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17. Transcatheter aortic valve implantation/replacement
(TAVI/TAVR) is indicated in which of the following
patients?
A. Only those with high surgical risk
B. Those with minimal aortic stenosis
C. Elderly patients with aortic valve disease
D. Patients with congenital bicuspid aortic valve disease
CHAPTER 47
18. What are the advantages of endovascular repair (EVAR)
of an abdominal aortic aneurysm (AAA) in elderly
patients?
A. A reduction in blood loss and operative time
B. A reduction in the need for postoperative intensive
care
C. The avoidance of abdominal and pulmonary compli-
Surgical Considerations in the Elderly
cations associated with open AAA repair
D. All of the above
Answer: C
TAVI/TAVR was initially considered as an alternative to
operative replacement of aortic stenosis only in high risk
patients. Recent trials have shown that the risks and outcomes
are comparable in older low- and medium-risk patients as in
younger patients. (See Schwartz 11th ed., p. 2056.)
Answer: D
Randomized controlled trials of EVAR versus open AAA
repair have shown equal or improved survival, fewer complications, and shorter length of stay. The procedure can be performed under epidural anesthesia in patients who are at high
risk for general inhalational anesthesia and has comparable or
improved outcomes. (See Schwartz 11th ed., p. 2056.)
CHAPTER 48
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Ethics, Palliative Care, and Care at the End of Life
1. Biomedical ethics is a system of analysis and deliberation
which is intended to direct physicians and surgeons to
moral “goodness” in patient care. It includes consideration of all of the following EXCEPT:
A. Autonomy—the patient’s right to decide for himself/
herself what care will be provided.
B. Beneficence—the concept that proposed treatments
will benefit the patient.
C. Nonmaleficence—the avoidance of treatments which
may harm the patient.
D. Equipoise—the lack of a preference for one treatment
over another.
2. What is implied by the “principalist approach” to medical ethics?
A. The principal caregiver determines which course will
be followed after discussions with the patient.
B. Identify the principles, such as autonomy and benefi-
cence, which appear to be in conflict and evaluate the
conflict taking into consideration of values such as
self-determination and quality of life.
C. The guiding principle of “first do no harm” requires
that risks to the patient be minimized.
D. The fundamental principle is that the discussion of
biomedical ethics needs to involve all members of the
care team as well as the patient.
Answer: D
The patient and the doctor decide together what treatment is
in the best interest of the patient and share the benefits and
the burdens of this joint decision-making. The physician’s
role is to clarify the indications, risks, and benefits of the possible treatment courses; the patient’s role is to decide what
course to take. Equipoise suggests that neither the patient nor
the doctor has a preference, which is not the case. The fourth
component of biomedical ethics is justice, meaning fairness
where both the benefits and burdens are distributed equally.
(See Schwartz 11th ed., p. 2061.)
Answer: B
In an apparent conflict or conundrum, the relevant principles
of autonomy, beneficence, nonmaleficence, and justice are
weighed together with the values at stake to determine jointly
the best course of action. (See Schwartz 11th ed., p. 2061.)
3. Informed consent contains all of the following elements
EXCEPT:
A. The physician must document that the patient or the
surrogate decision maker has the capacity to make a
medical decision.
B. The surgeon describes the risks and benefits of treat-
ment options sufficiently for the patient to make an
informed decision.
C. A member of the patient’s family must witness the
consent authorization.
D. The patient authorizes a treatment plan without
undue influence.
Answer: C
Documentation that the patient or the surrogate decision
maker has the capacity to make a decision is a primary element. To the extent known, the risks of any treatment options
as well as the likelihood of functional recovery need to be
explained in detail. In elective situations, patients are allowed
time to consult with others before making a decision, but
family members are not required to witness the authorization
to proceed with care. (See Schwartz 11th ed., p. 2063.)
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4. Living wills are documents which are meant to guide
decision-making when:
A. The patient’s family cannot be contacted.
B. The patient is rendered incompetent or unresponsive
by an illness judged to be terminal.
C. Multiple attempts at resuscitation have failed.
D. The patient’s family disagrees with the course of
treatment.
CHAPTER 48
5. “Informed consent” implies all of the following, EXCEPT:
A. The patient has been provided with the pertinent
details of his/her diagnosis, prognosis, and the
options for and risks of treatment.
B. The information has been provided according to
what a reasonable person would be expected to
Ethics, Palliative Care, and Care at the End of Life
6. The durable power of attorney for health care is an
understand.
C. The discussion of the options, risks, and possible haz-
ards has been documented.
D. There are witnesses to the discussion who also under-
stand the discussion.
alternative to “living wills” where a patient designates
a specific individual to make decisions if and when the
patient is unable to. All of the following statements about
the durable power of attorney for health care are true
EXCEPT:
A. The durable power of attorney has the authority to
make decisions regarding the provision or the withdrawal of care.
B. The durable power of attorney is expected to provide
decisions which are consistent with the patient’s preferences and judgment.
C. Decisions made by durable power of attorneys
are highly accurate in predicting the patient’s own
decision.
D. Respecting the decision of the durable power of attor-
ney is a form of respecting the self-determination of
the incapacitated patient.
Answer: B
Living wills are intended to guide decisions by physicians,
family members, and/or surrogate decision makers when the
patient himself/herself is unable to render an opinion and the
condition or disease is judged to be terminal or “hopeless.”
(See Schwartz 11th ed., p. 2064.)
Answer: D
The “reasonable person” standard for informed consent has
precedent in a 1972 court case which rejected the notion
that “simple consent” for treatment was sufficient. The court
decided that the facts of diagnosis, treatment options, and
risks that a “reasonable person” would want to know should
be included in the discussion to obtain consent for treatment.
(See Schwartz 11th ed., pp. 2062–2063.)
Answer: C
Studies indicate that individual identified as the durable
power of attorney for health care makes decisions which are
consistent with the patient’s own determination only about
two-thirds of the time. (See Schwartz 11th ed., p. 2064.)
7. Surgical palliative care can be defined as “the treatment
of suffering and the promotion of quality of life for seriously or terminally ill patients under the care of surgeons.” All of the following statements about surgical
palliative care are true EXCEPT:
A. Surgical intervention is prohibited in patients who
are receiving palliative care.
B. The lessening of pain is a priority for surgical pallia-
tive care.
C. Psychosocial support for family members is part of
surgical palliative care.
D. Bereavement support for the patient care staff is
included in surgical palliative care.
Answer: A
Surgical interventions are not prohibited if the procedure
provides relief of pain or distressing symptoms or otherwise
improves the quality of life. Adequate treatment of pain is
a fundamental pillar of surgical palliative care, and is also
accompanied by psychosocial support for family member and
for members of the care team upon the death of a patient. (See
Schwartz 11th ed., pp. 2066–2067.)
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8. The distinction between surgical innovation and surgical research can be unclear and requires ethical considerations. All of the following statements about surgical
innovation are true EXCEPT:
A. A novel or revised part of an operation that a surgeon
makes in order to best treat an individual patient is
considered surgical innovation.
B. An innovation introduced into an operation requires
approval of Institutional Review Board (IRB) if it is
used on more than three patients.
C. An innovative modification of an existing surgical
instrument or device can be used in patients with IRB
approval.
D. When employing an innovative modification to an
operative procedure, explicit informed consent of the
patient is required.
Answer: C
Modification to an existing device or the development of a
new device to be used in surgery requires approval of the
Office of Product Evaluation and Quality of the Food and
Drug Administration. IRB approval alone is not sufficient
approval alone to authorize its use. Surgical innovations are
part of managing operative challenges but when they are used
on more than three patients they become surgical research
and require IRB approval. Informed consent of patients is
required. (See Schwartz 11th ed., p. 2073.)
CHAPTER 48
Ethics, Palliative Care, and Care at the End of Life
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CHAPTER 49
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Global Surgery
1. A 55-year-old East African woman presents with a palpable mass in her right breast that has been present for
several years. You are concerned for cancer and know
her case fatality rate is significantly higher than a similar
patient in North America. Why?
A. Patients present with later stages of cancer.
B. Patients often decline screening.
C. Cultural prohibitions preclude surgery as an accept-
able treatment option.
D. Improper treatment of surgically correctable disease.
2. When considering surgical care in low- and middleincome countries (LMICs), “task sharing” is one approach
that can provide patients with expanded access to surgical
care. What does this term refer to?
A. Transporting patients from lower to higher resource
settings
B. Training advanced care practitioners to deliver sur-
gery and anesthesia services
C. Establishing a system that allows select surgical dis-
ease to be treated medically
D. Sharing training materials and tele-teaching between
high-income countries (HIC) and LMIC centers
Answer: A
Previously thought to be a disease almost exclusive to highincome countries, nearly two-thirds of the 7.6 million cancer
deaths worldwide occur in low- and middle-income countries (LMICs). Mortality from cancer correlates inversely with
a country’s economy for certain treatable cancers, including
breast, testicular, and cervical cancer—LMICs have higher
case fatality rates. Breast cancer case fatality rates illustrate
the great disparity in outcomes between regions. Case fatality rates in East Africa reach an unacceptable 59% compared
to 19% in the United States. In LMICs, patients have very
limited access to screening. They present for care with much
later stages of cancer. The number and quality of training
programs in surgical oncology are also inversely related to a
country’s income, leaving LMICs with few adequately trained
providers. Collaborative training programs between highincome countries (HIC) and LMIC centers, as well as teleteaching and mobile consultation, may address this shortage
in a relatively low-cost, high-impact way. (See Schwartz 11th
Ed., pp. 2082–2083.)
Answer: B
Primary care physicians, nurses, midwives, or advanced
care practitioners (ACPs) provide much of the basic surgical and anesthetic care in LMICs. Where regulations allow,
“task sharing,” or training ACPs to deliver surgery and anesthesia services previously allowed only under the purview of
fully trained specialists, can provide expanded access to care.
Non-MD practitioners, known as assistant medical officers
(AMOs) or tecnicos de cirurgia in Mozambique, often have
extensive operative experience, including obstetrical care,
and are the primary surgical providers in some regions. Task
sharing with ACPs also occurs in the United States and other
countries where they fill a need otherwise unmet by specialists
even in major tertiary care centers. However, concerns about
the quality of care, lack of adequate supervision, and the effect
on prestige and professional development for specialists and
ACPs, continue to be topics for debate. (See Schwartz 11th Ed.,
p. 2081.)
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3. You are planning to work abroad but a colleague mentions that “surgery is too expensive” in low- and middleincome countries (LMICs) and you should focus on providing mosquito netting instead. You disagree. Which of
the following answers could help you support your case?
A. Developing surgical care capabilities can be below
the U.S. $100 per disability-adjusted life year (DALY)
averted per day threshold for cost-effective care.
CHAPTER 49
B. Surgical treatment is often primary prevention for
additional disease.
C. Essential surgical procedures rank among the most
cost-effective of all health interventions.
D. All of the above.
Global Surgery
Answer: D
The World Bank arbitrarily defined U.S. $100 per DALY averted
per day in low-income countries as highly cost-effective.
Compared to other public health initiatives, developing basic
and emergency surgical care at the district level hospital is as
cost-effective as, or more so, than typical public health programs
such as retroviral treatments for HIV/AIDS or immunization
for measles (Fig. 49-1). Male circumcision is one example of
a well-documented preventative, minor surgical procedure,
capable of reducing the transmission of HIV. The DCP3 adopted
a working definition of essential surgical conditions as those
that (a) are primarily or extensively treated by surgery; (b) have
a large health burden; and (c) can be successfully treated by a
surgical procedure that is cost-effective and feasible to promote
globally. Using this definition, the DCP3 identified 44 essential procedures, most of which can be performed in first-level
hospitals (Table 49-1). The first-level (district) hospital is the
appropriate platform to provide essential surgical service. These
procedures rank among the most cost-effective of all interventions and include those that treat injuries, obstetric complications (including fistulas), abdominal emergencies, cataracts,
and congenital anomalies. (See Schwartz 11th Ed., p. 2086.)
FIG. 49-1. Cost-effectiveness of surgical interventions,
compared to two key medical interventions. Note:
DALY = disability-adjusted life year. (Illustration reproduced
with permission from Intermountain Healthcare.)
TABLE 49-1 Essential surgical procedures that can be performed in first level (district)
Obstetric Complications
Severe postpartum hemorrhage, obstructed labor, prolonged labor, eclampsia, prolapsed cord, fetal distress,
tubal pregnancy, postabortion endometritis/myometritis, postabortion sepsis, intrauterine fetal death
Trauma and Violence
Major limb fracture/injury, joint dislocation, major soft tissue injury, pneumo/hemothorax, ruptured spleen
Acute Surgical Emergencies
Strangulated hernia, intestinal obstruction, intestinal perforation, appendicitis, liver abscess, major wound
infection, osteomyelitis/septic arthritis
Nonacute Surgical Conditions
Congenital hernia, hernia, breast cancer, chronic osteomyelitis, hydrocele, urethral stricture, prostatic
hypertrophy, cataract, eye injury
Orthopedic surgery trip
Trauma center
Cesarean delivery
Hydrocephalus repair
Trachoma surgery
Cleft lip and palate repair
Hernia repair
Surgical hospital
Cataract surgery
Obstetric hospital
Measles vaccination
Antiviral therapy for HIV
hospitals (DCP3)
$1/DALY
$10/DALY
Range - Cost/DALY (2012 US$)
$100/DALY
$1000/DALY
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4. Global surgery interventions can be prioritized by targeting diseases that impose the largest burden on a society
and have a highly successful surgical outcome. The four
broad, high-priority surgical areas that contribute most
to the public health mission in low- and middle-income
countries (LIMCs) include all of the following EXCEPT:
A. Acute surgical emergencies.
B. Nonacute surgical conditions.
C. Obstetrical emergencies.
D. Organ transplantation.
E. Trauma care.
Answer: D
In 2015, the Lancet Commission on Global Surgery (LCGS)
reported that maternal mortality was closely related to density of surgical, anesthetic, and obstetrical providers (SAOPs).
They showed that maternal mortality throughout the world
appeared to decrease—by 13.1% on average—for every
10 unit increase in SAOPs per 100,000 persons, a strong argument for addressing maldistribution of providers related to
surgical disease. High-priority surgical procedures to improve
maternal health include cesarean section, hysterectomy for
postpartum bleeding and uterine rupture, management of
ectopic pregnancy, and dilatation and curettage. In terms
of nonobstetrical acute surgical emergencies, about 90%
could be addressed by developing the capability to care for
the 10 most common acute surgical conditions in any local
region. Even common nonacute conditions can have significant impact on quality of life and socioeconomic status,
such as cleft lip and cleft palate, hernias, and cataracts. Nearly
2 million lives could be saved each year if LMICs could design
and implement simple trauma care initiatives that reduced
the case fatality rates among seriously injured patients to
equal those in high-income countries (HICs) (Fig. 49-2).
Transplantation, though an area of great interest to people
in poor countries, still eludes most of the developing world,
where cultural and legal prohibitions preclude cadaveric and
nonrelated organ donation. (See Schwartz 11th Ed., p. 2095.)
CHAPTER 49
Global Surgery
FIG. 49-2. Case fatality rates for severely injured people,
1998. Note: ISS = injury severity score. Income classifications
are based on status at the time of the study. Ghana is
now a lower-middle income country, and Mexico is an
upper-middle-income country. (Illustration reproduced with
permission from Intermountain Healthcare.)
5. You are developing a novel device to facilitate virtual laparoscopic skills training for surgeons in LMICs. Which
of the following will help innovations such as yours be
effective in resource-limited settings?
A. Collaborate with a single, local manufacturer
B. Utilize qualitatively superior technology to the status
quo
C. Establish a profit-driven business model
D. Employ widely accessible technologies
80
60
40
(ISS ≥ 9)
20
Fatalities (percent)
0
Kumasi,
Ghana
Low Middle
Monterrey,
Mexico
Country income
Seattle,
Washington
United States
High
Answer: D
The pressing need for surgical care at all levels and the shortage of fully trained surgeons, anesthesiologists, and support
personnel as well as equipment and supplies means that
opportunities abound for innovation. Innovation that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly
changes an older and more expensive system in favor of a less
expensive, more widely available technology or process. The
ability for disruptive innovations to transform products and
services into affordable realities requires three main factors:
a sophisticated technology that simplifies, a low-cost business model, and an economically coherent value network
(Fig. 49-3). Regulations and standards that vary between
countries and locales can facilitate or impede disruptive
change. While disruptions often are not qualitatively superior
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CHAPTER 49
Global Surgery
FIG. 49-3. Elements of disruptive innovation. (Illustration
reproduced with permission from Intermountain Healthcare.)
to the status quo, they make the process both less expensive
and more accessible, and through multiple iterations, ultimately improve quality as they cycle through the transformative process. (See Schwartz 11th Ed., p. 2106.)
Sophisticated
technology that
simplifies
Regulations and
standards that
facilitate
change
Low-cost,
innovative
business models
Economically
coherent value
network
6. Patients in rural areas and in countries with poor infrastructure often lack access to safe, timely, and affordable
surgical care. Support for Global Surgery has grown significantly in recent years due in part to all of the following EXCEPT:
A. Trained surgeons migrating to areas of need.
B. Improved control of acute infectious diseases previ-
ously the cause of significant morbidity.
C. Technology allowing improved access to health care
information and training.
D. Recognition of the cost-effectiveness of surgery as
a public health intervention.
Answer: A
Disparities in care and outcomes are multidimensional, and
no simple solution exists to improve access to appropriate and
affordable surgical care. Yet, five major forces are reshaping priorities and strategies leading the charge for the globalization of
surgical care:
1. The epidemiologic transition of diseases from primarily
infectious to more chronic conditions
2. The mobile nature of the world’s populations, allowing
people to move freely between more isolated areas of the
world, leading to a more integrated global community
3. Ubiquitous information access exponentially enabling
widespread participation in understanding and designing
innovative opportunities for high-quality surgical care
4. A revolution for equity and human rights where the
world’s poor are demanding benefits to surgical care similar to those found in high-income countries (HICs)
5. Recognition of the cost-effectiveness of surgical care and
its potential to build economies, demonstrating the value
of including surgery in global health strategies
Trained practitioners commonly migrate to economically and
culturally favorable locales, leaving low-resource countries
underserved. Investments in training greater numbers of doctors in these countries, including surgical specialists, have been
only partially successful in meeting demand in poor countries.
Until economic conditions improve or opportunities for professional development increase, and incentives enticing migration
of health care workers to HICs abate, it is unlikely that the most
skilled practitioners will remain in resource-poor areas beyond
their immediate obligations. (See Schwartz 11th Ed., p. 2078.)
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Optimizing Perioperative Care:
Enhanced Recovery and Chinese Medicine
1. The use of preoperative evaluation is associated with
which of the following?
A. Increased preoperative testing
B. Decreased case cancellations
C. Decreased time from clinic to surgery
D. Decreased patient satisfaction
2. Preoperative immunonutrition supplements provide
greater quantities of which of the following as compared
to preoperative standard oral supplements?
A. Trace minerals
B. Arachidonic acid
C. Arginine
D. Amino acids
3. A 65-year-old woman is undergoing an elective lowanterior resection for rectal cancer. Which of the following would not be recommended to counter the effects of
insulin resistance perioperatively?
A. Preoperative carbohydrate supplementation
B. Use of a laparoscopic versus open approach
C. Appropriate pain management
D. Low glycemic index diet postoperatively
Answer: B
The use of a preoperative evaluation results in identifying
patients at elevated respiratory risk, a 55% decrease in preoperative testing, an 88% reduction in case cancellations, reduction in day of surgery delays, reduced total length of stay, a
positive impact on hospital finances with cost reduction, and
lower in-hospital mortality. (See Schwartz 11th ed., p. 2113.)
Answer: C
Immunonutrition supplements have the addition of arginine
to improve immunity and tissue repair and omega-3 fatty acids
to mediate the inflammatory response. However, the dosages, duration, and frequency of immunonutrition needed to
improve surgical outcomes are unknown. Both types of preoperative nutritional supplementation have been demonstrated
to be beneficial, but there is no statistically significant difference in infectious complications, complications, or hospital
length of stay between the two types. (See Schwartz 11th ed.,
p. 2115.)
Answer: D
Low glycemic index diets are not part of enhanced recovery
pathways. Preoperative and postoperative fasting states
trigger insulin resistance resulting in a catabolic state with
gluconeogenesis and protein breakdown. Preoperative carbohydrate supplementation and early postoperative feeding
are both recommended. Hyperglycemia that results from
postoperative fasting can be corrected with exogenous insulin, and achievement of normoglycemia in the perioperative
period normalizes the main components of metabolism. Both
pain and magnitude of surgery are associated with increased
insulin resistance; thus, adequate pain control and use of a
minimally invasive approach are preferred. When epidural
analgesia is added to preoperative carbohydrate supplementation, there is even greater improvement in insulin resistance.
(See Schwartz 11th ed., pp. 2116–2117.)
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