General Surgery Board Review Risk Assessment & Management 3 — Questions and Answers
Question 1: A 55-year-old man with end-stage renal disease on hemodialysis requires elective inguinal hernia repair. Compared to patients with normal renal function, which complication risk is most significantly elevated?
- Hernia recurrence
- Wound infection and poor healing (Correct answer)
- Intraoperative cardiac arrhythmia
- Mesh rejection
Correct answer: Wound infection and poor healing
ESRD impairs immune function, platelet aggregation, and collagen synthesis, leading to significantly elevated rates of wound infection, dehiscence, and impaired healing.
Question 2: Which of the following best defines 'frailty' in the surgical risk assessment context?
- Age greater than 75 years
- BMI less than 18.5 kg/m²
- A state of decreased physiologic reserve and resistance to stressors (Correct answer)
- Albumin less than 3.0 g/dL alone
Correct answer: A state of decreased physiologic reserve and resistance to stressors
Frailty is a multidimensional syndrome of decreased physiologic reserve across multiple organ systems, making patients vulnerable to adverse outcomes after surgical stress.
Question 3: A patient on chronic therapeutic anticoagulation with a DOAC (rivaroxaban) requires urgent (within 6 hours) abdominal surgery. What is the best reversal strategy?
- Andexanet alfa (Andexxa) (Correct answer)
- 4-factor PCC off-label
- Fresh frozen plasma
- Vitamin K IV
Correct answer: Andexanet alfa (Andexxa)
Andexanet alfa is the FDA-approved specific reversal agent for rivaroxaban and apixaban, providing rapid and complete reversal of anti-Xa activity.
Question 4: The 'surgical stress response' to major surgery includes all of the following EXCEPT:
- Increased cortisol secretion
- Hyperglycemia
- Decreased catecholamine release (Correct answer)
- Sodium and water retention
Correct answer: Decreased catecholamine release
The surgical stress response involves increased catecholamine release, not decreased — this drives the hyperglycemia, tachycardia, and sodium retention seen postoperatively.
Question 5: A 64-year-old diabetic patient undergoes elective colectomy. Perioperative glucose control targeting which range is associated with the best outcomes?
- 80-110 mg/dL (tight control)
- 110-180 mg/dL (Correct answer)
- 140-200 mg/dL
- >200 mg/dL is acceptable if symptomatic hypoglycemia is avoided
Correct answer: 110-180 mg/dL
Targeting glucose 110-180 mg/dL perioperatively reduces wound infections and mortality while avoiding the serious risk of hypoglycemia associated with tighter control protocols.
Question 6: Which preoperative laboratory test has the strongest evidence for routine ordering in asymptomatic patients before elective low-risk surgery?
- Complete blood count
- Comprehensive metabolic panel
- Coagulation studies (PT/INR)
- None — routine labs are not indicated without specific clinical indication (Correct answer)
Correct answer: None — routine labs are not indicated without specific clinical indication
Evidence-based guidelines do not support routine preoperative laboratory testing in asymptomatic patients without specific clinical indications, as results rarely change management.
Question 7: A 70-year-old patient with a serum albumin of 2.1 g/dL requires elective sigmoid resection. What is the most appropriate next step?
- Proceed with surgery with perioperative TPN
- Delay surgery 2-4 weeks for preoperative nutritional optimization (Correct answer)
- Cancel surgery — malnutrition is an absolute contraindication
- Order parenteral albumin infusions for 1 week before proceeding
Correct answer: Delay surgery 2-4 weeks for preoperative nutritional optimization
Severe malnutrition (albumin <3.0 g/dL) significantly increases operative morbidity; delaying elective surgery 2-4 weeks for preoperative nutritional support (enteral preferred) improves outcomes.
General Surgery Board Review Risk Assessment & Management 3
A 55-year-old man with end-stage renal disease on hemodialysis requires elective inguinal hernia repair.
Compared to patients with normal renal function, which complication risk is most significantly elevated?