Quality
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Miscellaneous- A hospital is designing a quality improvement project to lower their surgical site intection rate using National Surgical Quality Improvement Data (NSQIP) data. Which type of data will they be using?
- You have been asked to develop a quality improvement plan for your surgical department. As you view topics of interest to investigate, which of the following statements are correct?
- A newly trained surgeon completes her fellowship and then attends a course to complete her robotic training, which is paid for by the medical device company. Which act requires that this payment be disclosed?
- Benign Disease
- A 46-year-old woman with a history of ulcerative colitis (UC) presents for evaluation because of difficulties with catheterization of her Kock pouch and intermittent incontinence. Which of the following is the most likely etiology?
- A 35-year-old patient with a BMI of 33 presents after his third episode of diverticulitis in the past 6 years is referred to your clinic for follow-up from a recent diverticulitis flare. He completed a 10-day course of augmentin and is currently nontender. Computed tomography (CT) of the abdomen and pelvis completed 2 weeks ago is shown. Colonoscopy from 1 year ago demonstrated diverticulosis in the sigmoid colon. This third attack marks the second time he has had to cancel a business trip because of his diverticulitis. The best recommendation for him at this point is
- For quality assurance of the completeness of a colonoscopy, it is mandatory to achieve which of the following?
- A 51-year-old healthy female without family history of colorectal cancer presents for her first screening colonoscopy. Which of the following colonoscopy quality measures is most strongly associated with the reduced risk of interval colorectal cancer and disease-related mortality?
- A 19-year-old woman diagnosed with severe Crohn’s proctosigmoiditis 18 months ago suffers from debilitating perianal pain, swelling, discharge, and incontinence. She has undergone numerous anorectal operations including several incision and drainage procedures and seton placements for three separate fistulas, including one with a supralevator extension. She currently has three setons and a mushroom catheter in place with significant ulceration in the anal canal. In addition to prolonged courses of antibiotics, she had been on infliximab for 12 months prior to being on ustekinumab for the past 6 months without improvement. What is the best next course of action?
- A 46-year-old man presents as an inpatient consult for persistent watery diarrhea, nausea, and abdominal cramps. The patient has a history of acute myeloblastic leukemia and received an allogeneic stem cell transplant 6 months ago. The patient notes compliance with his immunosuppression medications. The most common cause of diarrhea in this patient is most likely caused by which of the following?
- A 45-year-old female patient presents with chronic, watery, nonbloody diarrhea. A colonoscopy is performed with normal-appearing mucosa; however, random biopsies demonstrate mild inflammatory changes with mononuclear infiltrates, with few neutrophils and eosinophils in the lamina propria. Patient should be treated using
- A 65-year-old man who underwent a recent colostomy for fecal incontinence presents to your office with a symptomatic parastomal hernia, despite multiple appliance changes. What is the best step for definitive treatment?
- A 41-year-old healthy woman with no prior history presents to urgent care with a 2-day onset of worsening moderate left lower quadrant pain. She is afebrile, her white blood cell count is 13, and computed tomography (CT) shows mild stranding around the sigmoid colon consistent with uncomplicated diverticulitis. Which of the following is recommended?
- A 24-year-old man with history of ulcerative colitis (UC) is 3 days status postemergent subtotal colectomy with end ileostomy for toxic megacolon. He has a low-grade fever of 38.0 °C, rising heart rate to the 110s, rising leukocytosis to 15 x 109, and lower pelvic pain and pressure. Computed tomography (CT) of the abdomen and pelvis demonstrates abscess with fluid and gas adjacent and superior to the rectal stump staple line. How could the chance of complication have been reduced?
- Malignancy
- A 67-year-old man who has never had colonoscopy presented to the emergency room reporting abdominal pain, distention, constipation, and blood per rectum for the past 2 days. He says his bowel movements are thin in caliber. Computed tomography (CT) of abdomen and pelvis shows a large mass in the mid rectum with proximal colonic distention. Magnetic resonance imaging (MRI) of the pelvis with rectal cancer protocol shows a mid-rectal T4N2M0 lesion. The mass is not amendable to endoscopic placement of stent due to angulation. The best next step is
- A 45-year-old man with quadriplegia and fecal incontinence presents for discussion of elective colostomy. What is the most important step to decrease postoperative complications?
- A 53-year-old man with rectal cancer starting at 2 cm from anorectal ring presents to the office to discuss further management. He has undergone chemoradiation and consolidation FOLFOX chemotherapy for cT3N1aM0 microsatellite proficient tumor. He has a partial response with a residual palpable mass. He normally has up to five bowel movements per day with urgency and fecal leakage. What is the best next surgical treatment for him?
- A 47-year-old man presents to the emergency department with a single episode of rectal bleeding and abdominal pain, prompting a computed tomography (CT) of the abdomen and pelvis. A right colon mass is identified as well as numerous masses throughout the liver and the visible portions of the lungs bilaterally. His pain resolves and his bleeding ceases. He denies obstipation or constipation. He does not require a blood transfusion and is not anemic on laboratory evaluation. A colonoscopy is performed, and a nonobstructing lesion is identified in the proximal ascending colon with pathology consistent with adenocarcinoma. A CT-guided biopsy of the liver confirms pathology consistent with adenocarcinoma of colonic origin. Genetic sequencing is pending. The intervention shown to have the least favorable outcome is
- A 72-year-old women reports perianal rash, pruritus, and intermittent bleeding for the past 3 years. She has tried topical creams and topical steroids without improvement. On examination, a 1-cm raised erythematous lesion is seen at the anal margin. A biopsy of the lesion demonstrates large cells with pale, clear cytoplasm. Endoscopic examination is unremarkable. What is the recommended treatment for her?
- A healthy 51-year-old man has a poorly differentiated right colon adencarcinoma with mucinous features and mismatch repair (MMR) deficient protein expression. After germline testing was performed, a diagnosis of Lynch syndrome made. The patient reports no issues with incontinence to gas or stool. What is the recommended surgery in this patient?
- A 47-year-old woman presents with rectal pain and feculent discharge from her vagina. A digital rectal exam (DRE) in the office reveals a 4-cm, firm, palpable mass starting just below the dentate line; it is immobile and contiguous with the posterior vaginal wall. You perform a biopsy that confirms squamous cell carcinoma. After completing the staging workup, you find she has T4N0, stage IIIB disease. The recommended treatment is
- A 57-year-old man undergoes total neoadjuvant therapy (TNT) for management of a cT3N1M0 rectal cancer. After completion of both chemotherapy/radiotherapy and consolidation chemotherapy, the presence of complete clinical response to treatment is assessed by
- Which technical/surgical factor during proctectomy most influences the risk of local recurrence?
- A 55-year-old male patient presents to the clinic for evaluation of intermittent fecal incontinence and fecal urgency. The patient has a history of stage III rectal cancer for which he completed total neoadjuvant therapy (TNT) and low anterior resection (LAR) with diverting loop ileostomy. He is now 3 months status post ileostomy reversal. Despite fiber supplementation and intermittent antidiarrheal medication use, he experiences stool stacking and incomplete evacuation 3 days per week. The patient’s symptoms are consistent with
- A 67-year-old man with cT3cN0 with threatened circumferential radial margin chooses to undergo primary surgery without neoadjuvant chemoradiotherapy. The clinical impact of a curative resection (R0) versus R1 resection is increased rate of
- A 50-year-old man presents with abdominal pain. Colonoscopy with biopsy revealed a large B cell lymphoma in the ascending colon. Staging workup reveals a nonobstructing mass in the ascending colon without evidence of metastatic or multifocal disease. The best next step is
- Perioperative
- A 45-year-old man undergoes his first screening colonoscopy. On the left and transverse colon, there is excellent visualization of the mucosa. The right colon has larger volume of residual stool precluding visualization of part of the mucosa. The Boston Bowel Preparation score (BBPS) for this patient is
- An 88-year-old man presents from a local nursing home with a new onset rectal bleeding. The patient has multiple medical comorbidities, including coronary heart disease previously treated with coronary artery bypass graft surgery, congestive heart failure, and peripheral vascular disease. The patient is wheelchair-bound and has an Eastern Cooperative Oncology Group performance status of 4. The patient is found to have an ascending colon adenocarcinoma without evidence of metastatic disease on staging computed tomography (CT). His preoperative carcinoembryonic antigen (CEA) is 2.1 ng/mL. After an extensive conversation with the patient and his family he desires to proceed with minimally invasive right hemicolectomy. Which of the following is a marker for increased postoperative morbidity, mortality, and length of stay?
- A 50-year-old man undergoes low anterior resection for rectal cancer. Five days later he developed focal pelvic discomfort without generalized abdominal pain, fevers of 102 °C, and a leukocytosis count of 18,000. His blood pressure is 118/72 mmHg and his heart rate is 112. Computed tomography (CT) with rectal contrast confirms an anastomotic leak with a 6-cm abscess with contrast extravasation. What is the best next step?
- A 55-year-old man undergoes a low anterior resection without diverting ileostomy for an T2N0M0 rectal cancer with anastomosis 5 cm from the anal verge. On postoperative day 10, he presents to the emergency department with low abdominal pain and bloating, decreased bowel function, urinary hesitancy, and low-grade fever. On examination, his heart rate is 90, blood pressure is 110/55 mmHg, and temperature is 100.5 °C. He has some localized low abdominal tenderness. His white blood cell count is 15. Computed tomography (CT) of the abdomen and pelvis with oral, intravenous (IV), and rectal contrast shows a 5-cm perianastomotic abscess with some stranding but no free air. What is the best next step in the management of this patient?
- Which of the following bowel preparation strategies is most likely to improve adenoma detection rates for routine screening colonoscopies?
- Pelvic Floor
- A 35-year-old woman develops fecal incontinence after the difficult childbirth. Endoanal ultrasound shows a 30% defect in the external anal sphincter. She undergoes overlapping sphincteroplasty. When can she expect recurrence of symptoms of fecal incontinence?
- A 75-year-old female patient with fecal incontinence presents for stage 1 sacral neuromodulation. Upon lead stimulation, which of the following findings would be associated with optimal lead position?
- A 75-year-old man with a remote history of fistulotomy and radiation therapy for prostate cancer presents for evaluation of his worsening fecal incontinence. He has poor sphincter tone and a palpable muscular defect. Anal manometry confirms diminished resting and squeeze pressures that do not improve after pelvic floor physical therapy with biofeedback. His symptoms persist despite bowel habit optimization and sacral nerve stimulator implantation. The best next option for ths patient is
- A 45-year-old patient reports difficulty upon defecation with needed digitation to evacuate. Physical examination reveals a rectocele. Which of the following surgical approaches has the highest tendency for postoperative dyspareunia?
- Colon and Rectal Surgery Educational Program (CARSEP)
- Anorectal Disease
- A 43-year-old man presents with perianal fistula. Examination revealed an internal opening to be at the dentate line. Magnetic resonance imaging revealed a transsphincteric fistula encompassing half of the external sphincter with the mucosal opening at the right anterior location. No abscess or collections are present. What is the most appropriate surgical management for this patient?
- A 20-year-old male patient with a history of a previous incision and drainage of pilonidal abscess presents to the office with gluteal cleft pain and intermittent bleeding and drainage from several midline pits with no improvement with conservative management. He is a college student with a summer internship while at home and would like to address the problem before he goes back to school. What is the best recommendation for this patient at this time?
- A 36-year-old patient was diagnosed with Crohn’s disease of the terminal ileum 4 years ago. She is currently in remission on infliximab; however, she is concerned about anal skin outgrowth that is frequently irritated. Physical examination reveals a 1.2-cm round anal skin tag that is soft, nontender with a smooth surface. Anoscopy shows normal appearing anorectal mucosa without evidence of perianal abscess or fistula. The most appropriate next step in management for this patient is