100+ Free FCS(SA) Final Practice Questions

Explanation: Siewert Type II oesophagogastric junction adenocarcinoma (true cardia cancer extending from 1 cm above to 2 cm below the EGJ) with locally advanced features (T3N1M0) is optimally managed with neoadjuvant chemoradiotherapy (e.g., CROSS protocol) followed by surgical resection (transthoracic or transhiatal subtotal oesophagectomy with proximal gastrectomy and lymphadenectomy). Preoperative multimodality therapy significantly improves overall survival and R0 resection rates. Endoscopic mucosal resection is limited to early mucosal (T1a) lesions, while surgery alone is inadequate for T3N1 tumors.

Explanation: The clinical presentation describes Boerhaave syndrome (spontaneous transmural oesophageal rupture). Water-soluble contrast swallow fluoroscopy (e.g., Gastrografin) or contrast-enhanced CT of the chest/abdomen with oral water-soluble contrast is the definitive diagnostic procedure of choice to demonstrate the transmural perforation site and extravasation. Endoscopy should be avoided in acute suspected perforation due to the risk of converting a small tear into a larger defect via insufflation. Manometry and pH monitoring play no role in acute trauma or perforation.

Explanation: Surgical management of localized gastric GISTs (>2 cm) requires wedge resection with clean macroscopic and microscopic negative margins (R0 resection). Routine lymphadenectomy is not indicated because GISTs metastasize hematogenously rather than lymphatically. Complete radical gastrectomy with lymph node dissection or organ resections is unnecessary unless direct invasion into adjacent organs occurs.

Explanation: Zenker diverticulum is a false pulsion diverticulum arising through Killian triangle above the cricopharyngeus muscle. Definitive treatment requires division of the underlying hypertonic cricopharyngeus muscle (cricopharyngeal myotomy) combined with diverticular division or excision via transoral endoscopic stapling (endoscopic diverticulotomy) or open pouch excision/pexy. Medical therapy, LES dilatation, or oesophagectomy do not correct cricopharyngeal dysfunction or pouch mechanics.

Explanation: Type III (spastic) achalasia is characterized by distal oesophageal spasm alongside elevated IRP. Peroral Endoscopic Myotomy (POEM) allows a longer, tailored oesophageal muscle myotomy (extending high into the smooth muscle body to encompass spastic segments) compared to standard laparoscopic Heller myotomy. POEM achieves significantly higher clinical success rates in Type III achalasia than Heller myotomy or pneumatic dilatation.

Explanation: A standard D2 lymphadenectomy for gastric cancer encompasses the perigastric nodes (D1: stations 1 to 6) plus the lymph nodes along the main branches of the coeliac axis: station 7 (left gastric artery), station 8a (anterosuperior common hepatic artery), station 9 (coeliac trunk), station 11p (proximal splenic artery), and station 12a (proper hepatic artery). Station 16 (para-aortic) represents D3/D4 dissection and is not routine.

Explanation: Marginal ulceration post-RYGB occurs at or adjacent to the gastrojejunal anastomosis, most commonly driven by mucosal ischemia, acid exposure, NSAID use, and cigarette smoking. First-line management involves strict cessation of NSAIDs and smoking, coupled with high-dose proton pump inhibitor (PPI) therapy and sucralfate. Surgery is reserved for perforation, bleeding refractory to endoscopic intervention, or dense stricture formation.

Explanation: Early diagnostic endoscopy following corrosive ingestion should be performed between 12 and 48 hours after ingestion, provided the patient is hemodynamically stable and the airway is secured. Performing endoscopy within this window allows accurate Zargar grading of mucosal injury while minimizing perforation risk (which increases dramatically after 48 hours due to tissue softening and necrosis during days 3–14).

Explanation: A Dieulafoy lesion is a large-caliber, dysplastic submucosal artery that fails to branch normally and erodes through mucosal epithelium into the lumen, typically along the proximal lesser curvature of the stomach. It manifests as severe, recurrent, pulsatile bleeding through otherwise normal gastric mucosa. Management involves endoscopic haemostasis (hemoclips, thermocoagulation, or band ligation).

Explanation: Chronic peptic gastric outlet obstruction due to scarring and fibrosis that fails endoscopic balloon dilatation requires surgical decompression and acid-reduction. Truncal vagotomy with antrectomy (Billroth I or II) or truncal vagotomy with gastrojejunostomy provides effective drainage and lowers ulcer recurrence. Graham patch is for acute perforations, not chronic outlet obstruction.