FRCS Edinburgh February 2016
Viva Questions
ICU/Principles
Post-op something with SOB
Repiratory failure, definitions, types, causes, escalation, ventilator settings (only interested in pressure vs volume driven, cut me off when answering the other settings), what is PEEP, patient suddenly deteriorates on ventilator, potential cause – pneumothorax, rupture of alveoli discussed.
Post-op some kind of deterioration post left hemicolectomy, sepsis
Potential causes, definitions, management, AKI, definition, classification etc.
Trauma (can’t remember the exact scenario)
Asked to define massive transfusion, give complications associated with transfusions and discuss transfusion reactions and asked for the evidence for Tranexamic acid and a brief discussion of CRASH 2 trial.
Post-Op Lap gynae division of adhesions with Abdominal distension
Asked to review, What will you do. No matter how many times I asked for a CT they would not let me have one. Bloods normal. Obs normal but massive distension. Took back to theatre. Abdomen full of “clear fluid.” Had no idea what they were talking about, envisaging water-coloured fluid. They then told me it was a bladder injury after the bell rang.
Breast Abscess
History, management, examination, treatment options, when to use US, out of hours when would I aspirate, when would I do I&D and why, why did I want to distinguish actational from non lactational and what were the common causative organisms for both
General/ Emergency
Lady three months post gynae open hysterectomy attends clinic with RIF mass
How will you manage/potential differentials/requested CT scan – RIF abscess with retained swab visisble. How will you manage now – what else must you do. Incident reporting, clavien dindo, never events, WHO checklist, what can you do as a surgeon to prevent scenarios like this from happening
Swollen leg day 5 post Anterior resection
Risk factors for DVT, Wells Score, management options, discussed unavailability of duplex, to anticoagulated or not anticoagulated, then asked me if I knew of any other potential treatment options. I said I knew of catheter directed thrombolysis and the examiner said “congratulations, you have just killed your patient by causing them to exanguinate to death.” Seemed a little harsh! I clarified it would need to be limb threatening and would involve weighing up potential risks and benefits but still not overly impressed, hence I started talking about caval filters which he said was what he was looking for (although I clarified this is NOT a treatment option for a DVT!)
Splenomegaly
Patient presenting to clinic with abdominal mass. What do I want to know from examination. I think it is a spleen, what finding are consistent with this/ How will I investigate. Given a CT scan showing a very large splenic cyst. Discussed potential causes for splenic cysts and treatment options. Asled to describe splenectomy and pre/post op management.
Incisional Hernia
Very overweight patient with large incisional hernia. Asked for assessment and management options. I was keen to avoid operating. They pushed me to say the patient insisted on surgery. I said that she met the new NICE criteria for bariatric surgery therefore I would recommend referring her for that instead. They did not seem overly impressed but allowed me to run through the criteria and raised eyebrows but offered no objection! However I also gave the surgical strategies for repairing her hernia if symptoms merited it.
Neck lump
How would you assess and investigate, what symptoms would I ask for, differential diagnoses, progressed to biopsy and discussion of lymphoma. Asked what symptoms I might expect, kind of biopsy, what staging investigations I could arrange prior to referral to Haematology MDT, discussion of stages of lymphoma related to distribution of lymphadenopathy above and below the diaphragm.
Colorectal Academic
Paper – national mortality rates compared Friday to other weekdays for all elective colorectal surgery, BJS 2015
What did I think of the paper, the stats, how else could the findings be explained, what was missing from the conclusions, how was this relevant in the current climate, how could this potentially be misrepresented.
Colorectal Basic Science
* Embryology of anal canal
* Innervation of GI tract, disorders affecting innervation
* Perianal abscess common bacteria and aetiology.
* Fistula classification and aetiology, cryptoglandular hypothesis
Colorectal Subspeciality
CRC
Case discussion about man presenting with CRC symptoms. How would you manage them. CT scan shown – advanced colon cancer. Treatment options discussed. Asked about relevant trial – Foxtrot discussed. Discussed ileostomies and colostomies – asked for potential complications and percentage rates of developing parastomal hernias.
Prolapse
22 year old man with full thickness rectal prolapse. Discussion of management options and investigation. What would I do in clinic to reproduce the prolapse? Discussion of Prosper trial and the quality of the findings. Kept being asked to justify my extensive over-invesitgation which stemmed from me not believing that a healthy 22 year old would have a prolapse. Awkward moment- Examiner 1 (Karen Nugent) “do you not do a rigid sig on every patient you see in clinic?”
Me: “No.” Examiner 1: “Oh, I always do.” (Turns to examiner 2) “Do you?” Examiner 2: “Yes.” Me: “Oh.” Silence.
Anal fissure
Management options. Asked for exact statistics on expected cure rates for Diltiazem, Nifedipine, botox. Asked to describe the procedure of botox injection – where to inject, how many injections, how many units. Asked for one year failure rate and how to describe this to a patient.
Pouch
Can’t remember how we got on to talking about pouches but was asked how to explain to a patient what normal pouch function involved, how many times a day they could expect to have their bowels open, and how to council a patient appropriately.
Clinical Cases
Colorectal
Short Case 1 – Caecal cancer with liver mets
70 (ish) male, asked to take brief history. Described diarrhoea and abnormal blood test leading to referral to hospital.
Question: What did I think had happened?
Likely iron deficiency anaemia with change in bowel habit leading to 2WW referral to exclude colorectal cancer
Patient showed print out of CT scan – caecal cancer seen. Told by examiners he had liver mets also.
Question: discuss treatment strategies
Discussed staging investigations, MDT colorectal and HPB, liver MRI, PET, right hemi open/vs lap and potential liver resection if amenable. Asked which resection first, liver or colon. Reasons given.
Question: How do PET scans work and what else other than cancers light up?
Colorectal
Short Case 2 – Peutz-Jeghers
50 (ish) male lying in bed. Asked to take a brief history. Colicky central abdominal pain with PR bleed and mucus in childhood (aged 4). Recurrence of symptoms.
Question: asked for potential causes of symptoms
IBD (no) FAP (no) MAP (no) HNPCC (no) (In desperation) Juvenile polyp (sarcastic no – that would not cause a recurrence in his 50s!)
Question: since you have mentioned the polyposis syndromes, tell us about them. (brief desciptions given, questions answered regarding inheritance patterns) Now … what else could it be?
Silence from me. Silence from them.
Question: Have another look at him.
Looking, staring, and silence from me.
Question: Look at his face.
Staring for what felt like an hour. Then I spotted the tiny pathetic 2 freckles on his bottom lip.
“Peutz-Jeghers?”
Question: Yes. Now tell us all about it. (Questions on screening protocol, age to start, management of polyps, told me he had multiple small bowel polyps and one was very symptomatic). How will you identify the small bowel polyps? Barium meal/follow-though. Okay, how will you identify the small bowel polyps in THIS century? MR small bowel or capsule endoscopy? Okay, he had capsule endoscopy and it was negative. What is the sensitivity of capsule endoscopy? How often does it take a photograph? From what angles? Does it visualise all of the lumen?
(Don’t knows to most of the above) – bell went and they kept me in the bay.
Question – before you move on, describe to us how you are going to identify which polyp in the small bowel is the problematic one and how you are going to deal with it.
(I couldn’t think of much more to say but I believe other candidates discussed laparotomy with enterotomy and on table endoscopy via the enterotomy)
Colorectal
Long Case- Pouch with perianal fistulation (Crohns)
60 (ish) man lying in a bed. Instructed to spend 10 minutes taking a history and examining him followed by 10 mins of questions. History – pouch formed in Edinburgh 30 years ago for Ulcerative colitis. Very well ever since, happy with pouch function, BO 3/24 hours, no complaints until a few months ago when developed perianal abscesses drained and three setons left in situ. O/E perineum three perianal fistulas visible with one remaining seton and no active sepsis.
Questions: Pretend you are consenting him for his pouch surgery and we will listen to the consent. Then…now modify your consent imagining he is 20 years old, and again pretending he is a 20 year old female.
Question: How would you manage this man from here?
I discussed reviewing the histology suggesting he had UC, checking he did not in fact have Crohns – they said yes, the histology did show Crohn’s. I suggested leaving the setons in situ, removing and trial of infliximab. Unlikely success with other local fistula treatments, they asked me to outline all the treatments I was aware of and why they would/would not work in his case. Then they asked about pouch removal/ stoma and asked why I was not recommending that. I said it was an option if his perianal disease was difficult to manage but that at present he was well with good pouch function. Final questions: would I perform the pouch on this patient if I knew he had Crohns? Why not, since he had such a good outcome for 30 years? What about for indeterminate colitis? Why not?
General
Short Case 1
Incisional hernia.
Take a brief history and examine this lady.
Obese lady with two previous operations and large incisional hernia. Asked to comment on its dimensions and reducibility.
Question: Consent this patient for an incisional hernia repair.
That took up the rest of the station.
General
Short Case 2
Take a short history from this man and examine him quickly.
Obese man with: gynaecomastia, DM, 3 MIs, intermittent claudication, haemangioma on his foot, sweating, scar on his nose from excision of something with skin graft.
Questions: what is he describing? (intermitten claudication) Examine his peripheral vasculature and comment on it. What is the lesion on his foot (haemangioma) The patient tells us someone biopsied that lesion. What do you think happened? (bleeding) What else does he have? (gynaecomastia( list the causes. Which medications exactly? What do you think the scar on his nose may be from? (BCC, SCC, Melanoma) Tell us about the types of melanoma? What unusual sites can you find them (subungal, retina, perianal) And what else? (bell went – examiner told me he wanted metastasis to mucous membranes i.e. bowel)
General
Long Case
Liver transplant
Question: Spend 10 minutes taking a history and examining the patient then we will question you.
History – donated blood to a research project and found out he had abnormal LFTs. Monitored over the years until he developed itching and jaundice and became unwell then had an operation. Later developed bloody diarrhoea and had a second operation for that. Patient enjoying being in the exam very much and kept asking “have I given you enough clues yet? Have you guessed it yet? What are my medical conditions and what operations have I had?” O/E Rooftop incision and transverse infa-umbilical incision. I asked him if he had developed liver failure and had a liver transplant – yes – I asked was this for primary sclerosing cholangitis and did he then develop UC and have a subtotal colectomy? He said no. Spent two minutes clarifying that he was being a pain in the arse about the fact that he had a panproctocolectomy, not a subtotal colectomy, but otherwise I was correct.
Questions: What medications would you expect him to be on? What classes are they? He is on Sirolimus. What is that? Why might he be on that? Why are the risks associated with Sirolimus? What are the other risks associated with transplants? Which cancers specifically? Which infections? Which are they screened for? Discussion about CMV and pneumocystis.