This patient likely has achalasia. Key points are:
- Progressive dysphagia to solids over weeks
- Weight loss without nausea/vomiting
- Smoking history
- No other alarm symptoms
Initial workup would include barium swallow and EGD. Barium swallow would show "bird's beak" deformity and failure of the LES to relax with swallowing. EGD allows biopsy and ruling out malignancy. Manometry confirms achalasia diagnosis by showing failure of LES relaxation and esophageal pressurization. Treatment is pneumatic dilation or laparoscopic Heller myotomy with fundoplication to disrupt the LES and allow emptying. Prognosis is good with treatment
3. The Osler Institute
GS_SDS_Oralrevised03012010 (6/2/2010) GS-SDS-Oral 2010 page 3
How to Pass the Oral Boards
Joel Goldberg, MD
Harvard University
I. American Board of Surgery
A. Written Boards (qualifying) - tests your knowledge.
1. Can’t test judgment.
B. Oral Exam (certifying) - tests your judgment and
knowledge.
1. Are you rational?
2. Are you safe?
3. Are you ethical?
4. Do you have sound knowledge and decision making.
II. The Examiners: there are two of them per room
A. Permanent member of the ABS - - -chances are, if you’ve
read the “textbooks” you will know this guy!
1. He’s usually very nice - he knows he knows more than
you.
2. He’s also very smart - don’t BS him.
B. Associate Examiner (“local guy”) - no clue who this
turkey is!
1. He’s usually not as nice as the first guy.
2. Trying to prove to the first guy that he knows more
than you.
3. Doesn’t always know more than you. Nonetheless -
don’t BS or challenge him either.
III. The Topics most frequently addressed: three rooms along
these lines.
A. Upper Gastrointestinal/Endocrine/Soft Tissue room
1. Esophagus: Boerhaave’s, achalasia, Zenker’s,
Barrett’s, cancer
2. Stomach: afferent loop syndrome, non-healing gastric
ulcer, gastric outlet obstruction
3. Pancreas: painless jaundice, pancreatic abscess,
pseudocyst, splenic vein thrombosis, Infected
Pancreas, Necrosis/acute pancreatitis,
4. Duodenum: perforated, bleeding DU
5. Liver and Biliary tree: cholangitis, CBD injury,
solitary liver mass
6. Spleen: ITP, post splenectomy abscess with pancreatic
fistula
4. Surgery Review Course
page 4 GS-SDS-Oral 2010 GS_SDS_Oralrevised03012010 (6/2/2010)
7. Melanoma: extremities vs. trunk, SLNB vs. node
dissection vs. mets
8. Sarcoma: extemities vs. retroperitoneal, XRT/chemo
9. Endocrine: thyroid nodule, primary HPTH,
Pheochromocytoma, MEN syndromes, Gastrinoma
B. Trauma and Critical Care room
1. Burns
2. ARDS
3. Pelvic Fracture
4. Pulmonary Embolus
5. Trans mediastinal GSW
6. Stab wound neck
7. ACLS/ATLS
8. Post-op MI
9. Necrotizing Fascitis
10. Abdominal Compartment
11. Oliguria p-op AAA: Dx is ischemic colitis/cold
leg/ARF/MI/CHF/ARDS/Pneumonia/acute
ccy/ acute pancreatitis as all of these can present
with low u/o, acidosis, hypoxia and tender abdomen.
C. Lower GI/Vascular/Breast/Endocrine/Pediatric room
1. Small Intestine: Crohn’s disease, enterocutaneous
fistula, SBO, early prop SBO
2. Colon: ischemic colitis, UC, Toxic Megacolon,
colon cancer at AAA, diverticulitis, colovesical
fistula, LGIB
3. Appendix: octopus, i.e. every variation
of RLQ pain
4. Rectum: low rectal CA, perianal DZ,
anal cancer.
5. Vascular
a. Cold leg
b. Ruptured AAA
c. Renovascular Hypertension
d. Mesenteric ischemia; art vs. ven; acute vs.
chronic
e. Carotid artery disease
f. Diagnosis and work up of DVT
6. Breast: Everything. Everyone gets a breast
question.
7. Pediatrics: testicular torsion vs. hernia.
Traumatic duodenal hematoma.
8. Thoracic: solitary pulmonary nodule,
empyema, thymoma
5. The Osler Institute
GS_SDS_Oralrevised03012010 (6/2/2010) GS-SDS-Oral 2010 page 9
Passing the Oral
Surgical Board Exam
Robert Youngblood, MD
East Carolina University
I. PASSING The Oral Surgical Board Exam
• Your objective in taking a preparatory course is to pass the
General Surgery Oral Board Exam. Your examiner’s purpose
is to access your clinical judgement and the ability to apply
cognitive knowledge to practical surgical problems. My
purpose is to do all that I can to assist you in passing. It is
important for you to outline your thought processes in
arriving at a diagnosis and describing your management
decisions.
A. The American Board of Surgery expects you to be
knowledgeable and proficient in five areas:
• You must have a central core of knowledge in Anatomy,
Physiology, Pathology, Immunology, Nutrition,
Metabolism, Shock Resuscitation, Intensive Care and
Wound Healing.
• You must possess the comprehensive knowledge and skill
in the diagnosis and pre-intra and postoperative care in 9
areas. (Alimentary tract, abdominal contents, skin and soft
tissue including breast, head, and neck, vascular system,
endocrine system, surgical oncology, trauma management
and critical care.)
• You should be significantly familiar with the surgical
management of pediatric, general thoracic, transplant and
plastic surgical patients.
• You must understand the management of the more
common problems in anesthesia, cardiac surgery,
gynecology and neuro, orthopedic and urologic surgery.
• You must be able to perform endoscopic techniques
including bronchoscopy, laryngoscopy, upper gastro-
intestinal endoscopy, colonoscopy and basic laparoscopic
surgery.
B. The examinations are conducted by two
examiners, both of which are board-certified
surgeons, and one of whom is a member of the
American Board of Surgery.
1. A few practical points:
• I would suggest your initial impression is important.
Dress conservatively; shake hands firmly; establish eye
contact; be friendly, smile conservatively and treat
your examiner with respect.
• You will be presented a series of cases to discuss. Pause
briefly and organize your thoughts. Proceed in logical
6. Surgery Review Course
page 10 GS-SDS-Oral 2010 GS_SDS_Oralrevised03012010 (6/2/2010)
order evaluating history, physical, laboratory studies
and special studies. Establish in your mind a diagnostic
decision tree and outline for your examiner the
purpose, result, and significance of the test you do in
establishing the diagnosis. Likewise, describe in logical
order the therapeutic steps eliciting how and why you
do what you do. Do not omit preoperative preparations
if indicated such as cardiac evaluation, pulmonary
toilet electrolytes, blood typing, antibiotics, nutritional
evaluations, etc.
• Your examiner may proceed with a line of questioning
until he stumps you. Be careful do not B.S.! Tell him
how you would go about finding the information you
are uncertain about or seek consultation with
appropriate authorities.
• If you are quite knowledgeable and very comfortable
with a clinical problem your examiner may stop you
and go to a different subject. You may be wise to deal
thoroughly and deliberately with the situation in which
you are knowledgeable but do not give the appearance
of stalling.
• Listen to the facts of the case carefully as presented and
be alert for “prompters” both in the original
presentation and in subsequent questions. Prompters
are subtle clues – be alert for them.
2. The following is a list of things the examiner is looking
for:
a. Do you recognize the basic problem?
b. Do you analyze and interpret the data correctly?
c. Do you ask clarifying questions and seek appropriate
additional data?
d. How is your problem solving ability?
e. What is your basic knowledge level?
f. Do you choose realistic, effective therapies?
g. Do you anticipate and manage complications?
h. Do you adopt alternative therapies, if needed?
i. Do you communicate effectively?
j. Are you a safe surgeon?
k. Do you know when not to operate?
3. To pass the examination, you must have basic knowledge;
but how you organize and apply that knowledge is equally
important.
• In summary, appear respectful, friendly and confident.
Address the question you are asked. Organize your
replies and verbalize your thought processes. Outline
not only what and how, but why you do what you do.
Be alert for prompters.
• Good luck, but good preparation is better.
7. The Osler Institute
GS_SDS_Oralrevised03012010 (6/2/2010) GS-SDS-Oral 2010 page 11
Breast Topics
For the Oral Boards
Charles D. Goldman, MD
Des Moines University/Mercy Medical Center Des Moines
Initial interview of patient: Get family history of
malignancy, especially early onset breast (including male
relatives) and ovarian at any age. Softer link to early onset
colon and prostate. All are associated with BRCA tumor
suppressor gene deletions. Look for pattern of multiple first-
degree family members with these associated malignancies
and at least one with early age of onset (prior to age 50).
Early onset ovarian cancer has especially ominous prognosis.
Ask about age of first full-term pregnancy (earlier the better)
and age of menarche (later the better). Nulliparity or first
pregnancy after age 35 increases risk of breast cancer.
Work-up: Make diagnosis of cancer before staging for
distant disease. There should be almost no employment of
open biopsy, except for those who cannot undergo
stereotactic biopsy. Core biopsy now standard, FNA rarely
used. Advantage of core needle biopsy is ability to display
invasion (and thereby R/O DCIS) and to obtain receptor
analysis, including her-2 neu status. Mammography is not a
diagnostic test; to call mass benign or malignant, look for
triple concordance of tissue diagnosis, physical exam and
mammography. Ultrasound is an adjunctive test. If mass
palpable but negative mammography, get biopsy unless has
all characteristics of simple cysts or fibroadenoma on
ultrasound.
DCIS: Characterized as high or low grade depending on
nuclear changes and presence/absence of comedonecrosis.
Not clear that any more than 25% of these lesions will ever
progress to frank carcinoma; therefore, many observers feel
less aggressive management, especially omission of
radiotherapy, in the older patient can be justified. Although
standard is to offer radiotherapy to all DCIS patients, no
evidence of any survival benefit to adding radiation in DCIS.
Aim for clear margin excision; if disease is multifocal this
may be impossible. Recent NCCN guidelines state that while
1 cm margin is optimal, clear margin is adequate (<1 mm) in
constrained sites such as against chest wall or at skin.
Although controversial, radiation therapy is generally added
to excision except for small low grade DCIS excised with at
least 1 cm margin in the older patient. Partial breast
irradiation has been used on protocol. Tamoxifen reduces
8. Surgery Review Course
page 12 GS-SDS-Oral 2010 GS_SDS_Oralrevised03012010 (6/2/2010)
both invasive and DCIS recurrence, but has no effect on
survival. It should be considered in all patients with high-
grade ER (+) DCIS unless there is a contraindication such as
concern for endometrial cancer or prior thromboembolic
disease. Mastectomy not needed except for extensive DCIS
that cannot be encompassed by lesser surgery, up to and
including quadrantectomy. Lymph node surgery generally
not needed in DCIS. SNB in DCIS is not standard of care
except in setting of microinvasion, mass-associated DCIS,
or when doing mastectomy for DCIS (ASCO and NCCN
guidelines).
LCIS: Lobular carcinoma in situ is marker for enhanced
lifetime risk of developing infiltrating cancer, usually of
ductal variety. Risk is same in both breasts and is not
associated with the location that the LCIS is encountered.
Generally LCIS is an incidental finding on biopsy done for
other reasons; not associated with microcalcifications. Unless
patient is difficult to follow closely or has LCIS along with
significant family history, intensive surveillance is best
option, perhaps adding MRI if patient is difficult to assess
with mammography. Consider chemoprophylaxis with
tamoxifen for about 50-60% proportional risk reduction. In
very high risk patients, bilateral simple mastectomies will
reduce risk of subsequent cancer about 95%.
Staging: Stage I—primary smaller than 2 cm, no nodes;
Stage II A-regional nodal disease or tumor from 2-5 cm with
no nodes; Stage II B—primary from 2-5 cm with nodes, or >5
cm tumor no nodes; Stage III A- tumor > 5 cm with nodes, or
tumors with bulky but operable axillary adenopathy; Stage
IIIB—signs of inoperability such as chest wall invasion, peau
d’orange, ulceration and inflammatory breast cancer;
supraclavicular adenopathy; Stage IV-metastatic disease
Early breast cancers (Stage I-IIA): Stage prior to surgery
with serum liver function tests and chest X-ray. No need for
bone scans or CT’s unless patient has suggestive symptoms or
lab abnormality. All lesions < 5 cm can be considered for
conservative therapy, even if nodes clinically positive. May
even consider larger lesion for conservation if large breast
size would allow for reasonable cosmetic results and no signs
of unresectability. Send to radiotherapist preoperatively to
assess for any contraindication to radiotherapy, e.g. multiple
quadrant disease, high tumor to breast size ratio, collagen
vascular disease. Remember that for lesions < 5 cm
mastectomy and lumpectomy with radiation are equivalent
therapies; always lean towards breast conservation where
appropriate. Sentinel node biopsy is now standard of care for
9. The Osler Institute
GS_SDS_Oralrevised03012010 (6/2/2010) GS-SDS-Oral 2010 page 89
Case 1
A 65-year-old male comes to you complaining of a two-week
history of increasing difficulty swallowing solid food. He is not
vomiting. It just seems the "food is sticking behind his
breastbone." He has lost about ten pounds in the last month,
although his appetite is good. He has a 60-pack year history of
smoking and drinks a fair amount of beer on the weekends.
1. What is your differential?
Answer: Esophageal cancer, stricture from reflux, diverticula,
and motility disorder
2. What is your initial workup?
Answer: R/O obvious mets from cancer on physical
examCXRLFTS; UGI and EGD to confirm presence of cancer
3. The biopsy shows a circumferential squamous cell carcinoma at 35
cm, nearly obstructing. What next?
Answer: (You must start from worst case scenario, that being patient
is not an operative candidate due to distant mets or locally advanced
disease.) R/O distant mets with chest/abdominal CT;
mediastinoscopy if CT is suspicious for upper mediastinal
adenopathy. Assess depth invasion with CT, possible endoluminal
ultrasound. Get bronchoscopy if CT or symptoms suggest TE fistula,
a definite sign of inoperability. (No mets.) Question enlargement of
lymph nodes at esophageal hiatus.
4. What are treatment options?
Answer: Chemo rads as only therapy vs esophagectomy
with/without preoperative chemo/RT/chemo-RT.
5. Decide on OR, what preop tests do you want?
Answer: PFTs mandatory as aid in deciding whether
thoracotomy is safe. Might want to workup heart due to
smoking history. Discuss indications and conduct of OR:
transhiatal esophagectomy vs Ivor-Lewis approach.
Case 2
A 45-year-old male comes into the ER complaining of painless
abdominal distension about 3 weeks after recent hospitalization
for acute exacerbation of his alcohol-induced chronic
pancreatitis. Exam reveals a massively protuberant abdomen,
dull to percussion, with positive fluid wave, also has notable
peripheral muscle wasting.
1. What do you do to make the diagnosis?
Answer: CT or U/S of abdomen to check pancreas and to
confirm ascites; tap abdomen and send fluid for usual labs; get
routine bloods and X-rays, including CXR to R/O pleural
effusion. (The peritoneal fluid has an amylase of 10,000 and a
high protein level; serum amylase is 80.)
2. What is your diagnosis?
Answer: (pancreatic ascites)
3. What is the cause of the ascites?
10. Surgery Review Course
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Answer: (In alcoholic pancreatitis, almost always rupture of the
pancreatic duct; less likely, pseudocyst rupture)
4. Treatment?
Answer: Repeated abdominal taps; thoracentesis if
symptomatic; support nutrition with TPN (feeding distal to
pancreas probably not good answer); somatostatin to dry up
secretions. (After 7-10 days, still requiring daily paracenteses).
5. What do you want to do?
Answer: Get ERCP and see if a leak can be identified and place stent
across. (ERCP shows ductal leak, but cannot stent across.)
6. What next?
Answer: Continue conservative RX for 3-4 weeks and if still
leaking, take to OR to drain leak into longitudinal
pancreaticojejunostomy.
7. Point: this is not a surgical emergency and these patients are
very protein depleted. Be sure to adequately aliment these
patients before you explore.
Case 3
A 74-year-old male comes to you complaining of gurgling in his
neck, regurgitation of undigested food, and bad breath.
Appetite OK; no weight loss. Physical exam unremarkable.
1. What workup do you want?
Answer: Need to R/O esophageal motility disorder vs
diverticulum. Get UGI first, not endoscopy as latter runs the
risk of perforation with Zenker's. (UGI reveals a Zenker's
diverticulum.) Ask what size, as this can affect your choice of
operative therapy.
2. How do you repair this?
Answer: If less than 2 cm, can simply do myotomy of
cricopharyngeal muscle; if larger, do myotomy and either
diverticulectomy or suspend diverticulum from precervical
fascia.
3. What side of the neck do you make incision?
Answer: Generally on left, paralleling sternocleidomastoids
anterior border. After the operation, the patient is notably
hoarse with slight inspiratory stridor.
4. What's the problem?
Answer: Recurrent injured laryngeal nerve, probably from
retraction. Most will come back to normal; if not, be prepared
to discuss options for treatment of vocal cord paralysis.
