Pediatric Surgery Question Bank

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1. All of the following conditions are derived from the primitive embryonic foregut except:

The bronchopulmonary foregut malformations (bronchogenic cyst, congenital cystic adenomatoid/pulmonary airway malformation) and gut duplications such as gastric duplication all arise from the embryonic foregut. A mesenteric cyst is a lymphatic (mesothelial/lymphangiomatous) lesion of the mesentery and is not of foregut origin, so it is the exception.

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2. A full-term male newborn experiences respiratory distress immediately after birth. A prenatal sonogram was read as normal. An emergency radiograph is shown here. The patient is intubated and placed on 100% O 2 . Arterial blood gases reveal pH 7.24, PO 2 60 kPa, and PCO 2 52 kPa. The baby has sternal retractions and a scaphoid abdomen. Which of the following should be performed in the management of this patient?

The scaphoid abdomen, immediate respiratory distress and abnormal chest film indicate a congenital diaphragmatic hernia with pulmonary hypoplasia. Management is gentle ventilation that minimizes barotrauma; low-tidal-volume (lung-protective, 'permissive hypercapnia') ventilation avoids damaging the hypoplastic lungs. Tube thoracostomy and immediate thoracotomy are wrong, and the herniated bowel must not be mistaken for pneumothorax.

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3. Which of the following statements is/are true of infants with gastroschisis

Gastroschisis results from a paraumbilical abdominal wall defect with extrusion of bowel that never returns to rotate and fix normally, so malrotation is essentially always present. Unlike omphalocele, gastroschisis has a LOW incidence of associated anomalies (apart from intestinal atresia in roughly 10-15%), so malrotation is the correct true statement.

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4. Hepatoblastomas are childhood liver tumors characterized by which of the following features?

Hepatoblastoma classically arises in an otherwise non-cirrhotic liver and is usually unifocal. A key therapeutic principle is that initially unresectable tumors frequently become resectable after neoadjuvant (cytoreductive) chemotherapy, allowing complete resection with good long-term survival. Multicentricity, cirrhosis and jaundice are not characteristic.

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5. A 1-year-old child has repeated episodes of vomiting and abdominal distention. An x-ray shows obstruction at the second portion of the duodenum. Laparotomy is performed and an annular pancreas is discovered. For a symptomatic partial duodenal obstruction secondary to an annular pancreas, which of the following is the operative treatment of choice?

Annular pancreas causing symptomatic duodenal obstruction is bypassed rather than divided, because dividing the pancreatic ring risks pancreatic injury, fistula and recurrent obstruction. Duodenoduodenostomy creates a side-to-side bypass around the obstruction and is the procedure of choice. A Whipple is far too radical for a benign condition.

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6. A 1-month-old female infant presents with persistent jaundice. A serum direct bilirubin is 4.0 mg/dL and an ultrasound of the abdomen shows a shrunken gallbladder and inability to visualize the extrahepatic bile ducts. Which of the following is the most appropriate initial management of this patient?

A 1-month-old with persistent conjugated (direct) hyperbilirubinemia, a contracted gallbladder and non-visualized extrahepatic ducts is highly suspicious for biliary atresia. The diagnosis must be confirmed and treated promptly, so operative exploration with intraoperative cholangiogram (and Kasai portoenterostomy if confirmed) is the appropriate step. Medical measures alone would dangerously delay the time-sensitive Kasai procedure.

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7. Meckel's diverticulum may present with which of the following signs or symptoms?

A Meckel diverticulum can present in several ways: painless lower GI bleeding from ectopic gastric mucosa, intussusception (acting as a lead point), volvulus (around a persistent vitelline band), diverticulitis or obstruction. Because all the listed presentations occur, 'all of the above' is correct.

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8. The most common cause of pyogenic liver abscess in children today is which of the following?

In contemporary pediatric practice the most common setting for a pyogenic liver abscess is the immunocompromised child (e.g., chronic granulomatous disease, malignancy/chemotherapy, immunosuppression), in whom hematogenous seeding occurs. This has overtaken appendicitis-related portal pyemia as the leading cause.

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9. Which of the following statements regarding gastroschisis are true?

Gastroschisis has an excellent prognosis today, with overall survival in the 80-90% (often higher) range. Primary fascial closure is achievable in the majority of infants, associated anomalies are uncommon (aside from intestinal atresia), and routine cesarean delivery has not been shown to improve outcome, making the survival statement the correct one.

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10. Which of the following statements regarding rhabdomyosarcoma are true?

Despite multimodal therapy, overall survival for all rhabdomyosarcoma patients is roughly 50-70%. Surgery alone cures only a minority, alveolar histology is an UNFAVORABLE prognostic feature, and current management often uses chemotherapy before resection of bulky tumors, so the overall-survival statement is the accurate choice.