoma is a malignancy of minor salivary glands that usually arise in the parotid gland. Histology shows the presence of mucous, squamous, and intermediate-type cells. Due to the difference in location and histology characteristics, this option is incorrect.

Tracheoesophageal puncture (TEP) is a voice prosthesis that works as a one-way valve between the esophagus and trachea to allow air from the trachea to the esophagus but prevents retrograde flow of food/saliva into the trachea. With the help of this air circulation, words are articulated. This has a >90% success rate of achieving functional speech; therefore, this option is correct.

Electrolarynx is a device that articulates words by catching vibrations from the neck or cheek. It is usually used in inpatient settings for immediate post-operative periods. Moreover, as the patient is not in favor of using any external device, this option is incorrect.

Functional endoscopic evaluation of swallowing (FEES) is done postoperatively to visualize the larynx during swallowing and evaluate for any laryngeal penetration of food/saliva. It is not helpful for speech rehabilitation; therefore, this option is incorrect.

Lee Silverman speech therapy (LSVT) is a comprehensive treatment to improve articulation by strengthening laryngeal muscles and improving vocal control. It will not be helpful in this case as the patient has undergone total laryngectomy; therefore, this option is incorrect.

Second trial of esophageal speech is achieved by actively swallowing and releasing air from the esophagus, causing the esophageal and pharyngeal walls to vibrate to articulate words. Only <20% of patients develop esophageal speech successfully, and the second trial will not be helpful in this patient if he was not successful in the first trial; therefore, this option is incorrect.

Suction rectal biopsy is correct. This case describes a child with Hirschsprung’s disease or congenital aganglionosis. It is characterized by the absence of ganglion cells in the nerve plexus of the intestine because of a defect in the migration of neural crest cells. Aganglionosis leads to aperistalsis and obstruction. It is usually caused by mutation of rearranged during transfection (RET) proto-oncogene. The most commonly affected region is the rectosigmoid (75%), followed by the splenic flexure or transverse colon (17%) and the entire colon (8%). It presents as a functional distal intestinal obstruction. About 96% of cases fail to pass meconium in the first 24 hours of life. The clinical features of this patient are typical (i.e., explosive bowel movement upon rectal examination). The abdominal radiograph of this patient shows intestinal obstruction with a dilated bowel. Diagnosis involves suction rectal biopsy (the gold standard – more likely to confirm the diagnosis), contrast enema, and anal manometry. A rectal biopsy should include epithelium and submucosa showing the absence of ganglion cells, and the acetylcholinesterase stain is positive. Initial management involves rectal irrigation, fluid resuscitation, and IV antibiotics. Surgical treatments include pull-through operations such as Swenson, Duhamel, and Soave. Enterocolitis is a complication that may be fatal if left untreated.

Contrast enema is incorrect because it only helps to identify the transition zone between the proximal dilated ganglionic colon and the distal narrowed aganglionic segment. It does not confirm the diagnosis of Hirschsprung’s disease.

Anorectal manometry is incorrect because it is not practical in neonates and would yield unreliable results.

Ultrasound of the abdomen is incorrect because it does not diagnose Hirschsprung’s disease. It is utilized in diagnosing pyloric stenosis and intussusception.

Genetic testing for rearranged during transfection (RET) mutations is incorrect because it is suggested in suspected cases with a genetic or family history.

Decreased venous return is correct. The elevated abdominal pressure and transmitted intrathoracic pressure cause compression of the inferior vena cava, thereby reducing the venous return. Moreover, it increases the systemic vascular resistance by compressing the aorta and splanchnic circulation leading to an increase in afterload and reduced stroke volume.

Increased compliance is incorrect. There is cephalad pressure on the diaphragm which results in reduced compliance.

Increased residual volume is incorrect. The decrease in compliance affects pulmonary functions and causes a reduction in the tidal volume, residual volume, and functional residual capacity.

Hypocapnia is incorrect. Changes in compliance lead to subsequent hypoventilation, which eventually manifests as hypercapnic respiratory failure. Renal injury is a common phenomenon and occurs due to both prerenal and intrarenal processes.

Decreased renal vascular resistance is incorrect. The increase in renal vascular resistance decreases renal plasma flow along with the glomerular filtration rate. Moreover, a decrease in venous return contributes to pre-renal failure.

Sedate the patient is correct. A patient with intra-abdominal hypertension (i.e., intra-abdominal pressure between 12 and 20 mmHg without end-organ damage) has multiple treatment options. Initially, pharmacological paralysis, administration of sedation. diuresis, paracentesis, and loosening of the abdominal closure device are done particularly in a stable patient.

Immediate decompressive laparotomy is considered mainly when the intra-abdominal pressure rises above 20-25mmHg, which is Grade IV especially when there are signs of end-organ dysfunction. This patient can be managed first with medical approaches prior to a decompressive laparotomy.

Diurese the patient is incorrect. This patient does not show signs of volume overload therefore diuresis is not appropriate.

Paracentesis is incorrect. This patient has no ascites therefore a paracentesis is not appropriate.

Increase tidal volume on mechanical ventilator is incorrect. Rather, lowering tidal volumes (not raising them) will aid in decreasing intra-abdominal pressures.

“Flow” phase – elevated serum glucagon levels is correct. This patient is within the hypermetabolic “flow” phase of the stress response, occurring either after initiation of fluid resuscitation or spontaneously within hours of a burn injury (reaching a plateau within 5 days of the injury). It is characterized by a hyperdynamic circulation (i.e., a rise in cardiac output which manifests as tachycardia, increased core temperature, and peripheral capillary leak). There is an associated elevation in serum lactate due to increased glycolysis, insulin resistance manifesting as hyperglycemia, and elevated cortisol levels are also typical features. In addition, there is an increase in basal metabolic rates and serum glucagon levels.

“Ebb” phase – mobilization of free fatty acids is incorrect. The “ebb” phase of the stress response occurs within the first 48-72 hours of a burn injury and is characterized by a decrease in cardiac output, oxygen consumption, and metabolic rate. It also results in impaired glucose tolerance and subsequent hyperglycemia.

“Ebb” phase – elevated basal metabolic rate is incorrect. The “ebb” phase of the stress response occurs within the first 48-72 hours of a burn injury and is characterized by a decrease in cardiac output, oxygen consumption, and metabolic rate. It also results in impaired glucose tolerance and subsequent hyperglycemia.

“Anabolic” phase – restoration of lean body mass is incorrect as it is the recovery phase which involves the restoration of lean body mass, weight, and well-being.

Anticoagulation with unfractionated heparin (UFH) is correct. After the initiation of respiratory and hemodynamic support, the next most appropriate step in the management is anticoagulation. Anticoagulation is the standard treatment of pulmonary embolism as suspected in this patient. UFH (unfractionated heparin) is the drug of choice when there is a high risk of bleeding. The reason is that UFH is the shortest-acting agent and can be reversed by protamine sulfate. It is also preferred in individuals presenting with an underlying renal compromise because levels can be easily monitored.

Thrombolytic alteplase infusion is indicated in individuals with persistent hypotension. Persistent hypotension is defined as a systolic blood pressure less than 90 mmHg or a drop greater than 40 mmHg. The presence of persistent hypotension is a sign of massive pulmonary embolism. This is, however, not the case in this patient as evidenced by normal systolic pressure.

Catheter-directed thrombolysis is incorrect. Recent surgery in this patient is also an absolute contraindication to the initiation of thrombolysis. This is an option for individuals who have undergone recent surgical procedures but require thrombolysis. Less systemic exposure through catheter-directed thrombolysis makes it an attractive option in such patients.

Pulmonary embolectomy is reserved for patients presenting with a massive pulmonary embolism, the presence of right ventricular strain, as seen on echocardiography, and the possibility of an imminent hemodynamic collapse.

Anticoagulation with low molecular weight heparin (LMWH) is incorrect. While LMWH is also a drug designated for anticoagulation in cases of pulmonary embolism, the higher risk of bleeding and underlying renal compromise makes unfractionated heparin (UFH) a more attractive option.

Norepinephrine therapy is the most likely next step in management. The initiation of vasopressor therapy is essential in the scenario of a patient with septic shock, unresponsive to fluid resuscitation. Amongst the vasopressors, norepinephrine is the first-line drug of choice.

Dopamine therapy might prove helpful in the setting of decreased systolic function in the septic patient. However, dopamine use is linked with a higher incidence of tachycardia and arrhythmias compared to norepinephrine. Therefore, its routine use is avoided.

Epineprhine therapy is incorrect. In septic shock, initiation of epinephrine therapy before norepinephrine is controversial due to the possibility of deleterious effects on the splanchnic circulation. Therefore, initiation of epinephrine is not the best next step in the management of this patient.

Addition of vasopressin dose of 2 U/min can be used in addition to norepinephrine in cases where salvage therapy is required. This patient, however, does not require salvage therapy.

Dobutamine therapy is a part of the inotropic support regimen in individuals with septic shock in whom euvolemia has been achieved. However, this patient shows no evidence of reduced cardiac output, and euvolemia has not been achieved yet.

Crystalloid infusion is correct. Volume resuscitation for hypotension is the essential first step in the management of individuals presenting with septic shock. In individuals presenting with sepsis, crystalloid infusions are preferred over colloids due to the low cost of crystalloids and similar outcomes from administering either choice.

Hydroxyethyl starches have an absence of beneficial effects and a potential for worsening acute kidney injury. Therefore, they are to be avoided in cases of severe sepsis or septic shock.

Use of pulmonary artery catheters has no established efficacy, while the risk of harm exists. Therefore, its use in septic patients is not recommended.

Antiviral therapy can only be initiated after volume resuscitation has been performed. Furthermore, the addition of antiviral therapy to the established chemotherapy regimens requires the presence of immunosuppression. Since this patient does not have concurrent immunosuppression, this is an unlikely inclusion.

Culture-directed therapy is resorted to after the de-escalation of established antibiotic therapy regimens. This de-escalation occurs by the third day after the initial presentation.

Thrombosis is correct. Vascular thrombosis is the most common post-transplant complication of transplants with an incidence of up to 15%. It usually occurs in the first week following transplant and presents with a sharp rise in insulin requirement or a drop in urinary amylase levels. Venous thrombosis is more common and presents with a swollen and tender graft, lower extremity edema, and deep vein thrombosis. Surgical exploration in recipients may require a graft pancreatectomy.

Intra-abdominal abscess is a common complication but occurs in about 5%-10% of the cases. It is typically managed with percutaneous drainage, as well as empiric antibiotics.

Pancreatic pseudocysts are a pancreas-specific complication that may require drainage but is not as common as thrombosis. This typically involves endoscopic drainage and surgical drainage if surgical intervention is unsuccessful.

Graft pancreatitis frequently occurs due to reperfusion or procurement and is a pancreas-specific complication, but is not the most common complication. This typically leads to elevated lipase and amylase as well as abdominal pain radiating to the back.

Bleeding is a common complication but only occurs in about 6%-8% of the patients. It is a serious complication and often requires a redo laparotomy to address the bleeding.

Basal ganglia (putamen) is correct. This case describes a patient with spontaneous intracranial hemorrhage (ICH), which most commonly occurs in the basal ganglia (putamen), followed by the thalamus, brainstem (pons), and cerebellum. He has risk factors for ICH including hypertension, alcoholism, and also history of previous transient ischemic attack (TIA)-like symptoms. The typical clinical features seen in basal ganglia (putaminal) hemorrhage are acute severe headache, vomiting, altered level of consciousness, and hemiparesis/hemiplegia. These symptoms are spontaneous in onset and there is a smooth gradual progression of symptoms, unlike in ischemic/embolic stroke wherein the symptoms are maximum at the onset. Hemisensory loss is usually seen in thalamic hemorrhages.

Cerebellum is incorrect because cerebellar hemorrhages are usually associated with hydrocephalus, and these patients usually become comatose before first having hemiparesis.

Cerebral lobes is incorrect because the lobar intracranial hemorrhage (ICH) presents as a distinctive form of syndromes; frontal lobe with contralateral hemiparesis & frontal headache; parietal lobe with contralateral hemisensory deficit; temporal lobe with dysphasia & auditory dysfunction; and occipital lobe with contralateral homonymous hemianopsia.

Brainstem is incorrect because brainstem hemorrhages are usually associated with coma, motor disturbances, respiratory disturbances, hyperthermia, and pupillary abnormalities (pinpoint pupils, anisocoria).

Thalamus is incorrect because thalamic hemorrhages are usually associated with contralateral hemisensory deficit, with/without hemiparesis.

Scrotal sonography is correct. This case describes a patient with a right testicular tumor. He has the typical symptoms. Although his family history is negative, there is a well-defined risk factor, i.e. right cryptorchidism (undescended testes) during infancy. Cryptorchidism increases the risk for testis cancer four to six times; there is a risk of developing cancer in the contralateral testis as well. Testicular cancers are commonly germ cell tumors (GCTs), which are usually localized seminoma. Scrotal sonography is considered to be an extension of physical examination as it is inexpensive, non-invasive, and widely available. A typical GCT appears hypoechoic. Moreover, a firm/hard testicular mass should be considered cancer unless proven otherwise, and evaluated with a scrotal ultrasound scan.

Estimation of serum tumor markers (AFP, LDH and beta-hCG) is incorrect because tumor markers are more helpful for staging after orchidectomy. LDH is usually elevated in seminomas.

Trans-scrotal biopsy/orchidectomy is incorrect because it is contraindicated, as it alters the lymphatic drainage of the testis with a risk of developing local recurrence and inguinal/pelvic lymph node metastasis.

FDG-PET scanning is incorrect because it has no role in the routine diagnostic evaluation of testicular tumors.

CT scan of the abdomen and pelvis is incorrect because it is mainly helpful for the clinical staging of testicular tumors as well as detecting any metastasis.

End-to-end anastomosis is correct. Brachial artery transection can be repaired often via end-to-end anastomosis in stab wound injuries. There is typically no tension on the repair unless a large segment of the artery (i.e., longer than 2 cm in length) is lost (as is the case in gunshot wounds).

Primary repair of the arterial wall is incorrect. A small laceration in any arterial wall area can be directly sutured without debridement. In this patient, there is a complete transection of the artery with a small loss of arterial length. Hence, a primary repair is not suitable and an end-to-end re-anastomosis is needed.

Placement of interposition vein graft is incorrect. Interposition graft placement depends on the severity of the arterial injury. If a long segment of an artery (typically longer than 2 cm) is injured, then the damaged segment is removed and repaired using an interposition autologous vein (often the greater saphenous vein) graft.

Interposition prosthetic graft is incorrect. If a long segment of an artery (typically longer than 2 cm) is damaged (or lost) and a suitable vein is not available for autologous grafting, then an interposition prosthetic (typically PTFE) graft is used.

Temporary vascular shunt is a damage control method for polytrauma patients with other life-threatening injuries to perfuse the distal ischemic limbs so that the artery can be reconstructed once the patient is stable. A vascular shunt is not a definitive management strategy for major vascular trauma.

Distal splenorenal shunt (DSRS) more effectively prevents recurrent esophageal bleeding in patients with stable liver function compared to endoscopic procedures. It is not suitable for emergent therapy due to its high difficulty and technical complexity; therefore, transjugular intrahepatic portosystemic shunt (TIPS) has replaced DSRS in emergent settings. However, compared to TIPS, a DSRS is associated with reduced re-operation rates, decreased rebleeding, encephalopathy, and thrombosis rates. DSRS and TIPS have equal effectiveness. Since TIPS is not an option to this question, DSRS is an effective alternative (given the patient is relatively hemodynamically stable at this time).

Urgent endoscopic injection sclerotherapy is incorrect. This patient has recurrent episodes of variceal bleeding already treated with repeated banding, ligation, and sclerotherapy. Therefore, sclerotherapy is not appropriate for this patient.

Repeat banding and ligation of esophageal varices is incorrect. This patient has recurrent episodes of variceal bleeding already treated with repeated banding, ligation, and sclerotherapy. Therefore, banding and ligation are inappropriate for this patient since they likely will not be effective given his prior history.

Continue beta-blockers is incorrect. The patient is already on prophylactic beta-blockers and still suffered a major variceal bleed; therefore, another intervention is required in addition to beta-blocker therapy.

Splenectomy is incorrect. Despite removing the splenic component of the portal circulation, a simple splenectomy is usually ineffective in preventing recurrent esophageal bleeding. Splenectomy is appropriate in individuals presenting with splenic vein thrombosis who typically present with an upper GI bleed and isolated varices within the fundus of the stomach.

Flexible endoscopy septum division (FESD) is a minimally invasive option for patients with Zenker’s diverticulum. It is generally used for reduction in the size of the diverticula and improvement of symptoms, compared to endoscopic stapling and open approaches, which aim at complete excision of the diverticula. FESD is associated with an acceptable success rate and lower rates of complications. It does not require general anesthesia. It is, therefore, suitable for patients with contraindications to anesthesia and a higher incidence of perioperative mortality. It is typically reserved for diverticular between 3 and 5 cm. Diverticula under 3 cm undergoing FESD have a higher risk of an incomplete myotomy. This patient also has a contraindication to general anesthesia (i.e., recent myocardial infarction and implantable cardioverter defibrillator [ICD] placement) and can be treated with flexible endoscopy for symptoms of Zenker’s diverticulum.

CO2 laser-assisted excision is incorrect. This patient suffers from Zenker’s diverticulum, as evident on barium examination, endoscopy, and CT scan. Laser-assisted diverticulectomy requires general anesthesia and endotracheal intubation. It is generally reserved for small diverticulum (< 2 cm). Studies have demonstrated that laser-assisted excision is associated with a higher failure rate, complication rate, and recurrence rate as compared to the recommended endoscopic procedures. This patient has a large diverticulum measuring 5 cm, He recently had a myocardial infarction (MI) and has an implanted ICD device due to the risk of fatal arrhythmia. He is, therefore, unsuitable for general anesthesia and CO2 laser-assisted diverticulectomy, via rigid endoscopy.

Endoscopic stapling is generally considered the first-line treatment for larger diverticula. It is a less invasive procedure with a high success rate and minimal complications. However, this approach requires rigid endoscopy and general anesthesia. This procedure is also associated with higher intraoperative abandonment, with frequent conversion to an open approach. This procedure is not recommended for this patient, as he has recently had an myocardial infarction (MI) and has an implantable cardioverter defibrillator (ICD) device due to the risk of arrhythmia. This patient is unsuitable for general anesthesia and cannot afford open diverticulectomy in case of a difficult endoscopic procedure and intraoperative abandonment.

Open surgical excision or transcervical diverticulectomy is also associated with a high success rate and is usually suitable for larger diverticula, which are difficult to treat endoscopically. However, it is invasive and associated with higher morbidity and mortality rates. It is also associated with higher recurrence rates and requires general anesthesia. This patient’s condition is unsuitable for invasive procedures and general anesthesia. Open diverticulectomy is not an appropriate choice for this patient.

Harmonic scalpel assisted excision utilizes ultrasonic vibrations to coagulate tissues. It is also reserved for small diverticulum (i.e., < 2 cm). Studies have demonstrated that harmonic scalpel-assisted excision is associated with a higher failure rate, complication rate, and recurrence rate as compared to the recommended endoscopic procedures. This procedure also requires rigid endoscopy and general anesthesia. This patient has a large diverticulum measuring 5 cm, He recently had a myocardial infarction (MI) and has an implanted implantable cardioverter defibrillator (ICD) device due to the risk of fatal arrhythmia. He is, therefore, unsuitable for general anesthesia and harmonic scalpel-assisted diverticulectomy, via rigid endoscopy.

Laparoscopic trans-hiatal esophagectomy (THE) involves mobilization and resection of the lower end of the esophagus through the abdomen and neck via a laparoscope. Laparoscopic surgery is generally less invasive as compared to an open approach. It is associated with less perioperative morbidity, shorter hospital stays, and fewer pulmonary complications, as compared to open THE. Since a laparoscopic THE does not involve thoracic dissection, it is preferred for patients with poor pulmonary function. This patient has chronic obstructive pulmonary disease (COPD) and can benefit from a laparoscopic THE. This patient has presented with locally advanced esophageal adenocarcinoma without distant metastasis, which is amenable to surgical resection.

Open trans-hiatal esophagectomy (THE) involves resection of the esophagus, from the abdomen and neck, without entering the chest. An open THE is an invasive procedure with a high risk of complications, longer hospital stays, and increased mortality. It is usually reserved for more complicated cases or failed laparoscopic approaches.

McKeown esophagectomy involves esophageal resection via the abdomen, right thorax, and neck, with cervical anastomosis. This approach is for patients with mid-esophageal and proximal tumors or significant nodal metastasis requiring extensive thoracic nodal dissection This patient has evidence of lower esophageal disease without thoracic lymph node involvement and distant metastasis. He also has chronic obstructive pulmonary disease (COPD), which would make thoracic dissection of the esophagus difficult.

Open transthoracic esophagectomy allows esophageal resection via thoracotomy and laparotomy. This approach is usually encouraged for young patients, who are physically fit with extensive lymph node involvement, especially in the thoracic region. This patient has no evidence of thoracic lymph node involvement and has chronic obstructive pulmonary disease (COPD), indicating pulmonary compromise.

Endoscopic surgical resection is reserved for patients with a mucosal disease without submucosal invasion and lymph node involvement. This patient has a 3 cm tumor with local lymph node involvement and is not a candidate for endoscopic resection.

Fluorescein angiography is currently the gold standard for measuring intraoperative bowel viability after mesenteric ischemia. This technique involves the intravenous administration of a fluorescein dye and visualizing its emission under UV light or wood lamps during laparotomy. Several studies have demonstrated the superiority of this method to clinical inspection for guiding resection of ischemic bowel. This patient should also undergo fluorescein angiography for assessment of bowel viability during surgical exploration.

Photoplethysmography is incorrect.This patient is suffering from acute mesenteric ischemia and is transferred to surgery for resecting non-viable bowel. Various experimental studies have demonstrated the use of pulse oximetry in detecting intraoperative viability of the bowel surface. Pulse oximetry/photoplethysmography can assess oxygen saturation in arterial blood by measuring the absorbance of wavelength in red and infrared regions, corresponding to oxygenated and deoxygenated hemoglobin. However, current evidence is confined mostly to animal models and studies in humans are inconsistent. It is, therefore, not the most preferred intraoperative technique for evaluation of bowel viability and should not be used in this patient.

Clinical inspection is incorrect. Intraoperative bowel viability can be determined by inspecting its color, extent of distension, peristalsis, arterial pulsation, and bleeding from cut surfaces. However, in many instances, the extent of bowel viability becomes unclear, resulting in catastrophic consequences. Although physical inspection is the most common method for intraoperative assessment of ischemic bowel, it is less reliable than fluorescein flowmetry, which is the gold standard.

Electromyography detects ischemic bowel by measuring muscle contractility of the healthy bowel, However, this technique is still in preliminary phases and is complex. It is also less preferred in critically ill patients such as those with acute mesenteric ischemia due to various risks associated with electrodiagnostic. It is, therefore, not the best intraoperative technique to assess bowel viability in this patient.

Radiolabeled microspheres is currently not an acceptable option for assessing bowel viability in patients with acute mesenteric ischemia due to the cost and risks of radiation exposure in already critically ill patients.