American Board of Surgery Recertification Examination

April 7, 2008
Surgical Rounds®, March 2008, Volume 0, Issue 0

These questions are similar to those asked on the American Board of Surgery Recertification Examination. Use them to prepare for the examination, fulfill learning requirements for various maintenance of competence programs, or simply improve your surgical knowledge. Answers can be viewed by following the "Read the Answers" link at the end.

  1. In patients with cirrhosis Decompensation occurs in 15% to 20% per year Carcinoma occurs in 10% to 20% per year More than 80% become symptomatic within 2 years Variceal bleeding occurs in 25% to 30% per year The presence of ascites is a good indicator of expected mortality

  1. Femoral-femoral bypass grafting Has a 1% to 2% postoperative amputation rate Is the procedure of choice for unilateral iliac stenosis Is more likely to fail in women than in men Is indicated in the presence of infected aortobifemoral grafts Should be performed between superficial femoral arteries

  1. All of the following arteries are branches of the superior mesenteric artery, except: Ileocolic Replaced left hepatic Inferior pancreaticoduodenal Jejunal Replaced right hepatic

  1. Lung cancer Is the most common cause of cancer death in men but not in women Risk disappears with cessation of smoking Is identified in 50% of patients with a history of smoking Is increasing in frequency in women Presents no increased risk for spouses of smokers

  1. The most common organism found in normal gallbladder bile is Escherichia coli Pseudomonas Klebsiella Bacteroides No organisms

  1. The superior laryngeal nerve Is a branch of the glossopharyngeal nerve Is purely motor Courses posterior to the thyroid Can be injured if the superior pole vessels are divided too far above the gland If injured, results in hoarseness

  1. Which of the following statements regarding the Puestow procedure (lateral pancreaticojejunostomy) is true? It should only be performed if the duct is dilated It relieves the pain of chronic pancreatitis in less than 30% of patients It mandates performance of a splenectomy It requires removal of the ductal stones It includes a 3-cm anastomosis

  1. Typhoid enteritis Mainly affects the jejunum Is most successfully treated with chloramphenicol (Chloromycetin) Can only be diagnosed by stool culture Rarely causes ulceration and resultant hemorrhage Has been eradicated in the United States

  1. Mesenteric cysts Occur primarily in the mesocolon Are discovered mainly in children Can contain chyle or serous fluid Require total enucleation for a cure Are neoplastic

  1. The histologic type of ductal carcinoma in situ (DCIS) that is associated with the highest rate of multiplicity is Micropapillary Solid Papillary Comedo Cribiform

  1. Decompression for abdominal compartment syndrome should be performed If the urine output falls to 30 mL/hour When the patient's respiratory rate increases to 24 breaths per minute Based purely on physical findings When bladder pressure exceeds 35 mm Hg If the patient becomes hypoxemic

  1. Anal fissures Are caused by sphincter hypotonia Should initially be treated with topical steroid application Are effectively cured with an injection of botulinum toxin Occur at the posterior midline Are best surgically treated using the Lord procedure (sphincter dilation)

Read the Answers

Answers

  1. e—In patients with cirrhosis, the presence of ascites? particularly refractory ascites?is ominous. The 1-year mortality rate for patients with severe ascites is almost 50%. The rates of decompensation, carcinoma, and variceal hemorrhage are 2% to 6%, 1% to 4%, and 5% to 8%, respectively. Only 35% of cirrhotic patients become symptomatic within 2 years.
  2. c—Femoral-femoral grafts are more than twice as likely to fail in women as in men, and this is used as an argument against doing this procedure in females. The postoperative amputation rate averages 8% to 10% (not 1%?2%) because of the severity of vascular disease in those patients who are candidates. Iliac artery stenting and aortofemoral bypass grafting are the procedures of choice for unilateral iliac stenosis, not femoral-femoral bypass grafting. Femoral-femoral grafts do not avoid the involved areas in patients with infected aortofemoral grafts and should not be performed in this situation; other extra-anatomic routes are more effective. To utilize the deep femoral arteries, these grafts should be performed between common femoral arteries.
  3. b—Anomolous, replaced left hepatic arteries come off the left gastric artery, a branch of the celiac trunk. In contrast, replaced right hepatic arteries derive from the superior mesenteric artery. The inferior pancreaticoduodenal artery is the first branch of the superior mesenteric artery. The ileocolic and jejunal branches are nutrient vessels for the small intestine and proximal colon.
  4. d—The frequency of lung cancer has increased ten-fold in women over the past two decades. The disease is the most frequent cause of cancer death in men and women. Ninety percent of patients who develop lung cancer are smokers, not 50%. Unfortunately, the changes in respiratory epithelium that result from smoking increase a smoker's susceptibility to lung cancer and are irreversible. As a result, lung cancer risk does not disappear after cessation of smoking. The risk of lung cancer is markedly increased for spouses or housemates of smokers, presumably because the carcinogens in exhaled smoke are not filtered.
  5. e—Normal gallbladder bile is sterile and harbors organisms only when gallbladder function becomes abnormal and loses its ability to concentrate bile salts, which are bacteriostatic.
  6. d—The superior laryngeal nerve runs anterior (not posterior) to the thyroid. It enters the cricothyroid membrane through a medial course and is accessible to injury if the superior pole vessels are divided too high (before the nerve courses medially). The superior laryngeal nerve is a branch of the vagus nerve. The larger internal branch is sensory, while the external branch is motor and, if injured, results in a loss of voice strength and quality (not hoarseness).
  7. a—The Puestow procedure is successful only if the pancreatic duct is dilated, usually to 1.0 cm in diameter. Done for appropriate indications, the procedure provides long-term pain relief in 60% of patients. While splenectomy was a component of the initial description of the Puestow procedure, it is unnecessary and is no longer performed. The ductal stones cause symptoms only by obstruction, and the Puestow procedure provides adequate drainage. The stones tend to fall into the jejunum through the anastomosis. The anastomosis must be as long as possible, extending from the tail to the mesenteric vessels, as close to the pancreatic head as possible.
  8. b—Despite chloramphenicol's side effects, it is the most effective therapy for typhoid enteritis; ampicillin, amoxicillin, and other agents also have been used with success. Typhoid enteritis infection primarily affects the distal ileum. In addition to stool cultures, it can be diagnosed by blood cultures (90% positiv-ity rate) and bone marrow culture. Ulceration and hemorrhage occur in 20% to 30% of affected patients. There are 500 to 1,000 new cases of typhoid enteritis diagnosed each year in the United States.
  9. c—Chyle is routinely found in mesenteric cysts. These lesions occur primarily in the small bowel mesentery and are diagnosed in adults (mean age of 45 years), not children. Mesenteric cysts also can be cured by internal drainage into the peritoneum, although aspiration is associated with a high recurrence rate. Although the etiology of mesenteric cysts is obscure, they are non-neoplastic.
  10. a—Multiplicity is characteristic of micropapillary ductal carcinoma in situ (DCIS), occurring in 80% of cases. The lowest rates of multiplicity occur in the solid and cribiform types of DCIS, while its frequency is intermediate in the papillary and comedo types.
  11. d—While manifestations of abdominal compartment syndrome can occur with an abdominal compartment pressure of 15mm Hg, decompression must be performed if bladder pressure (a manifestation of peritoneal pressure) rises to 35mm Hg. Urine output of 30 mL/hour represents adequate renal perfusion and does not mandate decompression. There are many reasons for mild tachypnea and hypoxemia other than abdominal compartment syndrome; thus, operative intervention may not be indicated. Physical findings are not reliable and cannot be used to determine whether an operation is warranted.
  12. d—Anal fissures occur at the posterior midline because of localized mucosal ischemia at that site. Fissures are caused by sphincter hypertonia (spasm), not hypotonia. There are no objective data that document the effectiveness of topical steroid therapy. An injection of botulinum toxin causes temporary striated muscle denervation, but recurrence occurs in almost half of patients. The best surgical treatment is partial lateral internal sphincterotomy.