General Surgery Board Review Risk Assessment & Management 2 — Questions and Answers
Question 1: A 68-year-old man with COPD (FEV1 55% predicted) requires elective sigmoid resection. Which preoperative pulmonary optimization is MOST effective in reducing postoperative pulmonary complications?
- Preoperative incentive spirometry training
- Smoking cessation at least 8 weeks before surgery (Correct answer)
- Preoperative systemic corticosteroids
- Prophylactic postoperative bronchodilators
Correct answer: Smoking cessation at least 8 weeks before surgery
Smoking cessation ≥8 weeks before surgery significantly reduces postoperative pulmonary complications by allowing airway inflammation to resolve and mucociliary function to recover.
Question 2: The Revised Cardiac Risk Index (RCRI) assigns one point for each of six independent predictors. Which of the following is NOT one of those predictors?
- Ischemic heart disease
- Peripheral vascular disease
- Hypertension requiring medication (Correct answer)
- Creatinine >2.0 mg/dL
Correct answer: Hypertension requiring medication
The six RCRI predictors are: high-risk surgery, ischemic heart disease, CHF, cerebrovascular disease, insulin-dependent diabetes, and creatinine >2.0 mg/dL — hypertension is not included.
Question 3: A patient undergoing elective abdominal aortic aneurysm repair has a dobutamine stress echocardiogram showing new wall motion abnormalities at low heart rates. What is the most appropriate next step?
- Proceed with surgery with invasive monitoring
- Cancel surgery permanently
- Refer for coronary angiography and possible revascularization (Correct answer)
- Start beta-blocker therapy and retest in 4 weeks
Correct answer: Refer for coronary angiography and possible revascularization
New wall motion abnormalities at low heart rates indicate significant myocardial ischemia with a large territory at risk, warranting coronary angiography before elective high-risk vascular surgery.
Question 4: Which Child-Pugh class carries an operative mortality of approximately 25-30% for major abdominal surgery?
- Child-Pugh A
- Child-Pugh B
- Child-Pugh C (Correct answer)
- Child-Pugh A and B equally
Correct answer: Child-Pugh C
Child-Pugh C cirrhosis carries approximately 25-30% operative mortality for major abdominal surgery, making elective procedures generally contraindicated.
Question 5: A 72-year-old woman requires emergency appendectomy. Her medications include warfarin (INR 3.2) for atrial fibrillation. What is the most appropriate anticoagulation management?
- Proceed immediately without reversal
- Give vitamin K alone and wait 24 hours
- Administer 4-factor PCC (Kcentra) and proceed with surgery (Correct answer)
- Transfuse FFP only until INR <1.5
Correct answer: Administer 4-factor PCC (Kcentra) and proceed with surgery
For emergent surgery requiring rapid INR reversal, 4-factor PCC provides faster, more reliable reversal than FFP with less volume load and is the agent of choice.
Question 6: Which scoring system is specifically validated to predict 30-day morbidity and mortality in general surgery patients and is used by the ACS NSQIP surgical risk calculator?
- ASA Physical Status Classification
- POSSUM score
- Surgical Risk Scale (SRS)
- Patient-specific risk factors combined via logistic regression model (Correct answer)
Correct answer: Patient-specific risk factors combined via logistic regression model
The ACS NSQIP Surgical Risk Calculator uses a logistic regression model incorporating patient-specific factors and procedure type to generate individualized 30-day risk estimates.
Question 7: A 58-year-old patient with BMI 42 is scheduled for elective cholecystectomy. Which perioperative risk is most directly increased by obesity in laparoscopic surgery?
- Anastomotic leak
- Conversion to open due to difficult dissection (Correct answer)
- Postoperative ileus
- Wound dehiscence at port sites
Correct answer: Conversion to open due to difficult dissection
Obesity significantly increases the risk of conversion from laparoscopic to open cholecystectomy due to difficult visualization, excess omental and hepatic fat obscuring Calot's triangle.
General Surgery Board Review Risk Assessment & Management 2
A 68-year-old man with COPD (FEV1 55% predicted) requires elective sigmoid resection.
Which preoperative pulmonary optimization is MOST effective in reducing postoperative pulmonary complications?