• Scientific Foundations
    • 1

      Choice and Type of Anesthesia

      By George P. Yang, MD, PhD; Steven K. Howard, MD
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      Choice and Type of Anesthesia

      • GEORGE P. YANG, MD, PHDAssociate Professor, Department of Surgery, Stanford University School of Medicine, Stanford, CA and Palo Alto VA Health Care System, Palo Alto, CA
      • STEVEN K. HOWARD, MDAssociate Professor, Department of Anesthesia, Stanford University School of Medicine, Stanford, CA and Palo Alto VA Health Care System, Palo Alto, CA

      The primary purpose of anesthesia is to allow enough patient comfort to permit the performance of surgery. The choice of anesthetic depends on a variety of factors including the type of surgery, the mental status of the patient, and the patient’s comorbidities. This review is far from definitive and is simply meant to lay the framework for surgeons to understand what is happening on the other side of the screen. Having a basic understanding also facilitates important discussions about the choice of anesthetic between the surgeon and the anesthetist. This chapter covers the pre-operative assessment of the patient and the association between preexisting medical conditions and adverse outcomes. The authors cover all anesthesia techniques individually, including local; local/MAC; regional; and general, but stress that all techniques exist along a continuum. Patient intra-operative monitoring is described, and commonly used drugs are described in detail, including anxiolytics/amnestics; analgesics; intravenous anesthetics; inhalational agents; paralytics; local anesthetics; and how drug shortages impact perioperative care. The special scenarios section discusses the difficult airway; morbid obesity; cardiac risk; pulmonary risk; massive transfusion; hypothermia; and loss of airway/lack of oxygenation.
      This review contains 6 figures, 13 tables, and 142 references.

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    • 2

      Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

      By Laura Stafman, MD; Sushanth Reddy, MD, FACS
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      Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care

      • LAURA STAFMAN, MDResident, Department of Surgery, University of Alabama, Birmingham, AL
      • SUSHANTH REDDY, MD, FACSAssistant Professor, Department of Surgery, University of Alabama, Birmingham, AL

      In 2005, Terri Schiavo collapsed at home and was found by her husband without respirations or a pulse. She was resuscitated, but suffered severe anoxic brain injury and after 21/2 months was diagnosed as being in a persistent vegetative state. A court appointed her husband as her legal guardian as she did not have a written advance directive and had not specified a power of attorney for health care (POAHC), but heated court battles raged between her husband and her parents regarding who should be making decisions and what the appropriate decisions were. This case highlights the importance of writing down instructions for end-of-life care or designating someone to make decisions in their best interest in the event they could not make these decisions themselves. This review covers advance directives, do-not-resuscitate orders, and POAHC. Figures show an extended values history form, an example of a living will, the California’s Physician Orders for Life-Sustaining Treatment form, components of the CURVES mnemonic to assess decision-making capacity in critical/emergency situations, and activation and deactivation of power of attorney for health care. Tables list the most common types of advance directive and description of each, barriers to the use of advance directives, common themes in surgeons’ attitudes regarding advance directives, general requirements and exclusions for POAHC, and requirements for decision-making capacity in patients.

      This review contains 5 highly rendered figures, 5 tables, and 56 references

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    • 3

      Postoperative Pain Management

      By Abhishek Mathur, MD; Steven B. Goldin, MD, PhD, FACS, MPH, CPH
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      Postoperative Pain Management

      • ABHISHEK MATHUR, MDSenior Surgical Resident, Morsani College of Medicine, University of South Florida, Tampa, FL
      • STEVEN B. GOLDIN, MD, PHD, FACS, MPH, CPHProfessor of Surgery, Chief of Hepatobiliary and Pancreatic Surgery, Vice Chairman of Surgical Education, Medical Student Clerkship Director, Morsani College of Medicine, University of South Florida, Tampa, FL

      Postoperative pain consists of a constellation of unpleasant sensory, emotional, and mental experiences associated with autonomic, psychological, and behavioral responses precipitated by the surgical injury. Guidelines for postoperative pain are described, including the efforts to develop procedure-specific perioperative pain management guidelines. Treatment modalities are defined and include complementary and alternative medicine interventions; the systemic opioids, how they work, and their side effects; epidural and subarachnoid opioids, how they work, and their side effects; the epidural local anesthetics and other regional blocks; and the roles of NSAIDs, COX-2 inhibitors, and acetaminophen. Other analgesics are touched upon, including glucocorticoids; transcutaneous electronic nerve stimulation; and combination regimens. The physiologic mechanisms of acute pain are described, and include peripheral pain receptors and neural transmission to the spinal cord; dorsal horn control systems and modulation of incoming signals; the descending pain control system; spinal reflexes; and postinjury changes in peripheral and central nervous systems. The effects of pain relief are given and in particular the detrimental effects of incorrect or incomplete postoperative analgesia on the cardiovascular, pulmonary, and gastrointestinal systems. The effects of nociceptive blockage and pain relief on postoperative morbidity are also discussed. The review also describes the developments and prevention of chronic postoperative pain and the barriers to effective postoperative analgesia. Figures show a decision tree for selection of postoperative analgesia and describe the neural pathways involved in nociception. Tables list contributing causes of inadequate pain treatment; psychological preparation of surgical patients; opioid receptor types and physiologic actions; the intrinsic activity of opioids; typical intravenous patient-controlled analgesia regimens; typical dosing of neuraxial opioids; typical patient-controlled epidural analgesia regimens; procedures for maintenance of epidural anesthesia for longer than 24 hours; recommended location of catheter insertion for surgical procedures; typical dosing for common NSAIDs, COX-2 inhibitors, and acetaminophen; and approximate incidences and risk factors for development of postoperative chronic pain.

      This review contains 4 figures, 7 tables, and 118 references.

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    • 4

      Clinical Pharmacology

      By Molly E. Moore, PharmD; Eric W. Mueller, PharmD; Bryce R.H. Robinson, MD, FACS
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      Clinical Pharmacology

      • MOLLY E. MOORE, PHARMDClinical Pharmacy Specialist, Trauma, Surgery, and Orthopedics, UC Health-UniversityHospital, Adjunct Clinical Instructor of Pharmacy Practice, University of Cincinnati, Cincinnati, OH
      • ERIC W. MUELLER, PHARMDClinical Pharmacy Specialist, Critical Care, Director, Critical Care Pharmacy ResidencyProgram, UC Health-University Hospital, Adjunct Associate Professor of Pharmacy Practice, Clinical Instructor of AdvancedPractice Nursing, University of Cincinnati, Cincinnati, OH
      • BRYCE R.H. ROBINSON, MD, FACSAssistant Trauma Medical Director, Assistant Professor of Surgery, Division of Traumaand Critical Care, Department of Surgery, University of Cincinnati, Cincinnati, OH

      Contemporary management of critically ill surgical patients depends on the use of pathophysiology-focused, evidence-based pharmacotherapy. Although the primary aim for initiating pharmacotherapy is intended therapeutic benefit, adverse drug events (defined as injuries caused by the use or nonuse of drugs) or adverse drug reactions (defined as nonpreventable drug reactions resulting from the appropriate use of drugs) remain prevalent in complex patients (e.g., critically ill patients) requiring complex pharmacotherapy. Amid complicated physiologic changes and a high likelihood of polypharmacy, understanding the interactions between critical illness and drug activity is imperative to minimize potential harm while maximizing the therapeutic benefits of pharmacotherapy. This review covers the basic pharmacokinetic principles: absorption, distribution, metabolism, and elimination (ADME), the pharmacokinetic parameters reflecting magnitude of drug exposure, pharmacodynamics, physiologic alterations, pharmacogenomics, therapeutic drug monitoring, drug interactions, and adverse drug reactions.

      This review contains 9 figures, 2 tables, and 36 references.

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    • 5

      Clinical Trial Design and Statistics

      By Julie Ann Sosa, MA, MD, FACS
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      Clinical Trial Design and Statistics

      • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT

      A clinical trial is a planned experiment designed to prospectively measure the efficacy or effectiveness of an intervention by comparing outcomes in a group of subjects treated with the test intervention with those observed in one or more comparable group(s) of subjects receiving another intervention.  Historically, the gold standard for a clinical trial has been a prospective, randomized, double-blind study, but it is sometimes impractical or unethical to conduct such in clinical medicine and surgery. Conventional outcomes have traditionally been clinical end points; with the rise of new technologies, however, they are increasingly being supplemented and/or replaced by surrogate end points, such as serum biomarkers. Because patients are involved, safety considerations and ethical principles must be incorporated into all phases of clinical trial design, conduct, data analysis, and presentation. This review covers the history of clinical trials, clinical trial phases, ethical issues, implementing the study, basic biostatistics for data analysis, and other resources. Figures show drug development and clinical trial process, and type I and II error. Tables list Food and Drug Administration new drug application types, and types of missing data in clinical trials.

      This review contains 2 highly rendered figures, 2 tables, and 38 references

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    • 6

      Evidence-based Medicine

      By Emily R. Winslow, MD
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      Evidence-based Medicine

      • EMILY R. WINSLOW, MDDepartment of Surgery, Section of Surgical Oncology, University of Wisconsin, Madison, WI

      Descriptions of “evidence-based” approaches to medical care are now ubiquitous in both the popular press and medical journals. The term evidence-based medicine (EBM) was first coined in 1992, and over the last two decades, the field has experienced rapid growth, and its principles now permeate both graduate medical education and clinical practice. The field of EBM has been in constant evolution since its introduction and continues to undergo refinements as its principles are tested and applied in a wide variety of clinical circumstances. This review presents a brief history of EBM, EBM: fundamental tenets, a critical appraisal of a single study, reporting guidelines for single studies, a critical appraisal of a body of evidence, evidence-based surgery, and limitations in EBM. Tables list strength of evidence for treatment decisions (EBM working group), Oxford Centre for Evidence-Based Medicine revised levels of evidence for treatment benefits , “4S” approach to finding resources for EBM, critical appraisal of individual studies examining therapeutic decisions, reporting guidelines by study design, and key resources for evidence-based surgery.

      This review contains 6 tables and 85 references

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    • 7

      Acid-base Disorders

      By James Orr, MD, FACS; Suresh Agarwal, MD, FACS, FCCM; Ann P. O'Rourke, MD, MPH
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      Acid-base Disorders

      • JAMES ORR, MD, FACSAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI
      • ANN P. O'ROURKE, MD, MPHAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Anticipation and early identification of conditions that alter the body's ability to compensate for acid-base disorders are vital in managing surgical patients. This review describes the general principles and classification of acid-base disorders. Metabolic acid-base disorders are presented, including metabolic acidosis and alkalosis. Respiratory acid-base disorders are also presented, including respiratory acidosis and alkalosis. Tables show the differentiation of acid-base disorders, causes of positive–anion gap acidosis, the differential diagnosis for normal–anion gap metabolic acidosis, the mechanisms associated with increased serum lactate concentration, and the differential diagnosis for metabolic alkalosis.

      This review contains 7 highly rendered figures, 5 tables, and 135 references.

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    • 8

      Disorders of Water and Sodium Balance

      By Micah Katz; Herbert Chen, MD, FACS
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      Disorders of Water and Sodium Balance

      • MICAH KATZUniversity of Wisconsin School of Medicine and Public Health, Madison, WI
      • HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI

      Water is vital to life. Cells, the blood bringing nutrients and oxygen to them, and the interstitial fluid bathing them are all mostly water. Each day, water and salt are lost and replaced. To maintain stability of the internal milieu, body fluids are processed by the kidney, guided by intricate physiologic control systems that regulate fluid volume and composition. When regulatory pathways are disrupted or overwhelmed by medical interventions, irreversible deficits may be caused. Factors affecting the fluid homeostasis include osmolality, fluid movement between compartments, renal processing, and cell volume regulation in hypotonicity and hypertonicity. This review presents the diagnosis and management of disorders of water excess (hyponatremia), water deficiency (hypernatremia), saltwater excess (edematous states), and saltwater deficiency (volume depletion). Tables present the causes of acute hyponatremia (water intoxication), the syndrome of inappropriate antidiuretic hormone (SIADH), and hypernatremia. Figures depict the mechanisms of sodium resorption, the normal relation between plasma vasopressin levels/urine osmolality and sodium concentration, and dose-response curves for a loop diuretic in patients with normal and reduced renal function.

      This review contains 5 figures, 7 tables, and 66 references.

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    • 9

      Nature and Clinical Impact of Physiologic Changes Associated With Aging

      By Clinton D. Protack, MD; Alan Dardik, MD, PhD, FACS
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      Nature and Clinical Impact of Physiologic Changes Associated With Aging

      • CLINTON D. PROTACK, MDResident Physician, Department of Surgery, Veterans Affairs Connecticut Healthcare System, West Haven, CT
      • ALAN DARDIK, MD, PHD, FACSChief, Division of Peripheral Vascular Surgery, Department of Surgery, Veterans Affairs Connecticut Healthcare System, Associate Professor of Surgery (Vascular), Yale University School of Medicine, West Haven, CT

      Older persons are the fastest-growing demographic group in the United States. It is estimated that by 2020, Americans older than 65 years will account for more than 20% of the total population. For some older patients, losing functional independence as a result of a major surgical intervention may be a far worse outcome than living with, or even dying of, the disease for which surgery is offered. Aging is characterized by progressive loss of physiologic reserve in nearly all organ systems. This chapter covers all changes by organ system, along with changes in immune response and glucose homeostasis. A solid understanding of the physiologic changes associated with aging can facilitate preoperative assessment of the elderly patient’s functional reserve and thus, ultimately, help ensure a more accurate assessment of the operative risk. Studies have shown that the development of postoperative complications is associated with a higher 30-day postoperative mortality, as well as an increased risk of death within the first 3 months after surgery. The authors describe in detail the complete preoperative assessment of the elderly patient. The goals of preoperative assessment of an elderly patient are to define the extent of physiologic decline, characterize and optimize comorbid diseases, and determine how the stress of the surgical treatment will impact the patient’s postoperative function and overall quality of life. Specific postoperative complications are covered, and surgical oncology is organized by each type of cancer. Vascular surgery and trauma are covered as well.

      This review contains 5 Figures, 7 Descriptive Tables, and 118 References.

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    • 10

      Evaluation of Surgical Risk

      By Ryan Schmocker, MD; Suresh Agarwal, MD, FACS, FCCM
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      Evaluation of Surgical Risk

      • RYAN SCHMOCKER, MDResident, Department of Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI

      In assessing surgical risk, appropriate preoperative evaluation should systematically address a patient's pre-existing medical conditions and identifies unrecognized comorbidities, ideally leading to the anticipation and treatment of potential complications both pre- and postoperation. Thus, a thorough evaluation of the patient history and physical examination is essential. Various risk assessments discussed in this review are those for cardiac, pulmonary, renal, hepatic, and hematologic concerns. Cardiac risk assessment focuses on patient-related risk factors, including coronary artery disease, congestive heart failure, valvular heart disease, arrhythmias and conduction defects, implanted pacemakers and implantable cardiac defibrillators, cardiomyopathy, and hypertension. The pulmonary patient-related risk factors are explored and include age and general health status, smoking, chronic obstructive pulmonary disease, asthma, obstructive sleep apnea, obesity, pulmonary hypertension, and heart failure. Preoperative medication management is also explored. Tables show the revised cardiac risk index to predict major cardiac risk associated with surgery; the metabolic equivalents of certain tasks; the Gupta calculator for postoperative respiratory failure or postoperative pneumonia; the American Society of Anesthesiologists score for a patient's overall health and ability to undergo surgery; an assessment or renal failure; contraindications to elective surgery in patients with liver disease; the Child-Turcotte-Pugh score to predict mortality of cirrhotic patients and the need for liver transplantation; the Model for End-Stage Liver Disease (MELD), recommendations for cardiovascular agents, antiplatelet agent anticoagulants, and herbal medications; and ACS NSQIP Risk Calculator outcomes.

      This review contains ­3 figures, 12 tables, and 107 references.

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    • 11

      Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

      By Irene Lou, MD; Herbert Chen, MD, FACS
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      Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis

      • IRENE LOU, MDPostdoctoral Trainee, Department of Surgery, University of Wisconsin, Madison, WI
      • HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI

      The management of perioperative anticoagulation, antiplatelet therapy, and perioperative venous thromboembolism (VTE) prophylaxis is essentially a balancing act between patient risk factors for thrombosis and surgical risk factors for bleeding. The purpose of this review is to assist surgeons with the identification of patients at increased risk for thromboembolism when antithrombotic therapy is interrupted, patients for whom bridging anticoagulation should be considered, patients who require perioperative VTE prophylaxis, and patients at increased risk for bleeding complications and to briefly review the literature and major guidelines regarding perioperative antithrombotic therapy management and perioperative VTE prophylaxis. Figures show approaches to the management of perioperative anticoagulation, antiplatelet therapy, and VTE prophylaxis. Tables list the BleedMAP score and rate of major hemorrhage, the suggested method of perioperative thromboembolism risk stratification, the CHADS2 scoring system, risk stratification and annual stroke rate, and the Caprini score risk assessment model for VTE.

      This review contains 3 figures, 5 tables, and 74 references.

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    • 12

      Preoperative Evaluation of the Elderly Surgical Patient

      By Jennifer Roberts, MD; Tracy S. Wang, MD, MPH, FACS
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      Preoperative Evaluation of the Elderly Surgical Patient

      • JENNIFER ROBERTS, MDDepartment of Surgery, Medical College of Wisconsin, Milwaukee, WI
      • TRACY S. WANG, MD, MPH, FACSAssistant Professor, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI

      The following is a detailed approach to the preoperative evaluation of the elderly surgical patient. A focus is placed on physiologic changes in the elderly that predispose them to complications and a systems-based approach to appropriate perioperative evaluation. Specifically, recommendations on the workup of cardiovascular, pulmonary, and renal systems are discussed. We also introduce the concept of frailty as a measure of an elderly patient's overall physiologic reserve. Finally, a diagnostic approach to common elderly-specific disease processes such as decreased functional status, malnutrition, and delirium is outlined. Throughout, an emphasis is placed on how to carefully assess this specific patient population and optimize preoperative functional status to improve surgical outcomes in the elderly. This review has 1 figure, 4 tables, and 62 references.

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    • 13

      Perioperative Management of Patients on Steroids Requiring Surgery

      By Dawn M. Elfenbein, MD, MPH; Alexandra Reiher, MD; Rebecca S. Sippel, MD, FACS
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      Perioperative Management of Patients on Steroids Requiring Surgery

      • DAWN M. ELFENBEIN, MD, MPHEndocrine Surgery, University of California, Irvine, Irvine, CA
      • ALEXANDRA REIHER, MDEndocrinology Fellow, Division of Endocrinology, University of Wisconsin, Madison, WI
      • REBECCA S. SIPPEL, MD, FACSAssistant Professor Surgery, Department of Surgery, University of Wisconsin, Madison, WI

      Patients with chronic lung disease, inflammatory bowel disease, rheumatoid arthritis, and solid-organ transplantations are often on steroid supplementation either intermittently or chronically. Endogenous steroid use results in decreased adrenocorticotropic hormone secretion by the pituitary gland through negative feedback mechanisms. Over several weeks, this can result in adrenal gland atrophy, eventually leading to secondary adrenal insufficiency. Appropriate management of perioperative glucocorticoid replacement therapy can be challenging, but appropriate replacement is essential to optimize patient outcomes. Insufficient dosing of glucocorticoids during the perioperative period can result in hypotension and even death. Excessive treatment with glucocorticoids decreases wound healing, increases the risk of hyperglycemia, and increases susceptibility to infection. This review covers the historical perspective, the hypothalamic-pituitary-adrenal (HPA) axis, when to suspect an impaired HPA axis, an argument against supraphysiologic glucocorticoid treatment in the perioperative period, the rationale for treating patients with impaired renal function, guidelines for dosing glucocorticoids in the perioperative period, and consulting a specialist. Figures show a clinical algorithm for evaluation and treatment of adrenal insufficiency in the perioperative period and the HPA axis. Tables list steroid conversions and perioperative glucocorticoid treatment recommendations.

       

      This review contains 2 highly rendered figures, 2 tables, and 22 references.

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    • 14

      Pharmacologic Considerations in the Elderly Surgical Patient

      By Tara A. Russell, MD, MPH; Linda Sohn, MD, MPH; Joe C. Hong, MD; Michael W. Yeh, MD, FACS; Marcia M. Russell, MD, FACS
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      Pharmacologic Considerations in the Elderly Surgical Patient

      • TARA A. RUSSELL, MD, MPH
      • LINDA SOHN, MD, MPHMedical Director, VA Greater Los Angeles Healthcare System, Community Living Centers, Assistant Clinical Professor, UCLA School of Medicine/Geriatrics, Los Angeles, CA
      • JOE C. HONG, MDAssistant Clinical Professor, Department of Anesthesiology, David Geffen School of Medicine at UCLA, Ronald Reagan UCLA Medical Center, Los Angeles, CA
      • MICHAEL W. YEH, MD, FACSAssistant Professor of Surgery and Medicine (Endocrinology), Division of General Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
      • MARCIA M. RUSSELL, MD, FACSAssistant Professor, Department of Surgery, VA Greater Los Angeles Healthcare System, Los Angeles, CA

      The most rapidly growing segment of the elderly population corresponds to persons age 85 and over. As of 2006, elderly patients accounted for 35.3% of the inpatient and 32.1% of the outpatient surgical procedures occurring in the United States. Because age-related changes occur in each organ system in all elderly individuals, this population merits special consideration when undergoing surgical procedures. Furthermore, there is a high probability that older adults will have multiple chronic medical problems, which may present a complex medication management challenge. This review covers the pharmacologic impact of physiologic changes associated with aging, preoperative assessment, preoperative medication management, delirium and the impact of perioperative medications in the elderly, anesthesia and related medications, and specific drug classes and their use in the elderly surgical patient. Figures show an overview of the management of the elderly surgical patient, and preoperative medication management. Tables list medications that should be avoided in older patients with reduced renal function, drugs that exhibit additive adverse effects, medications with high anticholinergic activity, medications that inhibit and induce the CYP450 system, herbal supplements, 2015 Beers Criteria summary of potentially inappropriate medication use in older adults, drugs associated with postoperative delirium, risk factors for postoperative delirium, and clinical pharmacology of commonly used anesthetic agents.

       

      This review contains 2 highly rendered figures, 9 tables, and 61 references

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    • 15

      Transplant Immunology: Basic Immunology and Clinical Practice

      By David P. Foley, MD; Lung-Yi Lee, MD
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      Transplant Immunology: Basic Immunology and Clinical Practice

      • DAVID P. FOLEY, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, and Veterans Administration Surgical Services, William S. Middleton Veterans Hospital, Madison, WI
      • LUNG-YI LEE, MD

      Engraftment of a transplanted organ into an allogeneic host triggers a cascade of immunologic responses in the host that are designed to facilitate graft rejection. Modern donor-to-host matching techniques and immunosuppression protocols have successfully tempered this natural immune response so that graft survival has dramatically improved. However, optimizing graft survival by precisely downregulating the host response to graft rejection while preserving host immune defenses against pathologic and infectious agents remains poorly understood and elusive in current clinical practice. This review discusses transplant immunology with respect to host versus graft and the basis of allorecognition, as well as clinical management of the transplanted allograft. Figures show human leukocyte antigen (HLA), direct allorecognition, T cell receptor and CD3, T cell–associated second messenger signaling pathway, CD8 molecules directly ligating class I HLAs and CD4 molecules directly binding HLA class II, detection of alloantibodies by enzyme-linked immunosorbent assay or flow cytometry, recipient-donor crossmatch, histopathology of kidney allograft with antibody-mediated rejection, and an algorithm for assessment and management of renal allograft rejection. Tables list costimulatory molecules and ABO blood group compatibility for solid-organ transplantation.

       

      This review contains 9 highly rendered figures, 2 tables, and 65 references.

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    • 16

      Prevention and Diagnosis of Infection

      By Sara M. Demola, MD; Taylor S. Riall, MD, PhD, FACS
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      Prevention and Diagnosis of Infection

      • SARA M. DEMOLA, MDClinical Instructor, Fellow in Critical Care, University of Texas Medical Branch, Galveston, TX
      • TAYLOR S. RIALL, MD, PHD, FACSAssociate Professor, John Sealy Distinguished Chair in Clinical Research, Department of Surgery, The University of Texas Medical Branch, Galveston, TX

      Infections are common complications treated in surgical and trauma intensive care units. Identification of infections in surgical patients is rarely incidental; it is sought most often in response to clinical signs. The presence of surgical infectious disease is usually determined clinically and confirmed microbiologically. Precision in terminology is vital; though similar in connotation, infection is not interchangeable with similar terms like sepsis and bacteremia. This chapter describes the signs and symptoms of infection, including the key signs of inflammation, pain, vital sign changes, and confusion. The approach to diagnosing infections is provided and includes an evaluation for the presence of infection, a history and physical examination, and various diagnostic tests, including hematologic and biochemical tests, microbiologic studies, and radiology. The various surgical/trauma infections are described and include the diagnostic approach to specific surgical infection like appendicitis, diverticulitis, and skin and soft tissue infections; postoperative infections referred to as surgical site infections; and nosocomial infections such as urinary tract infection, vascular catheter infection, septic shock, pulmonary infection, and Clostridium difficile infection. Figures show the interrelationships among infection, sepsis, and the systemic inflammatory response syndrome, and the percentage of critically ill trauma patients with fever or leukocytosis in the first week after admission, and the cardinal signs of localized inflammation. A table shows the fundamental approach to diagnosis of infection. Algorithms include diagnosis of superficial surgical site infection, Diagnosis of catheter-associated urinary tract infection, and diagnosis of central line–associated and catheter-related bloodstream infections.

      This review contains 8 figures, 4 diagnostic algorithms, 5 tables, and 58 references.

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    • 17

      Surgical Considerations in Solid-organ Transplant Recipients

      By Thomas A. Pham, MD; Marc L. Melcher, MD
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      Surgical Considerations in Solid-organ Transplant Recipients

      • THOMAS A. PHAM, MDFellow, Division of Abdominal Transplant, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
      • MARC L. MELCHER, MDAssociate Professor, Division of Abdominal Transplant, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA

      Advances in the management and the surgical techniques of solid-organ transplantation have led to a growing number of patients living longer with transplanted organs. Surgical intervention in these patients ideally should be carried out by the original transplant team; however, the goal of this review is to provide information for practicing surgeons who are not at a transplant center so that they may recognize transplant-related problems, to help decide when to perform an intervention or operation and when to consider transfer to a transplant center. With careful attention to medications and symptoms, general surgery principles will hold true with transplant patients. Minor procedures can usually be conducted without much modification, and major procedures may require some adjustment of the medication regimen. This review covers preoperative considerations, diagnostic and radiologic considerations, intraoperative considerations, management of perioperative infection, management of perioperative immunosuppression, postoperative management, when to consider transfer to a transplant center, special considerations, and annotated key references. Tables list anatomic and diagnostic details of abdominal organ transplants, and considerations for common immunosuppressive agents.

      This review contains 2 tables and 44 references

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    • 18

      Viral Infection

      By Jason A. Castellanos, MD; Nipun B. Merchant, MD, FACS
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      Viral Infection

      • JASON A. CASTELLANOS, MDGeneral Surgery Resident, Vanderbilt University Medical Center, Nashville, TN
      • NIPUN B. MERCHANT, MD, FACSProfessor of Surgery and Cancer Biology, Director, Vanderbilt Pancreas Center, Vanderbilt University Medical Center, Nashville, TN

      Although surgeons are seldom required to treat viral infections, viral infection exposure should still be a topic of concern to surgeons, because infection can cause illness in patients after surgery, and can spread to the hospital staff. This review discusses the prevention of transmission of HIV and hepatitis B and C viruses and the management of exposure to these viruses. A discussion of virus size and structure is presented, and six methods for detection are reviewed: serologic testing, isolation of virus, histologic examination, detection of viral antigens, detection of viral nucleic acid, and electron microscopy. Also discussed are viral infections that are of interest to surgeons, including HIV, hepatitis, herpes viruses, and viral infections from animal bites.

      This review contains 5 figures, 10 tables, 1 diagnostic HIV algorithm, and 137 references.

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    • 19

      Fungal Infections

      By Sara Buckman, MD, PharmD; Luis A. Fernandez, MD, FACS
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      Fungal Infections

      • SARA BUCKMAN, MD, PHARMDSurgical Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • LUIS A. FERNANDEZ, MD, FACSAssociate Professor of Surgery, Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant patients, and sick neonates all being especially vulnerable. Over the past few decades, technological and scientific advancements have improved physicians’ ability to sustain life in critically ill patients, developments in chemotherapeutics and immune-based therapies have yielded increased survival for many cancer patients, organ transplantation has evolved dramatically, and the use of invasive therapies has increased markedly. With these changes has come an increase in the incidence of serious Candida infections, as well as an increase in the less common but potentially fatal noncandidal infections caused by Aspergillus and the Zygomycetes Mucor and Rhizopus. Antifungal prophylaxis has emerged as a potential means of reducing the occurrence of serious fungal infections. This review covers fungal colonization versus infection, types of fungal infection, epidemiology and risk factors, clinical evaluation, investigative studies, management of acute candidemia and acute disseminated candidiasis, management of nonhematogenous candidiasis, peritonitis and intra-abdominal abscess, management of other fungal infections (Aspergillus, Cryptococcus, Mucor, Rhizopusi), systemic antifungal agents, and the pathogenesis of Candida infection. Tables describe the clinical presentation and diagnostic methods for common fungal infections, antimicrobial agents of choice for candida infections, antifungal chemotherapy, and characteristics of currently available antifungals. Figures show Candida endophthalmitis; superficial candidiasis; biopsy samples of chronic progressive disseminated histoplasmosis and thick-walled, broad-based budding yeasts typical for Blastomyces dermatitidis; and the various forms of Candida. Algorithms demonstrate the approach to the surgical patient at risk for candidiasis, aspergillosis, and other types of fungal infection.

      This review contains 5 figures, 4 tables, and 189 references.

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    • 20

      Prevention of Postoperative Infection

      By Mamta Swaroop, MD, FACS; Carla M. Pugh, MD, PhD, FACS
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      Prevention of Postoperative Infection

      • MAMTA SWAROOP, MD, FACSAssociate Professor of Surgery, Vice-Chair - Education and Patient Safety, Department of Surgery, University of Wisconsin, Madision, WI
      • CARLA M. PUGH, MD, PHD, FACSAssociate Professor of Surgery, Vice-Chair - Education and Patient Safety, Department of Surgery, University of Wisconsin, Madision, WI

      Surgical site infections (SSIs) continue to be prevalent and continue to exact a clinical and financial toll. The three determinants of infection (bacteria, local environment, and systemic host defences) are described. Factors that are under the surgeon's control, such as operating room hygiene practices, choice of drains, and use of electrocautery are listed. Host factors, such as local blood flow, advanced age, shock, and smoking are described. Sources of bacteria (endogenous and exogenous) and their properties are described. An algorithm for effective use of antibiotic prophylaxis is given. Figures and tables are presented to elucidate factors and determinants of SSI. The tables and figures assist recommendations to follow and clarify concepts presented in the review.

      This review contains 4 figures, 13 tables, and 155 references.

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    • 21

      Sepsis, Severe Sepsis, and Septic Shock

      By Sara Buckman, MD, PharmD; James Orr, MD, FACS; Suresh Agarwal, MD, FACS, FCCM
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      Sepsis, Severe Sepsis, and Septic Shock

      • SARA BUCKMAN, MD, PHARMDSurgical Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • JAMES ORR, MD, FACSAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI

      Sepsis continues to be a common and potentially lethal problem for surgical patients. This chapter describes the definitions of sepsis, severe sepsis, and septic shock. The initial assessment and evaluation is provided, including early identification of sepsis, initial assessment, initial resuscitation efforts, and various therapies to be employed such as vasopressor therapy, steroids, and empirical antimicrobial therapy. A discussion of the pathophysiology of sepsis ensues. Sepsis screening is evaluated. Implementing evidence-based guidelines, including the use of computerized clinical decision support is weighed. Modalities of treatment are discussed, including crystalloid versus colloid fluid resuscitation, the value of using steroids in septic shock, and the importance of early broad-spectrum antimicrobials. A figure reflects the protocol for early goal-directed therapy. Tables show Systemic Inflammatory Response Syndrome criteria; sepsis bundles; the Surviving Sepsis campaign guidelines regarding vasopressors, steroids, and antimicrobial therapy; and recommendations for source-specific empirical antibiotic selection.

      This review contains 3 figures, 6 tables, and 100 references.

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    • 22

      Infection Control in Surgical Practice

      By Caroline E. Reinke, MD, MSHP; Rachel R. Kelz, MD, MSCE, FACS
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      Infection Control in Surgical Practice

      • CAROLINE E. REINKE, MD, MSHPInstructor of Surgery, Department of Surgery Education, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
      • RACHEL R. KELZ, MD, MSCE, FACSAssistant Professor of Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA

      Optimal infection control in surgical practice is centered on the ability of health care providers to protect patients from infectious organisms that are often present in medical settings while limiting occupational exposures. Health care–associated infections are associated with substantial morbidity and mortality, and come with an economic cost on $28 to 45 billion annually in the US. The American College of Surgeons National Surgical Quality Improvement Program is collaborating with the Centers for Disease Control and Prevention (CDC) to help hospitals address the issue of infection prevention using standardized risk-adjusted outcomes data to benchmark performance. This review covers health care–associated infections and infection control in surgical practice, including historical perspective, identification of risk factors, preventive measures, infection control programs. The role of central venous catheters, urinary catheters, and ventilators in infection control and the health status of the health care team are also discussed. Tables describe risk factors and prevention strategies for control of surgical site infection, activities of an infection control program, components of an intervention to decrease catheter-related bloodstream infections in the intensive care unit, risk factors and prevention strategies for control of catheter-associated bloodstream and urinary tract infections and ventilator-associated pneumonia, American College of Surgeons recommendations for preventing the transmission of hepatitis, and CDC recommendations for prevention of HIV and hepatitis B virus transmission during invasive procedures. Figures include drawings of a surgical site infection, a healed wound, and the three categories of surgical site infections (SSI). A map shows states with legislation for SSI monitoring and those that make data publicly available.

      This review contains 4 figures, 8 tables, and 134 references.

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    • 23

      Minimally Invasive Surgery: Equipment and Troubleshooting

      By Luke M. Funk, MD, MPH; Jacob A. Greenberg, MD, EDM
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      Minimally Invasive Surgery: Equipment and Troubleshooting

      • LUKE M. FUNK, MD, MPHDepartment of Surgery, Brigham and Women’s Hospital, Boston, MA
      • JACOB A. GREENBERG, MD, EDMAssistant Professor, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI

      The field of minimally invasive surgery continues to evolve. The techniques and equipment needed to access, expose, and dissect vary according to the type of operation and surgeonÕs preference, but a basic set of equipment is essential for any laparoscopic procedure, and this chapter discusses basics--laparoscope, camera, light source, signal processing unit, video monitor, insufflator and gas supply, trocars, and surgical instruments. The chapter also reviews the potential technical difficulties that surgeons may encounter while using laparoscopic equipment and instruments and provides suggestions for troubleshooting these problems. Understanding how to use and troubleshoot laparoscopic equipment is critical for any surgeon, and other member of the surgical team, who performs minimally invasive surgery. Figures show various laparoscopes, including a laparoscopic Maryland dissector and a laparoscopic Babcock grasper. A table shows some troubleshooting techniques of laparoscopic equipment. This review contains 38 references.

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    • 24

      Principles and Techniques of Abdominal Access and Physiology of Pneumoperitoneum

      By Jon C. Gould, MD, FACS; Kathleen Simon, MD
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      Principles and Techniques of Abdominal Access and Physiology of Pneumoperitoneum

      • JON C. GOULD, MD, FACSAssociate Professor of Surgery, Department of Surgery, University of Wisconsin School of Medicine and Public Health.
      • KATHLEEN SIMON, MDSurgery Resident, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI

      When compared with the open approach to many abdominal operations, the laparoscopic technique is often associated with decreased morbidity and a quicker recovery. Unfortunately, there are also specific complications related to the laparoscopic approach that would not necessarily be seen with a laparotomy. Many of the most significant complications occur very early in the operation during the act of attaining abdominal access. There are three general types of laparoscopic access, with many variations and modifications. This review examines the advantages and disadvantages of the three types of abdominal access in laparoscopic surgery: the Veress needle, the direct trocar insertion, and the open or Hasson technique. The physiology of pneumoperitoneum is also reviewed, including cardiovascular effects and effects of carbon dioxide, along with postsurgical pain, and nausea and vomiting. Figures show a Veress needle, saline drop test, conical flat-bladed trocar, nonbladed optical trocar, and a Hasson cannula. Videos show Veress needle insertion at the Palmer point and optical-viewing trocar access.

      This review contains 5 highly rendered figures, 2 videos, and 75 references.

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    • 25

      Technical Aspects of Laparoscopic Surgery

      By James G. Bittner IV, MD, FACS; Charlotte Rabl, MD; Guilherme M. Campos, MD, FACS
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      Technical Aspects of Laparoscopic Surgery

      • JAMES G. BITTNER IV, MD, FACSAssistant Professor, Division of Bariatric and Gastrointestinal Surgery, Department of Surgery, Virginia Commonwealth University School of Medicine, Richmond, VA
      • CHARLOTTE RABL, MDVisiting Assistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI and Surgical Specialist, Paracelsus Private Medical University, Salzburg, Austria
      • GUILHERME M. CAMPOS, MD, FACSAssociate Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Laparoscopic surgery is now an integral part of general surgery and is used in almost all known surgical procedures. There are many advantages to laparoscopic surgery, including faster patient recovery, shorter hospital stay, decreased pain and analgesic requirements, and faster return to work. A thorough understanding of the different technical aspects of laparoscopic surgery is necessary to perform procedures correctly, as well as to avoid certain predictable difficulties and complications that can occur. This review details operating room setup and patient and surgery team positioning; the laparoscope and instruments used; laparoscopic suturing; laparoscopic training and simulators; when and why to convert to open surgery; and the use of single-port or single-incision laparoscopic surgery. Figures show a schematic representation of a ceiling-mounted articulated boom for laparoscopic surgery; blueprints and photographs of the first endoscope; images of an articulated 5 mm scope and high-definition camera head, assorted laparoscopic instruments, 10 and 5 mm LigaSure sealing devices and a 5 mm Harmonic scalpel, an Endoloop ligature with a 2-0 polyglactin tie, various sizes of the 5 mm Nathanson retractor and the round Snake retractor, and 5 mm needle drivers and a 10 mm Endo Stitch suturing device; and an illustration of laparoscopic suturing (using a square knot). Tables list patient positions used for laparoscopic surgical procedures, guidelines for optimal laparoscopic surgery suites, and staple heights and colors.

      This review contains 9 figures, 2 tables, and 78 references.

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    • 26

      Robotic Surgery

      By Alfredo M. Carbonell, DO, FACS, FACOS; Jeremy A. Warren, MD
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      Robotic Surgery

      • ALFREDO M. CARBONELL, DO, FACS, FACOSPrfessor of Surgery and Chief, Division of Minimal Access and Bariatric Surgery, Department of Surgery, University of South Carolina School of Medicine-Greenville, Greenville Health System, Greenville, SC
      • JEREMY A. WARREN, MDAssistant Professor of Surgery, Division of Minimal Access and Bariatric Surgery, Department of Surgery, University of South Carolina School of Medicine-Greenville, Greenville Health System, Greenville, SC

      Robots have revolutionized industrial production, from automobiles to pharmaceutical manufacturing, and offer an exciting, novel approach to surgical diseases. Robots employed in surgical use initially raised some concern related to malfunction and independent action. However, the surgeon’s decision-making capability is still crucial for each surgical procedure because of the anatomic or physiologic variables of each clinical situation. Currently, surgical robots consist of instruments that are remotely manipulated by a surgeon using an electromechanical interface and represent extensions of the surgeon’s mind and hands. This review provides an overview of robotic surgery, and covers the application of robotic surgery in general surgery. Figures show the AESOP 3000 robotic arm, the da Vinci robotic surgical system, the ZEUS Surgical System, the ZEUS robotic arms,  the da Vinci Si, the da Vinci wristed endoscopic stapler, the da Vinci Xi patient side cart and robotic arms, the da Vinci Single-Site robotic instruments, and the da Vinci Single-Site port with instruments positioned and robotic arms docked. The video shows a robotic Rives-Stoppa retromuscular incisional hernia repair with bilateral transversus abdominis release.

       

      This review contains 9 highly rendered figures, 1 video, and 85 references

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    • 27

      Nutritional Support

      By Panna A. Codner, MD, FACS; Karen J. Brasel, MD, MPH
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      Nutritional Support

      • PANNA A. CODNER, MD, FACSAssistant Professor of Surgery, Department of Surgery. Division of Trauma/Critical Care, Medical College of Wisconsin, Milwaukee, WI
      • KAREN J. BRASEL, MD, MPHProfessor of Surgery, Bioethics and Medical Humanities, Department of Surgery, Division of Trauma/Critical Care, Medical College of Wisconsin, Milwaukee, WI

      Therapy for critical illness includes nutritional assessment and treatment to optimize outcomes. Specific diseases can cause a greater stress response and therefore elicit a greater catabolic response. The inadequate provision of nutrients to counteract this catabolic state leads to a patient who is malnourished and more likely to experience infectious morbidity, prolonged hospital stay, and increased mortality. This chapter describes nutritional/energy needs; routes of entry and possible complications; and the use of nutrients to modulate tissue metabolism and organ system function, a role referred to as nutrition pharmacotherapy. Guidelines are given for when nutritional screenings and assessments are indicated.
      Nutritional support guidelines are provided for specific disease states (cardiac, pulmonary, liver, and renal disease; pancreatitis; short-bowel syndrome; inflammatory bowel disease; solid organ transplantation; and burns). Figures depict how the magnitude of weight loss is a rough predictor of its effect on clinical outcome and the decision-making approach for pharmacologic and dietary treatment of diarrhea associated with enteral nutrition. Tables describe alterations in metabolic rate; vitamin requirements; trace mineral requirements; composition of modified diets; procedure for inserting nasoenteric tubes; standard orders for enteral nutrition; indications for central venous or peripheral venous infusions; composition of central venous solutions; electrolytes added to central venous solutions; diagnosis, treatment, and prevention of potential mechanical and metabolic complications associated with total parenteral nutrition; metabolic complications of total parenteral nutrition; and variables to be monitored during intravenous alimentation and suggested frequency of monitoring.

      This review contains 3 figures, 4 tables, 2 algorithms, and 76 references.

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    • 28

      Cancer Epidemiology and Prevention

      By Carlo M. Contreras, MD
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      Cancer Epidemiology and Prevention

      • CARLO M. CONTRERAS, MDAssistant Professor, Division of Surgical Oncology, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL

      Cancer remains a significant public health problem in the United States and is now the leading cause of death for men and women younger than 85 years of age. The etiology of cancer development is often multifactorial, although direct links have been made between specific cancer types and environmental exposures, infections, pharmaceutical agents, and hereditary syndromes. There has been a slight decrease in both incidence and mortality over the past decade, but there is significant room for progress with respect to cancer prevention, screening for early detection, and treatment. This review covers cancer epidemiology, cancer prevention, and screening and early detection. The tables list known human carcinogens, radiation doses for common diagnostic radiology evaluations, common hereditary cancer syndromes, risk-reducing surgery and associated clinical entities, and American Cancer Society screening recommendations for individuals of average risk.

       

      This review contains 5 tables and 65 references

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    • 29

      Molecular Genetics of Cancer

      By Christina W. Lee, MD; Gregory D. Kennedy, MD, PhD
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      Molecular Genetics of Cancer

      • CHRISTINA W. LEE, MDGeneral Surgery Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • GREGORY D. KENNEDY, MD, PHDAssistant Professor, Section of Colon and Rectal Surgery, Department of Surgery, University of Wisconsin, Madison, WI

      Cancer involves an accumulation of genetic alterations that result in a stepwise progression toward unregulated growth and invasion. Understanding the evolution of a normal cell to its neoplastic state, including knowledge of the precipitating genetic defects, is vital to the development of potential treatments to combat unregulated growth. This review discusses the accession of specific critical properties underlying neoplastic transformation. Specifically, the cell cycle, the primary characteristics of cancer (continuous growth signaling, insensitivity to growth inhibition, evasion of apoptosis, angiogenic potential, immortalization, and invasion or metastasis), and cancer therapeutics are described. Figures show a simplified schematic of the cell cycle, cyclin-CdK complex function during the cell cycle, growth factor binding receptors, the mechanism of oncogene production, various transmembrane tyrosine kinases, the translocation of Ig heavy and light chains to the Myc locus on chromosome 8 in Burkitt lymphoma, a translocation observed in chronic myelogenous leukemia, the INK4A locus, and the apoptotic pathway. Tables include nonexhaustive lists of oncogenes in human malignancies and selected tumor suppressor genes associated with inherited susceptibility.

      This review contains 9 figures, 2 tables, and 186 references.

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    • 30

      Cancer Immunology

      By Amanda Contreras, BS; Clifford S. Cho, MD, FACS
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      Cancer Immunology

      • AMANDA CONTRERAS, BSGraduate Student, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • CLIFFORD S. CHO, MD, FACSAssistant Professor, Section of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      The immune system conducts a continuous process of immunologic surveillance for new cancer cells that is likely capable of eradicating many potential malignancies before they become clinically evident. Nascent tumors can, however, use escape mechanisms to avoid this control. It is hoped that therapeutic manipulation of this balance between cancer and host may allow us to harness the immune system as an effective means of treating established tumors. This review summarizes the immunologic response, immunoediting, and clinical strategies in cancer immunotherapy. Figures show activation of CD8+ cytotoxic T lymphocytes and CD4+ T helper cells by an antigen-presenting cell; inhibition of T cells specific for an antigen being presented in the absence of a full complement of costimulatory interactions, as might be present on an immature dendritic cell, engagement of cytotoxic T lymphocyte–associated protein 4 by B7, which serves to downregulate T cell function, and downregulation of major histocompatibility proteins on the surfaces of tumor cells; and the kinetics of activated T cell homeostasis in the presence of cancer.

      This review contains 3 figures and 39 references.

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    • 31

      Principles of Cancer Treatment

      By Rebecca A. Busch, MD; David F. Schneider, MD, MS
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      Principles of Cancer Treatment

      • REBECCA A. BUSCH, MDGeneral Surgery Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • DAVID F. SCHNEIDER, MD, MSClinical Instructor of Surgery, Department of Surgery, University of Wisconsin, Madison, WI

      As knowledge of cancer pathology deepens, so does the complexity of cancer care. Recommendations from the National Cancer Care System focus on using high-volume centers for patients undergoing high-mortality procedures and clinical trials to develop evidence-based guidelines for cancer prevention, diagnosis, treatment, palliative care, and quality care. A multidisciplinary team approach has become the benchmark of care, and patient-centered care is increasingly important. This review surveys tumor nomenclature, initial evaluation of cancer patients, and cancer treatment options, including surgical therapy, radiation therapy, pharmacologic cancer treatment, targeted therapy, hormonal therapy, and immunotherapy. Tables outline common tumor nomenclature for benign and malignant disease based on tissue of origin, prophylactic surgery for inherited cancer syndromes, and common adjuvant regimens for specific causes. Figures include a diagram of tissue architecture with benign and malignant tumors, incisional versus excisional biopsy of a skin lesion, and R0 versus R1 versus R2 resection of a pancreatic neoplasm.

      This review contains 3 figures, 3 tables, and 57 references.

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    • 32

      The Skin and the Physiology of Normal Wound Healing

      By Sahil K. Kapur, MD; Timothy W. King, MD, PhD
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      The Skin and the Physiology of Normal Wound Healing

      • SAHIL K. KAPUR, MDResident Physician, Division of Plastic Surgery, University of Wisconsin-Madison, Madison, WI
      • TIMOTHY W. KING, MD, PHDAssistant Professor of Surgery and Pediatrics, Director of Research, Division of Plastic Surgery, University of Wisconsin-Madison, Madison, WI

      This review presents normal wound healing as a complex process that is generally carried out in three overlapping stages: an inflammatory phase, a proliferative phrase (made up of fibroplasia, contraction, neovascularization, and granulation), and a remodeling phase. In addition, wound healing occurs under the influence of multiple cytokines, growth factors, and extracellular matrix signals. Figures show the layers of the skin and the cycles of wound healing. Tables describe the chemoattractants that recruit neutrophils to a wound and monocyte and macrophage chemoattractants. This review contains 48 references.

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    • 33

      Management of Acute Wounds

      By Lee D. Faucher, MD, FACS; Angela L. Gibson, MD, PhD
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      Management of Acute Wounds

      • LEE D. FAUCHER, MD, FACSAssociate Professor of Surgery University of Wisconsin School of Medicine & Public Health, Madison WI.
      • ANGELA L. GIBSON, MD, PHDAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Acute wounds are the result of local trauma and may be associated with severe life-threatening injuries. All patients with acute wounds should be assessed for comorbidities such as malnutrition, diabetes, peripheral vascular disease, neuropathy, obesity, immune deficiency, autoimmune disorders, connective tissue diseases, coagulopathy, hepatic dysfunction, malignancy, smoking practices, medication use that could interfere with healing, and allergies. The authors address the key considerations in management of the acute wound, including anesthesia, location of wound repair (e.g., operating room or emergency department), hemostasis, irrigation, débridement, closure materials, timing and methods of closure, adjunctive treatment (e.g., tetanus and rabies prophylaxis, antibiotics, and nutritional supplementation), appropriate closure methods for specific wound types, dressings, postoperative wound care, and potential disturbances of wound healing. The introduction briefly reviews the physiology of wound healing and the conclusion addresses new technologies in acute wound care.

       This review contains 11 figures, 16 tables, and 101 references.

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    • 34

      Management of Chronic Wounds

      By Angela L. Gibson, MD, PhD; Dana Henkel, MD
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      Management of Chronic Wounds

      • ANGELA L. GIBSON, MD, PHDAssistant Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • DANA HENKEL, MDSurgical Resident, University of Wisconsin Hospitals and Clinics, Madison, WI

      Chronic wounds are challenging for both the practitioner and the patient. These wounds often cause pain and lead to unemployment, social activity disruption, and quality of life issues for the patient. As the world population advances in age and increases in body mass index, there has been an increase in diabetes and venous insufficiency, ultimately resulting in a rise in the number of patients with chronic wounds. This review covers disease definition, wound-healing necessities, treatment options for management of chronic wounds, special wound care considerations, and investigational therapies. Figures show distribution of chronic wound etiologies, vacuum-assisted closure treatment of chronic wounds, chronic arterial ulcer of the medial foot, a step-wise application of a multilayer compression dressing, and four stages of pressure ulcers. Tables list known causes of tissue hypoxia, types of débridement, common dressings used in chronic wounds, and stages of a pressure ulcer.

       

      This review contains 5 highly rendered figures, 4 tables, and 99 references

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    • 35

      Postoperative and Adjunctive Wound Care

      By Rebecca A. Busch, MD; Lee Faucher, MD, FACS
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      Postoperative and Adjunctive Wound Care

      • REBECCA A. BUSCH, MDGeneral Surgery Resident, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • LEE FAUCHER, MD, FACSAssociate Professor of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Wounds are a major source of complications in surgery, but many can be avoided by using a sound, evidence-based approach to wound care. Preoperative considerations are discussed and include smoking cessation, glycemic control, weight loss, and adequate nutritional intake. Intraoperative considerations are presented and include proper classification of surgical wounds, hyperoxia and warming, and fascia closure techniques. Postoperative considerations that are presented include recognizing both early and late fascia complications, understanding skin closure techniques, and using adjuncts to postoperative wound management. Tables present the criteria for defining a surgical site infection, the surgical wound classification, and management of early fascia complications. An algorithm outlines the classification of wounds. Clinical photographs show various types of wounds and wound therapies.
      This review contains 1 algorithm, 6 clinical photographs, 4 tables, 85 references, and 5 annotated key references

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    • 36

      Clinical Immunology and Innate Immunity

      By Lung-Yi Lee, MD; David P. Foley, MD
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      Clinical Immunology and Innate Immunity

      • LUNG-YI LEE, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • DAVID P. FOLEY, MDDepartment of Surgery, University of Wisconsin School of Medicine and Public Health, and Veterans Administration Surgical Services, William S. Middleton Veterans Hospital, Madison, WI

      Our body encounters a multitude of microorganisms in our daily lives. Due to surveillance of our robust immune system, these microbial encounters remain largely benign and only become pathologic at times. The majority of these pathogens are cleared rapidly by our innate immune system. The innate immune system is our body’s first line of defense that mounts a nonspecific response against pathogens. In this review, a contemporary summary of this complex system and its relevance to disease processes that are commonly seen in the surgical setting are presented, including components and activation of innate immunity, and relevant clinical scenarios. Figures show hematopoiesis, the complement system, leukocyte extravasation, pattern recognition receptors, pattern recognition receptor signaling pathways, phagocytosis, neutrophil extracellular traps, wound healing, ischemia-reperfusion injury, and innate immunity and deep vein thrombosis formation. Tables list tissue-resident macrophages, toll-like receptors, cytokines, and chemokines.

      This review contains 10 highly rendered figures, 4 tables, and 39 references

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  • Organ Systems: Anatomy and Physiology
    • 1

      The Cardiac System

      By Raja R. Gopaldas, MD; Scott A. LeMaire, MD
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      The Cardiac System

      • RAJA R. GOPALDAS, MDAssistant Professor of Cardiothoracic Surgery and Director of Research, Division of Cardiothoracic Surgery, Hugh E. Stephenson Department of Surgery, University of Missouri-Columbia, Columbia, MO
      • SCOTT A. LEMAIRE, MDProfessor of Surgery and Director of Research, Division of Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX

      The unique anatomic and physiologic characteristics of the heart not only make it somewhat challenging for basic scientists to understand but also impose significant technical challenges for surgeons who operate on the heart. After addressing the history of cardiac study, this chapter describes the structure and function of the cardiac system including the myocardial anatomy, cardiac electrical system, cardiac vasculature, fibrous skeleton of the heart, cardiac valves, cardiac valve adjuncts, cardiac chambers, intracardiac structures, and the pericardium. Nearly three dozen figures include details of the anatomy of the heart and visualization of coronary structures. This review contains 29 references.

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    • 2

      The Respiratory System

      By Suresh Agarwal, MD, FACS, FCCM; Hee Soo Jung, MD; Walker Julliard, MD
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      The Respiratory System

      • SURESH AGARWAL, MD, FACS, FCCMChief, Section of Trauma, Acute Care Surgery, Burn & Surgical Critical Care, Associate Professor, Department of Surgery, University of Wisconsin, Madison, WI
      • HEE SOO JUNG, MDAssistant Professor, Department of Surgery, University of Wisconsin, Madison, WI
      • WALKER JULLIARD, MDResident, Department of Surgery, University of Wisconsin, Madison, WI

      This review discusses gas exchange and transport processes in the lungs; anatomic considerations; impact on the circulatory system (airway pressure, lung volume, regional pleural pressures); normal ventilation, including the mechanics of breathing; and pulmonary function assessment, including pulse oximetry, capnometry, pulmonary function testing, physiologic variations in respiration, perioperative physiologic changes, risk factors for and strategies to prevent postoperative pulmonary complications, initial airway/respiratory evaluation and management, mechanical ventilator strategies, oxygenation, ventilation, adjuncts and rescue therapies, and weaning from mechanical ventilation. Tables describe patient-specific risk factors for noncardiothoracic postoperative pulmonary complication, chronic obstructive lung disease optimization strategies, the Glasgow Coma Scale, and the LEMON mnemonic. Figures show gas exchange at the alveolar capillary membrane, factors affecting the oxygen dissociation curve, uneven distribution of air and blood in different zones of the lung, carbon dioxide metabolism in the lungs and periphery, the lateral wall of the right nasal cavity, sagittal section of the upper aerodigestive tract, tracheobronchial tree, diaphragmatic motion during respiration, schematic diagram of normal filtration and resorption of fluid in the pleural space, respiratory tree, neurologic control of respiration, pressure gradient between the pleural space and the airway, pressure-volume curve, the four phases of a capnogram, lung volumes and capacities, the 3-3-2 rule, evaluation of the oropharynx, transnasal introduction of a flexible bronchoscope, ventilator waveforms, and the therapeutic ladder in the management of acute respiratory distress syndrome.

      This review contains 20 figures, 4 tables, and 113 references.

       

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    • 3

      The Renal System

      By Amal Alhefdhi, MD; David F. Schneider, MD, MS
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      The Renal System

      • AMAL ALHEFDHI, MDSurgical Fellow, Postdoctoral Fellow, Department of Surgery, University of Wisconsin, Madison, WI
      • DAVID F. SCHNEIDER, MD, MSClinical Instructor of Surgery, Department of Surgery, University of Wisconsin, Madison, WI

      The renal system plays an important role in keeping the other organ systems functioning normally and achieving fluids in balance. The renal system is comprised of two kidneys, two ureters, a urinary bladder, and the urethra. This review covers the development, anatomy, vascular supply, innervation, histology, and physiology of the Kidney, Ureter, Urinary Bladder, Urethra. The urination and the elimination of urine is also covered in depth. This review is beautifully illustrated with 16 figures and contains 4 tables and 71 references.

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    • 4

      The Esophagus

      By Michael V. Tirabassi, MD
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      The Esophagus

      • MICHAEL V. TIRABASSI, MDUniversity of Wisconsin, Madison, WI

      The goal of this reviewis to discuss the normal anatomy and physiology of the esophagus. The esophagus is a unique organ that crosses three regions of the body: the neck, thorax, and abdomen. The function of the esophagus is to deliver masticated food from the oropharynx to the remainder of the gastrointestinal tract. Prevention of gastroesophageal reflux is essential to the successful completion of this task. Unlike other segments of the gastrointestinal tract, the esophagus has no known active immunologic, digestive, absorptive, or secretory functions. The authors describe in depth the number of methods for studying both the anatomy and the function of the esophagus. Although each study has indications, they are often used in collaboration when evaluating complex disorders such as gastroesophageal reflux disease. This review includes 11 Figures of highly defined and described anatomic artwork and 16 References.

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    • 5

      The Endocrine System: Pituitary and Adrenal Glands

      By Haggi Mezeh, MD; Iddo Paldor, MD; Herbert Chen, MD, FACS
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      The Endocrine System: Pituitary and Adrenal Glands

      • HAGGI MEZEH, MDClinical Instructor, Section of Endocrine Surgery, Department of Surgery, University of Wisconsin, Madison, WI
      • IDDO PALDOR, MDClinical Instructor, Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
      • HERBERT CHEN, MD, FACSChairman, Division of General Surgery, Layton F. Rikkers M.D. Chair in Surgical Leadership, Vice-Chair for Research, Department of Surgery, University of Wisconsin, Madison, WI

      This review presents the pituitary gland--where the neural and endocrine systems function in continuity, maintaining homeostasis of many functional elements of the human body and the adrenal glands with their two hormone-secreting organs: the cortex and the medulla. The embryology and development, anatomy, normal physiology of each gland is presented. Figures show a midsagittal view of the brain; the pituitary blood supply, venous drainage, and portal system; a summary of pituitary hormones and their main acions; the adrenal layers and hormones; the adrenal blood supply and venous drainage; synthetic pathways for adrenal steroid synthesis; and major steps in catecholamine synthesis and degradation. This review contains 61 references.

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    • 6

      The Endocrine System: Thyroid and Parathyroid

      By David F. Schneider, MD, MS; Rebecca S. Sippel, MD, FACS
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      The Endocrine System: Thyroid and Parathyroid

      • DAVID F. SCHNEIDER, MD, MSClinical Instructor of Surgery, Department of Surgery, University of Wisconsin, Madison, WI
      • REBECCA S. SIPPEL, MD, FACSAssistant Professor Surgery, Department of Surgery, University of Wisconsin, Madison, WI

      Successful surgery of the thyroid and parathyroid glands depends on a thorough knowledge of their anatomic and developmental relations. The surgeon should understand the physiology and function of these glands. Physiology, not anatomy alone, often dictates the timing and course of thyroid or parathyroid procedures. Development, anatomy, blood supply, lymphatic drainage, histology, and physiology are covered in order for the thyroid and the parathyroid. This review contains 36 references. Seven figures of highly rendered artwork include well-illustrated anatomical position and orientation. Figure 4 illustrates thyroid hormone synthesis and secretion.

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    • 7

      The Liver and Portal System

      By Ankush Gosain, MD, PhD
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      The Liver and Portal System

      • ANKUSH GOSAIN, MD, PHDAssistant Professor of Surgery, Section of Pediatric Surgery University of Wisconsin School of Medicine and Public Health, Madison, WI

      The last 40 years have seen a tremendous advancement in our understanding of the anatomy and function of the liver as well as the development of techniques and technology enabling safe anatomic and nonanatomic liver resections, both open and laparoscopic. This chapter reviews the surface and functional anatomy of the liver and highlights the relevant anatomic and physiologic characteristics of the liver and portal system for the practicing surgeon. The portal vein; hepatic arterial supply; hepatic venous drainage; biliary tree; gallbladder; hepatic blood flow; metabolism; bile and bilirubin metabolism; and carbohydrate, lipid, and protein metabolism are covered in order. This review contains 15 references. Fourteen figures include details of the anatomy of the liver and portal system and visualization of relevant structures.

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    • 8

      The Gallbladder and Biliary Tree

      By Ioannis Hatzaras, MD, MPH; Timothy M. Pawlik, MD, MPH, PhD
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      The Gallbladder and Biliary Tree

      • IOANNIS HATZARAS, MD, MPHFellow in Surgical Oncology, Johns Hopkins Hospital, Baltimore, MD
      • TIMOTHY M. PAWLIK, MD, MPH, PHDAssociate Professor of Surgery and Oncology, Chief Division of Surgical Oncology, Hepatobiliary Surgery Program Director, Department of Surgery, Johns Hopkins University, Baltimore, MD

      The gallbladder is a pear-shaped sac located in a fossa on the inferior surface of the liver and is divided into four anatomic areas: the fundus, the body, the infundibulum, and the neck. The gallbladder receives its arterial supply from the cystic artery. The extrahepatic bile ducts consist of the right and left hepatic ducts, the common hepatic duct, the cystic duct, and the common bile duct. The anatomic variations of the cystic duct are common and should be kept under consideration. The sphincter of Oddi surrounds the common bile duct at the ampulla of Vater. It controls the flow of bile, and in some cases pancreatic juice, into the duodenum. It is a complex structure that is functionally independent from the duodenal musculature and creates a high-pressure zone between the bile duct and the duodenum. Bile functions as a key role in fat digestion and absorption and assists with absorption of the essential fat-soluble vitamins. In addition, bile serves as a vehicle for excretion of several metabolic by-products from the liver, such as bilirubin, an end product of hemoglobin destruction. Nearly 95% of bile salts are reabsorbed from the small intestine, usually at the distal ileum. The bile salts then enter the portal blood and pass back to the liver. On reaching the liver, these salts are absorbed almost entirely back into the hepatic cells and then resecreted into the bile.

      This review contains 2 figures, 6 tables, and 165 references.

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    • 9

      The Pancreas

      By John A. Windsor, MBChB, MD, FRACS, FACS
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      The Pancreas

      • JOHN A. WINDSOR, MBCHB, MD, FRACS, FACSProfessor of Surgery, Department of Surgery, University of Auckland, Auckland, New Zealand

      The pancreas is the body’s largest digestive gland, situated in the center of the body, on either side of the transpyloric plane. It is notable for its complex anatomy and the co-location of exocrine and endocrine organs. Pancreatic surgery requires a detailed understanding of the anatomy of the pancreas and its relation to adjacent vital structures. This review describes the morphology of the pancreas, its ductal system, the major duodenal papilla, arterial anatomy, venous anatomy, lymphatic draining, and nerve supply. Because managing patients with pancreatic diseases requires a detailed understanding of the physiology of the exocrine and the endocrine pancreas, both are discussed here. This review contains 15 references and more than a dozen images of the various planes of the pancreas.

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    • 10

      The Spleen

      By Donald P. Lesslie III, DO; Lillian S. Kao, MD, MS
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      The Spleen

      • DONALD P. LESSLIE III, DOAssistant Professor, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX
      • LILLIAN S. KAO, MD, MSAssociate Professor, Department of Surgery, University of Texas Health Science Center at Houston, Houston, TX

      The structure of the spleen allows it to carry out its major functions, which can be categorized as hematologic and immunologic. The importance of the spleen in the immunologic response is evidenced by the increased risk of infection in patients with congenital absence of splenic dysfunction and in splenectomized patients. The presence of one or more accessory spleens is the most common congenital abnormality related to splenic development. This review covers the history, embryology, congenital anomalies, anatomy, and histology/pathophysiology of the spleen. It is important for the student and general surgeon to understand the anatomy and physiology of the spleen to perform operative procedures on the spleen, to avoid intraoperative complications during splenectomy as well as procedures such as mobilization of the splenic flexure and distal pancreatectomy, and to care for the postoperative splenectomized patient.

      This review contains 7 figures of highly rendered artwork and 17 references.

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    • 11

      The Stomach and Duodenum

      By Hasan B. Alam, MD, FACS
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      The Stomach and Duodenum

      • HASAN B. ALAM, MD, FACSProfessor of Surgery, Harvard Medical School, Boston, MA

      This review focuses on the normal anatomy and physiology of the first two portions of the intra-abdominal alimentary tract: the stomach and the duodenum. These two structures share a common embryologic origin (foregut) and are intimately interconnected in terms of physiologic functions and regulation. Embryology; anatomic divisions/parts; blood supply; lymphatics; innervation; microstructure; storage, digestion, and absorption; and endocrine and immune function are covered in order. This review contains 38 references. Seven figures of highly rendered artwork include anatomic illustrations of the stomach, the duodenum, and all relevant structures. Microstructure of the duodenal/small bowel mucosa and gastric microstructure are illustrated as well.

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    • 12

      The Small Bowel

      By Adam S. Brinkman, MD; Peter F. Nichol, MD, PhD
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      The Small Bowel

      • ADAM S. BRINKMAN, MDResident, Division of General Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI
      • PETER F. NICHOL, MD, PHDAssistant Professor, Section of Pediatric Surgery, Division of General Surgery, University of Wisconsin, Madison, WI

      The anatomy and physiology of the small bowel are highly specialized and designed to provide maximal nutrient digestion and absorption, electrolyte acquisition, defense from pathogenic microorganisms, innate and adaptive immunity, and enteroendocrine function. The small bowel is composed of the duodenum, jejunum, and ileum and is a retroperitoneal and intraperitoneal structure as a result of embryologic development. The primary function of the small bowel is nutrient digestion and absorption, water and electrolyte homeostasis, and vitamin absorption. In this review, embryology, normal anatomy and physiology, and motility of the small bowel are reviewed, allowing for better understanding of pathologic states and therapeutic interventions. Only after pathology arises, such as inflammatory bowel disease, mesenteric ischemia, midgut volvulus, or malignancy, can one truly appreciate the vital functions that the small bowel provides.

      This review includes 8 anatomical illustrations, 1 table, and 33 references.

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    • 13

      The Human Adult Reproductive System

      By Dina Marie Pitta, BS, MPP; Kelly Boyle, BS; Lee Gravatt Wilke, MD, FACS
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      The Human Adult Reproductive System

      • DINA MARIE PITTA, BS, MPPShapiro Research Fellow, Department of Surgery, University of Wisconsin School of Medicine and Public Health and University of Wisconsin, Madison, WI
      • KELLY BOYLE, BSShapiro Research Fellow, Department of Surgery, University of Wisconsin School of Medicine and Public Health and University of Wisconsin, Madison, WI
      • LEE GRAVATT WILKE, MD, FACSAssociate Professor, Division of General Surgery, Director, UW Breast Center, Department of Surgery, University of Wisconsin School of Medicine and Public Health and University of Wisconsin, Madison, WI

      The human reproductive system is a unique combination of organs and endocrine components that is surprisingly unnecessary for individual survival but is required for maintenance of the human species. Unlike any other anatomic or physiologic system, the reproductive organs are uniquely different between human males and females, as are the endocrine pathways that promote the development of each system. This chapter describes the anatomic and endocrine features of both human reproductive systems, as well as their associated processes of maturation and aging.

      This review contains 4 figures, 2 tables, and 14 references.

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    • 14

      The Colon, Appendix, Rectum, and Anus

      By Laura E. Fischer, MD, MS; Charles P. Heise, MD, FACS
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      The Colon, Appendix, Rectum, and Anus

      • LAURA E. FISCHER, MD, MSResident Physician, Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, WI
      • CHARLES P. HEISE, MD, FACSAssociate Professor, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      The large intestine is composed of the cecum, appendix, ascending colon, transverse colon, descending colon, and sigmoid colon. The anatomy of each (including innervation, blood supply, and lymphatic drainage) is described as well as the physiology. The large intestine plays a role in immune function, nutrient absorption, and water and electrolyte absorption and secretion. The anatomy and physiology of the rectum and anus are also described as well as their function in the maintenance of continence and elimination of waste through defecation. Figures show the layers of the colonic wall, the blood supply to the colon, the various types of colonic motility, a complex system of electroneutral and electrogenic transporters, the lateral view of the rectum demonstrating the surrounding fascial components, and the internal and external sphincters of the anal canal. This review contains 46 references.

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  • Basic Surgical and Perioperative Considerations
    • 1

      Postoperative Management of the Hospitalized Patient

      By Edward Kelly, MD, FACS
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      Postoperative Management of the Hospitalized Patient

      • EDWARD KELLY, MD, FACS

      Effective surgical treatments are available for a wide variety of diseases in the modern era; at the same time, surgical interventions have become increasingly complex and specialized. The contemporary surgeon must coordinate evaluation and management of patients with multiple medical diagnoses and shepherd these patients through an increasingly elaborate process of medical and surgical care. To provide effective care, the organ systems–oriented approach is key. This approach, demonstrated in the following review, guides the practitioner through each organ system in order and can be used to generate a differential diagnosis for each system and a comprehensive problem list for each patient. The comprehensive problem list and surgical care plan have found new interest as extended recovery after surgery (ERAS) pathways.

      This review contains 107 references and 5 tables.

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    • 2

      Bleeding and Transfusion

      By Garth H. Utter, MD, MSc, FACS; Robert C. Gosselin, MT; John T. Owings, MD, FACS
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      Bleeding and Transfusion

      • GARTH H. UTTER, MD, MSC, FACSAssistant Professor, Department of Surgery, University of California Davis Medical Center, Sacramento, CA
      • ROBERT C. GOSSELIN, MTCoagulation Specialist, Department of Clinical Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA
      • JOHN T. OWINGS, MD, FACS Professor, Department of Surgery, University of California Davis Medical Center, Sacramento, CA

      This review describes the approaches taken for patient with massive hemorrhage, a derangement of hemostasis, and anemia. For hemorrhage, control of the source of bleeding, restoration of the blood volume, and management of the coagulopathy is presented. Exclusion of technical causes of bleeding, an initial assessment of potential coagulopathy, and an interpretation of coagulation parameters is described for derangements of hemostasis. For anemia, acute coronary artery ischemic syndromes and neurologic conditions are described. Additionally, bleeding disorders are presented. Figures depict various algorithms related to decision-making and treatment. Tables show the management of the patient with an increased International Normalized Ratio, coagulopathy scores, classification and management of Von Willebrand disease, and tests of platelet function. This review contains 83 references.

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    • 3

      Preparation of the Operating Room

      By T. Forcht Dagi, MD, MPH, FACS, FCCM
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      Preparation of the Operating Room

      • T. FORCHT DAGI, MD, MPH, FACS, FCCMDistinguished Scholar and Professor, The School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Northern Ireland, Lecturer, Harvard Medical School, Boston, MA

      The history and general principles of OR design are discussed, including physical layout and design standards, which encompass the layout and storage of devices and equipment. As both patient and staff safety are paramount, all of the risks that can be mitigated by good design are discussed: biologic, ergonomic, chemical, and physical. Environmental issues in the OR are listed and include temperature, humidity, and lighting. The proper use, storage, and risks of electronic and mechanical devices are discussed. Infection control is addressed and includes hand hygiene, gloves and protective barriers, antimicrobial prophylaxis and nonpharmacologic preventive measures. A housekeeping section discusses the benefits of segregating clean, clean-contaminated, and dirty cases. OR scheduling is noted. Tables outline International Commission on Radiological Protection–recommended radiation dose limits; key principles of the Joint Commission Universal Protocol; devices used in the operating room; standard equipment for endovascular operating rooms; benefits of voice activation technology in the laparoscopic operating room; criteria for defining a surgical site infection; factors that contribute to the development of surgical site infection (SSI); Centers for Disease Control and Prevention hand hygiene guidelines; distribution of pathogens isolated from surgical site infections: operating room cleaning schedules; classification of operations in relation to the epidemiology of SSIs; and basic principles of OR efficiency. Figures depict patient positioning and basic components of an ultrasound transducer,

      This review contains 3 figures, 12 tables, and 214 references.

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    • 4

      Enhanced Recovery Pathways: Organization of Evidence-based, Fast-track Perioperative Care

      By Liane S. Feldman, MD, FACS, FRCS; Gabriele Baldini, MD, MSc; Lawrence Lee, MD, MSc; Franco Carli, MD, MPhil
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      Enhanced Recovery Pathways: Organization of Evidence-based, Fast-track Perioperative Care

      • LIANE S. FELDMAN, MD, FACS, FRCSProfessor of Surgery, Director, Division of General Surgery, Steinberg-Bernstein Chair of Minimally Invasive Surgery and Innovation, McGill University, Montreal, QC
      • GABRIELE BALDINI, MD, MSCAnesthesiologist and Assistant Professor, Department of Anesthesia, McGill University, Montreal, QC
      • LAWRENCE LEE, MD, MSCSurgical Resident, Department of Surgery, McGill University, Montreal, QC
      • FRANCO CARLI, MD, MPHILProfessor of Anesthesia, Department of Anesthesia, McGill University, Montreal, QC

      Enhanced recovery pathways (ERPs) are standardized coordinated, multidisciplinary perioperative care plans that incorporate evidence-based interventions to minimize surgical stress, improve physiologic and functional recovery, reduce complications, and thereby facilitate earlier discharge from the hospital. Several perioperative elements contribute to enhance surgical recovery. Preoperative elements include patient education, optimization of medical conditions and functional status, nutritional support, smoking cessation programs, minimization of preoperative fasting and preoperative carbohydrate drinks, avoidance of mechanical bowel preparation when not indicated, and avoidance of long-active sedatives as premedication. Intraoperative elements aim to attenuate the surgical stress response and include regional or local anesthesia; pharmacologic adjuvants, nonopioid analgesics, and maintaining normothermia; intravenous fluid management; and opting to favor small incisions when possible. Postoperative elements include considering multimodal analgesia (opioid-sparing strategies); encouraging early postoperative feeding; stressing the importance of early mobilization; restricting the unnecessary use of intravenous fluids, drains, and catheters; and instituting a discharge and follow-up plan for patients. Tables describe the evolution of intraoperative fluid management, organization of a multimodal perioperative care plan for a specific procedure or group of procedures; key elements to include in developing an ERP; sample multimodal perioperative care plans for elective colorectal resection, esophageal resection, and ambulatory laparoscopic cholecystectomy.

      This review contains 1 figure, 6 tables, and 319 references.

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  • Breast, Skin, and Soft Tissue
    • 1

      Soft Tissue Infection

      By Mark A. Malangoni, MD, FACS; Christopher R. McHenry, MD, FACS
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      Soft Tissue Infection

      • MARK A. MALANGONI, MD, FACSAssociate Executive Director, American Board of Surgery, Philadelphia, PA; Adjunct Professor of Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
      • CHRISTOPHER R. MCHENRY, MD, FACSProfessor of Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center, Cleveland, OH

      Soft tissue infections are a diverse group of diseases that involve the skin and underlying subcutaneous tissue, fascia, or muscle. The authors review the diagnosis and management of the main soft tissue infections seen by surgeons, including both superficial infections and necrotizing infections. When the characteristic clinical features of necrotizing soft tissue infection are absent, diagnosis may be difficult. In this setting, laboratory and imaging studies become important. Studies emphasizes that computed tomography should continue to be used judiciously as an adjunct to clinical judgment. The delay between hospital admission and initial débridement is the most critical factor influencing morbidity and mortality. Once the diagnosis of necrotizing soft tissue infection is established, patient survival and soft tissue preservation are best achieved by means of prompt operation. Bacterial infections of the dermis and epidermis are covered in depth, along with animal and human bites. Methicillin-resistant Staphylococcus aureus (MRSA) accounts for up to 70% of all S. aureus infections acquired in the community and is the most common organism identified in patients presenting to the emergency department with a skin or soft tissue infection. The more classic findings associated with deep necrotizing infections—skin discoloration, the formation of bullae, and intense erythema—occur much later in the process. It is important to understand this point so that an early diagnosis can be made and appropriate treatment promptly instituted. The review’s discussion covers in depth the etiology and classification of soft tissue infection, pathogenesis of soft tissue infections, toxic shock syndrome, and reports on mortality from necrotizing soft tissue infection.

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    • 2

      Principles of Wound Management and Soft Tissue Repair

      By Jonathan S. Friedstat, MD; Eric G. Halvorson, MD; Joseph J. Disa, MD, FACS
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      Principles of Wound Management and Soft Tissue Repair

      • JONATHAN S. FRIEDSTAT, MDPlastic Surgery Resident, University of North Carolina, Chapel Hill, NC
      • ERIC G. HALVORSON, MDAssociate Surgeon, Division of Plastic Surgery, Brigham and Women’s Hospital, Boston, MA
      • JOSEPH J. DISA, MD, FACSAttending Surgeon, Plastic and Reconstructive Surgery Service, Memorial Sloan-Kettering Cancer Center, New York, NY

      Problem wounds are characterized by one of the following: large size that precludes direct primary closure, gross infection or uncertain bacteriologic status, or threatened loss of critical structures exposed as a result of insufficient soft tissue coverage. This review describes the evaluation of difficult wounds, as well an initial management strategies, including débridement, high-pressure irrigation, quantitative bacteriology, systemic and topical antibiotics, topical antiseptics, damp dressings, negative-pressure wound therapy, and nutrition. Selection of coverage procedure, such as skin grafts or flaps, is described, and types of flaps and regional alternatives in flap selection are discussed in detail. Secondary reconstruction is also reviewed, including small localized scars, shortages of skin and subcutaneous tissue, complex defects, and postoperative care and flap monitoring. Tables describe indications for enteral nutrition and angle and degree of lengthening theoretically possible for Z-plasty. Figures include a bumper injury to the leg, skin flaps and related blood supply, drawings of five basic patterns of blood supply to the muscle, various types of skin flaps, Z-plasty, a drawing showing local versus free flaps, and photos depicting composite defects. Algorithms show the approach to surgical reconstruction and regional alternatives in flap selection.

      This review contains 15 figures, 2 tables, and 34 references.

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    • 3

      Breast Cancer

      By Lindi VanderWalde, MD, FACS; Alyssa D. Throckmorton, MD, FACS; Stephen B. Edge, MD, FACS, FASCO
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      Breast Cancer

      • LINDI VANDERWALDE, MD, FACSBreast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN
      • ALYSSA D. THROCKMORTON, MD, FACSBreast Surgical Oncologist, Baptist Cancer Center, Baptist Memorial Health Care Corporation, Memphis, TN; Clinical Assistant Professor, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
      • STEPHEN B. EDGE, MD, FACS, FASCOProfessor of Oncology, VP Healthcare Outcomes and Policy, Roswell Park Cancer Institute, Buffalo, NY

      Breast cancer is the most common malignancy in women in the Western world. Its prevalence and public health impact are increasing in developing countries, and breast cancer leads to the death of hundreds of thousands of women worldwide annually. In the United States, surgeons are involved in the treatment of most women with breast cancer and surgical care must be coordinated with other components of comprehensive breast cancer treatment. This review covers breast evaluation and management of findings suspicious for cancer, management of clinical or screening-detected findings, management of breast cancer, noninvasive cancer (carcinoma in situ), invasive breast cancer, special circumstances, and follow-up after breast cancer treatment. Figures show ultrasound images of representative breast lesions demonstrating key characteristics, structure of breast, impact of basement membrane invasion: invasive cancer, histologic subtypes of ductal carcinoma in situ, specimen mammogram of breast cancer-localizing wire, breast cancer wide excision specimen painted with six colors of ink to orient the specimen for pathologic analysis of surgical margins, microscopic appearance of invasive ductal and invasive lobular cancer, overall survival from the NSABP B-06 study, and anatomy of the axilla. Tables list components of the breast history, BI-RADS classification, American Joint Committee on Cancer (AJCC) TNM staging system: T, N, and M categories, AJCC TNM staging system: anatomic stage/prognostic groups, Nottingham Grading System for invasive breast cancer, and relative indications for mastectomy.

      This review contains 9 highly rendered figures, 6 tables, and 216 references

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    • 4

      Evolving Molecular Therapeutics and Their Applications to Surgical Oncology

      By Valerie Francescutti, MD, MSc, FRCSC, FACS; Kelli Bullard Dunn, MD, FACS, FACRS
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      Evolving Molecular Therapeutics and Their Applications to Surgical Oncology

      • VALERIE FRANCESCUTTI, MD, MSC, FRCSC, FACSDepartment of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY
      • KELLI BULLARD DUNN, MD, FACS, FACRSChief, Division of Colon and Rectal Surgery, Associate Professor of Surgical Oncology, Roswell Park Cancer Institute, Associate Professor of Surgery, University at Buffalo, State University of New York, Buffalo, NY

      Despite major advances in the diagnosis and treatment of cancer, chemotherapy, the mainstay of therapy for systemic disease, is rarely curative and toxicity is common. Research efforts are focusing on the development of agents that target molecules that are specific to tumor cells with few effects on normal healthy cells. The ultimate goal of molecular therapeutics is to develop agents that are lethal only to tumor cells, that maintain efficacy without developing resistance, and that possess acceptable toxicities that make them well tolerated by patients. This review covers tyrosine kinase inhibitors, angiogenesis inhibitors, cell cycle inhibitors, inducers of apoptosis, phosphatidylinositol 3-kinase/Akt/mammalian target of rapamycin inhibitors, and focal adhesion kinase inhibitors. Figures show activation of a receptor tyrosine kinase, the interaction of cyclin-dependent kinases and cyclins during regulation of the cell cycle, cyclin-cyclin-dependent kinase-regulated progression through each phase of the cell cycle, and the role of focal adhesion kinase in a signaling cascade that can lead to the tumorigenic properties of cancer cells. Tables list tyrosine kinase inhibitors, cell cycle inhibitors, and inducers of apoptosis.

       

      This review contains 4 highly rendered figures, 3 tables, and 242 references

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    • 5

      Soft Tissue Sarcoma

      By Aimee M. Crago, MD; Samuel Singer, MD, FACS
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      Soft Tissue Sarcoma

      • AIMEE M. CRAGO, MDAssistant Attending Surgeon, Sarcoma Disease Management Team, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY
      • SAMUEL SINGER, MD, FACSAttending Surgeon, Head, Sarcoma Disease Management Team, Chief, Gastric and Mixed Tumor Service, Memorial Sloan Kettering Cancer Center, New York, NY

      Soft tissue sarcoma (STS) refers to a rare group of cancers that develop from mesenchymal cells and their progenitors. Histologic subtype, in conjunction with tumor location and size, largely defines the biologic behavior of a given lesion and the associated clinical prognosis in these cancers. The diverse characteristics of these tumors means that their treatment is similarly complex. The etiology, tumor staging and prognosis, evaluation, and treatment of STS are discussed in this review, with an aim to present an algorithm for patient evaluation and treatment while highlighting common indications for diverging from this strategy as dictated by disease subtype and location. Figures show the histologic distribution of primary STS diagnosed in the extremity and retroperitoneum and intra-abdominal compartments; disease-specific survival for primary extremity and retroperitoneal and intra-abdominal tumors stratified by histologic subtype; local recurrence in primary extremity STS stratified by histologic subtype; disease-specific survival according to American Joint Committee on Cancer (AJCC) TNGM stage; a postoperative nomogram for prediction of sarcoma-specific death at 12 years postresection for patients with STS; representative cross-sectional images of an atypical lipomatous tumor, a myxofibrosarcoma, and a desmoid tumor; a treatment algorithm for STS of the extremity; a magnetic resonance image and intraoperative photographs showing a mixoid liposarcoma of the posterior thigh; and computed tomography showing a retroperitoneal dedifferentiated liposarcoma and a photograph of the surgical bed following resection. Tables list common histologic subtypes, anatomic distribution, and risk factors for STS; genomic alterations associated with STS and diagnostic tests based on these findings; AJCC staging of STS; and disease-specific survival according to the extent of resection among patients with primary retroperitoneal STS.

      This review contains 10 figures, 5 tables, and 66 references.

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    • 6

      Breast Procedures

      By D. Scott Lind, MD; Julie G. Grossman, MD; Melissa DeSouza, MD
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      Breast Procedures

      • D. SCOTT LIND, MDProfessor and Chairman of Surgery, Drexel University College of Medicine, Philadelphia, PA
      • JULIE G. GROSSMAN, MDGeneral Surgery Resident, Drexel University College of Medicine, Philadelphia, PA
      • MELISSA DESOUZA, MDGeneral Surgery Resident, Oregon Health and Science University, Portland, OR

      The procedures to diagnose, stage, and treat breast disease are becoming less invasive, with comparable oncologic outcomes. To remain up to date with contemporary breast procedures, surgeons must be familiar with current breast imaging. In addition, randomized trials demonstrate equivalent survival rates for breast conservation compared with mastectomy. Even for women for whom mastectomy is either required or preferred, advances in reconstructive techniques have enhanced cosmetic outcomes. This review covers the clinical breast examination process, breast imaging and biopsy, minimally invasive techniques, surgical options for breast cancer, and breast reconstruction. Tables outline the American College of Radiology Breast Imaging Reporting and Data System, contraindications to breast-conserving therapy, and five steps to a traditional mastectomy incision. Figures include photos of breast ultrasonography, cryoablation, and the inferior epigastric arterial system. Illustrations depict ductal lavage; core-needle, percutaneous excisional, open, and needle-localization biopsy; hematoma ultrasound-guided excision; terminal duct excision; accelerated partial-breast irradiation with a balloon catheter; mastectomy incisions; axillary dissection; and breast reconstruction after mastectomy. An algorithm outlines the major steps in breast reconstruction after mastectomy.

      This review contains 18 figures, 3 tables, and 207 references.

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    • 7

      Surgical Management of Melanoma and Other Skin Cancers

      By Jennifer A. Wargo, MD; Kenneth Tenabe, MD
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      Surgical Management of Melanoma and Other Skin Cancers

      • JENNIFER A. WARGO, MDInstructor in Surgery, Harvard Medical School, Assistant in Surgery, Massachusetts General Hospital, Boston, MA
      • KENNETH TENABE, MDProfessor of Surgery, Harvard Medical School, Chief of Surgical Oncology, Massachusetts General Hospital, Boston, MA

      The prevalence of malignant skin cancers has increased significantly over the past several years. Approximately 1.2 million cases of non-melanoma skin cancer are diagnosed per year. More alarming, up to 80,000 cases of melanoma are diagnosed per year, an incidence that has been steadily increasing, with a lifetime risk of 1 in 50 for the development of melanoma. The disturbing increase in the incidence of both non-melanoma skin cancer and melanoma can largely be attributed to the social attitude toward sun exposure. The clinical assessment and management of skin lesions can be challenging. This review describes the assessment process, including thorough history and examination; the need for possible biopsy; and excision criteria. Specific types of skin cancer are distinguished and include basal cell carcinoma; squamous cell carcinoma; and melanoma; and for each type the incidence; epidemiology; histologic subtypes; diagnosis; and both surgical and non-surgical treatments are provided. Stages I-IV of melanoma are detailed, with prognostic factors described. Surgical treatment for stages I and II include description of the margins of excision and sentinel lymph node biopsy. The surgical treatment of Stage III melanoma further includes therapeutic lymph node dissection and isolated limb perfusion. Adjuvant therapies are also presented and include radiotherapy and chemotherapy. The additional treatment of metastasectomy for Stage IV melanoma is described. For both Stage III and IV melanoma, the study of vaccines to host immune cells is reported. For Stage IV melanoma, the text also describes immunotherapy treatment. Operative procedures specific to superficial and deep groin dissections are outlined.

      This review contains 9 figures, 3 tables, and 96 references.

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    • 8

      Lymphatic Mapping and Sentinel Node Biopsy

      By David W. Ollila, MD, FACS; Karyn B. Stitzenberg, MD, MPH; Kristalyn Gallagher, DO, FACS
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      Lymphatic Mapping and Sentinel Node Biopsy

      • DAVID W. OLLILA, MD, FACSAssociate Professor of Surgery, University of North Carolina, Chapel Hill, NC
      • KARYN B. STITZENBERG, MD, MPHAssociate Professor of Surgery, University of North Carolina, Chapel Hill, NC
      • KRISTALYN GALLAGHER, DO, FACSAssistant Professor of Surgery, University of North Carolina, Chapel Hill, Chapel Hill, NC

      With an estimated 232,670 new cases in the United States in 2014, breast cancer is among the most common malignancies treated by US surgeons. Meanwhile, the incidence of melanoma is rising faster than for all other solid malignancies, with an estimated 76,100 new cases of invasive melanoma in the United States in 2014. Over the past 20 years, significant strides have been made in the management of these two diseases from the standpoint of both surgical and adjuvant therapy. For both diseases, the presence or absence of lymph node metastases is highly predictive of patient outcome and is the most important prognostic factor for disease recurrence and cancer-related mortality. This review covers lymphatic mapping and sentinel node biopsy for melanoma, special circumstances associated with sentinel node biopsy in melanoma, lymphatic mapping and sentinel node biopsy in breast cancer, and radiation exposure guidelines and policies. The figures show lymphatic mapping and sentinel lymph node biopsy for melanoma, lymphatic mapping and sentinel node biopsy for breast cancer, and touch-imprint cytology from lymphatic mapping and sentinel node biopsy for breast cancer.

       

      This review contains 3 highly rendered figures and 89 references.

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    • 9

      Benign Breast Disease

      By Helen Cappuccino, MD, FACS; Ermelinda Bonaccio, MD; Shich Kumar, MD
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      Benign Breast Disease

      • HELEN CAPPUCCINO, MD, FACSDepartment of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY
      • ERMELINDA BONACCIO, MDDepartment of Diagnostic Radiology, Roswell Park Cancer Institute, Buffalo, NY
      • SHICH KUMAR, MDDepartment of Surgical Oncology, Roswell Park Cancer Institute, Buffalo, NY

      Clinicians must have a firm understanding of the general management of clinical findings in the breast. Evaluating breast complaints and masses is discussed: specifically, taking a history, performing a physical examination, and doing a diagnostic workup to include both radiographic diagnostics (including MRI, mammography, and ultrasound) and invasive diagnostics (percutaneous and excisional biopsies). The general management and workup of clinical findings in the breast is described, including that of palpable, solid, and cystic masses. In addition, general management of specific benign breast complaints is evaluated. The specific complaints discussed include mastalgia, fibrocystic change, nipple discharge, fibroepithelial lesions, atypical ductal hyperplasia, fat necrosis, galactocele, Mondor disease, and gynecomastia. An evaluation of patients at high risk for breast cancer is also described. Tables show the American College of Radiology breast imaging reporting and data system (BI-RADS) and magnitude of known breast cancer risk factors.

      This review contains 23 figures, 10 tables, and 82 references.

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  • Care in Special Situations
    • 1

      The Elderly Surgical Patient

      By Sylvia S. Kim, MD, FACS; Michael E. Zenilman, MD, FACS
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      The Elderly Surgical Patient

      • SYLVIA S. KIM, MD, FACSStaff Surgeon, William Jennings Bryan Dorn VA Medical Center, Columbia, SC
      • MICHAEL E. ZENILMAN, MD, FACSProfessor of Surgery, Vice Chair and Director, National Capital Region, Johns Hopkins Medicine, Visiting Professor, SUNY Downstate School of Public Health, Bethesda, MD

      The elderly portion of the US population uses a substantial share of total health care resources, including surgical resources. Accordingly, care of older patients is likely to account for an increasing share of surgeons workloads; therefore, it is incumbent on surgeons to be aware of the particular concerns that apply to this surgical subpopulation. This review discusses the physiologic compromises per organ system seen with aging, highlighting their potential ramifications for surgery. The authors cover the tools available to risk stratify elderly patients beyond single organ system evaluation, such as the Comprehensive Geriatric Assessment, which categorizes patients as fit, intermediate, and frail. This review has 3 figures, 10 highly descriptive tables, and 94 references.

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    • 2

      The Pediatric Surgical Patient

      By Katherine A. Barsness, MD
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      The Pediatric Surgical Patient

      • KATHERINE A. BARSNESS, MDAssistant Professor of Surgery, Northwestern University Feinberg School of Medicine, Division of Pediatric Surgery, Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL

      Surgical care of neonates, infants, and children differs in many respects from that of adults, and an overview of specific surgical problems commonly encountered in pediatric patients is provided in this chapter. The physiologic differences are described first, and include homeostasis; nutrition; and hemodynamic imbalance and shock. The most common surgical problems of newborns are discussed: respiratory problems; intestinal obstruction; and abdominal wall defects. The chapter also outlines the most common surgical problems in infants and children: pyloric stenosis; gastroesophageal reflux; neck and soft tissue masses; abdominal wall hernias; undescended testicles; circumcision; and abdominal pain. The differences in care for pediatric trauma is also provided and includes airway management; pain relief; and sedation. Nonaccidental trauma (battered child syndrome) is given some attention.

      This review contains 5 figures, 5 tables, and 144 references.

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    • 3

      Gynecologic Considerations for the General Surgeon

      By Magdy P. Milad, MD, MS, FACOG; Eden R. Cardozo, MD
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      Gynecologic Considerations for the General Surgeon

      • MAGDY P. MILAD, MD, MS, FACOGProfessor, Obstetrics and Gynecology, Reproductive Endocrinology and Infertility, Northwestern University, Feinberg School of Medicine, Chicago, IL
      • EDEN R. CARDOZO, MDResident Physician, Obstetrics and Gynecology, Northwestern University, Feinberg School of Medicine, Chicago, IL

      Most of the general surgery residency programs in the United States offer no formal rotation in gynecology; however, general surgeons may be asked to assess possible gynecologic disorders in the emergency department or may encounter gynecologic abnormalities intraoperatively. Accordingly, the authors consider the gynecologic problems and their surgical management for the benefit of residents and practicing surgeons. Broadly classified as gynecologic emergencies, this chapter covers bleeding from ovarian cysts, adnexal torsion, pelvic inflammatory disease, ectopic pregnancy, and ovarian masses. Ovarian cancer is discussed in depth as it poses the greatest clinical challenge of all the reproductive tract malignancies. This review has 18 references. Figure 2 shows a retroperitoneal approach to a large, fixed ovarian mass that is adherent to adjacent structures.

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    • 4

      The Pregnant Surgical Patient

      By Nina Tamirisa, MD; Mostafa Borahay, MD, FACOG; Sami Kilic, MD, FACOG
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      The Pregnant Surgical Patient

      • NINA TAMIRISA, MDGeneral Surgery Resident, Department of Surgery, University of Texas Medical Branch, UCSF East Bay Foundation, Galveston, TX
      • MOSTAFA BORAHAY, MD, FACOGAssistant Professor, Minimally Invasive Gynecologic Surgeon, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
      • SAMI KILIC, MD, FACOGAssistant Professor, Minimally Invasive Gynecologic Surgeon, Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX

      The most vulnerable time for a fetus is during embryogenesis in the first 8 to 10 weeks of pregnancy, when women may be unaware of their pregnancy. Once pregnancy is established, a standard approach to the pregnant patient is the optimal way to ensure medical and surgical decisions are made within the context of maintaining the safety of both mother and fetus. This review describes the approach to the pregnant patient for surgical conditions within the context of physiologic changes of the patient and fetus at each trimester, anesthesia and critical care in pregnancy, imaging and drugs safe for use in pregnancy, and nongynecologic surgery in the pregnant patient and specific surgical conditions. Tables outline the classification of abortion, the assessment of pregnancy viability, physiologic changes in pregnancy, laboratory changes in pregnancy, imaging modality and radiation dose, and antibiotics and safety in pregnancy. Figures include a diagram of types of hysterectomy, respiratory changes in pregnancy, and enlargement of the uterus. Algorithms outline the approach to abdominal pain in the pregnant patient and diagnosis and management of ectopic pregnancy.

      This review contains 5 figures, 6 tables, and 85 references.

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    • 5

      Urologic Considerations for the General Surgeon

      By Samuel H. Eaton, MD; Robert B. Nadler, MD, FACS
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      Urologic Considerations for the General Surgeon

      • SAMUEL H. EATON, MDFellow in Endourology, Department of Urology, Northwestern University, Chicago, IL
      • ROBERT B. NADLER, MD, FACSProfessor and Vice Chairman of Urology, Department of Urology, Northwestern University, Chicago, IL

      An understanding of the anatomic, physiologic, and pathologic features of the urogenital system is a necessary component of general surgical education. Anatomic considerations include thorough knowledge of the kidneys and ureters; bladder; prostate and seminal vesicles; penis and urethra; and the testes. Urologic injuries are common when multiple organ systems are damaged, occurring in about 10% of cases of major trauma. Iatrogenic injuries can also occur during any open or laparoscopic procedure in the abdomen or the pelvis and may result from transection, ligation, laceration, resection, crushing, or ischemia; they are most likely during gynecologic procedures. The bladder is the genitourinary organ that is most frequently injured during an operation. Statistics and general treatment regimens for urologic malignancies are discussed and include renal cell carcinoma; bladder cancer; prostate cancer; and testicular cancer. The chapter concludes with the incidence and symptoms of benign prostatic hyperplasia, which is becoming increasingly common in the older, male population. Figures show the anatomic relationship of the kidneys to abdominal organs and venous drainage of the kidneys.

      This review contains 2 figures, 1 table, and 82 references.

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    • 6

      Plastic Surgery Considerations for the General Surgeon

      By Sonya P. Agnew, MD; Gregory A. Dumanian, MD, FACS
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      Plastic Surgery Considerations for the General Surgeon

      • SONYA P. AGNEW, MDDivision of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL
      • GREGORY A. DUMANIAN, MD, FACSDivision of Plastic Surgery, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, IL

      Plastic surgery does not claim a specific region of the body, a tissue type, a disease process, or a technique. Instead, plastic surgery holds central to its core the concepts of tissue perfusion and tissue rearrangement to restore function and appearance. Rather than being at the fringes of medicine and surgery, mastery of these issues allows the plastic surgeon to become a generalist and consultant to all of the surgical disciplines. Reconstructive surgery, wound healing, tissue perfusion, and vascularity are the general themes first discussed by the authors. Plastic surgery considerations for surgery of the abdomen, the breast, and the soft tissues are then covered in order, with all relevant procedures described. The authors discuss scar revisions and the principles of wound closure that favorably impact the final appearance in their conclusion. This review contains 11 references and 5 highly rendered photographs.

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    • 7

      General Surgery in Patients With End-stage Organ Disease

      By Amy R. Evenson, MD; Ramanathan M. Seshadri, MD; Jonathan P. Fryer, MD
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      General Surgery in Patients With End-stage Organ Disease

      • AMY R. EVENSON, MDInstructor in Surgery, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA
      • RAMANATHAN M. SESHADRI, MDFellow, Division of Transplantation Surgery, Northwestern Memorial Hospital, Chicago, IL
      • JONATHAN P. FRYER, MDProfessor, Division of Transplantation Surgery, Northwestern Memorial Hospital, Chicago, IL

      The number of patients with end-stage organ disease in the United States is substantial. Patients with end-stage organ disease are susceptible to all of the surgical problems seen in general surgical practice, with the added comorbidities associated with their organ failure. Hence, understanding of the principles of perioperative patient management is important as part of a general surgery practice. The chapter contains details on general and peripheral vascular surgical procedures, including dialysis access for patients with end-stage renal disease. Details on management of abdominal hernias, cholelithiasis, and disorders of the intestine in patients with end-stage liver disease are provided. Table 1 discusses the advantages and disadvantages of arteriovenous (AV) fistulas versus AV grafts. Table 2 describes “the rule of 6’s” for mature AV fistula. Table 3 has information on potential barriers to peritoneal dialysis. Table 4 is the Child-Pugh-Turcotte classification of severity of liver disease. Table 5 discusses the factors affecting the decision to operate and timing of operation in patients with end-stage liver disease. Figure 1 shows the increasing incidence of end-stage renal disease in the United States. Figure 2 is the five-stage classification system for chronic kidney disease. Figure 3 illustrates the various options for upper extremity AV fistula.

      This review contains 3 figures, 5 tables, and 68 references.

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    • 8

      Transplantation for the General Surgeon

      By Amy R. Evenson, MD; Ramanathan M. Seshadri, MD; Jonathan P. Fryer, MD
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      Transplantation for the General Surgeon

      • AMY R. EVENSON, MDInstructor in Surgery, Transplant Institute, Beth Israel Deaconess Medical Center, Boston, MA
      • RAMANATHAN M. SESHADRI, MDFellow, Division of Transplantation Surgery, Northwestern Memorial Hospital, Chicago, IL
      • JONATHAN P. FRYER, MDProfessor, Division of Transplantation Surgery, Northwestern Memorial Hospital, Chicago, IL

      Familiarity with the organ donation process, donor and recipient selection, organ procurement procedures, recipient procedures, and immunosuppression management is important for all practitioners. An overview of the organ donation process is provided, including the history, the evaluation and management of a deceased donor, general organ procurement procedures, and living donation. Thereafter, the procedures, postoperative management, and complications are discussed for renal, liver, pancreatic, and intestinal transplantation. Immunology and immunosuppression are discussed. Tables describe clinical requirements for the determination of brain death, the Maastricht Classification, recipient survival following living and deceased donor transplantation, advantages and disadvantages of living donor liver transplantation, the King’s College criteria for poor outcome of fulminant liver failure, and patient and graft survival following pancreas transplantation. Figures show donor renal transplantations from 1998 through 2011, access to the right retroperitoneum for kidney transplantation, a kidney in iliac fossa, ERCP and MRCP images of bile duct strictures in patients with hilar cholangiocarcinoma and primary sclerosing cholangitis, liver transplantation, ERCP images showing anastomotic bile duct stricture in living donor liver transplant and stent placement, and pancreatic transplantation.

      This review contains 7 figures, 8 tables, and 43 references.

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    • 9

      Organ Procurement

      By Talia B. Baker, MD, FACS; Anton I. Skaro, MD, PHD, FRCSC, FACS; Paul Alvord, MD, FACS; Prosanto Chaudhury, MD, MSc, FRCSC
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      Organ Procurement

      • TALIA B. BAKER, MD, FACSAssociate Professor of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL Transplant Surgeon, Department of Surgery, Northwestern Memorial Hospital, Chicago, IL
      • ANTON I. SKARO, MD, PHD, FRCSC, FACSAssistant Professor of Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL Transplant Surgeon, Department of Surgery, Northwestern Memorial Hospital, Chicago, IL
      • PAUL ALVORD, MD, FACSStaff Surgeon Scripps Mercy Hospital, San Diego, CA
      • PROSANTO CHAUDHURY, MD, MSC, FRCSCAssistant Professor of Surgery, McGill University and HPB and Transplant Surgeon, McGill University Health Centre, Montreal, Canada

      Improvements in immunosuppression, organ preservation, surgical technique, and recipient management have led to the widespread adoption of transplantation as a viable therapeutic option for end-stage organ disease. Consequently, more patients than ever are benefiting from organ transplantation. Unfortunately, the rate of organ donation has not kept pace with the increase in the number of recipients awaiting transplantation. The relative shortage of organs has necessitated an increasing reliance on creative strategies aimed at broadening or expanding the limits of the donor pool. For instance, organs now are frequently obtained from so-called extended-criteria donors (i.e., donors who are elderly or who have significant comorbid conditions) or from non-heart-beating donors. A particularly important strategy for alleviating the organ shortage has been the broader application of living donor transplantation. The authors outline the current state of organ procurement from both cadaveric and living donors, including donor evaluation, perioperative management, and the various donor procedures.

      This review contains 14 figures, 1 table, and 63 references.

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    • 10

      The Immunocompromised Surgical Patient

      By Rhiannon Deierhoi Reed, MPH; Brittany Shelton, MPH; Jayme E. Locke, MD, MPH, FACS
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      The Immunocompromised Surgical Patient

      • RHIANNON DEIERHOI REED, MPHClinical Database Manager, Comprehensive Transplant Institute Outcomes Center, University of Alabama at Birmingham, Birmingham, AL
      • BRITTANY SHELTON, MPHResearch Assistant, University of Alabama at Birmingham, Birmingham, AL
      • JAYME E. LOCKE, MD, MPH, FACSAssistant Professor of Surgery, Division of Transplantation, University of Alabama at Birmingham, Birmingham, AL

      General surgeons are encountering an increasing number of cases involving immunosuppressed patients due to a number of factors, including the improvement in treatment for HIV, increased survival following solid-organ transplantation, and more aggressive chemotherapy. These groups of patients present unique challenges for the surgeon and often require more comprehensive preoperative assessment and perioperative monitoring. This review addresses the surgical management of these immunocompromised populations, with specific recommendations for each type of patient. Tables outline opportunistic infections and antibiotic prophylaxis; common immunosuppressive medications, posttransplantation drug levels, and side effects for renal transplant recipients; components of preoperative workup involving suspected infection in immunocompromised patients; and anesthetics and demonstrated impact on immune response and cancer recurrence. Graphs display the number of AIDS diagnoses and deaths and people living with AIDS and HIV in the United States over time, and compare percentages of death certificates reporting opportunistic infection versus chronic disease in the HIV-infected population. Management algorithms outline approaches to patients with defects in host defenses and candidates for transplantation to be deliberately immunosuppressed.

      This review contains 2 graphs, 2 management algorithms, 4 tables, 157 references, and 5 annotated key references.

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    • 11

      Substance Use Disorders in the Surgical Patient

      By Abdul Q. Alarhayem, MD; Natasha Keric, MD; Daniel L. Dent, MD
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      Substance Use Disorders in the Surgical Patient

      • ABDUL Q. ALARHAYEM, MDGeneral Surgery Resident, Department of Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, TX
      • NATASHA KERIC, MDAssistant Professor, Department of Surgery, Banner–University Medical Center, University Of Arizona, Phoenix, AZ
      • DANIEL L. DENT, MDDistinguished Teaching Professor of Surgery, Department of Surgery, Division of Trauma and Emergency Surgery, The University of Texas Health Science Center at San Antonio, San Antonio, TX

      Large bodies of evidence link alcohol consumption and substance use disorders (SUDs) with motor vehicle collisions, as well as life-threatening intentional injury.  According to the substance use and mental health estimates from the 2013 National Survey on Drug Use and Health, 24.6 million individuals age 12 or older were current illicit drug users in 2013, including 2.2 million adolescents age 12 to 17, and 60.1 million individuals age 12 or older were binge drinkers in the past month.  Many people with SUDs become patients; therefore, the surgeon must be able to recognize and manage many of the related issues that can ensue. This review details the definition of SUDs, basic principles of toxicology, acute management of the patient with suspected substance use intoxication or withdrawal, managing life-threatening syndromes in patients with SUDs, overdose and withdrawal syndromes of opioids, stimulants, and depressants, surgical complications of SUDs, perioperative and postoperative considerations in patients with SUDs, and consultation and referral to a toxicologist and poison control center. Figures show first- and zero-order kinetics;  pupillary examination, laboratory and radiographic findings in SUDs; polymorphic ventricular tachycardia; consciousness as an interplay between arousal and awareness, an algorithm for the management of seizures, sine, mechanism of cocaine’s cardiac toxicity and hemorrhagic stroke in a cocaine abuser, necrotizing soft tissue infection, digit necrosis associated with intra-arterial injection of cocaine, scars from skin popping, nonocclusive thrombus in the left internal jugular vein, needle fracture with soft tissue dislodgment, oral contrast-enhanced computed tomographic scan showing rounded foreign bodies in the stomach, and fecal impaction associated with heroin. Tables list criteria for substance use disorders according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-V), frequently misused drugs, causes of death in SUD, cardiac, neurologic, and metabolic signs and symptoms caused by commonly abused substances , anion and osmolar gap equations, life-threatening manifestations of cocaine toxicity, and alcohol-related disorders.

      This review contains 15 figures, 7 tables, and 85 references.

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    • 12

      The Diabetic Surgical Patient

      By Cathline Layba, MD; Lance Griffin, MD
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      The Diabetic Surgical Patient

      • CATHLINE LAYBA, MDResident, Department of Surgery, The University of Texas Medical Branch, Galveston, TX
      • LANCE GRIFFIN, MDAssistant Professor, Department of Surgery, Division of Trauma, The University of Texas Medical Branch, Galveston, TX

      Diabetes mellitus is the seventh leading cause of death in the United States; diabetic patients have a 50% chance of undergoing a surgical procedure during their lifetime, and operations in this patient population have been associated with a reported mortality of 4% to 13%. Careful planning of operative management and perioperative care must be taken into account when scheduling surgery for diabetic patients, especially patients taking insulin or oral hypoglycemic agents. Debate continues and inconsistencies remain regarding the management of both diabetes and hyperglycemia in the surgical setting. The review covers the evaluation of the diabetic patient, preoperative management, intraoperative management, postoperative management, total parenteral nutrition and blood glucose, cardiovascular and renal assessment, infection, and special populations. Figures show preoperative and postoperative management of the diabetic surgical patient, and an example of normoglycemic protocol in the intensive care unit at University of Texas Medical Branch. Tables list preoperative insulin administration, representative protocol for insulin glucose infusion during the perioperative period, and management of diabetes in patients undergoing minor surgical procedures.

      This review contains 2 highly rendered figures, 3 tables, and 21 references

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    • 13

      The Morbidly Obese Surgical Patient

      By Mustafa W. Aman, MD; Michael A. Schweitzer, MD
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      The Morbidly Obese Surgical Patient

      • MUSTAFA W. AMAN, MDFaculty, Department of Surgery, Division of Bariatric Surgery, Guthrie Weight Loss Center, Robert Packer Hospital, Sayre, PA
      • MICHAEL A. SCHWEITZER, MDDirector of Bariatric Surgery, Associate Professor of Surgery, Johns Hopkins University, Baltimore, MD

      Over  the past few decades, the incidence of obesity has been steadily rising in the United States. The Centers for Disease Control and Prevention estimates that up to one-third of the US adult population is obese. Rising obesity rates are seen not only in the adult population but increasingly among children and adolescents as well. As a result, surgeons today are faced with the challenge of caring for an increasing number of morbidly obese patients, and this trend is only expected to worsen over time. This review covers preoperative evaluation, obesity-related comorbidities, respiratory insufficiency, anesthesia in patients with respiratory insufficiency, intraoperative management, postoperative management, complications of gastric surgery for obesity, diabetes mellitus, wound care, and other obesity-related diseases. Figures show impaired pulmonary function in the morbidly obese improved significantly after weight loss induced by bariatric surgery,  significant improvement in mean pulmonary arterial pressure in 18 patients 3 to 9 months after gastric surgery-induced weight loss of 42% ± 19% of excess weight, and a chronic venous stasis ulcer present for several years in a morbidly obese patient. Tables list evaluation and treatment of obstructive sleep apnea, and indications for extended postoperative chemoprophylaxis for venous thromboembolism in morbidly obese patients (body mass index > 30 kg/m2).

      This review contains 3 highly rendered figures, 2 tables, and 45 references

       

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  • Competency-based Surgical Care
    • 1

      Bedside Procedures for General Surgeons

      By Thomas H. Cogbill, MD; Benjamin T. Jarman, MD
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      Bedside Procedures for General Surgeons

      • THOMAS H. COGBILL, MDProgram Director Emeritus, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI
      • BENJAMIN T. JARMAN, MDProgram Director, Surgery Residency, Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI

      This review is focused on 12 procedures that are commonly performed by general surgeons in the emergency department, critical care unit, operating room, and outpatient clinic. The review begins with eight critical care procedures: percutaneous tracheostomy, saphenous vein cutdown, percutaneous arterial cannulation, subclavian venous catheter placement by landmark technique, internal jugular venous catheter placement under ultrasound guidance, needle chest decompression, tube thoracostomy, and pericardiocentesis for trauma. Next, the diagnostic procedure of focused assessment with sonography for trauma (FAST) is described. The review finishes with three procedures that are frequently performed in the outpatient setting: temporal artery biopsy, simple abscess drainage, and muscle biopsy. Although considered basic procedures, each has its own set of key steps that must be learned, practiced, and mastered. Included in the description for each procedure are technical points that are intended to facilitate successful performance of the procedures as well as pitfalls to avoid. The most frequent complications for each procedure are briefly discussed in an effort to raise awareness so that they can be recognized and managed expeditiously. Common to all of these procedures is a need to understand the indications based on careful history, physical examination, and review of pertinent objective data. Whenever possible, informed consent should be obtained from the patient or family prior to the procedure and a complete surgical timeout performed. Sterile technique and personal protective gear/universal precautions should be employed whenever feasible. Finally, these patients should be followed postoperatively and appropriate follow-up studies and/or treatments arranged. The figures illustrate key steps used in a number of the procedures and typical ultrasound images of the internal jugular vein during central venous catheter placement and the four standard FAST views, along with photo insets depicting appropriate ultrasound probe positioning. The tables include the lists of equipment necessary to perform each procedure.

      This review contains 17 figures, 14 tables, and 47 references

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    • 2

      Ethical Issues in Surgery

      By Jason D. Keune, MD, MBA; Ira J. Kodner, MD, FACS; Mary E. Klingensmith, MD, FACS
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      Ethical Issues in Surgery

      • JASON D. KEUNE, MD, MBAChief Resident in General Surgery, Washington University School of Medicine, St. Louis, MO
      • IRA J. KODNER, MD, FACSEmeritus Professor of Surgery, Washington University School of Medicine, St. Louis, MO
      • MARY E. KLINGENSMITH, MD, FACSChief Resident in General Surgery, Washington University School of Medicine, St. Louis, MO

      To be a good surgeon, one must be technically good and scientifically sound, but also ethical to the degree that has traditionally been demanded by our profession. In this chapter, the authors discuss what ethical problems in surgery are and how they might be approached. Respect for autonomy, nonmaleficence, beneficence, and justice define Principlism that forms the backbone of most discourse in clinical medical ethics. Consequentialism/utilitarianism, deontology, virtue ethics, “ethics of care”, and casuistry are all covered. The authors then scrutinize several contemporary problems in surgical ethics. Described and discussed in depth are issues associated with the ‘end of life’; surrogate decision making, futility, “do not resuscitate” orders in the operating room, conflicts of interest, industry payments, and surgical innovation, informed consent, and refusal of care. This review is not meant to be an exhaustive treatment of surgical ethics but a survey highlighting the most common ethical problems.

      This review contains 2 figures, 3 tables, and 61 references.

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    • 3

      Cost-effective Nonemergent Surgical Care

      By Robert S. Rhodes, MD, FACS; Charles L. Rice, MD, FACS; Julie Ann Sosa, MA, MD, FACS
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      Cost-effective Nonemergent Surgical Care

      • ROBERT S. RHODES, MD, FACSAmerican Board of Surgery, Philadelphia, PA
      • CHARLES L. RICE, MD, FACSUniformed Services University of the Health Sciences, Bethesda, MD
      • JULIE ANN SOSA, MA, MD, FACSAssociate Professor of Surgery, Divisions of Endocrine Surgery and Surgical Oncology, Department of Surgery, Yale University School of Medicine, New Haven, CT

      Providing broad access to high-quality health care at a reasonable cost is an increasing challenge. Individuals, employers, and governments all feel the strain of health care costs. The rapidly increasing shift of physicians from independent practice to an employed status makes it highly likely that their employers will increase the pressure for more cost-effective care. Therefore, it is essential that surgeons understand how to improve the cost-effectiveness of their practice. This review explores the fundamental principles of cost-effectiveness; surveys the attributes, complexities, and relationship of cost and quality; describes processes of care and experiences with various performance improvement efforts; identifies specific skills and attributes to help surgeons deliver more cost-effective care, and discusses the increasing role that value-based competition is likely to play in health care delivery. Tables show the categories and types of hospital costs, elective coronary artery bypass grafting results from ProvenCare, and questions to ask when innovations in surgical care are considered. Figures show health care spending per capita and life expectancy among selected countries, interactions of cost and quality in cost-effectiveness, the new concept of quality and cost, trends in in-hospital mortality rates, and the hierarchy of levels of evidence.

      This review contains 6 figures, 3 tables, and 131 references.

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    • 4

      Health Care Economics: the Broader Context

      By Charles L. Rice, MD, FACS; Linda G. Lesky, MD, MA; Robert S. Rhodes, MD, FACS
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      Health Care Economics: the Broader Context

      • CHARLES L. RICE, MD, FACSUniformed Services University of the Health Sciences, Bethesda, MD
      • LINDA G. LESKY, MD, MAGeorge Washington University, Washington, DC
      • ROBERT S. RHODES, MD, FACSAmerican Board of Surgery, Philadelphia, PA

      This review explores some of the issues surrounding health care spending on a national scale. It is important for surgeons to have a broad understanding of these issues, in particular because such concerns are increasingly becoming the subject of political debate. The discrepancy between costs and outcomes are described in terms of a model of supply and demand, the affordability of health cure, asymmetrical knowledge, markets, monopolies, new drugs, and technology, price transparency, and administrative costs. The Patient Protection and Affordable Care Act and other legislative initiatives are touched upon. Although individual physicians can do little to fix the society-wide problems created by market-based health care, surgeons can help restore confidence in the profession by helping to develop and then adhering to evidence-based approaches to surgical intervention. Communication skills and attention to the needs of patients should be stressed as vital to the best patient care. Figures show the model of supply and demand determines the quantity produced at a given price and how monopolies set prices to maximize profits by equating the marginal cost of production and the marginal revenue. A table shows the administrative costs of health care in the United States versus Canada. This review contains 38 references.

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    • 5

      Evidence-based Surgery

      By Samuel R. G. Finlayson, MD, MPH; Karl Y. Bilimoria, MD, MS
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      Evidence-based Surgery

      • SAMUEL R. G. FINLAYSON, MD, MPHChair, Department of Surgery, University of Utah School of Medicine, Salt Lake City, UT
      • KARL Y. BILIMORIA, MD, MSAssistant Professor of Surgery, Director, Surgical Outcomes and Quality Improvement Center (SOQIC), Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL

      Evidence-based surgery describes the consistent and judicious use of the best available scientific evidence in making decisions about the care of surgical patients. In this chapter, guidelines and secondary sources of scientific evidence are provided. Examples include Clinical Evidence, the Cochrane Database of Systematic Reviews, and the Institute for Healthcare Improvement. Levels of evidence are defined. Appraising scientific evidence via specific study designs is described, including studies’ internal and external validity (generalizability). In evaluating the quality of a study, the properties of chance (Type I and Type II errors); bias (selection bias and measurement bias); and confounding (along with randomization, restriction and matching, instrumental variable analysis, stratification, and propensity score risk adjustment) are defined. Interpreting and applying evidence to practice (external validity) are discussed. A discussion of evidence-based surgery and quality of care is provided and focuses on how efforts to assess quality on evidence-based processes of care or clinical outcomes are as much practical as philosophical. A figure shows processes that affect the internal and external validity of a clinical study. Tables show levels of evidence, as stratified by the U.S. Preventive Services Task Force, and methods observed in published clinical studies that demonstrate efforts to minimize the effects of chance, bias, and confounding.

      This review contains 1 figure, 3 tables, and 42 references.

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    • 6

      Minimizing Vulnerability to Malpractice Claims

      By William R. Berry, MD, MPH, FACS
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      Minimizing Vulnerability to Malpractice Claims

      • WILLIAM R. BERRY, MD, MPH, FACSResearch Associate, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA

      This review provides strategies for avoiding lawsuits and advice for dealing with a lawsuit if one is ever filed. Medical malpractice is explained as are the personal issues for the defendant physician. Strategies for preventing malpractice suits are presented, including those relative to communication and interpersonal skills, the informed consent process, and documentation. Advice is provided for what surgeons should do if sued or if threatened with a lawsuit, including measures for assisting in the defense and settling claims versus trying a case. Preparing for a deposition is discussed. How a surgeon should act when a defendants or witness in a courtroom trial is presented. This review contains 13 references.

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    • 7

      Nontechnical Skills in Surgery

      By Steven Yule, MA, MSc, PhD; Douglas S. Smink, MD, MPH
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      Nontechnical Skills in Surgery

      • STEVEN YULE, MA, MSC, PHDDirector of Education and Research, Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham & Women’s Hospital, Assistant Professor, Department of Surgery, Harvard Medical School, Boston, MA
      • DOUGLAS S. SMINK, MD, MPHProgram Director, General Surgery Residency, Associate Medical Director, Neil and Elise Wallace STRATUS Center for Medical Simulation, Brigham and Women’s Hospital, Department of Surgery, Harvard Medical School, Boston, MA

      Nontechnical skills are the cognitive and social skills that underpin knowledge and expertise in high-demand workplaces. In the operating room (OR), surgeons with good nontechnical skills can effectively share information about their perceptions of ongoing situations with other team members, elicit critical information from others regarding the task and patient safety, and allow the formation of better shared mental representations about the operation in real time. In rare OR crises, surgeons use their nontechnical skills to delegate tasks and effectively manage challenging operations under time pressure. This review covers approaches in high-risk industry; the development, testing, and usage of the non-technical skills for surgeons (NOTSS) system; and the underpinning theory of nontechnical skills. Tables outline the NOTSS skills taxonomy, behavioral rating tools in surgery, and the skills taxonomy used in the aviation industry.

      This review contains 3 tables, and 62 references.

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    • 8

      Patient Safety in Surgical Care

      By Amir Ghaferi, MD, MS, FACS; Caprice C. Greenberg, MD, MPH, FACS
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      Patient Safety in Surgical Care

      • AMIR GHAFERI, MD, MS, FACSAssistant Professor of Surgery, Center for Healthcare Outcomes and Policy, University of Michigan School of Medicine, Assistant Professor of Management and Organizations, University of Michigan Ross School of Business, Chief, Division of General Surgery, Ann Arbor Veterans Administration Healthcare System, Ann Arbor, MI
      • CAPRICE C. GREENBERG, MD, MPH, FACSProfessor of Surgical Research, Associate Professor of Surgery, Director, Wisconsin Surgical Outcomes Research Program, Department of Surgery, University of Wisconsin, Madison, WI

      The 1999 report of the Institute of Medicine, To Err Is Human: Building a Safer Health System, made national headlines with its estimates of the frequency and severity of adverse events in health care, including that as many as 98,000 medical error–related deaths occur each year in the United States. The observation that the basic principles of human error are highly applicable to clinical practice has markedly advanced our understanding and willingness to address error in this setting. This review seeks to address the characteristics of systems in general and the system of surgical care in particular. It describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. The review also outlines current obstacles to improving safety,  identifies  systems approaches to making improvements, and discusses ways in which surgeons can take the lead in overcoming these obstacles. An overall goal is that acceptance of error and a willingness to investigate its underlying causes will allow health care professionals to make use of the lessons learned from study of nonmedical systems. Tables include definitions of terms related to patient safety, the operation profile, handoff coordination and communication objectives and relevant strategies, nonmedical system techniques applicable to medical systems, Agency for Healthcare Quality and Research patient safety indicators, National Quality Forum list of health care facility–related serious reportable events, and examples of surgically relevant quality improvement practices appropriate for widespread implementation. Figures include the Swiss Cheese Model representing the relationship between latent and active errors and adverse outcomes, a schematic depiction of the process by which system failures may lead to injury, the Systems Engineering in Patient Safety Model of work system and patient safety, and a depiction of contrasting characteristics of medical practice in the 20th and 21st centuries.

      This review contains 4 figures, 7 tables, and 165 references.

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    • 9

      Performance Measurement in Surgery

      By Justin B. Dimick, MD, MPH
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      Performance Measurement in Surgery

      • JUSTIN B. DIMICK, MD, MPHUniversity of Michigan Medical School, Ann Arbor, MI

      With growing recognition that the quality of surgical care varies widely, good measures of performance are in high demand. An ever-broadening array of performance measures is being developed to meet these different needs; however, considerable uncertainty remains about which measures are most useful for measuring surgical quality. Current measures encompass different elements of health care structure, process of care, and patient outcomes. This review covers overview of surgical quality measures, categories of quality measures, structural measures of quality, process of care measures, direct outcome measures, matching the measure to the purpose, improving existing performance measures, and the future of performance measurement. Figures show relative ability of historical (2005-2006) measures of hospital volume and risk-adjusted mortality to predict subsequent (2007-2008) risk-adjusted mortality in US Medicare patients,  risk-adjusted mortality and morbidity for colon resection at individual hospitals before and after adjustment for reliability, variation in surgeon technical skill for 20 bariatric surgeons performing laparoscopic gastric bypass in the Michigan Bariatric Surgery Collaborative (MBSC), and relationship of surgeon technical skill and risk-adjusted complications and resource use after laparoscopic gastric bypass in the MBSC. The table lists primary strengths and limitations of structure, process, and outcome measures.

       

      This review contains 4 highly rendered figures, 1 table, and 34 references

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    • 10

      Preoperative Testing and Planning for Safer Surgery

      By Valerie Ng, MD, PhD; Sarah Markham, MD; Jill Antoine, MD; Alden H. Harken, MD, FACS
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      Preoperative Testing and Planning for Safer Surgery

      • VALERIE NG, MD, PHDProfessor Emeritus, Department of Laboratory Medicine, University of California, San Francisco-East Bay; and Chair Laboratory Medicine and Pathology, Alameda County Medical Center, Oakland, CA
      • SARAH MARKHAM, MDSurgical Resident, University of California, San Francisco-East Bay Surgical Residency Program, Department of Surgery, Alameda County Medical Center, Oakland, CA
      • JILL ANTOINE, MDMedical Director, Anesthesiology, Pre-Operative Clinic, Department of Anesthesia, Highland Hospital, Alameda Health Systems, Oakland, CA
      • ALDEN H. HARKEN, MD, FACSProfessor and Chair, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA

      Consensus statements and regulatory guidelines endorse the process of identifying patients at increased risk for surgical morbidity and mortality. This is termed prognostic testing, and it identifies patients who are deemed to be too sick to benefit from the anticipated gain of surgery. However, much more valuable than prognostic testing is predictive, or directive, testing. A predictive test pinpoints the patient’s problem that will benefit from a specific available intervention. This review covers what is risk?, changing paradigms of surgical success, building a case for moderation, so, does anyone disagree?, timing, frailty and age (and the eyeball test), is the heart the only organ that counts?, changing paradigms, the enhanced importance of functional capacity, resting electrocardiogram, exercise stress testing, ventricular function testing, stair climbing: putting it all together, pulmonary function tests, obstructive airway disease, perioperative nutrition, how can we make surgery safer?, enhanced recovery after surgery, putting it all together, extended enhanced recovery after surgery, tight glucose control, smoking cessation, and timing of collaboration with anesthesia. Figures show routine preoperative tests for elective surgery (adapted from the National Institute for Health and Care Excellence clinical guideline 3, preoperative assessment strategies and recommended risk-reducing therapy relative to American Society of Anesthesiologists (ASA) classification performed by the surgeon and age, ASA Class I and II patients may be safely be evaluated by an anesthesiologist on the day of their scheduled surgery for a full preoperative history and physical examination, flow volume loop. Tables list ASA physical status classification, effect of abnormal screening results on physician behavior, and minimum preoperative test requirements at the Mayo Clinic (in 1997).

       

      This review contains 4 highly rendered figures, 3 tables, and 111 references

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    • 11

      Process Improvement in Surgery

      By Frederick H. Millham, MD, MBA
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      Process Improvement in Surgery

      • FREDERICK H. MILLHAM, MD, MBAAssociate Clinical Professor of Surgery, Harvard Medical School, Chair of Surgery, South Shore Hospital, Weymouth, MA

      Process improvement is a skill all physicians need to be familiar with. This is particularly true for surgeons, who work in complex systems requiring multidisciplinary care in the health care system’s most expensive location: the operating room. Surgical leaders need to be familiar with the techniques and themes of process improvement. The current literature suggests that formal process improvement programs can be effective in improving clinical, operational, and financial performance of hospitals. This review outlines a general approach to process improvement, in addition to providing evidence for the efficacy of process improvement in health care, a definition of processes, and the history of process improvement. Tables outline forms of waste applied to health care and heuristic approaches to project improvement. Figures include a project charter, control chart, X-bar control chart, Pareto table and chart, Fishbone cause-and-effect diagram, diagrams of the Plan-Do-Study-Act process and cost/payoff matrix, statistical software control charts, and process flow maps.

      This review contains 10 figures, 2 tables, and 22 references.

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    • 12

      Professionalism in Surgery

      By K. Christopher McMains, MD, PhD, MS; Jo Shapiro, MD, FACS
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      Professionalism in Surgery

      • K. CHRISTOPHER MCMAINS, MD, PHD, MS
      • JO SHAPIRO, MD, FACSAssociate Professor, Otolaryngology, Harvard Medical School, Boston, MA

      The medical profession continues to be challenged along the entire range of its cultural values and its traditional roles and responsibilities. This review explores the meaning of professionalism, translating the theory of professionalism into practice, and the future of surgical professionalism. A table offers the elements of the American College of Surgeons’ Code of Professional Conduct. This review contains 22 references.

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    • 13

      Strategies for Improving Surgical Quality

      By Mark A. Healy, MD; Nancy J. O. Birkmeyer, PhD
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      Strategies for Improving Surgical Quality

      • MARK A. HEALY, MDFellow, Center for Healthcare Outcomes & Policy, Department of Surgery, University of Michigan Health System, Ann Arbor, MI
      • NANCY J. O. BIRKMEYER, PHDAssociate Professor, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI

      Surgical morbidity and mortality are major public health concerns. The outcomes of surgery have been shown to differ among providers; this variability in the outcomes of surgical procedures has long suggested opportunities to improve the quality of surgical care. Payers, health care policy makers, and surgeons’ professional organizations have implemented a range of strategies to effect large-scale quality improvement efforts targeted toward patients undergoing surgery. This review examines outcomes measurement and feedback, regional collaborative quality improvement, selective referral, pay for performance strategies, and new strategies for surgical quality improvement. Figures show example of provider desktop user interface for a regional quality collaborative; mortality after (30-day) bariatric surgery: Michigan hospitals versus non-Michigan hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) based on data from the 2007 to 2009 Michigan Bariatric Surgery Collaborative and national ACS-NSQIP registries; and percentage of mortality decline for esophagectomy, pancreatectomy, cystectomy, and lung resection attributable to increases in market concentration, based on 2001 to 2008 national Medicare data. Tables list characteristics of different strategies for improving surgical quality; components of the Institute for Healthcare improvement ventilator and central catheter insertion bundle checklists; evidence regarding the relationship between compliance with Surgical Care Improvement Project (SCIP) measures and clinical outcomes; SCIP measures retired as of January 15, 2015; and SCIP measures remaining.

      This review contains 3 highly rendered figures, 5 tables and 74 references.

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    • 14

      Surgical Palliative Care

      By Zara Cooper, MD, MSc, FACS; Anne Mosenthal, MD, FACS
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      Surgical Palliative Care

      • ZARA COOPER, MD, MSC, FACSAssistant Professor of Surgery, Harvard Medical School, Department of Surgery, Center for Surgery and Public Health, Brigham and Women’s Hospital, Boston, MA
      • ANNE MOSENTHAL, MD, FACSProfessor and Chair, Department of Surgery, Rutgers New Jersey Medical School, Newark, NJ

      Demographic and cultural shifts have prompted greater focus on the quality of end-of-life care provided by surgeons and other clinicians. There is increasing evidence that Medicare beneficiaries in the last 6 months of life are experiencing increasing rates of health care use, higher-intensity care, and shorter hospice stays. As a result, the vast majority of deaths in America now occur in hospitals and institutions, where active decisions must be made to withhold or withdraw interventions to allow a “natural” death. This review discusses the evolution and ethical and legal foundations of surgical palliative care, advance directives and advance care planning, and the practice of surgical palliative care, including palliative care assessment, goals of care, palliative surgery, the role of the interdisciplinary team, communication, withdrawal and withholding of life support, and caring for the dying patient and the family. Tables include the American College of Surgeons statements on the principles guiding care at the end of life and principles of palliative care, ethical principles in palliative care, common ethical issues in the surgical practice of palliative care, the legal basis for decision making at end of life, palliative care assessment, common symptoms in patients with serious illness, modified Edmonton Symptom Assessment Scale, SPIKES: A six-step protocol for delivering bad news, the VALUE approach for communicating with families of critically ill ICU patients, and symptom management for the imminently dying. Figures illustrate models of palliative care and the approach to shared decision making.

      This review contains 2 figures, 11 tables, and 51 references.

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    • 15

      Surgical Practice Management

      By Valentine N. Nfonsam, MD, MS; Leigh A. Neumayer, MD, MS
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      Surgical Practice Management

      • VALENTINE N. NFONSAM, MD, MSAssistant Professor of Surgery, General Surgery Residency Program Director, Department of Surgery, University of Arizona, Tucson, AZ
      • LEIGH A. NEUMAYER, MD, MSProfessor and Chair, Department of Surgery, University of Arizona, Tucson, AZ

      As individuals complete their surgical residencies and fellowships, their attention must soon turn toward choosing their career path. This review aims to help those individuals in making informed choices that will properly prepare a successful future in surgical practice. Included here is a survey of some principles that will help guide individuals to proper decision making, an analysis of several different practice settings, sections on negotiations, benefits, and contracts, and a guide to making a smooth transition and developing a successful practice. Helpful tips and possible pitfalls, such as general dos and don’ts for applying and interviewing, are also presented to ensure that the trainee is well prepared and well aware. Figures show a template for curriculum vitae format, a sample resume, a sample executive summary, a contract worksheet, an onboarding timeline, and screenshots of Surgeon Specific Registry. Tables list types of surgical practice, a summary of a personnel file, benefits packages, and lessons learned in kindergarten. Also included are suggested readings related to the topic of surgical practice management.

      This review contains 6 figures, 4 tables, 13 references, and 8 additional readings.

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    • 16

      The Impaired Surgeon

      By David B. Hoyt, MD, FACS; Krista L. Kaups, MD, MSc, FACS
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      The Impaired Surgeon

      • DAVID B. HOYT, MD, FACSExecutive Director, American College of Surgeons, Chicago, IL
      • KRISTA L. KAUPS, MD, MSC, FACSProfessor of Clinical Surgery, UCSF Fresno, Department of Surgery

      Among the obligations and responsibilities of a surgeon is to practice in a competent manner. From a professional standpoint, competence is widely defined as the ability to practice with reasonable skill and safety, and a surgeon is impaired when she or he is not able to do so. There are a number of potential reasons leading to impairment, which may be temporary or a limitation throughout a surgeon’s professional career. Impairment may range from mild degradation of skills to complete incapacitation. The consequences of surgical practice with impairment are wide ranging and include patient-related harm and failure to provide exemplary care; personal consequences to the surgeon’s health and well-being; interpersonal issues with family, colleagues, and staff; and disciplinary and legal issues. This review covers substance abuse, personality issues (character impairment), medical school, residency, the practicing surgeon, the faculty member, boundary issues, aging, the individual surgeon, the department/hospital, burnout, prevention and recognition, individual/personal, organizational, the unprepared or "out-of-date" surgeon, prevention, and dealing with the unprepared surgeon. The figure shows an algorithm outlining the approach to the impaired surgeon. Tables list signs of substance abuse–related impairment, signs of character impairment, and signs of age-related impairment.

      This review contains 1 highly rendered figure, 3 tables, and 123 references

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  • Critical Care
    • 1

      Cardiac Resuscitation

      By Konstantinos Chouliaras, MD; Kazuhide Matsushima, MD; Heidi L. Frankel, MD, FACS, FCCM
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      Cardiac Resuscitation

      • KONSTANTINOS CHOULIARAS, MDResearch Fellow, Acute Care Surgery and Surgical Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA
      • KAZUHIDE MATSUSHIMA, MDClinical Fellow, Acute Care Surgery and Surgical Critical Care, Keck School of Medicine, University of Southern California, Los Angeles, CA
      • HEIDI L. FRANKEL, MD, FACS, FCCMProfessor of Surgery, Director of Surgical Critical Care Services, Keck Hospital of University of Southern California, Los Angeles, CA

      Out-of-hospital sudden cardiac arrest claims the lives of more than 300,000 persons in the United States each year, making it the leading cause of death. Although 70 to 80% of victims have underlying coronary artery disease, sudden death is the first manifestation of the disease in half of these persons. The pathophysiology that culminates in sudden cardiac death likely represents a mix of electrical abnormalities combined with acute functional triggers, such as myocardial ischemia, central and autonomic nervous system effects, electrolyte abnormalities, and pharmacologic influences. This review describes the process for resuscitating an adult victim with sudden cardiac arrest (chain of survival), which involves activation of emergency medical services, initiation of cardiopulmonary resuscitation and defibrillation, provision of advanced care, and post–cardiac arrest care. Resuscitation outcomes improve when every link in the chain of survival is quickly and sequentially available. The primary and secondary surveys of cardiac resuscitation are listed, as are cardiac resuscitation based on rhythm findings and ending a resuscitation attempt. Tables describe initial resuscitation steps in the unresponsive patient, treatment of ventricular tachycardia, using an automatic external defibrillator in patients older than 8 years, using a manual defibrillator, drugs useful in cardiac arrest, goals of post–cardiac arrest care, a revised summary of American Heart Association (AHA) recommendations, special resuscitation situations reviewed in 2010 AHA guidelines, components of optimal and suboptimal chest compressions, confirmation of endotracheal tube placements, technical problems that may prevent successful resuscitation, potentially treatable conditions that may cause or contribute to cardiac arrest, resuscitation steps in the management of pulseless electrical activity and asystole, criteria for ending a prehospital or in-hospital resuscitation attempt, and criteria for ending a resuscitation attempt for a persistently asystolic patient. Figures illustrate the foundations of cardiac resuscitation, coronary perfusion pressure as a function of time, the four phases of a capnogram, a battery-powered intraosseous drill, the sudden cardiac arrest arrhythmias, and sample capnograms. Algorithms show the approach to cardiovascular resuscitation and management of the initial treatment of cardiac arrest,

      This review contains 7 figures, 17 tables, and 104 references.

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    • 2

      Acute Cardiac Dysrhythmia

      By Caesar M. Ursic, MD; Alden H. Harken, MD, FACS
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      Acute Cardiac Dysrhythmia

      • CAESAR M. URSIC, MDAssistant Professor, Department of Surgery, UCSF-East Bay Surgery Program, University of California, San Francisco, School of Medicine
      • ALDEN H. HARKEN, MD, FACSProfessor and Chair, Department of Surgery, University of California, San Francisco-East Bay, Oakland, CA

      After successful cardiopulmonary resuscitation (CPR), or any myocardial ischemic event, the most common source of hemodynamic instability is an abnormal heart rhythm. This review outlines the approach to a patient with an apparent acute cardiac dysrhythmia. The choice of therapy is determined by the stability of the patient and the origin of the dysrhythmia. Hemodynamically unstable patients are treated with cardioversion. Treatment of stable patients is guided by the ventricular rate and by electrocardiographic (ECG) findings. This review addresses the appropriate use of agents such as verapamil, adenosine, amiodarone, diltiazem, and magnesium, as well as the issues of dysrhythmias during pregnancy and proarrhythmia with antidysrhythmic agents. The classes of antidysrhythmic drugs are reviewed briefly, cellular electrophysiology is summarized, and the pathophysiology of cardiac dysrhythmias is discussed. Use of the intracardiac cardioverter defibrillator (ICD) is discussed in a sidebar, and another sidebar explains how to troubleshoot a pacemaker. This review contains an algorithm outlining the management of an acute dysrhythmia, 11 figures, 2 sidebars, and 62 references.

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    • 3

      Shock

      By James W. Holcroft, MD, FACS; John T. Anderson, MD, FACS; Matthew J. Sena, MD, FACS
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      Shock

      • JAMES W. HOLCROFT, MD, FACSProfessor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA
      • JOHN T. ANDERSON, MD, FACSAssociate Professor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA
      • MATTHEW J. SENA, MD, FACSAssistant Professor, Department of Surgery, University of California, Davis, School of Medicine, Sacramento, CA

      Shock is defined as a tissue hypoperfusion due to an imbalance between oxygen supply and demand in the tissues of the body. Identifying the category of shock (hypovolemic, inflammatory, compressive, obstructive, neurogenic, or cardiogenic) assists in identifying the underlying pathophysiology and determining treatment options. However, in many patients there is more than one cause of shock, and the surgeon must therefore treat more than one problem. This review discusses characteristic clinical markers; management of immediately life-threatening conditions; the pathology underlying different categories of shock; treatment of hypovolemic, inflammatory, compressive/obstructive, neurogenic, and cardiogenic shock; management based on information obtained from invasive monitoring; management with the goal of increased generation and transmission of energy; and management with the goal of minimizing edema and myocardial oxygen requirements. Tables describe mechanical energy in selected components of the cardiovascular system during the cardiac cycle, clinical markers of possible shock state, and treatable conditions that can kill quickly. Figures depict pressure in the aortic root, the pressure-volume relationship for the left ventricle over an entire cardiac cycle, pressure-volume loops, the pulmonary artery catheter, the effects of ventilation, the snap test, and catheter whip. An algorithm shows the approach to a patient in apparent shock.

      This review contains 8 figures, 3 tables, and 44 references.

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    • 4

      Mechanical Ventilation

      By Adrian A. Maung, MD, FACS; Lewis J. Kaplan, MD, FACS, FCCM, FCCP
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      Mechanical Ventilation

      • ADRIAN A. MAUNG, MD, FACSAssistant Professor of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Department of Surgery, Yale University School of Medicine, New Haven, CT
      • LEWIS J. KAPLAN, MD, FACS, FCCM, FCCPAssociate Professor of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Department of Surgery, Yale University School of Medicine, New Haven, CT

      This review is designed to enable the reader to manage the fundamentals of mechanical ventilation in both the emergent and the nonemergent setting. Physiology is described and includes spontaneous negative pressure respiration, positive pressure ventilation, and pressure-volume relation. Both conventional and advanced methods of ventilation are defined. Adjuncts such as prone positioning, nitric oxide, heliox, rib fracture plating, bronchoscopy, and sedation (including analgesia and neuromuscular blockage), and the use of beta agonists and magnesium is described. Approaches include those that are patient status-guided, for patients without lung injury, for at-risk patients, and for patients who have or who develop ALI/ARDS. Special problems in mechanical ventilation include chronic obstructive pulmonary disease, asthma, bronchopleural fistula, pleural space collections, abdominal and thoracic compartment syndrome, and pregnancy. A table shows the modes of ventilation. Figures show static and dynamic pressure-volume curves, a comparison of waveforms, mechanisms of gas exchange in high-frequency oscillation ventilation, and prone positioning. This review contains 83 references.

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    • 5

      Multiple Organ Dysfunction Syndrome

      By Vishal Bansal, MD, FACS; Jay Doucet, MD, FACS, FRCSC
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      Multiple Organ Dysfunction Syndrome

      • VISHAL BANSAL, MD, FACSAssociate Professor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA
      • JAY DOUCET, MD, FACS, FRCSCProfessor of Surgery, Division of Trauma, Surgical Critical Care and Burns, Department of Surgery, UC San Diego Health System, San Diego, CA

      The concept of and approach to multiple organ dysfunction syndrome (MODS), also known as progressive systems failure, multiple organ failure, and multiple system organ failure, have evolved over the last decade. Characterized by progressive but potentially reversible tissue damage and dysfunction of two or more organ systems that arise after a significant physiologic insult and its subsequent management, MODS evolves in the wake of a profound disruption of systemic homeostasis. Pre-existing illness, nutritional status, hospital course, and genetic variation all lead to the development of organ dysfunction in patients exposed to these risk factors. The ultimate outcome from MODS is influenced not only by a patient’s genetic and biological predisposition but also by specific management principles practiced by intensivists. This review details the clinical definitions, quantification, prevention, evaluation, support, and outcomes of organ dysfunction. A figure shows the increasing severity of organ dysfunction correlated with increasing intensive care unit mortality, and an algorithm details the approach to MODS. Tables list risk factors and prognosis for MODS, the multiple organ dysfunction (MOD) score, the sequential organ failure assessment (SOFA) score, intensive care unit interventions that reduce mortality or attenuate organ dysfunction along with unproven or disproven ICU interventions, and the temporal evolution of MODS.

      This review contains 1 figure, 7 tables, and 159 references.

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    • 6

      Pulmonary Insufficiency and Respiratory Failure

      By Bruce Chung, MD; J. Jason Hoth, MD, PhD, FACS
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      Pulmonary Insufficiency and Respiratory Failure

      • BRUCE CHUNG, MD
      • J. JASON HOTH, MD, PHD, FACSAssociate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC

      Pulmonary insufficiency is the most common complication after surgical procedures. From minor atelectasis to acute respiratory distress syndrome (ARDS), postoperative pulmonary insufficiency occurs in up to 50% of surgeries. Here we discuss the anatomy, mechanics, and pathophysiology of pulmonary insufficiency; preoperative and postoperative assessment of lung function; and treatment for pulmonary insufficiency with regard to atelectasis, pulmonary edema, and ARDS. Pulmonary insufficiency secondary to cardiac disease, thromboembolism, and central nervous system depression are discussed elsewhere. Preoperative identification of risk factors for pulmonary insufficiency and understanding the physiologic changes in the perioperative period can potentially mitigate postoperative respiratory failure.

       

      Key Advances

      1. Berlin definition of acute respiratory distress syndrome (ARDS)
      2. Use of pulmonary prehabilitation programs to optimize pulmonary function in elective surgery
      3. Advances in the understanding of ARDS and ventilation and treatment strategies in ARDS
      4. Recognition of pulmonary contusion and chest trauma as a significant risk factor for pulmonary insufficiency and the need for aggressive management early in the hospital course
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    • 7

      Hepatic Failure

      By Juan R. Sanabria, MD, MSc, FACS
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      Hepatic Failure

      • JUAN R. SANABRIA, MD, MSC, FACSAdjunct Associate Professor of Surgery, Nutrition and Preventive Medicine, Case Western Reserve University, Cleveland, OH, Professor of Surgery, Roslyn Franklin School of Medicine, Chicago University, Cancer Treatment Centers of America

      Hepatic failure continues to be a frequent and major cause of morbidity and mortality in critically ill patients. Hepatic failure may be encountered as an instance of primary organ failure caused by a liver-specific disease process, caused by a liver therapeutic intervention, or as part of the multiple organ dysfunction syndrome. Advances in critical care, the increasing use of sophisticated diagnostic modalities, and the adoption of a team approach to patient care have resulted in improved overall outcomes. This review outlines clinical evaluation and investigative studies related to liver disease and the management of acute liver failure and chronic liver disease, including classification, assessment of prognosis, treatment of complications, multidisciplinary medical therapy, and liver transplantation. The mechanism of hepatic encephalopathy and bioartificial liver support systems are also discussed. Tables describe liver disease risk factors, six major components in initial management of a patient with hepatic failure, etiology of acute liver failure, King’s College Hospital prognostic criteria predicting poor outcome for patients with fulminant hepatic failure (FHF), liver transplant evaluation and workup for FHF patients, etiology of chronic liver disease, common indications for liver transplantation, differentiation of spontaneous bacterial peritonitis from secondary bacterial peritonitis through analysis of ascitic fluid, the Glasgow Coma Scale, differentiation of hepatorenal syndrome from acute tubular necrosis, complications of parenteral nutrition, contraindications to liver transplantation, and the Child-Turcotte-Pugh scoring system. Figures show a transcutaneous intrahepatic portosystemic shunt, a patient with ascites, grading of portosystemic encephalopathy, etiology of liver disease among patients waiting for liver transplantation, estimated 3-month survival as a function of the Model for End-Stage Liver Disease score, and a hypervascular hepatocellular carcinoma of the left liver. An algorithm shows the approach to the patient with liver failure.

      This review contains 6 figures, 13 tables, and 135 references.

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    • 8

      Acute Kidney Injury

      By Aileen Ebadat, MD; Eric Bui, MD; Carlos V.R. Brown, MD
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      Acute Kidney Injury

      • AILEEN EBADAT, MDChief Resident, Department of Surgery, Dell Medical School, University of Texas at Austin, Austin, TX
      • ERIC BUI, MDSurgical Critical Care Fellow, Department of Surgery, Los Angeles County-University of Southern California, Los Angeles, CA
      • CARLOS V.R. BROWN, MDAssociate Professor, Department of Surgery, Dell Medical School University of Texas at Austin, Trauma Medical Director, University, Medical Center Brackenridge, Austin, TX

      Acute renal failure definitions have changed dramatically over the last 5 to 10 years as a result of criteria established through the following consensus statements/organizations: RIFLE (Risk, Injury, Failure, Loss of function, End stage renal disease), AKIN (Acute Kidney Injury Network), and KDIGO (Kidney Disease: Improving Global Outcomes). In 2002, the Acute Dialysis Quality Initiative was tasked with the goal of establishing a consensus statement for acute kidney injury (AKI). The first order of business was to provide a standard definition of AKI. Up to this point, literature comparison was challenging as studies lacked uniformity in renal injury definitions. Implementing results into evidence-based clinical practice was difficult. The panel coined the term “acute kidney injury,” encompassing previous terms, such as renal failure and acute tubular necrosis. This new terminology represented a broad range of renal insults, from dehydration to those requiring renal replacement therapy (RRT). This review provides an algorithmic approach to the epidemiology, pathophysiology, diagnosis, prevention, and management of AKI. Also discussed are special circumstances, including rhabdomyolysis, contrast-induced nephropathy, and hepatorenal syndrome. Tables outline the AKIN criteria, most current KDIGO consensus guidelines for definition of AKI, differential diagnosis of AKI, agents capable of causing AKI, treatment for specific complications associated with AKI, and options for continuous RRT. Figures show the RIFLE classification scheme and KDIGO staging with prevention strategies.

      This review contains 1 management algorithm, 2 charts, 6 tables, and 77 references.

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    • 9

      Brain Failure and Brain Death

      By Robert Hendry, MD; David Crippen, MD, FCCM
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      Brain Failure and Brain Death

      • ROBERT HENDRY, MDChief Neurology Resident, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA
      • DAVID CRIPPEN, MD, FCCMProfessor of Critical Care Medicine, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA

      As a type of organ system failure, brain failure invariably affects consciousness. Based on physical examination, altered consciousness may be described in various stratified states of severity, culminating in brain death. Multimodal monitoring of cerebral function may be helpful in supplementing the physical examination when assessing brain failure. The pathophysiology of brain failure is briefly reviewed, and the unique relationship between cardiac arrest and brain failure is considered. Brain failure can independently produce a wide-ranging set of deleterious effects on extracerebral organ systems. Definitions of death based on both cardiovascular and neurologic criteria are addressed, and the issue of whole-brain death as equivalent to traditional notions of death is discussed.

      This review contains 2 figures, 2 tables, and 76 references.

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    • 10

      Coma, Cognitive Impairment, and Seizures

      By Melissa H. Coleman, MD; Ali Salim, MD
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      Coma, Cognitive Impairment, and Seizures

      • MELISSA H. COLEMAN, MDSurgical Critical Care Fellow, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA
      • ALI SALIM, MDDivision Chief, Division of Trauma, Burn, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA

      When a patient presents with altered mental status, it is critical to assess the patient in a systematic manner to diagnose and treat the underlying cause. A careful history, a rapid and focused neurologic examination, laboratory testing, and radiologic imaging all aid in achieving a diagnosis. Once initial stabilization of the patient has been achieved, management of coma is determined by the specific underlying etiology, precipitating condition, or acute event. It is critical to accomplish rapid assessment of coma, especially identifying reversible causes, which are in an effort to improve outcome. This review is intended to be an introductory overview of disorders of consciousness that also provides a practical and streamlined approach to the diagnosis and management of coma and seizures. To that end, an algorithmic approach to diagnosis is formulated, general treatment measures for comatose patients are outlined, specific causes of coma are reviewed, and prognostic issues are considered. Tables outline the differential diagnosis of coma, Glasgow Coma Scale, focused neurologic examination (coma examination), general physical examination, Full Outline of UnResponsiveness (FOUR) score, and questions and possible causes when considering coma history. A noncontrast head computed tomographic scan suggesting basilar artery occlusion is provided.

      This review contains 1 management algorithm, 1 computed tomographic scan, 6 tables, and 23 references

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    • 11

      Glycemic Control in the Intensive Care Unit

      By Eden A. Nohra, MD; Grant V. Bochicchio, MD, MPH, FACS
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      Glycemic Control in the Intensive Care Unit

      • EDEN A. NOHRA, MDResearch Coordinator, Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO
      • GRANT V. BOCHICCHIO, MD, MPH, FACSEdison Professor of Surgery, Chief of Acute and Critical Care Surgery, Washington University in St. Louis School of Medicine, St. Louis, MO

      The human body is programmed to maintain constant homeostasis of all body systems through a complex neuroendocrine and autonomic network. Through a variety of exaggerated autonomic and cytokine responses, illness and injury alter this homeostasis. Mechanisms that are impaired include glucose cellular transport and peripheral and hepatic insulin uptake. Over the past several decades, numerous reports have described the deleterious effects of glucose variability and hyperglycemia. In a randomized prospective study of critically ill patients, Van den Berghe first reported that intensive glucose control (≤ 110 mg/dL) significantly decreased morbidity and mortality. This study was a catalyst for a multitude of subsequent reports evaluating the effects of glycemic control in other patient populations. This review focuses on the pathophysiology of hyperglycemia in critical illness, and then summarizes the recent literature on glucose control. Tables outline the mortality benefit of intensive insulin therapy in surgical and medical intensive care unit patients in relation to duration of application, and functions of the first four glucose transporters. An illustration depicts insulin binding to the insulin receptors on the cell membrane surface.

      This review contains 1 figure, 2 tables, and 103 references.

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    • 12

      Coagulation Disorders

      By Eric M. Campion, MD; Mitchell J. Cohen, MD
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      Coagulation Disorders

      • ERIC M. CAMPION, MDTrauma and Surgical Critical Care Fellow, Department of Surgery, University of California, San Francisco, San Francisco, CA
      • MITCHELL J. COHEN, MDProfessor of Surgery in Residence, Department of Surgery, University of California, San Francisco, San Francisco, CA

      There are multiple congenital and acquired disorders of coagulation that may result in unplanned bleeding or clotting. These disorders can result in an increase in morbidity and mortality to surgical patients. Unexpected bleeding during and after surgery can be prevented by having an adequate understandings of these entities and by being aware of the available treatment options. In addition to awareness of bleeding disorders, it is important to recognize the risks associated with disorders predisposing patients to clotting, or thrombophilias. This review discusses the major inherited disorders of the coagulation cascade resulting in bleeding or clotting tendencies in relation to surgical patients. von Willebrand Disease (vWD), hemophilia A, hemophilia B, hemophilia C, acute coagulopathy of trauma, disseminated intravascular coagulation (DIC), uremic bleeding, bleeding in cirrhosis, clotting disorders, and acquired thrombophilias are covered. Tables list the classification and differentiation of vWD, correlation of factor VIII coagulant activity level with bleeding patterns in hemophilia, causes of DIC, frequency and relative risk of venous thrombosis in hypercoagulable states, inherited and acquired hypercoagulable states, clinical features that suggest thrombophilia, screening tests for patients with suspected hypercoagulable state, and pretest probability of heparin-induced thrombocytopenia. Figures depict the clinical presentation of DIC, procoagulant and anticoagulant pathways, normal factor V and factor V Leiden, and heparin-induced thrombocytopenia.

      This review contains 4 figures, 8 tables, and 51 references.

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    • 13

      Stress Response and Endocrine Deregulation During Critical Illness

      By Paul E. Marik, MD, FCCP, FCCM
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      Stress Response and Endocrine Deregulation During Critical Illness

      • PAUL E. MARIK, MD, FCCP, FCCMEastern Virginia Medical School, Norfolk, VA

      The stress system receives and integrates a diversity of cognitive, emotional, neurosensory, and peripheral somatic signals that arrive through distinct pathways. Activation of the stress system leads to behavioral and physical changes that are remarkably consistent in their qualitative presentation. The stress response is mediated largely by the hypothalamic-pituitary-adrenal (HPA) axis and the sympathoadrenal system, which includes the sympathetic nervous system and the adrenal medulla. The stress response is normally adaptive and time limited and improves the chances of the individual for survival. The time-limited nature of this process renders its accompanying antigrowth, antireproductive, catabolic, and immunosuppressive effects temporarily beneficial and/or of no adverse consequence to the individual. However, chronic activation of the stress system as occurs in critically ill patients may lead to a number of disorders, including stress hyperglycemia, dysfunction of the HPA and hypothalamic-pituitary-thyroid (HPT) axes, and hypothalamic-pituitary growth hormone (GH) dysfunction. These disorders are reviewed in this chapter. Diagnosis of adrenal insufficiency/critical illness–related corticosteroid insufficiency and who to treat with steroids are also covered in depth. The author emphasizes the controversial management of these deregulated hormonal axes with only limited data supporting an improvement in outcome with hormonal replacement therapy.

      This review contains 3 Figures, 1 Table, 39 References, 5 Board-Styled MCQs, and a Teaching Slide Set for teaching and reference purposes.

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    • 14

      Hospital Infections

      By E. Patchen Dellinger, MD; Erik G. Van Eaton, MD; Heather L. Evans, MD, MS
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      Hospital Infections

      • E. PATCHEN DELLINGER, MDProfessor and Vice-Chair, Department of Surgery, University of Washington, Chief, Division of General Surgery, University of Washington Medical Center, Seattle, WA
      • ERIK G. VAN EATON, MDAssistant Professor of Surgery, University of Washington, Seattle, WA
      • HEATHER L. EVANS, MD, MSDepartment of Surgery, University of Washington, Seattle, WA

      Nosocomial infections are a threat to all hospitalized patients. They can increase morbidity, mortality, length of stay, and costs and occur in almost every body site. This review features an algorithmic approach to the risk, detection, and treatment of nosocomial infections. Respiratory infections include pneumonia, tracheitis or tracheobronchitis, paranasal sinusitis, and otitis media. Operative site or injury-related infections include those occurring in wounds, the intra-abdominal space, methicillin-resistant Staphylococcus aureus (MRSA), empyema, posttraumatic meningitis, osteomyelitis, and sternal and mediastinal infection. A review of intravascular device--associated infection focuses on catheter-related bacteremia and its management. Catheter-associated urinary tract infections (UTIs) and enteric infections are also considered. Enteric infections and transfusion-associated infections are covered in depth, reviewing the most important recent advances and studies. A discussion of postoperative fever addresses the magnitude and incidence of hospital infections, UTIs, and catheter duration and pathogens typically involved and considers the associated costs and the risks of acquiring a nosocomial infection.

      This review contains 5 figures, 1 table,1 algorithm, and 292 references.

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    • 15

      Intra-abdominal Infection

      By Zachary C. Dietch, MD; Puja M. Shah, MD, MS; Robert G. Sawyer, MD, FACS, FIDSA, FCCM
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      Intra-abdominal Infection

      • ZACHARY C. DIETCH, MDDepartment of Surgery, Charlottesville, VA, Puja M. Shah, MD, MS, Department of Surgery, Charlottesville, VA
      • PUJA M. SHAH, MD, MSDepartment of Surgery, Charlottesville, VA
      • ROBERT G. SAWYER, MD, FACS, FIDSA, FCCMProfessor, Department of Surgery, University of Virginia, Charlottesville, VA

      The basic principles of rapid diagnosis, timely physiologic support, and definitive intervention for intra-abdominal infections have remained unchanged over the past century; however, specific management of these conditions has been transformed as a result of numerous advances in technology. This review covers clinical evaluation, investigative studies, options for intervention, early source control and duration of antimicrobial therapy, infections of the upper abdomen, infections of the lower abdomen, other abdominal infections, and special cases.Figures show an algorithm outlining the approach to a suspected upper abdominal infection, abnormal abdominal ultrasounds showing calculi in the gallbladder and confirming the diagnosis of acute acalculous cholecystitis, endoscopic retrograde cholangiopancreatographies showing a distal common bile duct stone in acute pancreatitis, extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and endoscopic sphincterotomy for acute biliary decompression in acute obstructive cholangitis, air outlining the gallbladder and bile ducts in emphysematous cholecystitis, abdominal and pelvic CT scans showing pancreatic findings graded by Ranson into five categories, a splenic abscess, an inflamed and thickened appendix with surrounding fat stranding, appendiceal perforation and abscess formation, diverticulitis with a small amount of extraluminal air, left lower quadrant fluid collection consistent with peridiverticular abscess, diffuse inflammation and right upper quadrant extraluminal air, and thickening of the colonic wall with both intramural and extramural air, an algorithm outlining the approach to the patient with a suspected lower abdominal infection, upright chest x-ray and abdominal CT scans of patients with sudden-onset diffuse abdominal pain, and an omental (Graham) patch. Tables list diagnostic indicators of upper abdominal pain and fever, comparison of acute cholecystitis and emphysematous cholecystitis, Hinchey system for classification of perforated diverticulitis, Centers for Disease Control and Prevention (CDC) guidelines for diagnosis of pelvic inflammatory disease, and CDC guidelines for antibiotic treatment of pelvic inflammatory disease.

      This review contains 16 highly rendered figures, 5 tables, and 238 references

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    • 16

      Electrolytes

      By Matthew R. Rosengart, MD, MPH
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      Electrolytes

      • MATTHEW R. ROSENGART, MD, MPHAssociate Professor, Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA

      Cell function and thus life depend on the preservation of several electrochemical gradients. Evolutionary pressures have developed several regulatory mechanisms, the penultimate goal of which is to maintain total body and distribution of each electrolyte within the intracellular and extracellular compartments at concentrations compatible with life. Ultimately, patient survival depends on this balance despite the continual changes imposed by both internal physiologic processes and external stressors. During periods of critical illness, however, these mechanisms can be overwhelmed, necessitating additional support. Indeed, disorders of electrolyte homeostasis are highly prevalent among intensive care unit patients, and severe disturbances are associated with elevated mortality. As has been previously learned, merely normalizing laboratory abnormalities without addressing the underlying pathophysiology does little to improve outcome. Thus, for those providing this care, an in-depth understanding of the biochemistry and physiology of electrolyte disorders and a systematic approach to diagnosis and therapy are complementary components essential for patient survival. This chapter discusses the major electrolytes—sodium, potassium, calcium and phosphate, and magnesium—and covers the hyper- and hypodeficiencies and disturbances for each electrolyte.

      This review contains 7 Figures, 6 Tables, 5 Etiologic Algorithms, and 106 References.

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    • 17

      Metabolic Response to Critical Illness

      By Palmer Q. Bessey, MD
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      Metabolic Response to Critical Illness

      • PALMER Q. BESSEY, MDProfessor, Department of Surgery, Weill Medical College of Cornell University, and Associate Director, William Randolph Hearst Burn Center, New York Presbyterian Hospital-Cornell Medical Center

      A wide variety of factors and processes are involved in the metabolic response to critical illness; this chapter reviews some of these factors and metabolic responses in the critically ill surgical patient to help the clinician minimize patient debility. The features of critical illness that can cause debility include wounds, pain, inflammation, infection, and iatrogenic factors. The three major features of the metabolic response are discussed: the hyperdynamic or hypermetabolic state, muscle wasting, and glucose intolerance. Other topics considered include altered temperature regulation, the role of the central nervous system, the role of the gut, manipulating the response to critical illness, altered protein metabolism, altered carbohydrate metabolism, and systemic mediators (e.g., hormones and cytokines). This review contains five figures, eight tables, and 254 references.

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    • 18

      Molecular and Cellular Mediators of the Inflammatory Response

      By Amy T. Makley, MD; Michael D. Goodman, MD; Timothy A. Pritts, MD, PhD
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      Molecular and Cellular Mediators of the Inflammatory Response

      • AMY T. MAKLEY, MDAssistant Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH
      • MICHAEL D. GOODMAN, MDAssistant Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH
      • TIMOTHY A. PRITTS, MD, PHDAssociate Professor, Department of Surgery, University of Cincinnati, Cincinnati, OH

      Inflammation is a highly complex process involving vascular, neurogenic, humoral, and cellular responses. Although the descriptive features of acute inflammation have long been known (i.e., heat, redness, pain, swelling), a single satisfactory definition of this phenomenon is still lacking. Successful therapy for inflammation rests not only on investigating the type of injury, but also on the timing of the intervention. This review focuses on humoral and cellular responses to injury, defining essential and interrelated inflammatory pathways. Systemic inflammatory response system (SIRS), in relation to sepsis syndrome, is defined by the global proinflammatory physiologic response to a stimulus. In contrast, compensatory antiinflammatory response (CARS) results from a predominant antiinflammatory response to an insult, also causing immunosuppression and increased susceptibility to infection. Also discussed are the roles of cytokines, adhesion molecules, inflammatory cells such as neutrophils, mast cells, and lymphocytes, extracellular vesicles, sphingolipids, reactive oxygen metabolites, nitric oxide, the complement cascade, and eicosanoids. Therapeutic implications and trials are examined in relation to cytokines in SIRS and CARS, activated protein C, and inflammatory bowel disease.

      This review contains 11 figures, 4 tables, and 79 references.

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    • 19

      Postoperative and Ventilator-associated Pneumonia

      By Craig M. Coopersmith, MD, FACS; Marin H. Kollef, MD
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      Postoperative and Ventilator-associated Pneumonia

      • CRAIG M. COOPERSMITH, MD, FACSProfessor of Surgery, Department of Surgery and Emory Center for Critical Care, Emory University School of Medicine, Atlanta, GA
      • MARIN H. KOLLEF, MDProfessor of Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO

      Pneumonia is the third most common postoperative infection, after urinary tract infection and surgical site infection. In critically ill patients, the respiratory tract is the most common site of nosocomial infection, and in the intensive care unit can account for up to nearly half of all nosocomial infections. This review describes the pathogenesis, incidence, and risk factors of both postoperative pneumonia and ventilator-associated pneumonia. Diagnosis and management are described, which includes antibiotic therapy and adjunct treatments. Treatment failure is also addressed. Tables include preoperative predictors of postoperative pneumonia, the Centers for Disease Control and Prevention/National Healthcare Safety Network definition for pneumonia, and diagnostic techniques used in diagnosis of ventilator-associated pneumonia. An algorithm outlines the recommended approach to antibiotic treatment of suspected pneumonia after operation. This review contains 111 references.

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    • 20

      Severity of Illness Scoring Systems in Critical Care

      By Mark T. Keegan, MD
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      Severity of Illness Scoring Systems in Critical Care

      • MARK T. KEEGAN, MDAssociate Professor, Department of Anesthesiology, Division of Critical Care, Mayo Clinic, Rochester, MN

      Critical care consumes about 4% of national health expenditure and 0.65% of United States gross domestic product. There are approximately 94,000 critical care beds in the United States, and provision of critical care services costs approximately $80 billion per year. The enormous costs and the heterogeneity of critical care have led to scrutiny of patient outcomes and cost-effectiveness by a variety of governmental and nongovernmental organizations; furthermore, individual critical care practitioners and their hospitals should evaluate the care delivered. This review discusses scoring systems in medicine, critical care systems, development, validation, performance, and customization of the models, adult intensive care unit (ICU) prognostic models, model use, limitations, prognostic models in trauma care, perioperative scoring systems, assessment of organ failure, severity of illness and organ dysfunction scoring in children, and future directions. Figures show the distribution of predicted risk of death using two different prediction models among a population of patients who ultimately are observed to either live or die, a comparison of  “expected” deaths (based on the expectation that the predicted probability from the model is correct) to observed deaths within each of the 10 deciles of predicted risk, the importance of disease in the risk of death equation,  and the revised Rapaport-Teres graph for ICUs in the Project IMPACT validation set. Tables list three main ICU prognostic models, study characteristics and performance of the fourth-generation prognostic models, variables included in the fourth-generation prognostic models, potential uses of adult ICU prognostic models, variables included in the calculation of the organ failure scores, and sequential organ failure assessment.

       

      This review contains 4 highly rendered figures, 6 tables, and 293 references

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    • 21

      Quality Improvement in the Surgical Intensive Care Unit

      By Mark R. Hemmila, MD; Wendy L. Wahl, MD
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      Quality Improvement in the Surgical Intensive Care Unit

      • MARK R. HEMMILA, MDProfessor of Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, MI
      • WENDY L. WAHL, MDVice Chair of Surgery, Department of Surgery, Medical Director for Surgical Quality, Saint Joseph Mercy Health System, Ann Arbor, MI

      Programs to support clinical benchmarking of surgical outcomes have grown dramatically over the past decade. Selection of an appropriate project and preplanning with regard to strategy are often more important than management skill alone when undertaking and performing successful quality improvement in the intensive care unit (ICU) setting. This review covers an overview of a medical and surgical quality system, development of an ICU quality improvement program, scoring systems: risk assessment, evidence-based medicine and protocols, and a quality improvement framework. Figures show structure of the ICU quality improvement team, the C-index statistic reflecting the ability of a model to predict which patients will have the outcome of interest, a Shewhart statistical process control chart, venous thromboembolism (VTE) events by report number, and changes in the type of VTE prophylaxis agent administered over time.  Tables list Blue Cross Blue Shield of Michigan/Blue Care Network-sponsored, registry-based collaborative quality initiatives, critical care societies’ collaborative-based quality improvement task force priorities for performance measurement, possible ICU quality measures, predictive scoring systems, and multivariate and propensity score analysis of the Michigan Trauma Quality Improvement Program pilot data for VTE events and type of VTE prophylaxis.

       

      This review contains 5 highly rendered figures, 5 tables, and 59 references

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    • 22

      Principles of Empiric and Therapeutic Antimicrobial Therapy

      By Paul Waltz, MD; Matthew R. Rosengart, MD, MPH; Brian S. Zuckerbraun, MD
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      Principles of Empiric and Therapeutic Antimicrobial Therapy

      • PAUL WALTZ, MDGeneral Surgery Resident, Department of Surgery, University of Pittsburgh, Pittsburgh, PA
      • MATTHEW R. ROSENGART, MD, MPHAssociate Professor, Department of Surgery, Surgery and Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
      • BRIAN S. ZUCKERBRAUN, MDHenry T. Bahnson Professor of Surgery, Chief, Section of Trauma and Acute Care Surgery, Department of Surgery, University of Pittsburgh Medical Center, Chief, General Surgery Service, VA Pittsburgh Healthcare System, Pittsburgh, PA

      The goal of this review is to discuss basic principles for the appropriate use of antibiotics in the surgical patient, largely focusing on the treatment of intra-abdominal infections. Limited pharmacologic data on common antibiotics are provided. Current reference sources and institutional guidelines should be used for specifics on dosing and administration. This review covers general principles, including treatment of surgical infections, laboratory tests, pharmacokinetics and pharmacodynamics, adverse reactions, antimicrobial resistance, and antibiotic prophylaxis in surgical patients. In addition,  specific considerations of appropriate antimicrobial therapy, such as acute cholecystitis/cholangitis, pancreatitis, appendicitis, diverticulitis, Clostridium difficile, and skin and soft tissue infections are presented. Tables list high-risk factors in intra-abdominal infections, empirical antibiotic based on risk stratification for the treatment of community-acquired intra-abdominal infections, dose adjustments for obese patients, most common isolated pathogens from intra-abdominal infections, 2005–2010, with resistance trends, adaptation of Tokyo guidelines on severity scoring and recommended antimicrobial therapy,  and recommended antibiotics for necrotizing soft tissue infections.

      This review contains 6 tables and 56 references

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  • Gastrointestinal Tract and Abdomen
    • 1

      Abdominal Pain and Abdominal Mass

      By Blake D. Babcock, MD; Mohammad F. Shaikh, MD; Alexander E. Poor, MD; Wilbur B. Bowne, MD
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      Abdominal Pain and Abdominal Mass

      • BLAKE D. BABCOCK, MDSurgical Resident, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
      • MOHAMMAD F. SHAIKH, MDSurgical Resident, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA
      • ALEXANDER E. POOR, MDAssociate Director of Research, Department of Surgery, Vincera Institute, Philadelphia, PA
      • WILBUR B. BOWNE, MDAssociate Professor of Surgery, Department of Surgery, Drexel University College of Medicine, Philadelphia, PA

      Acute abdominal pain and abdominal mass are intimately connected; therefore, the diagnostic process for evaluating abdominal pain and abdominal masses is largely the same and has been preserved since ancient times. The primary goals in the management of patients with abdominal pain and/or abdominal mass are to establish a differential diagnosis by obtaining a clinical history, to refine the differential diagnosis with a physical examination and appropriate studies, and to determine the role of operative intervention in the treatment or refinement of the working diagnosis. This review describes the process of diagnosing abdominal pain, including taking a clinical history and performing a physical examination. Investigative studies, including laboratory tests, imaging, and pathology are reviewed. Management, including surgical treatment, is discussed. Tables describe intraperitoneal and extraperitoneal causes of acute abdominal pain, frequency of specific diagnoses in patients with acute abdominal pain, and common abdominal signs and findings noted on physical examination. Figures show abdominal pain in specific locations, a data sheet, the differential diagnosis of an abdominal mass by quadrant or region, characteristic patterns of abdominal pain, acute appendicitis with associated appendicolith, bilateral adrenal masses, adrenocortical carcinoma, retroperitoneal leiomyosarcoma, pancreatic mass, a sagittal ultrasonogram of the pancreas, ultrasonograms of the liver, a dark and well circumscribed abdominal mass, gastroesophageal junction adenocarcinoma, and percutaneous biopsy of a large abdominal mass. An algorithm outlines the assessment of acute abdominal pain and abdominal mass.

      This review contains 14 figures, 5 tables, and 143 references.

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    • 2

      Jaundice

      By Harry Lengel, BA; Harish Lavu, MD, FACS
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      Jaundice

      • HARRY LENGEL, BAMember, Sidney Kimmel Medical College, Department of Surgery, Thomas Jefferson University, Philadelphia, PA
      • HARISH LAVU, MD, FACSAssociate Professor of Surgery, Department of Surgery, Thomas Jefferson University, Philadelphia, PA

      The term jaundice refers to the yellowish-orange discoloration of skin, sclerae, and mucous membranes that results from excessive deposition of bilirubin in the tissues. A problem-based approach to the jaundiced patient that involves assessing the incremental information provided by successive clinical and laboratory investigations, as well as the information obtained by means of modern imaging techniques, is key. Current decision making in the approach to the jaundiced patient should include not only careful evaluation of anatomic issues but also close attention to patient morbidity and quality-of-life concerns, as well as a focus on a cost-effective diagnostic workup. For optimal treatment, an integrated approach that involves the surgeon, gastroenterologist, and radiologist is essential. This review covers terminology and epidemiology, clinical evaluation and investigative studies, workup and management of posthepatic jaundice, and postoperative jaundice. Figures show magnetic retrograde cholangiopancreatogram of a dilated extrahepatic biliary tree, pancreas protocol computed tomographic coronal image demonstrating a dilated extrahepatic biliary tree, endoscopic retrograde cholangiopancreatography (ERCP), transhepatic cholangiography and magnetic resonance cholangiopancreatography evaluation of  missing liver segments, ERCP demonstrating extrinsic compression of the common hepatic duct by a stone in the Hartmann pouch, and postoperative ERCP of the biliary tree demonstrating contrast extravasation from the cystic duct stump. Tables list causes of prehepatic jaundice, causes of hepatic jaundice, and causes of posthepatic jaundice.

       

      This review contains 5 highly rendered figures, 3 tables, and 139 references

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    • 3

      Intestinal Obstruction

      By Phillip A. Bilderback, MD; Ryan K. Smith, BA; W. Scott Helton, MD, FACS
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      Intestinal Obstruction

      • PHILLIP A. BILDERBACK, MDVirginia Mason Medical Center, Seattle, WA
      • RYAN K. SMITH, BAVirginia Mason Medical Center, Seattle, WA
      • W. SCOTT HELTON, MD, FACSVirginia Mason Medical Center, Seattle, WA

      Intestinal obstruction is a common medical problem and accounts for a large percentage of surgical admissions for acute abdominal pain. Because one of the most difficult tasks in general surgery is deciding when to operate on a patient with intestinal obstruction, this chapter outlines the approaches needed for this difficult decision. The steps of a thorough clinical evaluation are described, including the taking of a complete history and performing a physical examination of the abdomen. Investigative studies are discussed and include standards for imaging and laboratory tests as well as adjunctive tests for equivocal situations. Classification of obstruction is defined (mechanical versus nonmechanical), as is the potential need for operation (immediate, urgent, delayed, or no). Strategies for reducing the overall cost of managing patients with intestinal obstruction are outlined. Figures show a complete small bowel obstruction; an acute colonic pseudo-obstruction; postoperative ileus; a complete small bowel obstruction; massive sigmoid volvulus; cecal volvulus; a complete colonic obstruction; a partial small bowel obstruction; an adhesive partial small bowel obstruction; an early closed-loop small bowel obstruction; an incarcerated/strangulated bowel in right inguinal hernia; a partial small bowel obstruction contrast; an algorithm outlining an approach to management of ileus; and an algorithm outlining an approach to management of pseudo-obstruction. Tables list the causes of ileus; causes of small bowel obstruction in adults; causes of colonic obstruction; and guidelines for operative and nonoperative therapy.

      This review includes 15 Images, 3 Management Algorithms, 6 Tables, and 114 References.

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    • 4

      Upper Gastrointestinal Bleeding

      By Matthew B. Singer, MD; Andrew L. Tang, MD
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      Upper Gastrointestinal Bleeding

      • MATTHEW B. SINGER, MDAcute Care Surgery Fellow, Department of Surgery, Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona Medical Center, Tucson, AZ
      • ANDREW L. TANG, MDAssociate Professor of Surgery, Department of Surgery, Division of Trauma, Critical Care, Burns, and Emergency Surgery, The University of Arizona Medical Center, Tucson, AZ

      Despite continued advances in therapeutic endoscopy and potent medications to suppress acid production, upper gastrointestinal bleeding (UGIB), defined as bleeding that occurs proximal to the ligament of Treitz, continues to be a common reason for surgical consultation. UGIB results in considerable use of hospital resources, and carries a 2 to 14% mortality. This review covers presentation and initial management, clinical evaluation, risk stratification, investigative tests, and discussion and management of specific sources of UGIB. Figures show an algorithm for management of bleeding from duodenal or gastric ulcers, a technique for duodenotomy and three-point ligation of a bleeding duodenal ulcer, anatomic locations of gastric ulcers according to the modified Johnson classification, and an algorithm for management of bleeding from esophageal  or gastric varices. Table list the Glasgow Blatchford prediction score for UGIB, the AIMS65 prediction score for UGIB, the Rockall prediction score for UGIB, and the Forrest classification for stigmata of recent hemorrhage used to evaluate bleeding ulcers and prevalence data for each class.

       

      This review contains 4 highly rendered figures, 4 tables, and 91 references

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    • 5

      Diseases of the Peritoneum and Retroperitoneum

      By Amanda K. Arrington, MD; Joseph Kim, MD
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      Diseases of the Peritoneum and Retroperitoneum

      • AMANDA K. ARRINGTON, MDAssistant Professor, Division of General Surgery, Department of Surgery, University of South Carolina, Columbia, SC
      • JOSEPH KIM, MDAssociate Professor of Surgical Oncology, Department of Surgery, City of Hope Cancer Center, Duarte, CA

      The peritoneum, which lines the innermost surface of the abdominal wall and the majority of the abdominal organs, consists of a layer of dense stroma covered on its inner surface by a single sheet of mesothelial cells. This review covers the anatomy and physiology of the peritoneum and retroperitoneum; diseases of the peritoneum, such as ascites, peritoneal infections, and benign and malignant peritoneal tumors; and diseases of the retroperitoneum, including retroperitoneal abscesses, fibrosis, and sarcoma. Tables list the abdominal components, principal causes of ascites, ascitic fluid analysis, causes of abscesses, causes of secondary bacterial peritonitis, peritoneal cancer index scoring to determine eligibility for hyperthermic intraperitoneal chemotherapy (HIPEC), open versus closed HIPEC techniques, and the American Joint Committee on Cancer 7th edition staging system for sarcoma. Figures show peritoneal components, retroperitoneal structures, radiologic findings that can result in bacterial peritonitis, tuberculosis peritonitis on laparoscopy, scalloping of the liver surface, a diagram of the HIPEC system, and placement of cannulas and closure techniques for the closed abdominal HIPEC procedure. Algorithms describe the development of ascites in cirrhotic patients and the evaluation for cytoreductive surgery and HIPEC.

      This review contains 13 figures, 8 tables, and 69 references.

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    • 6

      Surgical Treatment of Obesity and Metabolic Syndrome

      By Robert B. Dorman, MD, PhD; Sayeed Ikramuddin, MD, FACS
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      Surgical Treatment of Obesity and Metabolic Syndrome

      • ROBERT B. DORMAN, MD, PHDSurgical Resident, Department of Surgery, University of Minnesota, Minneapolis, MN
      • SAYEED IKRAMUDDIN, MD, FACSProfessor of Surgery, University of Minnesota, Minneapolis, MN

      Bariatric surgery has changed dramatically in the last several years. Over the last two decades, jejunoileal bypass and vertical banded gastroplasty have become obsolete. The Roux-en-Y gastric bypass has become the ?gold standard.? The quick rise of the adjustable gastric band has been overcome by the introduction of vertical sleeve gastrectomy (VSG). The biliopancreatic diversion with duodenal switch (DS) has maintained a small but constant presence. The number of laparoscopic gastric bypass operations exceeds that of open procedures according to national studies. Open procedures are associated with larger incisions, greater postoperative pain, a greater number of wound-related complications, and a higher incidence of both readmission and mortality. In addition, laparoscopic procedures achieve comparable weight loss. Preoperative considerations have significantly evolved. Topics include obstructive sleep apnea, cardiac disease, weight loss, and nutrition. The four operational techniques described are laparoscopic adjustable gastric banding, laparoscopic Roux-en-Y gastric bypass, laparoscopic VSG, and laparoscopic biliopancreatic diversion with DS. Lifelong care is the focus of postoperative care. Complications are described in detail, and dramatic improvement in perioperative mortality rates is emphasized by the authors. Adequate preoperative and postoperative care is essential to optimize outcome regardless of the procedure.

      This review includes 12 Figures, 4 Tables, and 90 References.

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    • 7

      Gastroesophageal Reflux Disease and Hiatal Hernia

      By James A. Rydlewicz, MD; Matthew R. Pittman, MD; Kyle A. Perry, MD
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      Gastroesophageal Reflux Disease and Hiatal Hernia

      • JAMES A. RYDLEWICZ, MDClinical Instructor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
      • MATTHEW R. PITTMAN, MDClinical Instructor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
      • KYLE A. PERRY, MDAssistant Professor of Surgery, Division of General and Gastrointestinal Surgery, The Ohio State University Wexner Medical Center, Columbus, OH

      Gastroesophageal reflux disease (GERD) is common, affecting approximately 18 to 27% of adult Americans, and can have a considerable impact on quality of life. Hiatal hernias are present in 80% of patients with symptomatic GERD. This review covers the basic pathophysiology, evaluation, and treatment algorithms for patients with GERD and hiatal hernia. Figures show normal gastroesophageal junction anatomy, treatment algorithm for patients with symptomatic GERD, schematic and endoscopic images of long segment Barrett esophagus, a normal barium esophagogram, esophageal intraluminal pressures assessed by esophageal manometry, test results from a 48-hour wireless pH study, laparoscopic Nissen fundoplication, laparoscopic gastroesophageal junction reinforcement, classification of paraesophageal hernia, and endoscopic view of Cameron ulcers at the level of the diaphragm in the setting of a type III paraesophageal hernia. Tables list risk factors for GERD and a standardized approach to Nissen fundoplication.

      This review contains 10 figures, 2 tables, and 58 references.

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    • 8

      Diagnosis and Management of Benign Gastric and Duodenal Disease

      By Gentian Kristo, MD; Thomas E. Clancy, MD
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      Diagnosis and Management of Benign Gastric and Duodenal Disease

      • GENTIAN KRISTO, MDAcute Care Surgery Fellow, Division of Trauma, Burns, and Surgical Critical Care, Brigham and Women’s Hospital, Boston, MA, Instructor, Harvard Medical School, Boston, MA
      • THOMAS E. CLANCY, MDAssociate Director, Pancreatic Cancer, Division of Surgical Oncology, Brigham and Women’s Hospital, Boston, MA, Medical Director, Multispecialty Surgical Oncology, Dana-Farber/Brigham and Women’s Cancer Center, South Shore Hospital, Boston, MA, Assistant Professor, Harvard Medical School, Boston, MA

      The diagnosis of uncomplicated peptic ulcers is difficult to make on a solely clinical basis. Whereas radiographic upper gastrointestinal (UGI) series remain useful, endoscopy is the most accurate method of establishing the diagnosis of peptic ulcer disease. Laboratory tests play an important role in the diagnosis of Helicobacter pylori infection and Zollinger-Ellison syndrome. Figures showing UGI series with double contrast and H. pylori organisms on gastric biopsy samples are provided. The improved medical management of peptic ulcer disease has decreased the need for surgical intervention, which is now largely reserved for urgent management of complications such as hemorrhage, bleeding, and perforation, or the management of obstruction from intractable disease. The appropriate extent of preoperative evaluation for a patient undergoing surgery for a benign gastroduodenal disorder is dictated primarily by the nature of the presenting problem. Endoscopy is the main diagnostic tool to identify the source of bleeding, and in many cases endoscopic therapy can control the bleeding. Angiographic transarterial embolization may be considered following failed endoscopic hemostasis, particularly in high-risk surgical patients. Operative planning is described. The steps of the operative technique, complications, and outcome evaluations are provided for the main surgical interventions for peptic ulcer disease, including vagotomy and pyloroplasty for bleeding duodenal ulcer; resection of bleeding gastric ulcer; omental patch for duodenal perforation (Graham patch); antrectomy; highly selective vagotomy; laparoscopic treatment of peptic ulcer disease; and duodenal diverticulectomy. Operative figures show a Kocher maneuver; omental patch; truncal vagotomy; highly selective vagotomy; Taylor procedure; Heineke-Mikulicz pyloroplasty; Finney pyloroplasty; Billroth I and II antrectomy; Braun enteroenterostomy; and duodenal diverticulectomy.

      This review contains 15 figures, 2 tables, and 43 references.

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    • 9

      Tumors of the Stomach and Small Bowel

      By L. Mark Knab, MD; David J. Bentrem, MD, FACS; Jeffrey D. Wayne, MD, FACS
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      Tumors of the Stomach and Small Bowel

      • L. MARK KNAB, MDGeneral Surgery Resident, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
      • DAVID J. BENTREM, MD, FACSHarold L. and Margaret N. Method Research Professor in Surgery, Associate Professor in Surgery, Division of Surgical Oncology, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL
      • JEFFREY D. WAYNE, MD, FACSAssociate Professor, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL

      The overall incidence of gastric carcinoma has decreased in the past few decades, but it remains the second leading cause of cancer death worldwide. Malignant tumors of the small intestine are rare, and account for fewer than 5% of all gastrointestinal tract malignancies. This review details the classification, risk factors, clinical evaluation, investigative studies, staging, management, and follow-up and management of recurrent disease in gastric adenocarcinoma; in addition, it examines nonadenocarcinomatous gastric malignancies and small bowel malignancies. Figures show American Joint Committee on Cancer staging T1, T2, T3, and T4 diagrams, computed tomographic scan of a patient with advanced gastric carcinoma, endoscopic ultrasonographic images of a T3 gastric neoplasm and the presence of suspicious perigastric (N1) nodes, an algorithm illustrating the workup and treatment of a patient with gastric carcinoma, gastric lymphadenectomy, and an algorithm illustrating the workup and treatment of a gastrointestinal stromal tumor (GIST). Tables list American Joint Committee on Cancer (7th Edition) tumor-node-metastasis (TNM) clinical classification of gastric carcinoma, staging of gastric carcinoma, TNM clinical classification of GISTs, staging of gastric and small bowel GISTs, TNM clinical classification of small bowel carcinoma, and staging of small bowel carcinoma.

      This review contains 7 highly rendered figures, 6 tables, and 122 references

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    • 10

      Management of Uncomplicated Gallstones and Benign Gallbladder Disease

      By Carmen L. Mueller, BSc; Amy A. Neville, MD, FRCSC, MSc; Gerald M. Fried, MD, FRCSC, FACS, FCAHS
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      Management of Uncomplicated Gallstones and Benign Gallbladder Disease

      • CARMEN L. MUELLER, BSCMinimally Invasive Surgery Fellow, McGill University Health Centre, Montreal, Canada
      • AMY A. NEVILLE, MD, FRCSC, MSCBariatric Surgery Fellow, McGill University Health Centre, Montreal, Canada
      • GERALD M. FRIED, MD, FRCSC, FACS, FCAHSEdward W. Archibald Professor and Chairman, Department of Surgery, McGill University, Surgeon-in-Chief, McGill University Health Centre, Montreal, Canada

      Gallstones have an estimated prevalence of 5.3-8.9% in men and 13.9-26.7% in women, making gallstone disease one of the most common problems encountered by general surgeons. Gallstone disease is associated with a number of modifiable and non-modifiable risk factors. These risk factors include family history (notably 1st degree relatives), ethnicity, older age, female gender, diet, obesity, metabolic syndrome, female sex hormone use or excess, pregnancy, low physical activity, terminal ileum resection, Crohn disease, cystic fibrosis, chronic liver disease, gastric surgery, rapid weight loss, certain medications (including octreotide, statins and ceftriaxone), hematologic disorders resulting in increased hemolysis and prolonged total parenteral nutrition (TPN). This review covers the asymptomatic gallstones, symptomatic gallstones, imaging, and the operative and non-operative management and treatment of uncomplicated symptomatic gallstones associated with calculus biliary disease. The diagnosis and treatment of non-calculous benign gallbladder disease are detailed, and, in depth, functional gallbladder disorder. Classification, laboratory investigations, diagnostic imaging, and treatment are covered for sphincter of Oddi dysfunction and gallbladder polyps.

      This review contains 5 figures, 5 tables, and 90 references.

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    • 11

      Management of Complicated Gallstone Disease

      By Carmen L. Mueller, BSc; Amy A. Neville, MD, FRCSC, MSc; Gerald M. Fried, MD, FRCSC, FACS, FCAHS
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      Management of Complicated Gallstone Disease

      • CARMEN L. MUELLER, BSCMinimally Invasive Surgery Fellow, McGill University Health Centre, Montreal, Canada
      • AMY A. NEVILLE, MD, FRCSC, MSCBariatric Surgery Fellow, McGill University Health Centre, Montreal, Canada
      • GERALD M. FRIED, MD, FRCSC, FACS, FCAHSEdward W. Archibald Professor and Chairman, Department of Surgery, McGill University, Surgeon-in-Chief, McGill University Health Centre, Montreal, Canada

      Gallstones have an estimated prevalence of 5.3-8.9% in men and 13.9-26.7% in women, making gallstone disease one of the most common problems encountered by general surgeons. Of all patients with gallstones, 1-3% will develop complications annually, and this increases to 30% in patients with biliary colic. The most common complications include acute cholecystitis, common bile duct stones and gallstone pancreatitis, with less common complications including choledochoduodenal fistula and gallstone ileus. This review covers in depth the diagnostic imaging and treatment of acute cholecystitis; laboratory studies for suspected choledocholithiasis; imaging studies and treatment for common bile duct stones; pathophysiology, diagnosis, management, and management controversies in gallstone pancreatitis; classification, imaging, and treatment of Mirizzi syndrome and cholecystobiliary fistula; and diagnosis and treatment of gallstone ileus.

      This review contains 11 figures, 2 tables, and 92 references.

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    • 12

      Periampullary and Pancreatic Adenocarcinoma

      By Clifford S. Cho, MD, FACS
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      Periampullary and Pancreatic Adenocarcinoma

      • CLIFFORD S. CHO, MD, FACSAssistant Professor, Section of Surgical Oncology, Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI

      Effective surgical management of periampullary adenocarcinoma (ampullary adenocarcinoma, duodenal adenocarcinoma, and distal cholangiocarcinoma) and pancreas adenocarcinoma requires a familiarity with both anatomy and cancer biology. This review describes the clinical behavior of the various subtypes of periampullary adenocarcinoma, the appropriate diagnostic evaluation of the patient afflicted with these malignancies, the surgical anatomy of the pancreas and peripancreatic region, and the nature and outcome of contemporary therapeutic interventions.

      This review contains 9 figures, 7 tables, and 28 references.

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    • 13

      Neuroendocrine Tumors of the Pancreas

      By Katherine A. Morgan, MD, FACS
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      Neuroendocrine Tumors of the Pancreas

      • KATHERINE A. MORGAN, MD, FACSAssociate Professor of Surgery, Chief, Division of Gastrointestinal and Laparoscopic Surgery, Medical University of South Carolina, Charleston, SC

      Pancreatic neuroendocrine tumors (PNETs) comprise a diverse, heterogeneous group of tumours that range in presentation and biologic behavior, including small, asymptomatic, incidentally discovered, nonfunctional neoplasms, functional tumors (both localizable and unlocalizable) with associated clinical syndromes, and diffuse metastatic disease. Based on its functional status, the malignancy of a PNET can vary, from the benign (insulinoma) to that which is commonly malignant more than 50% of the time (gastrinoma, somatostatinoma). According to a recent study, PNETs appear to be increasing in incidence or at least in clinical detection; currently the disorder accounts for 1 to 2% of pancreatic tumors and with a reported clinical incidence of one to five cases per million persons annually in the United States. Nonfunctional PNETs make up the majority of cases, and comprise 2% of all pancreatic malignancies. Treatment has been primarily done through surgical management, particularly via resection. However, medical management has played a more increased role for patients where the disease is advanced, encompassing biotherapy, chemotherapy, and targeted therapies such as peptide receptor radionuclide therapy (PRRT). For nonfunctional PNETs—insulinomas, gastrinomas, glucagonomas, somatostatinomas, and VIPomas—the epidemiology, biology of disease, clinical presentation and diagnosis, localization of tumor, operative management considerations, surgical management of primary tumor, and prognosis and outcomes of each are discussed.

      This review contains 6 figures, 6 tables, and 73 references.

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    • 14

      Cystic Tumors of the Pancreas

      By Nicholas J. Zyromski, MD
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      Cystic Tumors of the Pancreas

      • NICHOLAS J. ZYROMSKI, MDAssociate Professor, Department of Surgery, Indiana University School of Medicine, Indianapolis, IN

      Pancreatic cysts are common, affecting up to 10% of the general population. Widespread use of abdominal cross-sectional imaging has increasingly identified asymptomatic patients with "incidental" pancreatic cysts. Our understanding of common pancreatic cysts has improved; however, the ideal management of patients with pancreatic cysts (particularly those with malignant potential) has not been standardized. This review discusses the clinical approach to patients with pancreatic cysts, with particular attention to those with "premalignant" cysts such as intraductal papillary mucinous neoplasms (IPMNs).

      This review contains 17 figures, 2 tables, and 50 references.

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    • 15

      Tumors of the Liver and Biliary Tract

      By Gabriela M. Vargas, MD; Purvi Parikh, MD, FACS; Kimberly M. Brown, MD, FACS
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      Tumors of the Liver and Biliary Tract

      • GABRIELA M. VARGAS, MDClinical Instructor, Department of Surgery, University of Texas Medical Branch, Galveston, TX
      • PURVI PARIKH, MD, FACSAssistant Professor, Department of Surgery, Albany Medical Center, Albany, NY
      • KIMBERLY M. BROWN, MD, FACSAssistant Professor, Department of Surgery, University of Texas Medical Branch, Galveston, TX

      This review discusses several different types of tumors that affect the liver, biliary tree, and gallbladder. Primary and secondary liver cancers are discussed, including hepatocellular carcinoma, intrahepatic cholangiocarcinoma, colorectal metastases, neuroendocrine metastases, and noncolorectal, nonneuroendocrine metastases. Clinical evaluation, investigative studies, tumor staging, and treatment options are presented for each. Benign or premalignant hepatic lesions are also discussed, including the appropriate workup and surgical options for hemangioma, hepatic adenoma, focal nodular hyperplasia, and nonparasitic cystic tumors. Cancers of the biliary tract (cholangiocarcinomas) are subdivided into intrahepatic and extrahepatic cholangiocarcinomas. The latter are subdivided into hilar and distal cholangiocarcinoma; their clinical evaluation, investigative studies, staging, and management are discussed. The clinical evaluation, investigative studies, testing, imaging, staging, and management are presented for gallbladder cancer, including incidentally discovered gallbladder cancer and gallbladder polyps. Figures include the anatomic divisions of the liver and Brisbane terminology for resections, CT and MR images showing characteristic features of the liver and biliary tract tumors, Bismuth-Corlette classification of hilar cholangiocarcinoma, and algorithms for the management of hepatocellular carcinoma and neuroendocrine metastases. Tables include the American Joint Committee on Cancer’s classification and staging systems for hepatocellular carcinoma, cholangiocarcinoma, and gallbladder cancer; Brisbane terminology for liver resections; and neuroendocrine tumors with their corresponding biochemical markers.

      This review contains 14 figures, 7 tables, and 83 references.

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    • 16

      Acute and Chronic Pancreatitis

      By Thomas J. Howard, MD, FACS
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      Acute and Chronic Pancreatitis

      • THOMAS J. HOWARD, MD, FACSWillis D. Gatch Professor of Surgery, Indiana University School of Medicine, Department of Surgery, Indiana University Medical Center, Indianapolis, IN

      Clinical evaluation and surgical decision making in patients with acute pancreatitis (AP) and chronic pancreatitis (CP) are two of the most complex conditions that a general surgeon faces. Each entity has unique laboratory and radiographic investigations, operations, and postoperative care. The clinical evaluation, history, and physical examination of AP is described. The clinical features necessary for diagnosis are listed, and contrast-enhanced computed tomography is described as the gold standard for diagnosis. This review uses definitions and terminology developed at the Atlanta symposium in 1992. The severity of an episode of AP is described in terms of established scoring systems (APACHE II [Acute Physiology and Chronic Health Evaluation II], Glasgow Coma Scale score, Ranson criteria). AP can range from mild to severe necrotizing, with each described. The clinical course is described in detail. For CP, the history, physical examination, and diagnosis via investigative and imaging studies are described. The anatomic and morphologic subtypes of chronic pancreatitis are listed and the operations directed at patients with CP are detailed, and can involve drainage or combined resection and drainage. Clinical results are discussed. Figures show surgical treatment options in patients with CP; a Whipple diagram; a Puestow diagram; and the Frey operation. Tables describe the classification of AP; etiologic factors for AP; a grading system for pancreatitis; a summary of the official guidelines for the surgical management of AP; surgically remedial complications of CP; and outcomes of certain surgical procedures for CP

      This review contains 12 figures, 11 tables, and 73 references.

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    • 17

      Portal Hypertension

      By Patrick S. Kamath, MD; David M. Nagorney, MD
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      Portal Hypertension

      • PATRICK S. KAMATH, MDMayo Clinic College of Medicine, Rochester, MN
      • DAVID M. NAGORNEY, MDMayo Clinic College of Medicine, Rochester, MN

      The pathogenesis of portal hypertension is described, as is the subsequent development of collateral circulation and varices. Methods for diagnosis of portal hypertension are discussed and can be suspected clinically in a patient with stigmata of chronic liver disease. The two most commonly used methods to assess the severity of liver disease are the Child-Turcotte-Pugh (CTP) class and the Model for End-stage Liver Disease (MELD) score. Upper gastrointestinal endoscopy is the most common method used to detect varices. The modalities for treating portal hypertension–related bleeding are given and may be pharmacologic or surgical. The surgical modality can involve shunts (portosystemic shunts) or nonshunt procedures (esophageal transection or devascularization). The management of specific causes of portal hypertension is given for esophageal varices; gastric varices; ectopic varices; portal hypertensive gastropathy and gastric vascular ectasia; ascites; and hepatic encephalopathy. Figures show various shunts and the primary and secondary prophylaxis for esophageal varices. A table describes the Child-Turcotte-Pugh classification of the severity of liver disease.

      This review contains 17 Figures, 5 Management Algorithms, 1 Table, and 30 References.

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    • 18

      Minimally Invasive Approaches in Pancreatic and Liver Surgery

      By Brian A. Boone, MD; Stephanie Downs-Canner, MD; Herbert J. Zeh, MD, FACS
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      Minimally Invasive Approaches in Pancreatic and Liver Surgery

      • BRIAN A. BOONE, MDResident, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
      • STEPHANIE DOWNS-CANNER, MDResident, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
      • HERBERT J. ZEH, MD, FACSChief, Division of GI Surgical Oncology, Co-Director, UPMC Pancreatic Cancer Center, Associate Professor of Surgery, Division of Surgical Oncology, Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA

      The rapid expansion of minimally invasive techniques over the last two decades has dramatically expanded the use of these approaches in hepatopancreaticobiliary surgery. While implementation of minimally invasive surgery has been slowed by the technically complex nature of liver and pancreatic surgery, the feasibility of laparoscopic and robotic major liver and pancreatic resections has been demonstrated at select centers. This review discusses the preoperative evaluation, indications and contraindications, operative techniques, and outcomes of minimally invasive major pancreatic and hepatic resections; including distal pancreatectomy, pancreaticoduodenectomy, right and left hepatectomy, segmentectomy, and ablative liver surgery. Tables list the clinical outcomes of large series of patients treated with laparoscopic and robotic approaches to each operation. Figures detail port placement and include a number of intraoperative photographs demonstrating anatomic and technical considerations. Videos of a robotic pancreaticojejunostomy and a robotic retropancreatic dissection are included to highlight some of the technical advantages of this approach. While the current literature suggests the safety and feasibility of minimally invasive pancreatic and liver surgery with encouraging early results, ongoing study is needed to more definitively demonstrate outcome benefits of these approaches while maintaining patient safety and oncologic principles and justifying costs associated with the technology. As more data emerges, it is likely that utilization of minimally invasive approaches for hepatopancreaticobiliary surgery will continue to expand.

      This review contains 12 figures, 2 videos, 10 tables, and 129 references.

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    • 19

      Splenectomy

      By Bindhu Oommen, MD, MPH; Kent W. Kercher, MD, FACS; B. Todd Heniford, MD, FACS; Ian A. Villanueva, MD, FACS
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      Splenectomy

      • BINDHU OOMMEN, MD, MPHMIS Fellow, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC
      • KENT W. KERCHER, MD, FACSChief, Minimal Access Surgery, Co-Director, Carolinas Laparoscopic and Advanced Surgery Program (CLASP), Director, CMC Adrenal Center, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, Clinical Professor of Surgery, Department of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
      • B. TODD HENIFORD, MD, FACSChief, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Co-Director, Carolinas Laparoscopic and Advanced Surgery Program (CLASP), Co-Director, Carolinas Hernia Center, Carolinas Medical Center, Charlotte, NC, Clinical Professor of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC
      • IAN A. VILLANUEVA, MD, FACSFaculty, Division of Gastrointestinal and Minimally Invasive Surgery, Department of Surgery, Carolinas Medical Center, Charlotte, NC, Adjunct Assistant Professor of Surgery, University of North Carolina School of Medicine, Chapel Hill, NC

      Laparoscopic splenectomy has become an established standard of care in the management of surgical diseases of the spleen, except in the hemodynamically unstable trauma patient requiring splenectomy. Although adoption of minimally invasive splenectomy has led to a gradual decrease in the indications for open splenectomy, both procedures are still essential components of spleen surgery. This review describes the indications and contraindications for procedure, preoperative preparation and consent, operative anatomy and technique, and long-term follow-up. Tables review the clinical indications for splenectomy, classification of splenectomy, a comparison of laparoscopic versus open postsplenectomy outcomes, indications and contraindications for partial splenectomy, and reported incidences of postoperative outcomes and complications after splenectomy. Figures depict splenomegaly, the American Society of Hematology 2011 evidence-based practice guidelines for management of primary idiopathic thrombocytopenic purpura in children and adults, a splenic mass, a splenic cyst, massive splenomegaly, laparoscopic splenectomy, the 2014 Centers for Disease Control and Prevention recommendations for adult and pediatric splenectomy vaccination, splenic artery embolization, various laparoscopic approaches to splenectomy, splenic vascularization, division of splenic artery branches, suspensory ligaments of the spleen, laparoscopic exposure and transection of splenic hilum, retrieval bags and related procedures, open splenectomy, stapling, and laparoscopic partial splenectomy. Videos demonstrate purely laparoscopic splenectomy and hand-assisted laparoscopic splenectomy.

      This review contains 26 figures, 5 tables, 2 videos,  and 111 references.

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    • 20

      Disorders of the Adrenal Glands

      By L. Michael Brunt, MD; Linda P. Zhang, MD
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      Disorders of the Adrenal Glands

      • L. MICHAEL BRUNT, MDProfessor of Surgery, Washington University School of Medicine, Department of Surgery, St. Louis, MO
      • LINDA P. ZHANG, MDClinical Fellow, Minimally Invasive Surgery, Washington University School of Medicine, Department of Surgery, St. Louis, MO

      The adrenal glands may be affected by a variety of different pathologic conditions. In this chapter, the clinical presentation, diagnostic evaluation, and management of the various adrenal tumors are reviewed, and the workup of incidentally discovered adrenal masses (adrenal incidentalomas) is outlined. Disorders of both the adrenal cortex and adrenal medulla are discussed. Indications for adrenalectomy are presented. Tables show subtypes of primary hyperaldosteronism, adrenal vein sampling results in a patient with primary hyperaldosteronism, symptoms and signs of Cushing syndrome, staging of adrenocortical carcinoma, equivalent dosages for commonly used glucocorticoids, and inherited pheochromocytoma syndromes. Figures include anatomical drawings, algorithms illustrating diagnostic evaluations, and computed tomographic scans.

      This review contains 20 figures, 7 tables, 2 diagnostic algorithms, and 81 references.

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    • 21

      Repair of Ventral Abdominal Wall Hernias

      By Clayton C. Petro, MD; Michael J. Rosen, MD, FACS
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      Repair of Ventral Abdominal Wall Hernias

      • CLAYTON C. PETRO, MDGeneral Surgery Research Scholar, Department of General Surgery, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH
      • MICHAEL J. ROSEN, MD, FACSProfessor of Surgery and Chief, Division of Gastrointestinal and General Surgery, Department of General Surgery, Co-Director, Case Comprehensive Hernia Center, University Hospitals Case Medical Center, Cleveland, OH

      The repair of noninguinal abdominal wall defects is one of the most common procedures general surgeons perform. Despite this, there is little agreement or consensus in the literature as to the ideal approach for this difficult problem. In recent years, population-based studies have provided better data on the true failure rates associated with the various herniorrhaphies. Wound morbidity has also emerged as an important outcome measure, and definitions by the Ventral Hernia Working Group (VHWG) have begun to standardize such benchmarks. Future evidence will come from the large multi-institutional collaborations currently forming. This topic review discusses the classification of ventral hernias, abdominal wall anatomy, and choices of prosthetic materials. Incisional hernia repair is discussed, as are the operative steps and techniques for both an open and a laparoscopic ventral hernia repair. Special circumstances, including loss of abdominal domain and contaminated surgical fields, periumbilical hernia repair, and atypical ventral hernias are also described. Tables present the European Hernia Society classification for primary ventral hernias, VHWG grading scale, HPW incisional hernia staging system and associated outcomes, select commercially available synthetic and biologic prostheses for abdominal wall hernia repair, causes of and comorbid factors associated with incisional hernias, reports of retrorectus hernia repair, and indications for repair of parastomal hernia. Figures include a cross-sectional anatomy of the abdominal wall, the relationship of the great muscles to the groin, the important nerves of the lower abdominal wall, incisional hernia repair, incisions to the posterior rectus sheath, exposure of the transversus abdominis muscle, and the spigelian hernia belt.

      This review contains 10 figures, 10 tables, and 185 references.

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    • 22

      Inguinal Hernia

      By Fadi T. Hamadani, MD; Simon Bergman, MD, MSC, FACS, FRCSC
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      Inguinal Hernia

      • FADI T. HAMADANI, MDGeneral Surgery Resident, McGill University, Montreal, Canada
      • SIMON BERGMAN, MD, MSC, FACS, FRCSCAssistant Professor of Surgery, McGill University, Chair, Undergraduate Surgical Education, McGill University, Associate Member, Division of Gastroenterology, Jewish General Hospital, Montréal, QC

      In the United States, approximately 1 million abdominal wall herniorrhaphies are performed each year, of which almost 80% are for inguinal or femoral hernias. The anatomy section covers all muscular layers of the abdominal wall, all nerves, the preperitoneal space, obliterated umbilical artery, spermatic cord structures, inferior epigastric vessels, Cooper ligament, internal inguinal ring, iliopubic tract, triangle of doom, and triangle of pain. Operative planning describes the choice of anesthesia, patient positioning, and equipment for both open and laparoscopic repairs. This chapter discusses open and laparoscopic repairs of both inguinal and incisional hernias. The open procedures described are anterior herniorrhaphy (Bassini repair; shouldice repair; McVay Cooper ligament repair; Lichtenstein repair; plug and patch repair; femoral hernia repair), posterior herniorrhaphy (transabdominal preperitoneal repair; totally extraperitoneal repair), and open posterior prosthetic repairs (Read-Rives repair; Stoppa-Rignault-Wantz repair; Kugel-Ugahary repair; bilayer prosthetic repair). Complications and pain are covered in-depth by the authors. Finally, selected trials measuring the results of laparoscopic repair against those of open repairs are reviewed. This review is richly illustrated with 18 Figures and contains 2 Tables, 83 References, 5 Board-Styled MCQs, and 1 Teaching Slide Set.

       

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    • 23

      Upper Gastrointestinal Endoscopy

      By Jeffrey Marks, MD, FACS; Hahn Soe-Lin, MD
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      Upper Gastrointestinal Endoscopy

      • JEFFREY MARKS, MD, FACSProfessor of Surgery, Director, Surgical Endoscopy, Program Director, Case General Surgery Residency Program, University Hospitals Case Medical Center, Cleveland, OH
      • HAHN SOE-LIN, MDDepartment of General Surgery, University Hospitals Case Medical Center, Cleveland, OH

      The development of flexible endoscopic techniques has contributed to improved diagnoses of gastrointestinal (GI) disease. With it, advancements in technology and methodology have made it possible to treat a host of conditions with the assistance of endoscopy, conditions that were once considered to be manageable only through surgical intervention. With endoscopic surgery a reality, and new tools and procedures continually being invented and reinvented to supplant surgical therapies for numerous GI diseases, the modern surgeon must stay aware of these advances to provide appropriate patient care. This review details endoscopy focusing on the upper GI tract, encompassing its history, structure, recent advancements in imaging technology such as narrow-band imaging (NBI) and spectroscopy, and an overview of various techniques that range from the basic upper endoscopy or esophagogastroduodenoscopy (EGD) to new and novel procedures exemplified by per oral endoscopic myotomy (POEM). Examples of endoscopic images featured in this review include normal appearances of the squamocolumnar junction, vocal cords, pylorus and antrum, duodenal bulb, second portion of the duodenum, and gastric fundus; evidence of GI diseases such as severe Candida esophagitis and small bowel stricture secondary to inflammatory bowel disease; EGDs revealing linitis plastica of the stomach, a small nonbleeding gastric ulcer, and gastric antral vascular ectasia; and images taken during surgical procedures such as endoscopic retrograde cholangiopancreatography and POEM. Also included is a drawing of percutaneous endoscopic gastrostomy placement pull technique and a video that details the technique of POEM.

      This review contains 21 figures, 1 video, and 38 references.

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    • 24

      Anatomy, Physiology, and Measurement of Physiologic Function for Colorectal Surgery

      By M. Nicole Lamb, MD; Andreas M. Kaiser, MD, FACS, FASCRS
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      Anatomy, Physiology, and Measurement of Physiologic Function for Colorectal Surgery

      • M. NICOLE LAMB, MDAnophysiology/Research Fellow, USC Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
      • ANDREAS M. KAISER, MD, FACS, FASCRSProfessor of Clinical Surgery, USC Division of Colorectal Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA

      Solid surgical decision making and operative planning are the cornerstones of excellence in outcomes and performance. Beyond the knowledge of the pathologic process, they require an in-depth understanding of the anatomy and physiology of the area impacted by disease or dysfunction. The embryology and anatomy, as well as the physiology of the appendix, colon, rectum, and anus, are reviewed here, with a particular focus on their impact on surgical evaluation and decision making. Tables outline artery-dependent embryologic development of the gastrointestinal system, embryologic development and related malformations, principles and critical structures during colorectal mobilization/resection, clinical impact of anatomic differences between colon and rectum, mediators and drugs affecting colonic motility, pelvic floor muscles, and anophysiology testing. Figures depict malrotation, colon walls, computed tomographic colonography, coronal and lateral views of the rectum, rectal cancer, vascular anatomy, colonic wall innervation, diurnal variation of colonic motility, assessment of colonic transit by means of a Sitzmark study, pelvic organ prolapse, and electrolyte transport mechanisms within the colonocyte.

      This review contains 12 figures, 7 tables, and 97 references.

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    • 25

      Lower Gastrointestinal Endoscopy

      By Parakkal Deepak, MBBS; David H. Bruining, MD
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      Lower Gastrointestinal Endoscopy

      • PARAKKAL DEEPAK, MBBSInstructor in Medicine; Advanced Fellow in Inflammatory Bowel Diseases, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN
      • DAVID H. BRUINING, MDAssociate Professor of Medicine; Consultant, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, MN

      Since the advent of the first flexible fiberoptic sigmoidoscope in 1967, lower gastrointestinal endoscopy equipment has technologically advanced and is used for a number of diagnostic and therapeutic procedures. This review covers the definition of and indications for lower endoscopy; diagnostic and screening colonoscopy, bowel preparation for colonoscopy, special considerations for patients on anticoagulants and antiplatelet agents; endocarditis prophylaxis; general technique; diagnostic and therapeutic techniques during colonoscopy, sigmoidoscopy, anoscopy, endoscopic ultrasonography, balloon-assisted colonoscopy, and lower endoscopy training; and innovations on the horizon. Figures show room setup and patient positioning for colonoscopy; technique for insertion of a colonoscope and endoluminal view of rectum, descending colon, transverse colon, and cecum; pinch biopsy and hot biopsy forceps; snare polypectomy and endomucosal resection of a polyp using the lift and cut and suction cap techniques; Haggitt classification of tissue invasion in a pedunculated polyp; endoscopic clips and their application; self-expanding uncovered metal stents and their method of deployment; an anoscope; and rigid endorectal probes for endoscopic ultrasonography. Tables list indications for colonoscopy, recommendations for screening for colorectal cancer (average risk) from the US Preventive Services Task Force, recommendations from the US Multi-Society Task Force for surveillance after baseline colonoscopy in average-risk individuals, recommendations from the US Multi-Society Task Force for screening and surveillance in colorectal cancer (high risk), bowel preparation scales, agents for bowel preparation prior to colonoscopy, and Haggitt classification of tumor invasiveness in an adenomatous polyp.

       

      This review contains 10 highly rendered figures, 7 tables, and 60 references.

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    • 26

      Intestinal Anastomosis

      By Neil J. Mortensen, MD, FRCS; Shazad Ashraf, DPhil, FRCS
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      Intestinal Anastomosis

      • NEIL J. MORTENSEN, MD, FRCS
      • SHAZAD ASHRAF, DPHIL, FRCS

      The creation of a join between two bowel ends is an operative procedure that is of central importance in the practice of a general surgeon. Leakage from an intestinal anastomosis can be disastrous, resulting in prolonged hospital stays and increased risk of mortality. To minimize the risk of potential complications, it is important to create a tension-free join with good apposition of the bowel edges in the presence of an excellent blood supply. This review discusses the factors that influence intestinal anastomotic healing, the various technical operations for creating anastomoses, and operative techniques currently used in constructing anastomoses. Tables review the principles of successful intestinal anastomosis, consequences of postoperative dehiscence, factors linked with dehiscence, anastomotic techniques ranked by best blood flow to the healing site, comparison of hand and stapled techniques, leak rates from the Rectal Cancer Trial on Defunctioning Stoma and the Contant and colleagues mechanical bowel obstruction trial, leak and wound infection rates from mechanical bowel obstruction meta-analyses, diseases and systemic factors associated with poor anastomotic healing, lifestyle-associated leakage rates, salvage after anastomotic leakage, standard checks for creation of anastomoses, and steps for left-sided stapled colorectal anastomoses for cancer. Figures show the phases of wound healing, the tissue layers of the jejunum, interrupted and continuous suture techniques, stitches commonly used in fashioning intestinal anastomoses, double-layer end-to-end anastomosis, traction sutures, anatomic relations between the colon and the retroperitoneal organs, single-layer sutured side-to-side enteroenterostomy, Finney strictureplasty, double-layer sutured end-to-side enterocolostomy, double-stapled end-to-end coloanal anastomosis, use of a “glove” port in laparoscopic surgery, and perfusion assessment at the time of anastomotic creation.

      This review contains 14 figures, 13 tables, and 85 references.

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    • 27

      Fecal Incontinence

      By Robert D. Madoff, MD; Sarah A. Vogler, MD
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      Fecal Incontinence

      • ROBERT D. MADOFF, MD
      • SARAH A. VOGLER, MDAdjunct Assistant Professor, Division of Colon and Rectal Surgery, Department of Surgery, University of Minnesota, Minneapolis, MN

      Fecal incontinence, defined as the involuntary loss of gas, liquid, or solid stool through the anal canal, occurs in an estimated 18 million adults in the United States. Fecal incontinence causes social isolation and confines patients to their homes; additionally, it contributes to medical morbidity, including urinary tract infections, perianal skin breakdown, and decubitus ulcers. Causes for fecal incontinence can be broken down into three broad categories: neurologic disease; functional gastrointestinal diseases or abnormalities; and structural injuries or abnormalities in the pelvic floor, rectum, or anal sphincter. This review describes the clinical evaluation of, investigative studies related to, and management of fecal incontinence. Tables review common causes of sphincter injury, the Fecal Incontinence Severity Index, and daily life factors measured by the Fecal Incontinence Quality of Life questionnaire. Figures show an obstetric sphincter injury, an algorithm outlining the workup and management of fecal incontinence, ultrasonograms of a normal anal sphincter and a sphincter defect, the steps involved in sphincteroplasty, sacral nerve stimulation, and an artificial anal sphincter.

      This review contains 6 figures, 3 tables, and 54 references.

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    • 28

      Constipation

      By Charles H. Knowles, MBBChir, PhD, FRCS
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      Constipation

      • CHARLES H. KNOWLES, MBBCHIR, PHD, FRCS

      This review presents an overview of the management of constipation. The review addresses the diagnosis of primary and secondary forms and then discusses in greater detail the investigative workup and modern management of chronic constipation (primary). The review addresses what simple and more advanced investigations are relevant for determining pathophysiology and gives an overview of treatment options, including pharmacologic, behavioral, and surgical approaches for thus defined subgroups of patients (evacuation disorder, slow transit constipation).

      This review contains 3 figures, 6 tables, and 89 references.

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    • 29

      Pelvic Floor Dysfunction

      By Michael A. Valente, DO, FACS, FASCRS; Tracy L. Hull, MD, FACS, FASCRS
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      Pelvic Floor Dysfunction

      • MICHAEL A. VALENTE, DO, FACS, FASCRSStaff Surgeon, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH
      • TRACY L. HULL, MD, FACS, FASCRSProfessor of Surgery and Staff Surgeon, Department of Colorectal Surgery, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH

      Pelvic floor dysfunction encompasses a broad spectrum of disorders and symptoms, including pelvic organ prolapse, fecal incontinence, dysfunctional bowel and/or bladder evacuation, urinary incontinence, and chronic pain. Challenges in treating these patients are due, in part, to inconsistent definitions and diagnostic criteria, an underreporting of symptoms, and complexities in understanding the underlying pathophysiology. Pelvic floor dysfunction is a multisystem process requiring a multidisciplinary team approach. This review describes the incidence, prevalence, and etiologic factors relating to pelvic floor dysfunction, as well as the clinical evaluation process, which includes history, physical examination, physiologic and neurophysiologic assessment, and anatomic assessment. Management of pelvic floor dysfunction is discussed. Tables include potential contributing factors in the development of pelvic floor dysfunction and anatomic and physiologic tests for pelvic floor dysfunction. Figures show an anal manometry apparatus; anorectal physiology report for a patient with fecal incontinence; pudendal nerve-stimulating electrode; pudendal nerve terminal motor latency tracing; surface electrode electromyography; anorectal ultrasound equipment; sonogram of the middle anal canal; ultrasound view of the puborectalis muscle; sonogram showing a defect in the external anal sphincter; defecography showing normal anatomy, rectocele and enterocele, sigmoidocele, and rectoanal intussusception; colonic transit study; rectocele; and enterocele.

      This review contains 19 figures, 2 tables, and 81 references.

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    • 30

      Pilonidal Disease

      By John L. Rombeau, MD; Kimberly J. Hwa, MMS, PA-C; George P. Yang, MD, PhD
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      Pilonidal Disease

      • JOHN L. ROMBEAU, MDStaff Surgeon, VA Palo Alto Health Care System, Palo Alto, CA, Emeritus Professor of Surgery, Perelman School of Medicine, Philadelphia, PA
      • KIMBERLY J. HWA, MMS, PA-CPhysician's Assistant Surgical Service, VA Palo Alto Health Care System, Palo Alto, CA
      • GEORGE P. YANG, MD, PHDAssociate Professor, Department of Surgery, Stanford University School of Medicine, Stanford, CA and Palo Alto VA Health Care System, Palo Alto, CA

      Despite having been described nearly 200 years ago, pilonidal disease (PD) continues to produce considerable morbidity and loss of work productivity, and the optimal treatment remains elusive. Surgeons must choose among numerous operative and nonoperative options that overlap and often confound therapeutic strategies. This review provides an overview of PD with an emphasis on operative treatments. Every attempt is made to guide selection of the best treatment for the specific variant of disease.

      This review contains 7 figures, 4 tables, and 69 references.

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    • 31

      Procedures for Rectal Prolapse

      By Steven D. Wexner, MD, PhD (Hon), FACS, FRCS, FRCS (ED); Susan M. Cera, MD, FACS
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      Procedures for Rectal Prolapse

      • STEVEN D. WEXNER, MD, PHD (HON), FACS, FRCS, FRCS (ED)Director, Digestive Disease Center, and Chairman, Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL
      • SUSAN M. CERA, MD, FACSPhysician, Department of Colorectal Surgery, Physician, Regional Medical Center, Naples, FL

      Rectal prolapse, also known as rectal procidentia, involves full thickness protrusion of the rectum through the anus. This disease process is different from occult rectoanal intussusception (which may be a precursor) and mucosal or hemorrhoidal prolapse. Factors associated with the pathophysiology of rectal prolapse include constipation, female sex, postmenopausal status, and previous anorectal surgical procedures. The constipation frequently arises from conditions such as colonic inertia, neurologic disease, psychiatric illness, and obstructed defecation. Patients with obstructed defecation experience significant pain and have difficulties passing stool; relief of the functional obstruction may necessitate digital manipulation or any of a variety of perineal maneuvers. The anatomic abnormalities resulting from rectal prolapse include a deep cul-de-sac, a redundant rectosigmoid, an elongated mesorectum, diastasis of the levator ani, perineal descent, a patulous anus, and loss of support of the uterus and the bladder. As there are more than 120 operations possible for treating rectal prolapse, this review focuses on a few key widely accepted procedures, divided into two categories: abdominal and perineal. Perineal procedures covered in this review include mucosal sleeve resection (Delorme procedure) and perineal rectosigmoidectomy; whereas abdominal procedures detail resection rectopexy (Frykman-Goldberg procedure), laparoscopic resection rectopexy, and mesh and sponge repairs (Ripstein procedure), among others. Each procedure is detailed with the step-by-step operative technique, postoperative care, troubleshooting, as well as preparation for any complications that may occur.

      This review contains 18 figures, 8 tables, and 47 references. 

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    • 32

      Colonic Volvulus

      By Kevin R. Kasten, MD; Peter W. Marcello, MD; Todd D. Francone, MD, MPH
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      Colonic Volvulus

      • KEVIN R. KASTEN, MDFellow, Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, MA
      • PETER W. MARCELLO, MDChairman, Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, MA
      • TODD D. FRANCONE, MD, MPHSurgeon, Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, MA

      Colonic volvulus accounts for 3 to 5% of bowel obstructions in the United States. Current data reveal sigmoid volvulus as the most common colonic volvulus, followed by volvulus of the cecum, transverse colon, and splenic fixture. Despite a low incidence in the United States, diagnosis, management, and patient outcome depend on an appropriate index of suspicion and adherence to the proposed algorithm highlighting the approach to the patient with colonic volvulus. This review outlines the definition, pathogenesis, and epidemiology of colonic volvulus, as well as its clinical evaluation and treatment. Tables review the demographics of colonic volvulus in the United States, the differential diagnosis of and risk factors for colonic volvulus, important radiographic findings in colonic volvulus, and nonoperative management of sigmoid volvulus. Figures show the types of ileosigmoid knot; plain radiographs of cecal,  sigmoid, transverse, and splenic flexure volvulus; contrast enema of cecal, transverse, splenic flexure, and sigmoid volvulus; cross-sectional abdominal imaging of cecal, sigmoid, and transverse colon volvulus and ileosigmoid knot; endoscopic evaluation in sigmoid volvulus; use of an esophageal overtube for placement of a rectal tube; necrotic cecum and transverse colon volvulus in the operating suite; and sigmoid volvulus in an elderly gentleman.

      This review contains 14 figures, 5 tables, and 158 references.

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    • 33

      Diverticular Disease

      By John P. Welch, MD, FACS; Jeffrey L. Cohen, MD, FACS, FASCRS
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      Diverticular Disease

      • JOHN P. WELCH, MD, FACS
      • JEFFREY L. COHEN, MD, FACS, FASCRS

      Diverticula are small (0.5 to 1.0 cm in diameter) outpouchings of the colon that occur in rows at sites of vascular penetration between the single mesenteric taenia and one of the antimesenteric taeniae. The sigmoid colon is the most common site and is involved in 90% of patients with diverticulosis. If a diverticulum becomes inflamed as a result of obstruction by feces or hardened mucus or of mucosal erosion, a localized perforation (microperforation) may occur—a process known as diverticulitis Both diverticulosis and variants of diverticulitis may be subsumed under the more encompassing term diverticular disease. This review describes the increasing incidence of diverticula, citing age and diet with this increase; the symptoms of both uncomplicated (simple) and complicated diverticulitis; and the expected findings on physical examination. Computed tomographic (CT) scan with oral and rectal contrast is offered as the most useful diagnostic imaging tool. Management is discussed and can include both medical treatment and surgical resection (open or laparoscopic). Special types of diverticulitis are discussed, including cecal diverticulitis, diverticulitis in young patients, diverticulitis in immunocompromised patients, atypical presentations (involving multiple organ systems), giant diverticula, recurrent diverticulitis after resection, and subacute and atypical diverticulitis. Preoperative evaluation, operative planning, emergency procedures, and complications are detailed. Tables describe the differential diagnoses of uncomplicated diverticulitis, advantages of minimally invasive procedures, necessary conditions for diverticulectomy in patients with cecal diverticulitis, the unusual extra-abdominal presentations of diverticulitis, and differential diagnoses of recurrent diverticulitis. Figures show a colon segment containing diverticula, segmentation in the colon, napkin ring carcinoma, major complications of diverticular disease in the sigmoid colon, the Hinchey classification, various CT scans of diverticulitis, extravasation images, a colonoscopic view of sigmoid diverticula, treatment options for complicated diverticulitis, a high-grade retrograde obstruction, proposed classification of pathologic types of cecal diverticulitis, perforated diverticulitis, a giant sigmoid diverticulum, trends in operative techniques, the Hartmann procedure, on-table colonic lavage, laparoscopic sigmoid resection, hand-assisted laparoscopic resection, and laparoscopic Hartmann closure. Videos include lateral medial mobilization of the sigmoid colon, hand-assisted division of the superior rectum and division of the rectosigmoid mesentery, and creation of colorectal anastomosis.

      This review contains 30 figures, 5 tables, 3 videos, and 232 references.

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    • 34

      Hemorrhoids

      By Anthony J. Senagore, MD, MS, MBA
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      Hemorrhoids

      • ANTHONY J. SENAGORE, MD, MS, MBAProfessor and Chair, Surgical Disciplines, Central Michigan University, College of Medicine, Saginaw, MI

      References to the medical management of hemorrhoids date back to the first era of written records. In fact, many of the proposed therapies, including anal dilation, topical ointments, and destructive therapy, are not all that different from those available today. This review discusses the anatomy and etiology and clinical evaluation of hemorrhoids, nonexcisional options, sclerotherapy, bipolar diathermy, hemorrhoidal ligation with rubber bands, excisional hemorrhoidectomy and its required instrumentation, procedure for prolapsing hemorrhoids, Doppler-guided hemorrhoidal dearterialization, and postoperative management after hemorrhoid surgery. Tables describe the standard classification for hemorrhoidal diseases, anal symptoms mistakenly attributed to hemorrhoids, and treatment alternatives for hemorrhoids. Figures illustrate the anatomy of the anal canal, the infrared coagulator and its application, the elastic ligation technique for internal hemorrhoids, acutely thrombosed hemorrhoids, patient positioning on the operating table, excisional hemorrhoidectomy, stenosis and ectropion, and local infiltration of bupivacaine.

      This review contains 9 figures, 3 tables, and 91 references.

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    • 35

      Fissure, Fistula, and Abscesses

      By Elisa H. Birnbaum, MD, FACS, FASCRS; Ira J. Kodner, MD, FACS
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      Fissure, Fistula, and Abscesses

      • ELISA H. BIRNBAUM, MD, FACS, FASCRSProfessor of Surgery, Section of Colon and Rectal Surgery, Washington University School of Medicine, St. Louis, MO
      • IRA J. KODNER, MD, FACSEmeritus Professor of Surgery, Washington University School of Medicine, St. Louis, MO

      This review described the etiology and symptoms associated with anal fissures. The physical examination, medical and surgical treatment, and follow-up are detailed. The symptoms and treatment of abscesses and fistula are reviewed. Figures show chronic anal fissures, the relationship between the location of anal fissures and their cause, patient positioning on the operating table, injection of bupivacaine, the closed and open approaches to posterior lateral internal sphincterotomy, classification of anorectal abscesses, alternatives for treating abscess or fistula associated with Crohn disease, a patient with a cryptoglandular abscess/fistula, drainage of an ischiorectal abscess, surgical treatment of a horseshoe fistula, classification of fistula, Goodsall’s rule, ligation of the intersphincteric fistula tract, and advancement flaps. An algorithm outlines the approach to the patient with fissure, abscess or fistula.

      This review contains 15 figures and 40 references.

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    • 36

      Inflammatory Bowel Disease

      By Tara M. Connelly, MB, BCh, MSc; Andrew Tinsley, MD, MS; Walter A. Koltun, MD, FACS, FASCRS
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      Inflammatory Bowel Disease

      • TARA M. CONNELLY, MB, BCH, MSC
      • ANDREW TINSLEY, MD, MS
      • WALTER A. KOLTUN, MD, FACS, FASCRS

      Crohn disease (CD) and ulcerative colitis (UC) were often considered one disease until Charles Wells first differentiated the two in 1952. This review outlines the disease features and symptoms of CD and UC. Indeterminate colitis is described, as are the epidemiology, diagnostic testing, and etiology of inflammatory bowel disease (IBD). The role of genetics in the development of IBD is discussed as well as innate immunity, the adaptive immune system, and cytokine signaling. Drugs used in the medical management of IBD and the future of surgical treatment for IBD are described. Tables detail histologic features and symptoms of CD and UC; genetic and demographic risk factors for IBD; common IBD-associated genes, including those associated with epithelial barrier dysfunction, innate immunity, antigen presentation, T cell differentiation, cytokine production, and cell signaling; the medical treatment of IBD; 5-aminosalicylate derivatives and sites of action; advantages of genetic markers in predicting disease course; surgical application of personalized medicine; and surgically relevant IBD genes. Figures show the timeline of IBD, gross CD pathologic specimens, gross UC colectomy specimens, histologic slides of CD- and UC-affected colonic tissue, genetic and environmental factors contributing to IBD, genes involved in innate and adaptive immunity of CD, three components of the gene key to bacterial recognition, typical course of CD, treatment for a hospitalized UC patient, top-down versus bottom-up treatment of IBD, and the Kono-S procedure.

      This review contains 12 figures, 10 tables, and 242 references.

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    • 37

      Surgical Management of Ulcerative Colitis

      By Robert R. Cima, MD, MA; Amy Lightner, MD; John H. Pemberton, MD
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      Surgical Management of Ulcerative Colitis

      • ROBERT R. CIMA, MD, MA
      • AMY LIGHTNER, MDResident in General Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
      • JOHN H. PEMBERTON, MD

      Inflammatory bowel disease is a chronic inflammatory disease of the intestine that can be divided into two main categories: Crohn disease and chronic ulcerative colitis (CUC). Although the role of medical therapy in CUC is directed at symptom control or the underlying inflammatory process, fortunately, the intestinal manifestations of CUC can be effectively cured by surgery. The operation of choice is an ileal pouch-anal anastomosis (IPAA), which can be performed open or laparoscopically, with a hand-sewn or stapled anastomosis, or in a one-, two-, or three-stage fashion. Although pouch function and quality of life remain good following IPAA, common complications include pouchitis, anal stricture, pouch fistulas, and small bowel obstructions. The most dreaded complication is an anastomotic leak resulting in pelvic sepsis and, often, eventual pouch excision. Less common complications include pouch dysplasia or cancer and de novo Crohn disease of the pouch. Overall, regardless of age, patient satisfaction following IPAA remains high, and more than 90% of patients retain their pouches for more than 20 years. 

      This review contains 11 highly rendered figures, and 83 references.

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    • 38

      Crohn Disease

      By Susan Galandiuk, MD, FACS, FASCRS
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      Crohn Disease

      • SUSAN GALANDIUK, MD, FACS, FASCRS

      The role of surgery in the management of Crohn disease has undergone a dramatic evolution over the past 50 years. Currently, surgical treatment of Crohn disease is seldom performed in the emergency setting; it is nearly always performed after failed medical therapy. The general indications for surgical treatment are described and include specific attention to complications of the disease, including obstruction, symptomatic fistulas, abscess formation, cancer or dysplasia, and failure to grow. The special considerations of surgical therapy are also described, including pregnancy, the marking of stoma sites, and the choice of incision, which may involve laparoscopy. Surgical management of Crohn disease is evaluated in terms of therapy at specific sites, including esophageal, gastric, and duodenal disease; jejunoileal disease; ileocolic disease; colonic disease; and anal disease. Chemoprophylaxis is also described, as is surveillance and behavioral modification. Tables outline the Vienna Classification System, Crohn Disease Activity Index, Harvey-Bradshaw Index, extraintestinal manifestations, and the medical treatment of Crohn disease. Figures show endoscopic images of Crohn disease, computed tomographic enterography, a capsule endoscopy showing large Crohn structures, surgery rates over time, caput medusa, an example of stenotic ileocolic Crohn disease, an enterocutaneous fistula, Heineke-Mikulicz strictureplasty, Finney strictureplasty, a fibrotic stricture, an example of a large ulcer, pyoderma gangrenosum, a sigmoid colon stricture, toxic megacolon, and vessel loops for drainage of abscesses.

      This review contains 15 figures, 5 tables, and 76 references.

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    • 39

      Appendectomy

      By Martin D. Zielinski, MD, FACS
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      Appendectomy

      • MARTIN D. ZIELINSKI, MD, FACSAssociate Professor of Surgery, Division of Trauma, Critical Care, and General Surgery, Department of Surgery, Mayo Clinic, Rochester, MN

      Appendicitis became recognized as a surgical disease during a presentation by pathologist R. H. Fitz at the 1886 meeting of the Association of American Physicians. In 1894, Charles McBurney first described the surgical technique that was to become the gold standard for appendectomy. Although the appendectomy has traditionally been performed as an open procedure, laparoscopy holds several advantages, such as a lower risk of wound infection, the ability to thoroughly explore the abdominal cavity, and improved outcomes in women of childbearing age, obese patients, and patients with unclear diagnoses. This review covers operative technique, special considerations, and complications and outcome evaluation associated with appendectomy. Figures show an algorithm for choosing among treatment options for patients with suspected acute appendicitis, an open appendectomy demonstrating landmarks, exposure of the abdominal cavity, and mobilization of the appendix, laparoscopic appendectomy showing positioning and placement of the operative ports, division of the mesoappendix, and removal of the appendix through the infraumbilical port,  a single-incision laparoscopic appendectomy, an algorithm for the management of an appendiceal mass encountered  during exploration for clinically suspected acute appendicitis, and trocar placement for the gravid uterus. Tables list results of 31 prospective, randomized trials comparing laparoscopic appendectomy with open appendectomy, and results of prospective, randomized clinical trials comparing medical versus surgical management of acute appendicitis.

       

      This review contains 12 highly rendered figures, 2 tables, and 92 references

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    • 40

      Hereditary Colorectal Cancer and Polyposis Syndromes

      By Jose G. Guillem, MD, MPH, FACS; John B. Ammori, MD
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      Hereditary Colorectal Cancer and Polyposis Syndromes

      • JOSE G. GUILLEM, MD, MPH, FACS
      • JOHN B. AMMORI, MD

      The majority of cases of inherited colorectal cancer (CRC) are accounted for by two syndromes: Lynch syndrome and familial adenomatous polyposis (FAP). In the management of FAP, the role of prophylactic surgery is clearly defined, although the optimal procedure for an individual patient depends on a number of factors. In the management of Lynch syndrome, the indications for prophylactic procedures are emerging. The authors address the clinical evaluation, investigation findings, medical and surgical therapy, and extracolonic diseases of FAP, attenuated form of FAP (AFAP), MYH-associated polyposis, Lynch syndrome, familial colorectal cancer type X (FCCTX), hyperplastic polyposis syndrome, Peutz-Jeghers syndrome, and juvenile polyposis syndrome. AFAP has been described that is associated with fewer adenomas and later development of CRC compared with classic FAP. The AFAP phenotype occurs in less than 10% of FAP patients. The clinical criteria for AFAP are no family members with more than 100 adenomas before the age of 30 years and (1) at least two patients with 10 to 99 adenomas at age over 30 years or (2) one patient with 10 to 99 adenomas at age over 30 years and a first-degree relative with CRC with few adenomas. Given that polyposis has a later onset and the risk of CRC is less well established in AFAP, some authors question whether prophylactic colectomy is necessary in all AFAP patients.

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    • 41

      Adenocarcinoma of the Colon and Rectum

      By Martin R. Weiser, MD; Leonard B. Saltz, MD
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      Adenocarcinoma of the Colon and Rectum

      • MARTIN R. WEISER, MDVice Chair for Education and Faculty Development, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
      • LEONARD B. SALTZ, MDChief, Gastrointestinal Oncology, Department of Medicine, Memorial Sloan-Kettering Cancer Center, New York, NY

      Colorectal cancer (CRC) is one of the most dynamic fields in oncology. Molecularly based therapies now in use may be harbingers of more elegant, tumor-specific CRC therapy. Clinically, CRC is a diverse disease, requiring individually tailored treatment strategies. This review describes the incidence and epidemiology, genetic pathways, risk factors, screening, and staging procedures of CRC. Treatment of primary colon and rectal carcinoma, rectal cancer surgery, special circumstances, chemotherapy, stage II colon cancer, rectal cancer, treatment of systemic metastatic (stage IV) disease, chemotherapy with surgery for metastatic disease, CRC post–resection follow-up, and tumor markers are discussed. Tables describe the Amsterdam Criteria II; dietary and lifestyle risks for CRC; screening guidelines for average-, increased-, and high-risk individuals; the American Joint Committee on Cancer–Union Internationale Contre le Cancer tumor, node, metastasis staging and classification of CRC; and selected pathologic prognostic factors in CRC. Figures include the relative frequencies of CRC for various anatomic subsites of the colon; the genetic model of CRC tumorigenesis; a graph showing CRC risk; classification of CRC; five-year survival by American Joint Committee on Cancer, fifth edition, system stages I to IV; algorithms outlining treatment of colon and rectal cancer; lymphatic drainage of colon cancer; operative strategies for CRC; and intersphincteric resection.

      This review contains 10 figures, 8 tables, and 187 references.

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    • 42

      Adjuvant and Neoadjuvant Management of Colorectal Cancer

      By Y. Nancy You, MD, MHSc; Christina E. Bailey, MD, MSCI; Eduardo Vilar, MD, PhD
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      Adjuvant and Neoadjuvant Management of Colorectal Cancer

      • Y. NANCY YOU, MD, MHSCAssistant Professor, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
      • CHRISTINA E. BAILEY, MD, MSCIFellow in Surgical Oncology, Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
      • EDUARDO VILAR, MD, PHDAssistant Professor, Department of Clinical Cancer Prevention, The University of Texas MD Anderson Cancer Center, Houston, TX

      Colorectal cancer (CRC) is the third most common and lethal cancer in men and women in the United States. At presentation, a significant proportion of patients with CRC are able to undergo resection with curative intent, but up to 50% of these patients will develop recurrent disease. Fortunately, recurrence rates for both colon and rectal cancer have improved with the introduction of multimodality therapies, which include chemotherapy, chemoradiation therapy, and radiation therapy. These therapies are adjuncts to surgery and can be administered before (i.e. neoadjuvant) or after (i.e. adjuvant) surgery. This review summarizes the current evidence for the use of adjuvant and neoadjuvant therapies in colon and rectal cancer.

      This review contains 2 figures, 5 tables, and 65 references.

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    • 43

      Operations for Colon Cancer

      By Kevork Kazanjian, MD, FACS; David A. Etzioni, MD, MSHS, FACS
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      Operations for Colon Cancer

      • KEVORK KAZANJIAN, MD, FACSDavid Geffen School of Medicine at UCLA, Los Angeles, CA
      • DAVID A. ETZIONI, MD, MSHS, FACSAssociate Professor of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Phoenix, AZ

      Colon cancer is the third most commonly diagnosed cancer in the United States. Partial colectomy is beneficial for the majority of these patients; more than 250,000 of these procedures are performed in the United States annually, with colon cancer being the most common indication. Although these procedures are commonly performed, there is considerable associated morbidity and mortality. This review details the indications for surgery, the preoperative planning, and technical considerations for colon cancer surgeries. Figures show the vascular anatomy of the colon, oncologic resections of carcinomas in different locations of the colon, anatomic relations between the colon and the retroperitoneal organs, port positioning for laparoscopic colectomy, right colon mobilization and mesenteric dissection in laparoscopic right hemicolectomy, configuration of an end-to-end stapled colorectal anastomosis, laparoscopic left hemicolectomy and sigmoid resection, and approaches to dissection of the splenic flexure. A video shows a laparoscopic right colectomy, and potential complications of colectomy are listed in a table.

      This review contains 9 figures, 1 video, 1 table, and 69 references.

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    • 44

      Procedures for Rectal Cancer

      By Bashar Safar, MBBS, MRCS, FACS; Jonathan Efron, MD, FACS
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      Procedures for Rectal Cancer

      • BASHAR SAFAR, MBBS, MRCS, FACSAssistant Professor of Surgery, Ravitch Division, Johns Hopkins School of Medicine, Baltimore, MD
      • JONATHAN EFRON, MD, FACSAssociate Professor of Surgery, Chief of Ravitch Division, Johns Hopkins School of Medicine, Baltimore, MD

      Cancer of the large bowel is the third most common cancer diagnosed in both men and women in the United States with the exclusion of skin cancers. Surgery represents the mainstay of therapy in early-stage rectal cancer and is frequently warranted in advanced cases for palliation. Complete resection and retention of gastrointestinal continuity with low recurrence rates are the ultimate goal in treating localized disease. Local recurrence in rectal cancer essentially represents a failure of surgical therapy and is avoidable in most cases. Radiation has been shown to reduce local recurrences. This review covers the surgical anatomy of the rectum, factors to consider when evaluating patients with rectal cancer, choosing a therapeutic protocol, obtaining patient consent, preoperative considerations, and surgical technique. Local (transanal local excision, transanal endoscopic microsurgery) and radical procedures (anterior resection technique, abdominoperineal resection) are described. Laparoscopic and robotic approaches, key intraoperative concepts in rectal cancer, perioperative care, adjuvant therapy, and follow-up regimens are also detailed. Tables describe general medical issues for surgeons to review, vital knowledge for the colorectal surgeon, American Joint Committee on Cancer TNM Clinical Classification of Colorectal Cancer, American Joint Committee on Cancer Staging System for Colon Cancer, the multidisciplinary team for treating rectal cancer, risk factors associated with high rectal cancer recurrence rate, National Comprehensive Cancer Network 2013 Guidelines for Transanal Excision, and total mesorectal excision score as categorized by Quirke. Figures show procedures for local, anterior, and abdominoperineal resection.

      This review contains 11 figures, 8 tables, and 66 references.

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    • 45

      Management of Hepatic Metastases From Colorectal Cancer

      By Rory Smoot, MD; David M. Nagorney, MD, FACS
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      Management of Hepatic Metastases From Colorectal Cancer

      • RORY SMOOT, MDAssistant Professor of Surgery, Mayo Clinic College of Medicine, Senior Associate Consultant, Division of General Surgery, Mayo Clinic College of Medicine, Rochester, MN
      • DAVID M. NAGORNEY, MD, FACSProfessor of Surgery, Mayo Clinic College of Medicine, Rochester, MN

      Colon cancer is the third most commonly diagnosed cancer in the United States. Partial colectomy is beneficial for the majority of these patients; more than 250,000 of these procedures are performed in the United States annually, with colon cancer being the most common indication. Although these procedures are commonly performed, there is considerable associated morbidity and mortality. This review details the indications for surgery, the preoperative planning, and technical considerations for colon cancer surgeries. Figures show the vascular anatomy of the colon, oncologic resections of carcinomas in different locations of the colon, anatomic relations between the colon and the retroperitoneal organs, port positioning for laparoscopic colectomy, right colon mobilization and mesenteric dissection in laparoscopic right hemicolectomy, configuration of an end-to-end stapled colorectal anastomosis, laparoscopic left hemicolectomy and sigmoid resection, and approaches to dissection of the splenic flexure. A video shows a laparoscopic right colectomy, and potential complications of colectomy are listed in a table.

      This review contains 9 figures, 1 video, 1 table, and 69 references.

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    • 46

      Anal Neoplasms, Presacral Tumors, and Rare Malignancies

      By David E. Beck, MD, FACS, FASCRS
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      Anal Neoplasms, Presacral Tumors, and Rare Malignancies

      • DAVID E. BECK, MD, FACS, FASCRS

      Tumors of the anorectum and presacral regions are uncommon and most surgeons will not encounter many during their career. Knowledge of the regional anatomy is essential for proper diagnosis and treatment. The anatomy of the anus, the anal margin, and malignant lesions are described, as are malignant conditions of the anal canal. The anatomy of retrorectal tumors is discussed, as well as lesions such as developmental cysts, teratoma and teratocarcinoma, anterior sacral meningocele, and neurogenic and osseus tumors. Clinical presentation, evaluation, and treatment, including abdominal- or perineal-only approaches, the combined abdominoperineal approach, and adjuvant therapy are discussed. Tables describe the tumor node metastasis staging system for anal cancer, characteristics to document during perineal examination, modalities used in clinical staging anorectal ultrasonography, squamous cell carcinoma of the anal canal, differential diagnosis of retrorectal tumors, classification of teratomas, and principles of preoperative biopsy for management of solid and heterogeneously cystic tumors. Figures show the anatomy of the anal canal; perianal squamous intraepithelial lesion; perianal Paget disease; results of histologic review of epidermoid carcinomas; anal cancer; an anoscope; the relationship of retrorectal space to pelvic structures; management flowcharts for retrorectal mass, pure cystic lesion, and solid or heterogeneous cystic lesion; and patient positioning.

      This review contains 11 figures, 7 tables, and 50 references.

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    • 47

      Acute and Chronic Radiation Injury to the Lower Gastrointestinal Tract

      By Rachel E. Beard, MD; Deborah Nagle, MD
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      Acute and Chronic Radiation Injury to the Lower Gastrointestinal Tract

      • RACHEL E. BEARD, MDGeneral Surgery Resident, Beth Israel Deaconess Medical Center, Boston, MA
      • DEBORAH NAGLE, MDChief, Division of Colon and Rectal Surgery, Beth Israel Deaconess Medical Center, Boston, MA

      Radiation is an integral part of therapy for many pelvic cancers, including rectal, prostate, cervical, and uterine cancers, and has been shown to decrease local recurrence and increase patient survival. Radiation injury is a sequela of treatment that manifests different symptoms depending on the organ affected. This review covers disease pathology, risk factors, disease prevention, clinical presentation, medical therapy, endoscopic therapy, and surgical therapy. Tables outline risk factors predisposing patients to the development of radiation injury, investigated prophylactic therapies to prevent radiation injury, reported frequencies of symptoms of chronic radiation proctitis, pharmacologic therapies that have demonstrated clinical benefit in randomized trials, and a scoring system for symptoms and endoscopic and histologic results. A management algorithm details evaluation and treatment of radiation-induced gastrointestinal injury. A microscopic section shows diffuse ulceration and granulation tissue formation. Photographs depict the rectal wall thickened by dense white tissue and severe perianal dermatitis.  Endoscopic views of radiation proctitis with ulceration, severe radiation proctitis, mild radiation proctitis, prominent telangiectasia, anal necrosis due to radiation, actively bleeding telangiectasia, and argon plasma coagulation are provided. Other figures include computed tomographic scans of an inflamed rectum and the rectal wall with thin mucosa, and magnetic resonance imaging of the pelvis.

      This review contains 13 figures, 5 tables, and 89 references.

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    • 48

      Intestinal Stomas

      By J. Graham Williams, MCh, FRCS
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      Intestinal Stomas

      • J. GRAHAM WILLIAMS, MCH, FRCS

      Formation of an intestinal stoma is frequently a component of surgical intervention for diseases of the small bowel and the colon. The most common intestinal stomas are the ileostomies (end and loop) and the colostomies (end and loop). Preoperative counseling, choice of procedure, and selection of stoma site are described. The general principles of the operative technique are listed, as is the creation of the stoma aperture. Types of colostomies are described and include end, loop, and double-barrel. For ileostomy, end, loop, loop-end, split, and continent are described. Details are provided on the stoma closure for loop ileostomy and loop colostomy. The chapter has sections on troubleshooting and complications, including ischemia, stenosis, prolapse, retraction, parastomal hernia, obstruction, and fistula. Figures show an end colostomy, loop colostomy, preparation of terminal ileum and placement of sutures for an end ileostomy, stoma closure for loop ileostomy, stabilization of retracted ileostomy, preperitoneal mesh repair of parastomal hernia, and laparoscopic intra-abdominal placement of polytetrafluoroethylene-coated mesh. Tables show indications for different types of intestinal stomas, incidence of common complications of the intestinal stomas, incidence of parastomal hernia formation, and additional complications arising after stoma formation.

      This review contains 12 figures, 5 tables, and 106 references.

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    • 49

      Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised Patient

      By Cindy Kin, MD; Amy Lightner, MD; Mark Welton, MD, MHCM
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      Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised Patient

      • CINDY KIN, MDAssistant Professor of Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA
      • AMY LIGHTNER, MDResident in General Surgery, Department of Surgery, University of California, Los Angeles, Los Angeles, CA
      • MARK WELTON, MD, MHCMProfessor of Surgery, Department of Surgery, Stanford University Medical Center, Stanford, CA

      The risks of surgical intervention in the immunosuppressed patient, with poor wound healing capabilities and the greater morbidity and mortality associated with infectious complications, must be carefully weighed against the potential benefits. It is important for surgeons to focus on the bigger picture and manage a multidisciplinary approach from the preoperative to postoperative stages. This review discusses immunosuppressive medications, management of benign colorectal diseases (e.g., diverticulitis or appendicitis) in immunocompromised patients, colorectal problems related to neutropenia, and neoplastic colorectal problems in immunocompromised patients. Figures show mucocutaneous separation, intra-abdominal abscess, Crohn colitis, and wound infection in a patient who underwent emergent sigmoid colectomy with end colostomy. Tables list causes of immunosuppression, immunosuppressive medications for inflammatory bowel disease and transplant patients, sample steroid taper for patients who are on prolonged high-dose systemic corticosteroid therapy prior to colectomy for medically refractory ulcerative colitis, and the etiology, risk factors, diagnosis, and treatment of human papillomavirus–related anal lesions.

      This review contains 4 figure, 5 tables, and 127 references.

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    • 50

      Reoperative Pelvic Surgery

      By Eric J. Dozois, MD, FACS, FASCRS; Daniel I. Chu, MD
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      Reoperative Pelvic Surgery

      • ERIC J. DOZOIS, MD, FACS, FASCRSProfessor of Surgery, Division of Colon and Rectal Surgery, Mayo Clinic, Rochester, MN
      • DANIEL I. CHU, MDAssistant Professor of Surgery, Section of Gastrointestinal Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, AL

      Reoperative pelvic surgery is technically challenging and carries with it significant potential risk. Pelvic pathology that requires reoperative surgery typically involves recurrent malignancies, complications from ileal pouch-anal anastomoses (IPAA) for inflammatory bowel disease, complications from low pelvic anastomoses, and palliative situations. The goals of reoperative pelvic surgery are resection/repair of the primary indication and reconstruction whenever possible. This review describes pelvic anatomy and operative management for recurrent rectal cancer. Complications following IPAA, low anastomotic complications, and palliative reoperative pelvic surgery are also detailed. Tables outline prognostic factors negatively impacting outcomes following surgery for recurrent rectal cancer, absolute and relative contraindications for exenterative surgery, survival following exenteration for recurrent rectal cancer, intraoperative radiotherapy doses related to resection margin, indications for reoperative pouch surgery, and mobilization techniques for difficult reconstructions. Figures show anterior and posterior exenteration; the anatomy of presacral space after rectal mobilization; vascular exposure and dissection; unicortical transverse osteotomy; placement of Silastic mesh; division of the sacrospinous and sacrotuberous ligaments and piriformis muscle; posterior sacral osteotomy; transperineal delivery of pedicled myocutaneous rectus flap; vertical rectus abdominis myocutaneous flap; gracilis flap; total thigh fillet flap; sacropelvic resection classification; and increasing colon length with primary, secondary, and tertiary maneuvers.

      This review contains 18 figures, 6 tables, and 89 references.

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    • 51

      Achieving Evidence-based Practices in Colorectal Surgery

      By Imran Hassan, MD, FACS, FASCRS
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      Achieving Evidence-based Practices in Colorectal Surgery

      • IMRAN HASSAN, MD, FACS, FASCRSClinical Associate Professor, Department of Surgery, University of Iowa, Cedar Rapids, IA

      The concept of evidence-based medicine (EBM) and evidence-based surgery (EBS) involves combining the best scientific evidence available with the clinician’s judgment while also considering the patient’s needs and preferences. In the past, the practice of colorectal surgery was based on tradition and anecdotal experience from experts rather than scientific rationale. However, the rise of EBM has led to changes in how colorectal surgery is performed. This review discusses the hierarchy of evidence, fundamental principles of EBS, and practicing evidence-based colorectal surgery. Tables review the Oxford Centre for Evidence-Based Medicine revised levels of evidence, four steps of evidence-based surgery, key resources for evidence-based surgery, the “PICO” technique, and the Dindo-Clavien classification system.

      This review contains 5 tables and 69 references.

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    • 52

      Advanced and Recurrent Rectal Cancer

      By Nicole de Rosa, MD; George J. Chang, MD, MS
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      Advanced and Recurrent Rectal Cancer

      • NICOLE DE ROSA, MDDepartment of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX
      • GEORGE J. CHANG, MD, MSChief, Colon and Rectal Surgery, Professor, Departments of Surgical Oncology and Health Services Research, Associate Medical Director, Colorectal Center, Director of Clinical Operations, Minimally Invasive and New Technologies in Oncology Surgery Program, The University of Texas MD Anderson Cancer Center, Houston, TX

      Rectal cancer accounts for one-third of all colorectal cancers and has an increasing incidence in patients under 40 years of 1.8 to 2.6% annually. Significant advances in multidisciplinary therapy for rectal cancer have resulted in an improved relative 5-year survival; prognosis is strongly dependent on the extent of disease. Although the majority of patients present with disease localized to the mesorectum, locally advanced rectal cancer (LARC) occurs in up to 10% of patients. Surgical extirpation remains the mainstay of curative therapy for LARC and locally recurrent rectal cancer (LRRC). This review covers risk factors for pelvic recurrence, clinical presentation, diagnosis and staging, preparation for surgery, multimodality therapy for advanced and locally recurrent rectal cancer, pelvic reconstruction, and palliative procedures. Figures show Harrison-Anderson-Mick applicator for intraoperative brachytherapy, an algorithm for treating LARC (extension beyond mesorectal fascia or advanced modal disease), an algorithm for treating LRRC, and intraoperative photographs showing oblique sacral resection, extended right lateral pelvic resection, and vertical rectus myocutaneous flap procurement. Tables list risk factors associated with rectal cancer recurrence, and a classification schema of LRRC.

       

      This review contains 6 highly rendered figures, 2 tables, and 119 references

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    • 53

      Lower Gastrointestinal Bleeding

      By Jennifer Nayor, MD; John R. Saltzman, MD
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      Lower Gastrointestinal Bleeding

      • JENNIFER NAYOR, MDClinical Research Fellow, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA
      • JOHN R. SALTZMAN, MDDirector of Endoscopy, Division of Gastroenterology, Brigham and Women’s Hospital, Boston, MA, Associate Professor of Medicine, Harvard Medical School, Boston, MA

      Of patients who present with major gastrointestinal (GI) bleeding, 20 to 30% will ultimately be diagnosed with bleeding originating from a lower GI source. Lower GI bleeding has traditionally been defined as bleeding originating from a source distal to the ligament of Treitz; however, with the advent of capsule endoscopy and deep enteroscopy allowing for visualization of the entire small bowel, the definition has been updated to GI bleeding originating from a source distal to the ileocecal valve. Lower GI bleeding can range from occult blood loss to massive bleeding with hemodynamic instability and predominantly affects older individuals, with a mean age at presentation of 63 to 77 years. Comorbid illness, which is a risk factor for mortality from GI bleeding, is also more common with increasing age. Most deaths related to GI bleeding are not due to uncontrolled hemorrhage but exacerbation of underlying comorbidities or nosocomial complications. This review covers the following areas: evaluation of lower GI bleeding (including physical examination and diagnostic tests), initial management, and differential diagnosis. Disorders addressed in the differential diagnosis include diverticulosis, arteriovenous malformations (AVMs), ischemic colitis, anorectal disorders, radiation proctitis, postpolypectomy bleeding, and colorectal neoplasms. Figures show an algorithm for management of patients with suspected lower GI bleeding, tagged red blood cell scans, diverticular bleeding, colonic AVM, ischemic colitis, bleeding hemorrhoid, chronic radiation proctitis, and ileocolonic valve polyp. Tables list descriptive terms for rectal bleeding and suggested location of bleeding, imaging modalities and differential diagnosis for lower GI bleeding, endoscopic techniques for hemostasis, and an internal hemorrhoids grading system.

      This review contains 8 highly rendered figures, 5 tables, and 100 references.

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  • Head and Neck
    • 1

      Parotid Mass

      By Harrison W. Lin, MD; Neil Bhattacharyya, MD, FACS
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      Parotid Mass

      • HARRISON W. LIN, MDDepartment of Otolaryngology–Head and Neck Surgery, University of California, Irvine, Orange, CA
      • NEIL BHATTACHARYYA, MD, FACSDepartment of Otology and Laryngology, Harvard Medical School, Division of Otolaryngology– Head and Neck Surgery, Brigham and Women’s Hospital, Boston, MA

      The spectrum of histopathologic entities encompassed by the term parotid mass is exceedingly broad and continues to evolve as knowledge of the origins and clinical behavior of the various tumors arising from the parotid glands expands. The anatomy and etiology of parotid masses are discussed. Differential diagnosis of nonneoplastic and neoplastic conditions, presentation and diagnostic workup, management, and survival rates are described. Tables review the World Health Organization histologic classification of benign and malignant epithelial tumors of the salivary glands, clinical features suggestive of primary lymphoma of the salivary gland, the most frequently reported salivary gland sarcomas, salivary and nonsalivary pathologic processes distinguished by fine-needle aspiration biopsy, American Joint Committee on Cancer clinical classification and staging system for major salivary gland tumors, principles of treatment of parotid tumors, indications for postoperative radiation therapy for parotid cancer, prognostic factors for salivary gland tumors, and histopathologic distribution of major salivary gland malignancies of the parotid. Figures show the anatomy of the parotid region, magnetic resonances images of a parotid pleomorphic adenoma, and various parotidectomy procedures. An algorithm depicts the approach to evaluation of a parotid mass.

      This review contains 6 figures, 11 tables, and 65 references.

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    • 2

      Neck Dissection

      By Miriam N. Lango, MD, FACS; Bert W. O'Malley Jr, MD, FACS; Ara Chalian, MD, FACS
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      Neck Dissection

      • MIRIAM N. LANGO, MD, FACSAssociate Professor, Department of Surgical Oncology-Head and Neck Section, Fox Chase Cancer Center, Temple University Health System Philadelphia, PA
      • BERT W. O'MALLEY JR, MD, FACSProfessor and Chair, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, PA
      • ARA CHALIAN, MD, FACSAssociate Professor, Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania Health System, Philadelphia, PA

      Need for neck dissection begins with thorough evaluation, including fine needle aspiration and possibly excisional lymph node biopsy. The incidence of the various neck metastases are provided, including those for cutaneous squamous cell carcinoma; salivary gland neoplasms; cervical lymph node metastases; squamous cell carcinoma of the upper aerodigestive tract; and metastatic well-differentiated thyroid cancer. Staging of neck cancer is also defined. Indications and contraindications for neck dissection are provided. Operative planning begins with the decision on the choice of procedure: a comprehensive dissection that will result in a radical or modified neck dissection; a selective neck dissection; an extended neck dissection; or a bilateral neck dissection. Neck dissection after chemoradiation is also discussed. Reconstruction after resection of large tumors with large margins is also described, along with current evidence relating to preservation of vascular structures and subsequent predisposition to recurrence. The operative steps for radical, modified, and selective neck dissection are described. Both intraoperative and postoperation complications are explained.

      This review contains 5 figures, 1 table, and 51 references.

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    • 3

      Oral Cavity Lesions

      By Kiran Kakarala, MD; Sook-Bin Woo, DMD, MMSc; Keith Saxon, MD
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      Oral Cavity Lesions

      • KIRAN KAKARALA, MD
      • SOOK-BIN WOO, DMD, MMSCDivision of Oral Medicine and Dentistry, Brigham and Women's Hospital, Associate Professor, Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA
      • KEITH SAXON, MDSenior Associate Surgeon, Lifestyle Lift, Kansas City Center, Kansas City, KS

      Lesions of the oral cavity reflect locally confined processes, but, on occasion, they are manifestations of systemic disease. Causes, diagnosis, and subsequent management can be based on clinical evaluation, physical examination, and investigative studies including laboratory tests, imaging, biopsy, or examination under anesthesia and panendoscopy. Oral cavity lesions can be infectious or noninfectious. Infectious lesions include viral stomatitis and candidiasis. Noninfectious lesions are described and include recurrent aphthous stomatitis, necrotizing sialometaplasia, pyogenic granuloma, lichen planus, ulcers from autoimmune disease, and traumatic ulcers. Tumor-like lesions are also described and management options presented; they include torus mandibularis and torus palatinus, mucocele and mucous retention cysts, fibromas, and odontogenic cysts. Neoplastic lesions can be benign, pre-malignant, or malignant. Benign lesions are defined and management options presented; these include squamous papilloma, giant cell lesions, minor salivary gland neoplasms, granular cell tumors, and ameloblastomas. Pre-malignant lesions are described and management options presented; these include leukoplakia and erythroplakia. Malignant lesions are defined and management options presented; these include minor salivary gland malignancies, mucosal melanoma, and squamous cell carcinoma. Additionally, oral cavity manifestations of HIV infection are discussed. Figures show the major anatomic subsites of the oral cavity, several infectious, noninfectious, tumor-like, benign, and malignant lesions of the oral cavity. Coccidioidomycosis of the tongue in an HIV-positive patient is also shown. A dozen tables include a listing of the clinical presentation and prognostic factors of several oral cavity lesions and the classification and staging system of head and neck cancer from the American Joint Committee on Cancer.

      This review contains 7 figures, 12 tables, and 69 references.

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    • 4

      Head and Neck Diagnostic Procedures

      By Donald J. Annino Jr, MD, DMD; Laura A. Goguen, MD, FACS
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      Head and Neck Diagnostic Procedures

      • DONALD J. ANNINO JR, MD, DMDDivision of Otolaryngology, Brigham and Women's Hospital, Boston, MA
      • LAURA A. GOGUEN, MD, FACSDivision of Otolaryngology, Brigham and Women's Hospital, Boston, MA

      Head and neck diseases can be inflammatory, infectious, congenital, neoplastic, or traumatic. The anatomy of the head and neck structures are described and include the ear, nose and paranasal sinuses (including the oral cavity, salivary glands, and pharynx), the larynx (including the supraglottis, glottis, and subglottis), and the neck. An accurate diagnosis is mandatory and is based on a detailed history and physical examination. Examination of the nose may be done with anterior or posterior rhinoscopy or rigid nasal endoscopy. The larynx and pharynx may be viewed by indirect, flexible, or direct laryngoscopy. Flexible or rigid esophagoscopy permits examination of the esophagus. The trachea and lungs are examined using rigid or flexible bronchoscopy, panendoscopy, or core or open biopsy. Imaging can include ultrasononography, barium swallow, computed tomography scans, positron emission tomography scans, and magnetic resonance imaging. Nearly one dozen figures show various anatomic structures and office equipment, including nasal specula, a laryngeal mirror, an esophagoscope, and a bronchoscope. Several recommended readings are provided.

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    • 5

      Parotidectomy

      By Kathryn T. Chen, MD; Shannon H. Allen, MD; John A. Ridge, MD, PhD, FACS
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      Parotidectomy

      • KATHRYN T. CHEN, MDSurgical Oncology Fellow, Department of Surgery, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA
      • SHANNON H. ALLEN, MDOtolaryngology Resident, Department of Otolaryngology, Temple University Hospital, Philadelphia, PA
      • JOHN A. RIDGE, MD, PHD, FACSChief, Head and Neck Surgery Section, Fox Chase Cancer Center, Temple University School of Medicine, Philadelphia, PA

      This review discusses the anatomy of the parotid gland; preoperative evaluation and operative planning procedures; operative techniques, including incision and skin flaps, identification of the facial nerve, parenchymal dissection, and drainage and closure; postoperative care; and complications, such as facial nerve injury, hemorrhage, gustatory sweating (Frey syndrome), siolocele (salivary fistula), and cosmetic changes. Outcome evaluation is also discussed. Figures include the anatomic boundaries of parotid space, the recommended head position for parotidectomy, creation of the anterior skin flap, dissection of the gland parenchyma and facial nerve, and drainage and closure after parotidectomy.

      This review contains 6 figures and 55 references.

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    • 6

      Neck Mass

      By Gerard M. Doherty, MD
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      Neck Mass

      • GERARD M. DOHERTY, MDUtley Professor and Chair of Surgery, Boston University, Boston, MA

      The evaluation of any neck mass begins with a careful, directed history focused on an appropriate differential diagnosis. Directed questions can narrow the diagnostic possibilities and focus subsequent investigations. For example, in younger patients, one might have an initial suspicion of congenital or inflammatory lesions, whereas in older adults, the primary concern is often neoplasia. The head and neck examination is challenging because much of the area to be examined is not easily seen. Patience and practice are necessary to master the special instruments and techniques of examination. Most neck masses in adults are abnormal and are often manifestations of underlying conditions that require treatment. In most cases, therefore, further diagnostic evaluation should be pursued. This review covers clinical evaluation, developing a differential diagnosis, investigative studies, and management of specific disorders associated with neck mass. Figures show cervical lymph nodes, a management algorithm for thyroid nodules, and the course of the thyroglossal duct from the foramen cecum to the pyramidal lobe of the thyroid gland. Tables list the etiology of neck mass, classification of cervical lymph nodes, and sonographic findings and size indications of biopsy of thyroid nodules.

       

      This review contains 3 highly rendered figures, 3 tables, and 7 references.

       

      Key words: cervical adenopathy; cervical lymph nodes; congenital neck mass; enlarged lymph nodes; fine-needle aspiration; neck mass; thyroid disease; thyroid mass; thyroid nodule

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    • 7

      Parathyroid Diseases and Operations

      By Matthew A. Nehs, MD; Daniel T. Ruan, MD; Francis D. Moore Jr, MD
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      Parathyroid Diseases and Operations

      • MATTHEW A. NEHS, MDInstructor in Surgery, Harvard Medical School, Associate Surgeon, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
      • DANIEL T. RUAN, MDAssistant Professor of Surgery, Harvard Medical School, Associate Surgeon, Department of Surgery, Brigham and Women’s Hospital, Boston, MA
      • FRANCIS D. MOORE JR, MDProfessor of Surgery, Harvard Medical School, Vice Chair, Department of Surgery, Chief, Division of General and Gastrointestinal Surgery, Brigham and Women’s Hospital, Boston, MA

      Diseases of the parathyroid glands include primary, secondary, tertiary, and renal hyperparathyroidism, parathyroid carcinoma, and multiple endocrine neoplasia syndromes. A standard surgical method is bilateral neck exploration, which enables the examination of all parathyroid tissue. A focused parathyroidectomy can also be considered when preoperative imaging tests (ultrasonography/sestamibi scanning/four-dimensional computed tomography) are concordant. This review discusses diseases of the thyroid glands, evaluation of primary hyperparathyroidism, treatment, operative planning, the operative technique for bilateral neck exploration and an alternative operative technique for focused parathyroidectomy, special concerns, postoperative care, and complications. Figures show the location of the initial incision for bilateral neck exploration, the location of the incision for exposing the thyroid gland, division of the middle thyroid veins to give better exposure behind the superior portion of the thyroid lobe, location of the recurrent laryngeal nerve in relation to the Berry ligament and upper and lower parathyroid glands, and surgical specimens in a case of renal hyperparathyroidism.

      This review contains 6 figures and 36 references.

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    • 8

      Thyroid Diseases

      By Karen R. Borman, MD, FACS; Erin A. Felger, MD, FACS
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      Thyroid Diseases

      • KAREN R. BORMAN, MD, FACSVice-Chair for Education and Quality, Department of Surgery, Medstar Washington Hospital Center, Washington, DC, Clinical Professor (Adjunct), Surgery, Temple University School of Medicine, Philadelphia, PA
      • ERIN A. FELGER, MD, FACSAssociate Program Director General Surgery Residency, Department of Surgery, Medstar Washington Hospital Center, Washington, DC, Assistant Professor of Surgery, Georgetown University School of Medicine, Washington, DC

      The thyroid plays a key role in normal metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and modulation of adrenergic regulation. Surgical consultations are most often requested for control of hyperthyroidism or for treatment of euthyroid nodular disease. This review describes the approach to the patient with hyperthyroidism and with euthyroid nodular disease, including papillary, follicular, anaplastic, medullary, and primary thyroid cancer, and oncocytic (Hürthle cell) carcinoma. Operative techniques of thyroidectomy are described and include positioning, incisions-making, and troubleshooting. Postoperative care, including thyroid hormone management, is described. Complications and outcome evaluation are discussed. Tables list the etiologies of hyperthyroidism, benign and malignant etiologies of euthyroid nodular disease, familial syndromes of thyroid disease, the Bethesda classification of fine needle aspiration cytology and associated malignancy risk, the elements of common prognostic schemes for well-differentiated thyroid cancer, and the staging of differentiated, medullary, and anaplastic thyroid cancer. Figures show the six levels of cervical lymph nodes, the initial incision in a thyroidectomy, a midline incision, the superior pole vessels, the upper and lower parathyroid glands, the recurrent laryngeal nerve, and Delphian lymph nodes. An algorithm shows the approach to the patient with thyroid disease

      This review contains 7 figures, 8 tables, and 64 references.

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    • 9

      Tracheostomy

      By H. David Reines, MD, FACS; Elizabeth Franco, MD, FACS
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      Tracheostomy

      • H. DAVID REINES, MD, FACSProfessor, Department of Surgery, Virginia Commonwealth University, Richmond, VA, Vice Chair, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
      • ELIZABETH FRANCO, MD, FACSAssistant Professor, Department of Surgery, Virginia Commonwealth University, Richmond, VA, Staff Surgeon, Trauma/Acute Care Surgery, Inova Fairfax Hospital, Falls Church, VA

       The most common indications for modern tracheostomy are prolonged ventilation for respiratory failure and airway protection following traumatic brain injury with neurologic dysfunction. For background purposes, history and facts related to early tracheostomy are provided. Thereafter, anatomy and physiology are discussed, as are other anatomical considerations, including the site of the procedures, anesthesia, and patient positioning. Counseling and informed consent are also discussed. The operative techniques are provided for emergent surgical airway (cricothyroidotomy and transtracheal needle ventilation and oxygenation) and open and percutaneous tracheostomy. Tracheostomy management is described. Complications are listed and described. Early complications include displacement, pneumomediastinum/pneumothorax, bleeding, infection, acute obstruction, and negative pressure pulmonary edema. Late complications include subglottic tracheal stenosis, tracheal granulation, vocal cord dysfunction, tracheoesophageal fistula, tracheoinnominate fistula, and tracheocutaneous fistula.

      This review contains 13 figures, 1 video, 2 tables, and 38 references.

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    • 10

      Oral Cavity Procedures

      By Carol R. Bradford, MD, FACS; Mark E.P. Prince, MD, FRCSC
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      Oral Cavity Procedures

      • CAROL R. BRADFORD, MD, FACSCharles J. Krause, MD, Collegiate Professor and Chair, Division of Head and Neck Surgery, Department of Otolaryngology, University of Michigan, Ann Arbor, MI
      • MARK E.P. PRINCE, MD, FRCSCProfessor and Chief, Division of Head and Neck Surgery, Department of Otolaryngology, University of Michigan, Ann Arbor, MI

      Oral cavity procedures are commonly performed to treat malignancies, and wide surgical margins are generally necessary for adequate treatment. In addition to describing the general diagnostic evaluation and meticulous detail that must be afforded to the components of speech and swallowing, this chapter describes the most common procedures. These include anterior glossectomy, excision of floor-of-mouth lesions, excision of superficial or plunging ranulas, removal of submandibular gland duct stones, resection of the hard palate, maxillectomy, and mandibulectomy. For all procedures, the operative planning, steps of the operative technique, troubleshooting, postoperative care, and complications are described. Figures are provided for the procedures.

      This review contains 13 figures, 7 tables, and 17 additional readings.

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  • Thorax
    • 1

      Dysphagia

      By Anna L. McGuire, MD, FRCSC; R. Sudhir Sundaresan, MD, FRCSC, FACS
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      Dysphagia

      • ANNA L. MCGUIRE, MD, FRCSCFellow, Division of Thoracic Surgery, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, ON
      • R. SUDHIR SUNDARESAN, MD, FRCSC, FACSProfessor of Surgery, Chief, and Chair, Department of Surgery, The Ottawa Hospital, University of Ottawa, Ottawa, Canada

      Dysphagia may be oropharyngeal or esophageal. Evaluation is described, including a thorough dysphagia history of associated painful swallowing, location, solids versus liquids, intermittent versus progressive, acute versus gradual onset, and associated symptoms such as weight loss. Physical examination and key diagnostic tests are also reviewed. The evidence-based management of various etiologies of esophageal dysphagia are summarized. Motor disorders described include achalasia, the other primary esophageal motility disorders, and the most common secondary esophageal motility disorders. Esophageal diverticulae are also reviewed in this section. Mechanical esophageal obstruction is presented, including discussions of esophageal webs, rings, peptic stricture, and cancer. Important inflammatory and infectious causes of dysphagia are described, including caustic ingestion, eosinophilic esophagitis, and esophageal infections. The oral phases of liquid and solid swallowing are presented, as are the pharyngeal and esophageal phases of swallowing. Figures show the results of several diagnostic tests and other conditions, including pharyngeoesophageal diverticulum, giant epiphrenic diverticulum, Schatzki ring, and midesophageal squamous cell carcinoma. A flowchart outlines evaluation and management of dysphagia. Tables list the etiologies of oropharyngeal and esophageal dysphagia, achalasia grouping based on high-resolution manometry, triple therapy for esophageal diverticulae, and clinicopathologic criteria for diagnosis of eosinophilic esophagitis. 

      This review contains 11 figures, 5 tables, and 61 references.

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    • 2

      Cough and Hemoptysis

      By Shahriyour Andaz, MD, FACS, FRCS; Svetlana Danovich, DO, PhD
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      Cough and Hemoptysis

      • SHAHRIYOUR ANDAZ, MD, FACS, FRCSDirector of Thoracic Oncology, South Nassau Community Hospital, Adjunct Professor, New York College of Medicine, Chairman, Cardiothoracic Section Nassau Surgical Society, Westbury, NY
      • SVETLANA DANOVICH, DO, PHDStaff Physician, Department of Surgery, Stonybrook University Medical Center, Stony Brook, NY

      Cough is one of the most common symptoms in patients. Hemoptysis may not be as common a presenting complaint, but even mild hemoptysis calls for prompt attention and diagnosis. Both may be signs of urgent or life-threatening disease, and patients who present with either or both should undergo a thorough, methodical workup including history, examination, and appropriate diagnostic studies. This chapter presents the management of both acute and chronic cough and other conditions that might be associated with cough. Hemoptysis is presented and includes discussion of diagnosis via examination and other investigations and both medical and surgical management. Figures show management algorithms for acute and chronic cough. Tables show the differential diagnosis of cough and hemoptysis, and the contraindications to surgical resection. This chapter contains 67 references.

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    • 3

      Chest Wall Mass

      By Erik A. Sylvin, MD; John C. Kucharczuk, MD
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      Chest Wall Mass

      • ERIK A. SYLVIN, MDFellow, Thoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA
      • JOHN C. KUCHARCZUK, MDChief, Division of Thoracic Surgery, Associate Professor of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA

      Chest wall masses are relatively uncommon in clinical practice. The chest wall contains a number of distinct tissues, including skin, fat, muscle, bone, cartilage, lymphatics, blood vessels, and fascia. Each of these component tissues has the capability of producing either a benign or a malignant primary chest wall mass. Initial clinical evaluation includes careful history-taking; CT scans; MRI; and fine-needle aspiration as the former cannot always distinguish between malignant and benign masses. The benign primary masses of the chest wall are described and include infectious masses such as sternal infections; sternoclavicular joint infections; and osteomyelitis of the rib. Benign neoplasms of the chest wall are listed and include bone and cartilage neoplasms such as osteochondromas and chondromas. Malignant primary masses of the chest wall are listed and include soft tissue sarcomas; plasmacytoma; chondrosarcoma; and synovial sarcomas. Secondary chest wall masses are also defined as direct extensions of a malignancy from a contiguous organ. Breast and lung cancer are the most common. The initial evaluation centers on staging the underlying disease. Figures show a sternoclavicular joint infection; a CT scan showing sternoclavicular joint infection; and a chest wall sarcoma. Tables describe the classification of primary and secondary chest wall masses; benign neoplasm of the chest wall by site of origin; and primary malignant chest wall masses according to tissue of origin.
      This chapter contains 11 figures, 3 tables, 57 references, 5 Board-styled MCQs, and 1 Teaching Slide Set.

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    • 4

      Pleural Effusion

      By Eitan Podgaetz, MD, MPH; Rafael S. Andrade, MD, FACS
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      Pleural Effusion

      • EITAN PODGAETZ, MD, MPHAssistant Professor of Surgery, Section of Thoracic and Foregut Surgery, Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN
      • RAFAEL S. ANDRADE, MD, FACSAssociate Professor of Surgery and Chief, Section of Thoracic and Foregut Surgery, Division of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN

      Pleural effusions can occur in a wide variety of clinical situations. The most important test for the initial diagnosis and evaluation of a pleural effusion is the chest radiograph. Further investigation, such as imaging, pleural fluid analysis, pleural biopsy, and thoracoscopy, may be required to determine the etiology of the pleural effusion. This review covers the clinical evaluation, investigative studies, and management of pleural effusion, as well as basic facts of the pleura. An algorithm shows the approach to the patient with a pleural effusion. Figures show chest radiographs of patients with pleural effusion; six computed tomographic scans (showing right-side empyema showing a loculated effusion; a free-flowing, sickle-shaped, right-side effusion; parapneumonic effusion [PPE] at diagnosis, after initial chest tube placement, and after fibrinolytics; and left-side chylothorax secondary to lymphoma); an algorithm to manage known malignant pleural effusions; and a photograph of a PleurX catheter after placement and subcutaneous tunneling. Tables list the pathophysiologic mechanisms of pleural effusion, differential diagnosis for pleural effusions, relationship between pleural fluid appearance and causes, pleural fluid tests for causative assessment, practical guidelines for definitive management of malignant pleural effusion, and categorization of PPE by risk of poor outcome. Techniques for bedside thoracentesis and tube thoracostomy as well as for bedside fibrinolytic use are also presented.

      This review contains 1 management algorithm, 8 figures, 6 tables, and 92 references.

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    • 5

      Solitary Pulmonary Nodule

      By Taine T.V. Pechet, MD, FACS
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      Solitary Pulmonary Nodule

      • TAINE T.V. PECHET, MD, FACSAssistant Professor of Surgery, University of Pennsylvania and Vice Chief of Surgery, Penn Presbyterian Medical Center, Philadelphia, PA

      The solitary pulmonary nodule is a common finding that is observed in more than 150,000 persons each year in the United States. In the initial clinical evaluation, factors influencing probability of malignancy are discussed, including age and environmental factors. Investigative studies are described. Imaging includes chest radiography, CT scanning, and positron emission tomography. Biopsy can be excisional or performed via transthoracic needle or bronchoscopy. The differential diagnosis is broad and can include malignant or benign lesions. Malignant lesions include non small-cell lung cancer, small cell lung cancer, pulmonary carcinoid tumor, or metastatic malignancies. Benign lesions can include pulmonary hamartoma or inflammatory or infectious nodules. Few, if any, randomized controlled trials exist to direct management. Most clinicians rely on a combination of single-institution studies, a few prospective trials, and clinical acumen to assess a given patient's risk profile to inform decisions on invasive and noninvasive testing. Tables describe the differential diagnosis of a solitary pulmonary nodule, factors affecting malignant probability of a solitary pulmonary nodule, and the initial assessment of probability of cancer in a solitary pulmonary nodule. This review contains 96 references.

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    • 6

      Paralyzed Diaphragm

      By Raymond P. Onders, MD, FACS; Philip A. Linden, MD, FACS
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      Paralyzed Diaphragm

      • RAYMOND P. ONDERS, MD, FACSDepartment of Surgery, University Hospitals Case Medical Center and Case Western Reserve School of Medicine
      • PHILIP A. LINDEN, MD, FACSDivision of Thoracic and Esophageal Surgery, University Hospitals Case Medical Center and Case Western Reserve School of Medicine

      Diaphragmatic dysfunction may be unilateral or bilateral, with symptoms ranging from dyspnea only on extreme exertion to ventilator dependence. The etiology, treatment, and prognosis are quite different in unilateral and bilateral paralysis. A paralyzed hemidiaphragm may occur in isolation or as part of a systemic disease, whereas bilateral diaphragmatic paralysis usually occurs as a result of a traumatic or neuromuscular degenerative process. This review covers clinical evaluation, investigative studies, and management of diaphragmatic dysfunction. Figures show diaphragmatic motion during respiration, a postoperative radiograph from a 55-year-old woman who underwent left upper lobectomy, a postoperative radiograph of a 70-year-old man who underwent left upper lobectomy for removal of a peripheral 3 cm lesion, three chest radiographs of a 25-year-old man with a residual anterior mediastinal mass after treatment for germ cell tumor, chest radiograph showing left diaphragmatic paralysis in a breast cancer patient with malignant adenopathy involving the left phrenic nerve near the left main pulmonary artery, several parallel rows of sutures placed in the muscular portion and central tendon of the diaphragm and tied with the aid of a knot pusher, a laparoscopic mapping probe  held onto the left diaphragm with suction and which receives electrical stimuli from an external clinical station, an electrode implant device that houses the electrode in the needle and is placed into the diaphragm tangentially, and the diaphragm pacing system programmed for conditioning and attached via percutaneously placed diaphragm electrodes in a spinal cord-injured child for early conditioning and weaning from the ventilator. Tables list causes of isolated diaphragmatic paralysis, general causes of unilateral and bilateral diaphragmatic paralysis, and differential diagnosis of elevated hemidiaphragm on chest radiograph. A video shows current technique of laparoscopic diaphragm pacemaker insertion.

       

      This review contains 9 highly rendered figures, 3 tables, 1 video, and 22 references

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    • 7

      Open Esophageal Procedures

      By Cameron D. Wright, MD, FACS
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      Open Esophageal Procedures

      • CAMERON D. WRIGHT, MD, FACSAssociate Chief of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Professor of Surgery, Harvard Medical School, Boston, MA

      The growing stature of minimally invasive approaches to esophageal diseases does not diminish the importance of the equivalent open approaches. This chapter describes common open operations performed to excise Zenker diverticulum, to manage complex gastroesophageal reflux disease, and to resect esophageal and proximal gastric tumors. For each of these open procedures, the preoperative evaluation, operative planning, steps of the operative techniques, postoperative care, complications, and outcome evaluation are described. Over two dozen figures show many of the operative steps for a cricopharyngeal myotomy and excision of Zenker diverticulum, a transthoracic hiatal hernia repair, a transhiatal esophagectomy, Ivor-Lewis esophagectomy, and a left thoracoabdominal esophagogastrectomy.

      This chapter contains 27 figures, 12 tables, 13 references, 5 Board-styled MCQs, and 1 Teaching Slide Set.

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    • 8

      Minimally Invasive Esophageal Procedures

      By Daniel C. Wiener, MD; Jon O. Wee, MD, FACS
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      Minimally Invasive Esophageal Procedures

      • DANIEL C. WIENER, MDAssistant Professor, Division of Thoracic Surgery, Tufts Medical Center, Boston, MA
      • JON O. WEE, MD, FACSCo-Director of Minimally Invasive Thoracic Surgery, Instructor, Harvard Medical School, Division of Thoracic Surgery, Brigham and Women’s Hospital, Boston, MA

      In most instances, laparoscopy has replaced open procedures as the standard of care. Nevertheless, equipoise remains in the literature regarding the benefits of surgery compared with alternative treatment strategies such as medications in the case of gastroesophageal reflux disease (GERD) or endoscopic procedures in the case of achalasia. According to Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) guidelines published in 2010, indications for surgery include (1) failure of medical management, (2) patient preference, (3) complications of GERD (Barrett esophagus, peptic stricture), and (4) extraesophageal manifestations (asthma, hoarseness, cough, chest pain, aspiration). This chapter is organized by surgical procedure, all of which are derivatives of the laparoscopic Nissen fundoplication. In this chapter, the authors focus on minimally invasive surgical approaches to the treatment of the following benign esophageal disorders: GERD, achalasia, and paraesophageal hernias. New in this chapter is the in-depth coverage of laparoscopic paraesophageal hernia repair. The majority of patients with paraesophageal hernias are asymptomatic, and their hernias are found incidentally with a retrocardiac gastric bubble on an upright chest x-ray or herniated gastroesophageal junction seen on a chest or abdominal computed tomographic scan. For patients who are symptomatic, surgical repair is indicated as there is no medical treatment for this mechanical problem. For asymptomatic patients, clinical judgment needs to be used. All surgical procedures are covered by preoperative evaluation, operative planning, and operative technique, with a troubleshooting note for every step. Procedure complications, postoperative care, and outcome evaluation follow each procedure, listing the most current reports and data.

      This review has 10 Figures, 1 Table, and 61 References.

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    • 9

      Chest Wall Procedures

      By Jason L. Muesse, MD; Seth D. Force, MD
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      Chest Wall Procedures

      • JASON L. MUESSE, MDResident, Division of Cardiothoracic Surgery, Emory University, Atlanta, GA
      • SETH D. FORCE, MDAssociate Professor of Surgery, Division of Cardiothoracic Surgery, Emory University, Atlanta, GA

      Chest wall procedures are an important component of any thoracic surgeon’s practice. The approach to these procedures is somewhat different from the approach to esophageal or pulmonary resections and requires specific knowledge of thoracic musculoskeletal anatomy, as well as of the different types of autologous and artificial grafts available for chest wall reconstruction. This review covers chest wall procedures, broadly divided into procedures for congenital chest wall disease and procedures for acquired chest wall disease. The major surgical techniques in both categories are described, and the pitfalls that may accompany them are reviewed. Figures show the various steps used in repair of pectus excavatum (Ravitch procedure and Nuss procedure), transaxillary first rib resection, chest wall resection, manubrial resection and reconstruction, and open chest drainage (Eloesser flap), as well as a chest computed tomographic scan revealing a large pulmonary and chest wall mass.

       

      This review contains 16 highly rendered figures and 46 references.

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    • 10

      Video-assisted Thoracic Surgery

      By Marcelo C. DaSilva, MD; Scott J. Swanson, MD
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      Video-assisted Thoracic Surgery

      • MARCELO C. DASILVA, MDInstructor in Surgery, Harvard Medical School, Associate Surgeon, Division of Thoracic Surgery, Brigham and Women’s Hospital, Consultant Surgeon, Dana-Farber Cancer Institute Boston, MA
      • SCOTT J. SWANSON, MDDirector Minimally Invasive Thoracic Surgery, Division of Thoracic Surgery, Brigham and Women’s Hospital, Chief Surgical Officer, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA

      Video-assisted thoracic surgery (VATS) has significantly reduced morbidity and mortality, and has been used to treat both benign and malignant chest diseases. This chapter provides the indications and contraindications for VATS. It includes a discussion of preoperative evaluation and planning, including anesthesia and monitoring, positioning of the patient, port placement, and instrumentation, including video equipment, thoracoscopes and thoracoports, staplers, instruments, and devices for tissue cauterization. VATS is indicated for several chest procedures, and the operative technique and troubleshooting for each is provided. These include pleural disease, pulmonary wedge resection, spontaneous pneumothorax and bullous disease, lung volume reduction, lobectomy and pneumonectomy, mediastinal lymph node dissection, esophagectomy, mediastinal masses, thoracic trauma, sympathectomy, and splanchnicectomy. Cost considerations and training is also discussed. Nearly two dozen figures show most operative aspects of VATS, from equipment to surgical technique. Tables show the indications and relative contraindications for VATS procedures, basic instruments and equipment used for VATS procedures, and operative steps for VATS lobectomy. This chapter contains 47 references.

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    • 11

      Mediastinal Procedures

      By Joseph B. Shrager, MD, FACS; Vivek Patel, MBBS
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      Mediastinal Procedures

      • JOSEPH B. SHRAGER, MD, FACSProfessor of Cardiothoracic Surgery, Chief, Division of Thoracic Surgery, Stanford University School of Medicine, Stanford, CA
      • VIVEK PATEL, MBBSClinical Instructor, Heart Lung Esophageal Surgery Institute, University of Pittsburgh Medical Center, Pittsburgh, PA

      This chapter describes procedures for resecting lesions of the anterior, middle, and posterior mediastinum. Procedures for lesions of the anterior mediastinum may be for biopsy or resection. The operative steps for biopsy procedures are discussed and include the Chamberlain approach, the transcervical approach, and video-assisted thoracic surgery (VATS). Operative steps for resection include a median sternotomy approach and a transcervical approach. VATS/robotic thymectomy is briefly presented. Procedures for lesions of the middle mediastinum for which resection is appropriate is discussed and the operative technique for mediastinoscopic partial resection of subcarinal bronchogenic cyst is presented. Although the majority of posterior mediastinal masses occurring in adults are benign, procedures for lesions of the posterior mediastinum are presented and include a VATS resection of a neurogenic tumor of the posterior mediastinum, resection of a benign cyst of the posterior mediastinum, and resection of an esophageal leiomyoma. Tables present the differential diagnosis for an anterior mediastinal mass and indications for a planned thoracotomy approach to a middle or posterior mediastinal mass. More than one dozen figures show the operative steps in many of the resections. This chapter contains 30 references.

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    • 12

      Pericardial Procedures

      By Dawn Emick, MD; Thomas A. D'Amico, MD
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      Pericardial Procedures

      • DAWN EMICK, MDResident in Surgery, Department of Surgery, Duke University Medical Center
      • THOMAS A. D'AMICO, MDProfessor of Surgery, Chief, Section of General Thoracic Surgery, Duke University Medical Center

      The pericardial processes for which surgical intervention is required can be divided into two broad categories: pericardial effusion and constrictive pericarditis. The anatomy, physiology, and pathophysiology of the pericardium are described. Pericardial drainage procedures for pericardial effusion are listed and include pericardiocentesis, subxiphoid pericardiostomy, and thoracoscopic periocardiostomy. For each procedure, the steps of the operative technique and complications are described. Evaluation for and the operative steps for constrictive pericarditis is also discussed. Figures show a view of the pericardium with the heart removed; right pleural and pericardial effusion; pericardiocentesis; subxiphoid pericardiostomy; thoracoscopic pericardiostomy; and for a pericardiectomy, both a median sternotomy approach and a left anterolateral thoracotomy approach. Tables list common causes of pericardial effusion and causes of constrictive pericarditis. This review contains 39 references.

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    • 13

      Decortication and Pleurectomy

      By Eric S. Lambright, MD
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      Decortication and Pleurectomy

      • ERIC S. LAMBRIGHT, MDAssistant Professor of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN

      The pleural space is a potential cavity between the lung and the chest wall—more specifically, between the visceral and parietal pleura. The pleura typically is less than 1 mm thick in the normal, healthy patient. However, a variety of pathologic processes can occur that alter the transport of cell and fluid within the pleural space. The processes compromising the pleural space can lead to severe clinical symptoms and resultant patient compromise. Blood and infection (bacterial and mycobacterium) remain the common causes of fibrothorax. The authors review the common causes, pathophysiology, and diagnosis of fibrothorax; management and indications for decortication; technical aspects of the operation and management of residual pleural space issues; and the expected outcomes.Comparative data as to optimal therapy are lacking, and clinical judgment is typically the driver of care decisions. As such, a multidisciplinary approach is a key factor to ensuring optimal patient outcomes. Thoracoscopy appears to have a clear clinical advantage over open thoracotomy in managing the earlier stages of empyema and clotted hemothorax. Technical goals of thoracoscopy must not be compromised. Complete lung expansion and avoidance of pulmonary parenchymal injury are critical. The successful management of the patient with fibrothorax requires adherence to basic surgical tenets: appropriate patient selection for surgery, preoperative optimization, exacting attention to the technical aspects of the procedure, and timely interventions for perioperative events. The combined expertise of the pulmonary medicine team, radiology, and the surgical team is typically needed to ensure optimal patient-centered outcomes.This review includes:5 Figures, 3 Tables, and 24 References.

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    • 14

      Computed Tomographic Screening for Lung Cancer

      By Doraid Jarrar, MD, FACS, FCCP; Grace Y. Song, MD; Scott Swanson, MD, FACS
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      Computed Tomographic Screening for Lung Cancer

      • DORAID JARRAR, MD, FACS, FCCPChief, Section of Thoracic and Robotic Surgery, Co-Director, Lung Cancer Screening Program, Clinical Assistant, Professor of Surgery, Jefferson Medical College Einstein Healthcare Network, Philadelphia, PA
      • GRACE Y. SONG, MDDepartment of Surgery, Einstein Healthcare Network, Philadelphia, PA
      • SCOTT SWANSON, MD, FACSDirector of Minimally Invasive Thoracic Surgery, Brigham and Women’s Hospital, Chief Surgical Officer, Dana-Farber Cancer Institute, Professor of Surgery, Harvard Medical School, Boston, MA

      Lung cancer is the leading cause of cancer deaths worldwide. Although lung cancer screening has been advocated, for a long time level 1 evidence has been absent, leaving physicians with the challenge of treating patients with mostly incurable disease. Even in 2014, the 5-year survival for lung cancer will only be around 16% despite sophisticated imaging and diagnostic tools. Physicians are thus taking a more proactive route, including early screening for lung cancer and efforts to curb tobacco use. This review discusses lung cancer screening in the context of the National Lung Screening Trial, risk of overdiagnosis, cost-effectiveness, U.S. Preventive Services Task Force recommendations, lung cancer screening in the community, improving the specificity of lung cancer screening, and treatment options for early-stage lung cancer. Tables review key principles of computed tomographic screening, cost-effectiveness of computer tomographic screening, predictors of malignancy in the Pan-Canadian screening study model, and follow-up and management of newly detected indeterminate nodules. Figures show common causes of cancer death in the United States, estimated new cancer cases and cancer deaths in men and women, a four-stage system used in clinical and surgical evaluation of lung cancer, secondary prevention lung cancer screening goals, and a low-dose computer tomographic scan.

      This review contains 5 figures, 4 tables, and 31 references.

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    • 15

      Pulmonary Resection

      By Rajeev Dhupar, MD; Ara Vaporciyan, MD, FACS
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      Pulmonary Resection

      • RAJEEV DHUPAR, MDProfessor of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, TX
      • ARA VAPORCIYAN, MD, FACSProfessor of Thoracic and Cardiovascular Surgery, MD Anderson Cancer Center, Houston, TX

      Anatomic resections of the lung (including pneumonectomy and lobectomy) are the standard operative techniques employed to treat both neoplastic and nonneoplastic diseases of the lung. Preoperative evaluation is described. Once assessment of sufficient pulmonary reserve to tolerate the procedure is made, guidance is provided for anesthesia (bilateral or unilateral lung ventilation); placement of catheters; positioning in the lateral decubitus position; and type of incision to be made (posterior lateral thoracotomy or small incisions). Special intraoperative issues are also touched upon, especially resections that begin with the finding of benign- or malignant-appearing adhesions. The operative techniques are described for a right and left hilar dissection; a right and left upper lobectomy; a right middle lobectomy; a right lower lobectomy; and a right and left pneumonectomy. For each technique described, the chapter addresses the anatomical considerations of the pulmonary veins and arteries; the fissure between the upper and lower lobes; and the bronchi. Figures indicate the various steps of the hilar dissection and upper, middle, and lower lobectomy of both the right and left lung and a left pneumonectomy.

      This review contains 13 figures, 5 tables, and 6 additional readings.

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    • 16

      Diaphragmatic Procedures

      By Ayesha S. Bryant, MSPH, MD; Benjamin Wei, MD; Robert James Cerfolio, MD, FACS, FCCP
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      Diaphragmatic Procedures

      • AYESHA S. BRYANT, MSPH, MDAssistant Professor, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL
      • BENJAMIN WEI, MDAssistant Professor, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL
      • ROBERT JAMES CERFOLIO, MD, FACS, FCCPProfessor, Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL

      The diaphragm is a dynamic anatomic structure that plays a pivotal role in the physiology of respiratory mechanics. Both developmental and classical anatomy are described, as is the diaphragm's vascular supply and innervation. Procedures for congenital diaphragmatic hernia are described—the preoperative evaluation and operative techniques are provided for repair of both Bochdalek and Morgagni hernias. Procedures are also given for diaphragmatic paralysis. For both diaphragmatic plication for unilateral paralysis and for diaphragmatic pacing for bilateral paralysis, the preoperative evaluation, operative planning, and operative techniques are listed. Although primary tumors of the diaphragm are extremely rare, the technique for resection of diaphragmatic tumors is explained. A table lists the common causes of diaphragmatic paralysis. Figures show an inferior view of the diaphragm, repair of a Morgagni hernia, diaphragmatic plication, diaphragmatic pacing, and resection of a diaphragmatic tumor. This review contains 26 references.

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    • 17

      Thoracic Diagnostic and Staging Procedures

      By Farzaneh Banki, MD; Larry R. Kaiser, MD, FACS
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      Thoracic Diagnostic and Staging Procedures

      • FARZANEH BANKI, MDAssistant Professor, Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX
      • LARRY R. KAISER, MD, FACSPresident, The University of Texas Health Science Center at Houston, Alkek-Williams Chair and Professor, Department of Cardiothoracic and Vascular Surgery, The University of Texas Medical School at Houston, Houston, TX

      This chapter reviews the diagnostic and staging procedures that relate to the most common thoracic malignancies in the thoracic cavity that are relevant to the general surgeon. Thoracic diagnostic and staging procedures involve the lungs, pleural space, and mediastinum, and include bronchoscopy (transbronchial needle aspiration, endobronchial ultrasound-guided needle aspiration, and rigid bronchoscopy), mediastinosocopy, parasternal mediastinotomy, video-assisted thoracic surgery, and mediastinal lymph node dissection. Diagnostic and staging procedures for the esophagus include esophagoscopy. The evaluation of a patient who presents with a question of intrathoracic pathology should begin with appropriate imaging studies, usually beginning with plain chest radiography followed by CT scanning of the chest done with intravenous contrast. Figures show various anatomic views, including a video-assisted thoracoscopic view. This chapter contains 26 references.

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    • 18

      Thoracic Outlet Syndrome

      By Mark W. Fugate, MD; Julie A. Freischlag, MD
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      Thoracic Outlet Syndrome

      • MARK W. FUGATE, MDAssistant Professor of Surgery, Department of Surgery, Division of Vascular Surgery, University of Tennessee College of Medicine, Chattanooga, TN
      • JULIE A. FREISCHLAG, MDProfessor of Surgery, Department of Surgery, The Johns Hopkins Hospital, Baltimore, ML

      Thoracic outlet syndrome (TOS) is caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. In this chapter, both the pertinent anatomy and predisposing factors are described. This chapter addresses the three distinct types of TOS: neurogenic, venous, and arterial. Both preoperative evaluation and treatment is discussed and is guided by the type of TOS that is diagnosed. Outcomes are addressed, including the most common complication, pneumothorax. Figures show operative treatment, including rib dissection and the neurovascular structures that are no longer restricted following rib resection. Tables provide the types and characteristics of TOS and specific physical therapy protocols. This chapter contains 25 references.

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  • Transplantation
    • 1

      Kidney Transplantation 1: an Overview--recipient Evaluation and Immunosuppression

      By Jamil Azzi, MD; Belinda T. Lee, MD; Anil Chandraker, MD
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      Kidney Transplantation 1: an Overview--recipient Evaluation and Immunosuppression

      • JAMIL AZZI, MDInstructor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
      • BELINDA T. LEE, MDCharles Bernard Carpenter Transplant Fellow, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
      • ANIL CHANDRAKER, MDMedical Director of Kidney and Pancreas Transplantation, Associate Professor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA

      Half a century after the first successful kidney transplantation, we still stand at the crossroads of immunology and transplantation, where science meets art in the management of complex end-stage renal disease (ESRD) patients. Successful transplantation requires not only a lifetime’s commitment from patients but also a multidisciplinary approach, bringing together surgeons, transplant nephrologists, primary care physicians, scientists, and nurses to provide coordinated care. Although transplantation is the treatment of choice for the vast majority of ESRD patients, many patients remain on dialysis due to a relative imbalance between demand for and supply of suitable organs. This chapter provides a comprehensive overview of recipient evaluation and immunosuppression. Risk factors that prohibit transplantation are discussed, as are human leukocyte antigen/ABO compatibility, transplant immunobiology, induction therapy, maintenance therapy, transplantation for special populations, and future directions in the field. Tables outline Amsterdam Living Donation Forum guidelines, ABO blood group compatibilities, and pretransplant immunologic testing. Visual aids include graphs, charts, cell illustrations, and an evaluative algorithm.

      This review contains 10 figures, 3 tables, and 101 references.

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    • 2

      Kidney Transplantation 2: Care of the Kidney Transplant Recipient

      By Belinda T. Lee, MD; Jamil Azzi, MD; Anil Chandraker, MD
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      Kidney Transplantation 2: Care of the Kidney Transplant Recipient

      • BELINDA T. LEE, MDCharles Bernard Carpenter Transplant Fellow, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
      • JAMIL AZZI, MDInstructor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA
      • ANIL CHANDRAKER, MDMedical Director of Kidney and Pancreas Transplantation, Associate Professor of Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA

      This chapter discusses the goals and challenges of caring for the kidney transplant recipient. This area has become increasingly specialized in recent years, with physicians needing a good understanding of immunology, nephrology, pharmacology, and infectious diseases as well as a good grasp of internal medicine. Topics covered include cardiovascular disease, new on-set diabetes, hypertension, dyslipidemia, infectious complications, malignancy, bone disease, recurrence of disease, drug reactions, rejection, and other challenges that face the kidney transplant population. Tables outline relevant medications, recommended vaccines, virus-associated malignancies, cancer rates, common drug interactions, and diagnostic categories. Figures include graphs, charts, and microscopic photos.

      This review contains 7 figures, 7 tables, and 111 references.

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    • 3

      Liver and Pancreas Transplantation

      By Julie A. Thompson, MD; Aleksandra Kukla, MD
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      Liver and Pancreas Transplantation

      • JULIE A. THOMPSON, MDAssistant Professor, Division of Gastroenterology and Hepatology, University of Minnesota, Minneapolis, MN
      • ALEKSANDRA KUKLA, MDAssistant Professor of Medicine, Medical Director of Pancreas Transplant Program, Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN

      More than 6,000 liver transplantations are performed annually in the United States. Enhancements in patient selection and surgical technique and the availability of more powerful immunosuppressive agents have resulted in steady improvement in patient survival. As a result, liver transplantation has been accepted as the standard of care for patients with severe acute or chronic liver disease in whom conventional modalities of therapy have failed. The major obstacle to patients receiving the procedure is the critical shortage of donor organs. Many more recipients of liver transplantation are now receiving the bulk of their care from general internists, gastroenterologists, and primary care physicians. As a result, recognition of potential long-term complications and the need for appropriate immunizations and regular screening visits have become increasingly important. This chapter discusses who qualifies as a candidate for liver transplantation, contraindications to transplantation, timing of transplantation, operative procedures, complications of transplantation (e.g., perioperative and surgical complications, immunologic complications, infectious complications, complications of medical and immunosuppressive therapy, and disease-specific complications), and transplantation outcome. Pancreas transplantation, which aims at providing physiologic insulin replacement, is a therapy that reliably achieves euglycemia in patients with type 1 diabetes mellitus. The discussion of pancreas transplantation focuses on topics such as evaluation of candidates for transplantation (including islet transplantation); contraindications to transplantation; operative procedures; outcome survival; and the effect of transplantation on disorders associated with type 1 diabetes mellitus. The figures show estimated 3-month survival as a function of the Model for End-Stage Liver Disease (MELD) score, the sections of the liver that can be used for transplantation, an algorithm for evaluation of patients with type 1 diabetes mellitus being considered for pancreas transplantation, and an illustration of enteric drainage technique used in whole pancreas transplantation. The tables provide the common indications for liver transplantation, the scoring system for the Child-Turcotte-Pugh classification of liver disease severity, drug interactions with immunosuppressants, and immunization recommendations for liver transplant patients.

      This chapter contains 4 figures, 4 tables, 101 references, 5 Board-styled MCQs, and 1 Teaching Slide Set.

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    • 4

      Heart Transplantation

      By Michael M. Givertz, MD
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      Heart Transplantation

      • MICHAEL M. GIVERTZ, MDMedical Director, Heart Transplant and Circulatory Assist, Brigham and Women's Hospital, Associate Professor, Harvard Medical School, Boston, MA

      Heart failure is a major public health problem with significant associated morbidity and mortality. Heart transplantation remains the standard of care for highly selected patients with end-stage heart failure and absence of contraindications to transplantation. This chapter discusses indications and contraindications for transplantation; recipient evaluation, selection, and management; donor selection; timing of the procedure and surgical technique; medical management, including immunosuppression, prevention and treatment of infections, and other standard or preventive therapy; late complications; and functional status and long-term survival. Tables describe patient referral to a specialized center for heart transplantations; guidelines of indications for cardiac transplantation; organ dysfunction; pretransplantation evaluation; waiting lists; therapeutic options for patients with advanced or refractory heart failure; treating highly sensitized patients; suggested vaccinations; guidelines for donor hearts with severe infection; high-risk donor behavior; hemodynamic effect of commonly used parenteral agents; frequency of follow-up evaluations; revised International Society for Heart and Lung Transplantation (ISHLT) formulation for diagnosis of cardiac allograft rejection and suggested treatment; function of immunosuppressive agents; administration, dosing, monitoring, and adverse effects of commonly used immunosuppressants; common agents that interfere with tacrolimus and cyclosporine; cytomegalovirus prophylaxis and valganciclovir based on estimated renal function; cumulative morbidity rates in adult heart transplant survivors; and therapies to prevent and treat osteoporosis posttransplantation. Figures depict the progression of heart failure; change in functional status over time in patients with chronic heart failure; US heart transplantations in 2012; percentage of US adult wait-listed patients who received a donor heart transplant within a year and donation rates by state; bicaval surgical technique; endomyocardial biopsies; timeline of infection following solid-organ transplantation; cardiac allograft vasculopathy; and squamous cell carcinomas in a heart transplant patient. Graphs show adult worldwide heart transplantation volume from 1982 to 2010; changing characteristics of US adult heart transplant recipients; relative risk of death and development of cardiac allograft vasculopathy; posttransplantation immunosuppression at 1 and 5 years in the ISHLT Registry; older donor age and risk of developing cardiac allograft vasculopathy; freedom from malignancy in the ISHLT Registry; employment status of adult heart transplant recipients; adult heart transplant survival; and patient survival among US heart transplant recipients by gender and race.

      This review contains 18 highly rendered figures, 20 tables, and 109 references.

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    • 5

      Lung Transplantation

      By Hilary J. Goldberg, MD, MPH
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      Lung Transplantation

      • HILARY J. GOLDBERG, MD, MPHProfessor of Medicine, Harvard Medical School, Boston, MA

      Lung transplantation is a potential therapeutic option for select candidates with advanced lung disease who have exhausted other therapeutic interventions, and in whom survival and/or quality of life are threatened by progression of disease. This chapter provides an overview of, and the indications for, lung transplantation (chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, primary pulmonary hypertension, and 1-antitrypsin deficiency emphysema) and discusses candidate selection and evaluation, timing of transplantation (general and disease-specific guidelines), and types of organ donors (i.e., brain-dead donors, non–heart-beating donors, and living donors). Also discussed are types of transplant procedures (i.e., single-lung transplantation, bilateral lung transplantation, heart-lung transplantation, living-donor lobar transplantation), transplantation outcomes, posttransplantation management, and complications (i.e., primary graft dysfunction, airway complications, allograft rejection [hyperacute, acute, and chronic, humoral], and posttransplantation infection. Figures depict indications for transplantation, procurement rates, bilateral lung transplantation, and 5-year survival rates. Also shown are examples of primary graft dysfunction and airway stenosis, plus pathologic manifestations of acute rejection and chronic rejection. Tables show contraindications to transplantation, disease-specific guidelines for referral and transplantation, predictors of poor prognosis in cystic fibrosis patients, donor criteria, causes of death after lung transplantation, classification and histologic features of allograft rejection, the staging system for bronchiolitis obliterans syndrome, and complications of lung transplantation and posttransplantation immunosuppression. A sidebar lists Internet resources and registries. The chapter has 118 references.

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    • 6

      The Future of Transplant Biology and Surgery

      By Marc Colaco, MD, MBA; Anthony Atala, MD
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      The Future of Transplant Biology and Surgery

      • MARC COLACO, MD, MBAResident, Department of Urology, Wake Forest School of Medicine, Winston-Salem, NC
      • ANTHONY ATALA, MDDirector, Wake Forest Institute for Regenerative Medicine, and W.H. Boyce Professor and Chair, Department of Urology, Wake Forest University, Winston-Salem, NC

      Although organ transplantation remains the mainstay of treatment for patients with severely compromised organ function, with the growing number of patients in need of treatment and the lack of organ supply, medical scientists have begun seeking out alternatives. In the last two decades, researchers have attempted to grow native and stem cells, engineer tissues, and design treatment modalities using regenerative medicine techniques for almost every tissue of the human body. This chapter discusses the basics of tissue engineering, including cell isolation and biomaterial selection. It then outlines specific advances and potential surgical uses.

      This review contains 9 figures, 2 tables, and 135 references.

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    • 7

      Transplantation Ethics and Policy

      By Anji Elizabeth Wall, MD, PhD; J. Michael Millis, MD
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      Transplantation Ethics and Policy

      • ANJI ELIZABETH WALL, MD, PHDChief Resident, Vanderbilt University Medical Center, Nashville, TN
      • J. MICHAEL MILLIS, MDProfessor of Surgery, Vice Chair of Global Surgery, University of Chicago, Chicago, IL

      Addressing all of the ethical and policy challenges in the field of organ transplantation is a daunting task for a short review. Rather than focusing on each issue, this review starts with a discussion of the underlying ethical principles that drive transplantation ethics and proceeds to address a few of the important ethical challenges in transplantation, recognizing that it is not a comprehensive overview of every issue. Just as policy should follow the underlying ethical principles, the second part of the review addresses policy development and implementation in the United States and selected challenges worldwide. Of note, this review covers underlying ethical principles, the dead donor rule, the allocation of scarce resources, organ allocation, deceased organ donors, living organ donors, speculation for the future, and transplantation policies.

       

      This review contains 15 references.

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    • 8

      Small Intestinal and Multivisceral Transplantation

      By B. John DuBray, MD; Douglas G. Farmer, MD
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      Small Intestinal and Multivisceral Transplantation

      • B. JOHN DUBRAY, MDThe Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
      • DOUGLAS G. FARMER, MDThe Dumont-UCLA Transplant Center, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA

      The role of transplantation in the management of intestinal failure continues to evolve. Since the development of parenteral nutrition in the late 1960s, permanent intestinal failure has been medically managed with visceral transplantation, reserved for those who develop life-threatening complications. A multidisciplinary approach to intestinal care has led to the emergence of intestinal rehabilitation programs that have successfully achieved nutritional autonomy for many individuals through the promotion of adaptation. Whereas the short-term results of visceral transplantation have improved dramatically to the level of other solid organs, durable long-term graft survival has been elusive. This review covers intestinal failure, epidemiology, intestinal and multivisceral transplantation, and the future of intestinal and multivisceral transplantation. Figures show the embryonic origin of the multivisceral allograft, en bloc retrieval of the intestinal allograft, preparation for engraftment, vascularization of the isolated intestinal allograft, enteric reconstruction of the intestinal allograft, the liver-intestine allograft, preparation for liver-intestine engraftment, the modified multivisceral graft, arterial reconstruction in modified multivisceral transplantation, vascularization of the modified multivisceral allograft, recipient preparation in modified multivisceral transplantation, intestinal alloreactivity, graft survival among intestinal transplant recipients, patient survival among intestinal transplant recipients, candidates waiting for an intestine transplant, and distribution of candidates waiting for intestinal transplantation. Tables list causes of intestinal failure, predictors of outcome in intestinal failure, failure of total parenteral nutrition therapy as defined by the Centers for Medicare and Medicaid Services, histologic grading of acute cellular rejection, and criteria for chronic rejection in visceral allografts.

       

      This review contains 16 highly rendered figures, 5 tables, and 54 references.

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  • Trauma and Thermal Injury
    • 1

      Initial Management of Life-threatening Trauma

      By Frederick A. Moore, MD, FACS; Ernest E. Moore, MD, FACS
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      Initial Management of Life-threatening Trauma

      • FREDERICK A. MOORE, MD, FACSProfessor of Surgery, University of Florida, Gainesville, FL
      • ERNEST E. MOORE, MD, FACSChief of Surgery Trauma, Denver Health, Professor and Vice-Chair of Surgery, Bruce M. Rockwell Distinguished Chair of Trauma, University of Colorado, Denver, CO

      Critical injury care requires a coordinated effort by an organized trauma system. This critical time for patient care can occur in a prehospital setting and in the emergency department. Prehospital care is described, including intervention at the injury site, field triage, and declaration of death at a scene. Emergency department management is described and consists of primary survey and initial resuscitation, evaluation and continued resuscitation, and secondary survey with definitive diagnosis and triage decisions. This chapter also includes discussion of topics of importance in critical care. Advanced trauma life support is a prehospital issue of importance. Current emergency department topics for discussion include those related to blood volume restitution and early identification of nonresponders. Controversies in postinjury coagulopathy are also mentioned. Figures show the technique for cricothyrotomy, a tube thoracostomy, the use of a Satinsky vascular clamp, the technique used for pericardiocentesis, a chest x-ray showing a massive hemothorax, the semiopen technique for peritoneal lavage, and the wrapping technique currently used for support of a mechanically unstable pelvic fracture. Tables list the 2006 field triage decision scheme recommendations, guidelines for declaring patients dead on arrival to the hospital, the 10 steps in rapid-sequence intubation, and scoring for hemodynamic instability. This review contains 100 references.

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    • 2

      Injuries to the Central Nervous System

      By Krista Keachie, MD; Kiarash Shahlaie, MD, PhD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD
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      Injuries to the Central Nervous System

      • KRISTA KEACHIE, MDResident Physician, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KIARASH SHAHLAIE, MD, PHDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • KEE D. KIM, MDAssociate Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA
      • MARIKE ZWIENENBERG-LEE, MDAssistant Professor, Department of Neurological Surgery, University of California Davis, School of Medicine, Sacramento, CA

      Both traumatic brain injury and spinal cord injury can cause death or disability. Treatment of head injury in the emergency department is described, followed by the protocol for operative management. Intensive care unit management is also described in terms of neurocritical care and the techniques for monitoring intracranial pressure, cerebral flood flow, and local and global cerebral oxygenation. The balance among hemoglobin, hematocrit, and blood viscosity is also described. The diagnosis and initial management of spinal cord injury is also defined and the treatment modalities explained. These include traction, pharmacologic treatment, and the role of neurosurgery (and its controversies) in the treatment of spinal fractures. The diagnosis and treatment of specific fractures and dislocations is provided and includes trauma to the cervical spine and the thoracolumbar spine. A discussion of the pathophysiology of head injury ensues, with attention given to the cerebral metabolism, regulation of blood flow, and cerebral circulation and metabolism after severe head injury. Figures include algorithms for managing the patient with severe head injury and acute spinal cord injury and algorithms depicting the protocol for radiologic evaluation and clearance of both cervical spinal cord and thoracolumbar spinal cord injury. Tables include the Glasgow Coma Scale. This review contains 123 references.

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    • 3

      Injuries to the Chest

      By Amy N. Hildreth, MD, FACS; J. Jason Hoth, MD, PhD, FACS; J. Wayne Meredith, MD, FACS
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      Injuries to the Chest

      • AMY N. HILDRETH, MD, FACSAssistant Program Director, Surgical Sciences-Surgery Trauma, Assistant Professor, Surgery, General, Wake Forest School of Medicine, Winston-Salem, NC
      • J. JASON HOTH, MD, PHD, FACSAssociate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
      • J. WAYNE MEREDITH, MD, FACSDirector, Surgical Sciences, Wake Forest School of Medicine, Winston-Salem, NC

      Thoracic injury is common and is associated with significant morbidity and mortality. Initial evaluation is presented, including the indications and technique for thoracostomy. Operative considerations are also presented and include indications for operative management, choice of incision, damage control tactics, and anesthetic concerns. Both blunt and penetrating chest wall injuries are discussed. Pulmonary injuries are described, which can be in the form of lacerations or contusions. Tracheobronchial injuries can be managed nonoperatively or operatively. Esophageal and thoracic duct injuries are also described. Both blunt and penetrating cardiac injuries are presented, as are blunt aortic injuries and both blunt and penetrating injuries to the great vessels. Tables show the surgical approaches for traumatic injuries to thoracic structures and the diagnostic measures for evaluating suspected esophageal injuries. Figures show the intraoperative placement of an endotracheal tube, x-ray of a flail chest, a pulmonary tractotomy, CT scan of a pulmonary contusion, and a segmental resection of a tracheal injury. Algorithms show the approach to the management of flail chest, the approach to management of suspected tracheobronchial injury, and the approach to management of transmediastinal penetrating injury.

      This review contains 11 figures, 1 table, and 100 references.

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    • 4

      Injuries to the Stomach, Small Bowel, Colon, and Rectum

      By Jordan A. Weinberg, MD, FACS; Timothy C. Fabian, MD, FACS
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      Injuries to the Stomach, Small Bowel, Colon, and Rectum

      • JORDAN A. WEINBERG, MD, FACSAssociate Professor, Department of Surgery, University of Tennessee Health Science, Center, Memphis, TN
      • TIMOTHY C. FABIAN, MD, FACSHarwell Wilson Alumni Professor and Chairman, Department of Surgery, University of Tennessee Health Science Center, Memphis, TN

      Hollow viscus injury is most often the consequence of penetrating abdominal trauma. As a result of blunt force trauma, bowel injury occurs with relative infrequency: in one multi-institutional analysis, only 1.2% of blunt trauma admissions had an associated hollow viscus injury. The diagnosis of hollow viscus injury remains a challenge in abdominal trauma patients, and subsequent evaluation is determined by the mechanism of injury. Regardless of the specific injury mechanism, however, the principles and techniques of operative management are largely the same. This review covers determination of need for operation, and operative management. Figures show algorithms outlining the evaluation of blunt hollow organ injury in a hemodynamically stable patient with an unreliable physical examination, the treatment of truncal stab wounds, the treatment of blunt bowel and mesenteric injury, the treatment of gastric injury, the treatment of small bowel injury, the treatment of colon injury, the treatment of rectosigmoid or rectal injury, and a demonstration of presacral drainage through a curved incision midway between the anus and the tip of the coccyx. Tables list the incidence of findings suggestive of blunt mesenteric and bowel injury in true positive and false positive computed tomography  scans, and the American Association for the Surgery of Trauma organ injury scales for gastrointestinal tract and pancreas.

       

      This review contains 8 highly rendered figures, 2 tables, and 56 references

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    • 5

      Injuries to the Face and Jaw

      By Mark E. Engelstad, DDS, MD; Richard A. Hopper, MD, MS
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      Injuries to the Face and Jaw

      • MARK E. ENGELSTAD, DDS, MDChief, Oral and Maxillofacial Surgery, Harborview Medical Center, University of Washington
      • RICHARD A. HOPPER, MD, MSService Chief, Craniofacial Plastic Surgery, Harborview Medical Center, Chief, Plastic Surgery, Surgical Director, Craniofacial Center, Seattle Children’s Hospital, Associate Professor, University of Washington, Seattle, WA

      Facial injuries occur most often through violence or vehicular accident. The main priorities after injury are to assess the airway and check for hemorrhage, followed by assessment of vision, a check for bony trauma or malocclusion, followed by assessment for soft tissue injuries. Most facial injury survey will be done via inspection, palpation, or diagnostic imaging, which includes plain radiography, CT scan, or MRI. Injuries to the face and jaw can be of the soft tissue variety. These include injuries to the facial and trigeminal nerve, parotid duct, scalp, eyelid, lacrimal duct, eyebrow, external ear, nasal passages, or lips. Treatment of maxillofacial fractures include dentoalveolar injuries, mandibular fractures, maxillary fractures, zygomatic fractures, orbital fractures, nasal fractures, nasoorbitoethmoid fractures, and frontal sinus fractures. Figures show common injuries and fractures. This review includes 28 references.

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    • 6

      Injuries to the Liver and Biliary Tract

      By Clay Cothren Burlew, MD, FACS; Ernest E. Moore, MD, FACS
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      Injuries to the Liver and Biliary Tract

      • CLAY COTHREN BURLEW, MD, FACSProgram Director, Trauma and Acute Care Surgery Fellowship, Department of Surgery, Denver Health Medical Center, Associate Professor of Surgery, University of Colorado, Denver, CO
      • ERNEST E. MOORE, MD, FACSChief of Surgery Trauma, Denver Health, Professor and Vice-Chair of Surgery, Bruce M. Rockwell Distinguished Chair of Trauma, University of Colorado, Denver, CO

      The liver is the most commonly injured solid organ in blunt trauma, and is frequently involved in penetrating trauma. This review covers initial evaluation, imaging and injury grading, operative exposure, hemorrhage control, definitive management of injuries, postoperative care, and complications and mortality. Figures show computed tomographic (CT) scan findings of high-grade hepatic injuries, contrast extravasation, indication for nonoperative management of penetrating trauma, CT evaluation of a stab wound to the liver, anatomic divisions of the liver, manual compression to control blood loss, perihepatic packing of injuries, the Pringle maneuver, venovenous bypass permitting hepatic vascular isolation, an endotracheal tube adapted into an atriocaval shunt, an interrupted chromic suture of a stab wound, Penrose expansion into a balloon with injection of saline to tamponade deep laceration, cholecystectomy for gallbladder injuries or ischemia, intraoperative cholangiogram showing filling of the bile and pancreatic ducts, recurrent bleeding following perihepatic packing, central hepatic injuries associated with biliary trauma, a biloma with an associated right hepatic duct injury, and abscesses following hepatic trauma. The table lists the American Association for the Surgery of Trauma organ injury scales for liver and biliary tract.

       

      This review contains 19 highly rendered figures, 1 table, and 58 references

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    • 7

      Injuries to the Neck

      By Joseph M. Galante, MD; Ian E. Brown , MD, PhD
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      Injuries to the Neck

      • JOSEPH M. GALANTE, MDAssistant Professor of Surgery, Department of Surgery, Division of Trauma and Emergency Surgery, University of California, Davis, Sacramento, CA
      • IAN E. BROWN , MD, PHDAssistant Professor of Surgery, Division of Trauma, Acute Care Surgery and Surgical Critical Care, Department of Surgery, University of California, Davis, Sacramento, CA

      Approximately 5% of all cases of trauma involve injury to the neck. This relatively low incidence together with improvements in diagnostic modalities has led to continuing evolution in the management of neck trauma. Injuries to the neck can be the result of blunt and penetrating trauma. Both mechanisms can cause devastating injuries, with high associated morbidity and mortality. This review examines the airway, penetrating neck trauma, and blunt trauma. Figures show an algorithm outlining operative management of known or suspected injuries to the carotid arteries, jugular veins, pharynx, and esophagus, a tracheotomy hook used to retract the thyroid cartilage cephalad to facilitate placing the airway, the traditional division of the neck into three separate zones, exposure of structures in the anterior areas of the neck through an incision oriented along the anterior border of the sternocleidomastoid muscle,  dissection of the sternocleidomastoid muscle carried down to the level of the carotid sheath, a balloon embolectomy  catheter used to occlude the distal internal carotid artery at the skull base, a number of important structures encountered during distal dissection of the internal and external carotid arteries, options for repair of the arteries in the neck, exposure of the vertebral artery and the vertebral veins surrounded by the transverse processes of the cervical vertebrae, exposure of the distal vertebral artery via an incision along the anterior border of the sternocleidomastoid muscle, control of bleeding from vertebral artery injuries located within the transverse process of the cervical, approaching proximal vertebral artery via a supraclavicular incision, and an algorithm outlining management of known injuries to the vertebral artery, which are most often discovered by angiography. The table lists screening criteria for blunt cerebrovascular injury.

       

      This review contains 13 highly rendered figures, 1 table, and 37 references

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    • 8

      Operative Exposure of Abdominal Injuries and Closure of the Abdomen

      By Christian Minshall, MD, PhD, FACS; Erwin R. Thal, MD, FACS, FRACS(Hon)
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      Operative Exposure of Abdominal Injuries and Closure of the Abdomen

      • CHRISTIAN MINSHALL, MD, PHD, FACSAssociate Professor, Division of Burn, Trauma and Critical Care, Director of Surgical Critical Care, Department of Surgery, University of Texas, Southwestern Medical School, Dallas, TX
      • ERWIN R. THAL, MD, FACS, FRACS(HON)Professor, Division of Burn, Trauma and Critical Care, Department of Surgery, University of Texas, Southwestern Medical School, Dallas, TX

      This review addresses operative treatment and management of the patient with abdominal injuries. Patient preparation, choice of incision, and initial exploration are discussed. Operative exposure of specific organs and vessels (i.e., the aorta and its branches, the vena cava and its branches, the liver, the spleen, the pancreas, the kidneys, the duodenum and the small intestine, the biliary tract, the colon, and the rectum) is outlined. Management priorities are reviewed, including control of hemorrhage and contamination and repair of vascular, gastrointestinal, and retroperitoneal injuries. General closure techniques are described, as well as specific techniques for skin closure. Abbreviated or damage-control laparotomy is addressed, and temporary closure techniques are cited. Various approaches to managing the open abdomen and achieving closure in situations where primary closure is not feasible are outlined. Drawings illustrate several key techniques. This review contains 9 figures, 1 table, and 53 references.

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    • 9

      Duodenal and Pancreatic Trauma

      By Robert T. Stovall, MD; Erik Peltz, DO; Gregory J. Jurkovich, MD, FACS
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      Duodenal and Pancreatic Trauma

      • ROBERT T. STOVALL, MDAssistant Professor of Surgery, University of Colorado School of Medicine, Denver Health Medical Center, Denver, CO
      • ERIK PELTZ, DOTrauma and Acute Care Surgery Fellow, Denver Health Medical Center, University of Colorado, Denver, CO
      • GREGORY J. JURKOVICH, MD, FACSVice Chairman of Surgery, University of Colorado School of Medicine, Chief of Surgery, Denver Health Medical Center, Denver, CO

      Duodenal and pancreatic injuries challenge the trauma surgeon because they are relatively rare, difficult to diagnose timely, and have a high morbidity and mortality rate. Diagnosis difficulties are described and include the inadequate sensitivity of computed tomography and the unwieldiness of magnetic resonance imaging. Intraoperative techniques are described and include endoscopic retrograde cholangiopancreatography, direct open ampullary cannulation, or needle cholangiopancreatography. The treatment of pancreatic injuries is detailed and includes the distal pancreatectomy; the pancreatectomy with splenic salvage; extended distal pancreatectomy; a Roux-en-Y pancreaticojejunostomy; an end jejunum-to-side pancreas anastomosis; and the Whipple resection. Complications are discussed and include fistula; abscesses; pancreatitis; secondary hemorrhage; pseudocysts; and exocrine and endocrine insufficiency. Figures describe the contusion to the body of the pancreas; treatment of pancreatic injury; distal pancreatectomy with and without splenic salvage; a Roux-en-Y pancreaticojejunostomy; treatment of duodenal injury; duodenal diverticularization; and pyloric exclusion. Tables describe the American Association for the Surgery of Trauma organ injury scales for pancreas and duodenum and factors determining severity of duodenal injury. This review contains 115 references.

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    • 10

      Injuries to the Great Vessels of the Abdomen

      By David V. Feliciano, MD, FACS; Juan A. Asensio, MD
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      Injuries to the Great Vessels of the Abdomen

      • DAVID V. FELICIANO, MD, FACSProfessor of Surgery, Emory University School of Medicine, Surgeon-in-Chief, Grady Memorial Hospital, Atlanta, GA
      • JUAN A. ASENSIO, MD

      In patients who have injuries to the great vessels of the abdomen, the findings on physical examination generally depend on whether a contained hematoma or active hemorrhage is present. This review covers resuscitation in profoundly hypotensive patients, damage control resuscitation, injuries in zones 1, 2, and 3, injuries in the porta hepatis or retrohepatic area, damage control laparatomy, endovascular therapies, and complications. Figures show algorithms illustrating management of intra-abdominal hematoma found at operation after penetrating trauma and blunt trauma; left medial visceral rotation performed by sharp and blunt dissection with elevation of the left colon, the left kidney, the spleen, the tail of the pancreas, and the gastric fundus; an autopsy view of the supraceliac aorta and the celiac axis, the proximal superior mesenteric artery, and the medially rotated left renal artery after removal of lymphatic and nerve tissue; injuries to the prepyloric area of the stomach and to the supraceliac abdominal aorta from a gunshot wound; a temporary intraluminal shunt inserted into the proximal superior mesenteric artery in a patient who had an adjacent injury to the neck of the pancreas after sustaining a gunshot wound; polytetrafluoroethylene patch repair of an injury to the infrarenal inferior vena cava; right perirenal hematoma and left external iliac artery and vein injury repaired with segmental resection and insertion of an 8 mm polytetrafluoroethylene graft and segmental resection and an end-to-end anastomosis, respectively. Tables list American Association for the Surgery of Trauma abdominal vascular organ injury scale, and survival rates after injuries to arteries and veins in the abdomen.

       

      This review contains 9 highly rendered figures, 3 tables, and 89 references

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    • 11

      Injuries to the Urogenital Tract

      By Alex J. Vanni, MD; Hunter Wessells, MD, FACS
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      Injuries to the Urogenital Tract

      • ALEX J. VANNI, MDClinical Instructor, Department of Urology, University of Washington, Harborview Medical Center, Seattle, WA
      • HUNTER WESSELLS, MD, FACSProfessor and Nelson Chair, Department of Urology, University of Washington, Harborview Medical Center, Seattle, WA

      New imaging modalities and a growing emphasis on nonoperative management of upper and lower urinary tract injuries have dramatically changed the field of urologic trauma. This chapter describes each of the major urogenital organs separately (kidneys, ureters, bladder, female urethra, penis, and scrotum/testes) in terms of initial evaluation and management, including both nonoperative and operative techniques, reconstruction and repair if applicable, and postintervention care. Figures depict various management algorithms, injury classifications, and imaging of various trauma. Tables show the criteria for imaging of renal injuries, the American Association for the Surgery of Trauma (AAST) organ injury scales for the urinary tract, management of urethral trauma, the AAST organ injury scales for the female reproductive tract, and the AAST organ injury scales for male genitalia. This review contains 88 references.

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    • 12

      Injuries to the Pelvis and Extremities

      By J.C. Goslings, MD, PhD; K.J. Ponsen, MD, PhD; O.M. van Delden, MD, PhD
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      Injuries to the Pelvis and Extremities

      • J.C. GOSLINGS, MD, PHDDirector Trauma Unit, Department of Surgery, Medical Director Trauma Center/TraumaNet, Academic Medical Center, Amsterdam, The Netherlands
      • K.J. PONSEN, MD, PHDTrauma Surgeon, Department of Surgery, Medisch Centrum Alkmaar, Alkmaar, The Netherlands
      • O.M. VAN DELDEN, MD, PHDInterventional Radiologist, Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands

      Injuries to the pelvis and extremities are common, occurring in approximately 85% of patients who sustain blunt trauma; improper management can have devastating consequences. Such trauma can result in injuries that are potentially life-threatening (e.g., pelvic disruption with hemorrhage, major arterial bleeding, and crush syndrome) or limb-threatening (e.g., open fractures and joint injuries, vascular injuries and traumatic amputation, compartment syndrome, and nerve injury secondary to fracture dislocation). In this chapter, the authors outline the basic knowledge the general or trauma surgeon requires for initial management of injuries to the pelvis, the extremities, or both. Such knowledge includes evaluation and assessment; timing and planning of operative intervention (if indicated); urgent management of life-threatening or limb-threatening injuries; general management of fractures; specific management of upper-extremity, pelvic, acetabular, and lower-extremity injuries; and management of complications.

      This review contains 12 figures, 10 tables, and 182 references.

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    • 13

      Management of the Patient With Thermal Injuries

      By Nicole S. Gibran, MD, FACS; Michael J. Mosier, MD, FACS, FCCM
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      Management of the Patient With Thermal Injuries

      • NICOLE S. GIBRAN, MD, FACSProfessor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA
      • MICHAEL J. MOSIER, MD, FACS, FCCMAssociate Professor of Surgery, Loyola Burn Center, Loyola University Medical Center, Maywood, IL

      Optimal care of the burn patient requires not only specialized equipment but also, more importantly, a team of dedicated surgeons, nurses, therapists, nutritionists, pharmacists, social workers, psychologists, and operating room staff. Burn care was one of the first specialties to adopt a multidisciplinary approach, and over the past 30 years, burn centers have decreased burn mortality by coordinating prehospital patient management, resuscitation methods, and surgical and critical care of patients with major burns. This review covers where to treat burn patients, fluid management, airway management, temperature regulation, airway control, nutrition, anemia, pain management, deep vein thrombosis prophylaxis, and putting it all together: an algorithmic approach to early care of the burn-injured patient. Figures show that the size of a burn can be estimated by means of the Rule of Nines, which assigns percentages of total body surface to the head, the extremities, and the front and back of the torso, the approach to the burn patient in the first 24 hours, and the approach to the burn patient during the second to fifth days after burn injury. Tables list American Burn Association criteria for burn injuries that warrant referral to a burn unit, criteria for outpatient management of burn patients, acute physiologic changes during burn resuscitation, acute biochemical and hematologic changes during burn resuscitation, measures of pulmonary function, mechanisms of pulmonary dysfunction and indications for mechanical ventilation, clinical manifestations of carbon monoxide poisoning, half-life of carbon monoxide–hemoglobin bonds with inhalation therapy, increased acute kidney injury in patients treated with hydroxocobalamin for suspected inhalation injury, clinical findings associated with specific inhaled products of combustion, bronchoscopic criteria used to grade inhalation injury, and formulas for estimating caloric needs in burn patients.

      This review contains 3 highly rendered figures, 12 tables, and 134 references

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    • 14

      Injuries to the Peripheral Blood Vessels

      By Charles J. Fox, MD, FACS
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      Injuries to the Peripheral Blood Vessels

      • CHARLES J. FOX, MD, FACSAssociate Professor of Surgery, University of Colorado School of Medicine, Chief of Vascular Surgery, Department of Surgery, Denver Health Medical Center, Denver, CO

      Contributions from the armed conflicts of the 20th century have defined the standards for vessel ligation or repair of arterial and venous injuries. Since the Vietnam War, there has been considerable modernization in the battlefield medical environment, and forward surgical capability, expeditious evacuation and new and effective resuscitation strategies have provided the foundation for innovation and progress. Lessons learned during current US military operations continue to advance the practice of vascular trauma surgery, and these techniques are directly translated to surgical practices in trauma centers around the world. This review covers mechanisms and sites of extremity vascular injury,  initial assessment,  management, and special considerations. Figures show an avulsion injury, in which an artery is stretched, an algorithm for the workup of a patient with a potential extremity vascular injury, an algorithm for the management of complex extremity trauma, exposure of the axillary artery, exposure of the brachial artery, exposure of the femoral artery, medial exposure of the proximal and distal popliteal arteries, the two-incision technique for lower leg decompression in compartment syndrome, and incisions for forearm decompression in compartment syndrome.

       

      This review contains 10 highly rendered figures and 84 references

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    • 15

      Miscellaneous Burns and Related Conditions

      By David A. Brown, MD, PhD; Nicole S. Gibran, MD, FACS
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      Miscellaneous Burns and Related Conditions

      • DAVID A. BROWN, MD, PHDChief Resident, Department of Surgery, University of Washington, Seattle, WA
      • NICOLE S. GIBRAN, MD, FACSProfessor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA

      This review covers the recognition and management of electrical injury, chemical burns, injury from chemicals of mass destruction, cold injury, toxic epidermal necrolysis (TEN), and ionizing radiation burns. Electrical injuries can be divided into low-voltage burns, high-voltage burns, and super-high-voltage burns. Chemical burns are commonly caused by strong alkalis or acids and less commonly by anhydrous ammonia. Chemicals used in war include napalm, white phosphorus, and vesicants such as mustard gas, lewisite, and phosgene. Cold injuries result either from direct freezing (frostbite) or from more long-term exposure to an environment just above freezing (chilblain, pernio, trench foot). TEN, though not a burn, can cause similar tissue damage and is managed similarly in a number of respects. Ionizing radiation burns may be encountered in three settings: (1) deliberate or accidental exposure to radiation in a hospital, laboratory, or industrial environment (by far the most common setting); (2) failure of a nuclear power plant (as at Chernobyl); and (3) nuclear explosion.

      This review contains 12 figures, 5 tables, and 122 references.

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    • 16

      Management of the Burn Wound

      By Jose P. Sterling, MD; David M. Heimbach, MD, FACS; Nicole S. Gibran, MD, FACS
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      Management of the Burn Wound

      • JOSE P. STERLING, MDBurn/Critical Care Fellow, Department of Surgery, University of Washington School of Medicine
      • DAVID M. HEIMBACH, MD, FACSProfessor, Department of Surgery, University of Washington School of Medicine
      • NICOLE S. GIBRAN, MD, FACSProfessor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA

      Current approaches to burn management are based on an understanding of the biology and physiology of human skin and the pathophysiology of the burn wound. The clinical evaluation and initial care of a burn wound is described and includes an assessment of burn depth, determining the need for escharatomy and daily burn wound care. Burns can be topical or surgical. Topical burn wounds require choice in the use of antibiotics. Considerations and techniques for surgical burn wound management are described and include early excision and grafting, wound excision, skin grafting, graft and donor-site dressings, postoperative wound care, biologic dressings and skin substitutes, allograft and xenograft skin, cultured epidermal autografts, and skin substitutes. Figures show the two distinct layers of the skin, various types of burns, and both fascial and tangential excision of burn wounds. Tables provide an overview of burn wound management and list the topical antimicrobial agents used in burn care. This review contains 83 references.

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    • 17

      Rehabilitation of the Burn Patient

      By Samuel P. Mandell, MD, MPH; Nicole S. Gibran, MD, FACS
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      Rehabilitation of the Burn Patient

      • SAMUEL P. MANDELL, MD, MPHActing Instructor, Department of Surgery, University of Washington, Senior Burn Fellow, University of Washington Regional Burn Center, Harborview Medical Center, Seattle, WA
      • NICOLE S. GIBRAN, MD, FACSProfessor of Surgery and Director, University of Washington Burn Center, Harborview Medical Center, Seattle, WA

      Of all the different processes that a burn patient undergoes, rehabilitation is the longest. Components of rehabilitation discussed in detail include quality of life, community integration, physical recovery, psychological recovery, pain and sensation, neuromuscular function, and skin care. Obstacles to recovery in each of these areas and their treatment plans are reviewed. Stepwise approaches to pain and itching are offered. The review touches on burn reconstruction techniques such as Z-plasty and the other various flaps that can be employed. Figures show stages of rehabilitation, range of motion techniques, splinting, pressure garments and their results, the use of virtual reality, itch therapy, and long-term results. Tables describe the approach to pain, splint guidelines, mobility guidelines, posttraumatic stress disorder screening, and a quality of life assessment tool.

      This review contains 13 figures, 6 tables, and 101 references.

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    • 18

      Trauma Imaging

      By Martin L. Gunn, MBChB, FRANZCR; Kathleen R. Fink, MD; Joel A. Gross, MD
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      Trauma Imaging

      • MARTIN L. GUNN, MBCHB, FRANZCRAssociate Professor, Department of Radiology, University of Washington, Seattle, WA
      • KATHLEEN R. FINK, MDAssistant Professor, Department of Radiology, University of Washington, Seattle, WA
      • JOEL A. GROSS, MDAssociate Professor, Director, Emergency Radiology, Department of Radiology, University of Washington School of Medicine, Harborview Medical Center, Seattle, WA

      Due to increased use of computed tomography (CT) and ultrasonography, technological advances in equipment design, and increased availability of imaging equipment in the emergency department, imaging studies have revolutionized the assessment of the trauma patient in the past three decades. This review examines commonly used imaging modalities in trauma evaluation, initial and additional imaging, brief introduction to CT, and an overview of CT image processing and reviewing a CT scan. Head imaging, spine imaging, chest imaging, and abdominal and pelvic imaging are presented, along with injury grading, solid-organ injury appearances and specific abdominal solid-organ injuries, urinary system injury, penetrating trauma, unexplained intraperitoneal fluid, vascular injury and musculoskeletal injury. Figures show lateral view of the cervical spine; volume rendering of the pelvis; CT windows; CT imaging of acute intracranial bleeding, herniation in acute subdural hemorrhage, post-traumatic pseudoaneurysm of descending thoracic aorta, subscapular hematoma of the liver, liver laceration, pseudoaneurysm of the liver, shattered kidney and the nonperfused right kidney attributable to a traumatic renal artery injury, tigroid spleen, a focus of gas and stranding adjacent to the lateral wall of the ascending colon, extravasated urinary contrast (white material) surrounding the proximal right indicating ureteral laceration or transection, intraperitoneal bladder rupture, and contrast extravasation in the liver; magnetic resonance imaging versus CT of shear injuries; and magnetic resonance imaging in the setting of cervical spine trauma. Tables list New Orleans Criteria, Canadian CT Head Rule, CT in Head Injury Patients (CHIP) Prediction Rule, Marshall CT Classification, Rotterdam Classification, Biffl Carotid Artery Injury Grading Scale, and Modified Denver Criteria for Blunt Cerebrovascular Injury (BCVI) Screening.

      This review contains 18 highly rendered figures, 7 tables, and 105 references.

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    • 19

      Geriatric Trauma

      By Areti Tillou, MD; Sigrid Burruss, MD; Lillian Min, MD, MSHS
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      Geriatric Trauma

      • ARETI TILLOU, MDAssociate Professor, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
      • SIGRID BURRUSS, MDDepartment of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA
      • LILLIAN MIN, MD, MSHSAssociate Professor, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA

      Although traumatic injury is a sentinel event that can precipitate a trajectory of functional decline in older patients, the geriatric population is heterogeneous in its vulnerability to deterioration in health and its ability to recover from injury, suggesting that better identification of older patients at the highest risk for death, hospital complications, and resource use may allow for improved targeting of inpatient and postdischarge interventions. This review describes pathophysiologic considerations, preexisting conditions and medications, mechanisms of injury, hospital and long-term outcomes, triage and initial management, and injuries. Rib, hip, pelvic, and head injuries are covered, along with geriatric-specific issues such as care coordination, syncope, delirium, depression, and cognitive impairment. Goals of care, nutritional assessment, and prevention of morbidity are discussed in depth.

      This review has 3 figures, 2 tables, and 216 references.

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    • 20

      Venomous Bites and Stings

      By J. Patrick Walker, MD
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      Venomous Bites and Stings

      • J. PATRICK WALKER, MDChief of Surgery, ETMC, Crockett, TX, Houston County Surgical Associates, Crockett, TX

      Since time immemorial, the interface between humans and animals has been a significant cause of morbidity and mortality. This reviewaddresses various venomous bites and stings. Although the bite of a pit viper might draw more excitement in emergency departments across the United States, the mortality from snakes (four to five deaths/year) is much less than the mortality rate from insects (> 500 deaths/year). Although most deaths from insect bites are from anaphylactic reactions, some are from overwhelming envenomation. This review covers venomous snakes in North America, as well as a number of arthropods, including ants, bees, spiders, centipedes, millipedes, and scorpions. This review is rich with 17 high-rendered clinical images and relative photographs of relevant arachnids, reptiles, and snakes, as well as 12 tables categorizing the species and venoms. There are 51 references.

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    • 21

      Injuries to the Spleen and Diaphragm

      By J. Jason Hoth, MD, PhD, FACS; Andrea M. Long, MD; Preston R. Miller, MD, FACS
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      Injuries to the Spleen and Diaphragm

      • J. JASON HOTH, MD, PHD, FACSAssociate Professor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
      • ANDREA M. LONG, MDClinical Instructor, Department of Surgery, Wake Forest School of Medicine, Winston-Salem, NC
      • PRESTON R. MILLER, MD, FACSAssociate Professor, Department of Surgery, Research Director, Acute Care Surgery, Wake Forest School of Medicine, Winston-Salem, NC

      The spleen is one of the most commonly injured abdominal organs in blunt trauma patients. The mechanisms of injury are similar to those seen with liver injuries: motor vehicle collisions, automobile-pedestrian collisions, falls, and any type of penetrating injury. Stab wounds to the abdomen are less likely to cause spleen injury compared with liver injury due to the spleen’s protected location. Stab wounds to the spleen typically result in direct linear tears, whereas gunshot wounds result in significant cavitary injuries. This review covers injuries to the spleen and injuries to the diaphragm. Figures show findings on imaging that may be associated with failure of nonoperative management for splenic injuries, intraparenchymal splenic blush noted on an initial computed tomographic scan, the first step in mobilizing the spleen by making an incision in the peritoneum and the endoabdominal fascia, beginning at the inferior pole and continuing posteriorly and superiorly, splenorrhaphy performed using interrupted mattress sutures through pledgets along the raw edge of the spleen, left diaphragm ruptures evident with the gastric bubble located in the left hemithorax, whereas right-sided ruptures present with the appearance of an elevated hemidiaphragm, and the use of Allis clamps to approximate the diaphragmatic edges, with the defect closed with a running No. 1 polypropylene suture. The table lists American Association for the Surgery of Trauma organ injury scales for diaphragm and spleen.

      This review contains 6 highly rendered figures, 1 table, and 42 references

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  • Vascular System
    • 1

      Medical Management of Vascular Disease

      By Deepak G. Nair, MD, MS, MHA, FACS, RVT; Russell H. Samson, MD, FACS, RVT
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      Medical Management of Vascular Disease

      • DEEPAK G. NAIR, MD, MS, MHA, FACS, RVTClinical Assistant Professor of Surgery (Vascular), Department of Surgery, Florida State University Medical School, Chief of Vascular Surgery, Sarasota Memorial Hospital, Sarasota, FL
      • RUSSELL H. SAMSON, MD, FACS, RVTAttending Physician, Sarasota Vascular Specialists; President of Mote Vascular Foundation; Clinical Associate Professor of Surgery (Vascular), Florida State University Medical School, Sarasota, FL

      Although surgeons may be able to bypass or open blocked arteries and replace aneurysms with minimally invasive surgery, patients continue to die from the other cardiovascular consequences of vascular disease. Surgeons must become more involved in the nonsurgical treatments of peripheral artery disease (PAD). A good understanding of the role of lipids in atherosclerosis is critical but surgeons must also recognize the threats of diabetes; smoking; hypertension; and hyperlipidemia on PAD. Treatments, including lifestyle modification, diet, exercise, and the influence of lipid-lowering agents is described. Medications that can alter PAD are described in detail and include statins; fibrates; niacin; bile acid sequestrants; ezetimibe; and antiplatelet agents. Side effects and monitoring is also described. Although much of the review covers the general principles of medical management of patients with PAD, components of this overall disease process are also provided and include pharmacological intervention for claudication; stroke; aortic aneurysms; and nonatherosclerotic vascular disease.

      This review contains 2 figures, 2 tables, and 181 references.

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    • 2

      Acute Limb Ischemia

      By Jovan N. Markovic, MD; Cynthia K. Shortell, MD, FACS
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      Acute Limb Ischemia

      • JOVAN N. MARKOVIC, MDGeneral Surgery Resident, Post-doctorate, Department of Surgery, Duke University School of Medicine, Durham, NC
      • CYNTHIA K. SHORTELL, MD, FACSChief of Vascular Surgery, Vascular Fellowship Program Director, Professor of Surgery, Duke University School of Medicine, Durham, NC

      Acute limb ischemia (ALI) is one of the most challenging conditions in vascular surgery and carries a high risk of amputation and mortality when treatment is delayed. Limb ischemia occurs when there is abrupt interruption of blood supply to an extremity because of either embolic or in situ thrombotic arterial or bypass graft occlusion. The goals of management include limb salvage, minimization of morbidity, and prevention of death. However, given that no objective markers of limb viability are currently available, the initial determination of whether a limb is likely to be viable must be made on clinical grounds. An early clinical evaluation is crucial for the diagnosis and identification of the underlying etiology of the ALI. As ALI is a clinical diagnosis, this review describes all aspects of the clinical evaluation as essential: patient history, staging of limb ischemia, and investigative studies. Atheromatous embolization is also discussed in depth. The characteristic signs of ALI may be summarized as the “six p’s”: pulselessness, pain, pallor, poikilothermia, paresthesia, and paralysis. Pain is the most common symptom in an ischemic limb and progresses along with the ischemia. As ischemia continues to progress, severe pain can be replaced by anesthesia of the limb, which can confound the examiner. Thus, pain should be documented with regard to severity, localization, and progression. ALI therapies covered are heparin therapy, thrombolytic therapy, thrombectomy, and surgical embolectomy and revascularization. The pathophysiology of limb ischemia is related to the progression of tissue infarction and irreversible cell death. Compared with other organs and tissues (e.g., the brain and the heart), the extremities are relatively resistant to ischemia. However, the various tissue types of which an extremity is composed have different metabolic rates.

      This review has 2 figures, 6 tables, and 165 references.

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    • 3

      Lower Extremity Ulcers

      By Robert D. Galiano, MD; Richard F. Neville, MD
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      Lower Extremity Ulcers

      • ROBERT D. GALIANO, MDNorthwestern University Feinberg School of Medicine, Chicago, IL
      • RICHARD F. NEVILLE, MDProfessor of Surgery, Chief, Division of Vascular Surgery, George Washington University MFA, Washington, DC

      Acknowledging and addressing common features of lower extremity ulcers will allow the surgeon to heal the vast majority of leg ulcers, either surgically or nonsurgically. The involvement of a surgeon interested in lower extremity preservation ensures the patient is offered a comprehensive set of management options. The authors discuss chronic and problem wounds, incidence and epidemiology, anatomic considerations, clinical evaluation and investigative studies, and general and specific management of the main types of leg ulcer (arterial, diabetic, venous, and inflammatory). Tables describe types and causes of lower extremity ulcers, common characteristics, members of the multidisciplinary team, conditions that interfere with healing, angiosomes of the foot, components of a leg ulcer that must be removed by débridement, benefits of hyperbaric oxygen and well-performed débridement, commonly used local pedicled flaps, staging systems for diabetic foot ulcer, and classes of compression stockings. Figures illustrate angiosomes of the anterior tibial, dorsalis pedis, peroneal, posterior tibial, lateral plantar, and medial plantar arteries; interplay between bacterial levels; types of wound dressing; ulcer locations as an indication of etiology; and management of arterial insufficiency ulcers, diabetic foot ulcers, and venous stasis ulcers.

      This review contains 11 figures, 11 tables, and 138 references.

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    • 4

      Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

      By Kenneth R. Ziegler, MD, RPVI; Thomas C. Naslund, MD
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      Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack

      • KENNETH R. ZIEGLER, MD, RPVI
      • THOMAS C. NASLUND, MD

      Nearly 800,000 strokes are reported in the United States annually, with an economic impact upward of $33 billion. Carotid artery disease, familiar to all vascular surgeons, accounts for just over one fifth of these strokes. However, these cases reflect an opportunity for the surgeon to intervene and mitigate the substantial burden of stroke. This review includes the epidemiology of stroke in the United States and the carotid artery and noncarotid etiologies of stroke, including atherosclerotic disease, fibromuscular dysplasia, carotid artery dissection, and cardioembolism. The clinical presentations of ischemic and hemorrhagic stroke and transient ischemia attacks are examined, as are the major findings expected in the patient history and physical examination. Strategies for further evaluation of the patient are discussed, including the use of sonographic imaging of the carotid artery and the relative advantages and disadvantages among the dominant modes of brain imaging. New updates to the review include interventional approaches toward the treatment of acute ischemic stroke, as well as the latest strategies regarding the timing of carotid endarterectomy after stroke and the utility of carotid artery stenting in these patients, with active areas of current research highlighted. Figures show a computed tomographic (CT) angiogram of fibromuscular dysplasia of an internal carotid artery, a CT angiogram of an internal carotid artery dissection showing a defect in the dissection, a CT scan demonstrating hemorrhagic conversion of cardioembolic stroke, a CT scan of acute thalamic hemorrhage, a CT scan of evolving ischemic stroke, a T2-weighted image demonstrating acute left frontal stroke and remote right frontal stroke, T1- and T2-weighted images of right parietal ischemic stroke, and M1 occlusion of a middle cerebral artery treated successfully with transcatheter thrombectomy. Tables list Society of Radiologists in Ultrasound and University of Washington criteria for duplex ultrasound diagnosis of carotid artery stenosis.

       

      This review contains 8 highly rendered figures, 2 tables, and 91 references.

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    • 5

      Surgical Treatment of Carotid Artery Disease

      By Wesley S. Moore, MD, FACS
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      Surgical Treatment of Carotid Artery Disease

      • WESLEY S. MOORE, MD, FACSProfessor, Division of Vascular Surgery, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, School of Medicine

      It has been estimated that a lesion in the distribution of the carotid artery is the underlying cause of ischemic stroke in 50 to 80% of patients. It follows, then, that surgical intervention in appropriately selected patients with carotid artery disease could significantly reduce ischemic stroke risk. Indeed, three major patient trials have confirmed that symptomatic patients with greater than 50% stenosis and asymptomatic patients with hemodynamically significant stenosis have a lower risk of stroke after carotid endarterectomy (CEA). This review describes CEA and reviews procedural details that are important for deriving the best short-term and long-term results from surgical intervention. Preoperative evaluation, operative planning, operative technique (including reconstruction options), postoperative management, and follow-up are covered and well illustrated with 17 high-rendered figures. The author confirms that trial patients have now been followed for 4 years, and the differences between carotid angioplasty with stenting (CAS) and CEA have held in favor of CEA. New major trials in recent years also confirm favor of CEA, appropriately reflected in Medicare guidelines. This review has 21 references; four references cover the patient trials.

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    • 6

      Pulsatile Abdominal Mass

      By Robert J.T. Perry, MD, FACS; Gilbert R. Upchurch Jr, MD, FACS
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      Pulsatile Abdominal Mass

      • ROBERT J.T. PERRY, MD, FACSFellow, Division of Vascular Surgery, Department of Surgery, University of Virginia, Charlottesville, VA
      • GILBERT R. UPCHURCH JR, MD, FACSDepartment of Surgery, Division of Vascular and Endovascular Surgery, University of Virginia Hospitals, Charlottesville, VA

      When a pulsatile abdominal mass is found, the patient’s medical and surgical histories, the location of the mass, and the associated symptoms are essential clues to formulating a diagnostic and treatment plan. The underlying condition may range in severity from benign to life threatening. Further evaluation is imperative because, depending on the source of the pulsatile mass, immediate transport to the operating room or endovascular suite may be necessary. Here, the evaluation and management of patients presenting with pulsatile abdominal masses in both the emergent and elective settings are discussed. The careful selection of patients appropriate for repair, an evidence-based approach to imaging and risk stratification, and new techniques in resuscitation of and endovascular or hybrid approaches to patients with ruptured aneurysms are emphasized. Figures show a diagnostic and treatment algorithm for the patient presenting with a pulsatile abdominal mass, computed tomography (CT) image of a pulsatile abdominal mass distorting the anterior abdominal wall, CT image of an isolated right iliac artery aneurysm, CT image of a previous endovascular repair with kinking of the left iliac limb, aortic color flow duplex ultrasound image of a ruptured abdominal aortic aneurysm  following aneurysm repair, a CT image of a ruptured aortic aneurysm, and an aortic occlusion balloon used to obtain proximal control in a ruptured infrarenal abdominal aneurysm. The video shows pulsations in the abdominal wall in a patient with a large aneurysm. Tables list classification of endoleaks, anatomic considerations for endovascular repair of aortic aneurysms using Food and Drug Administration-approved endografts, recommended surveillance intervals by aneurysm size, comparison of factors used to estimate risk in the Revised Cardiac Risk Index and the American College of Surgeons National Surgical Quality Improvement Project Myocardial Infarction or Cardiac Arrest, and risk factors for the prediction of long-term mortality following elective abdominal aortic aneurysm repair.

       

      This review contains 7 highly rendered figures, 1 video, 5 tables, and 92 references

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    • 7

      Asymptomatic Carotid Bruit/carotid Artery Stenosis

      By Ali F. Aburahma, MD; Patrick A. Stone, MD
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      Asymptomatic Carotid Bruit/carotid Artery Stenosis

      • ALI F. ABURAHMA, MDProfessor of Surgery, Chief, Division of Vascular and Endovascular Surgery, Program Director, Vascular Residency Program, Medical Director, Vascular Laboratory, Co-Director, Vascular Center of Excellence, Department of Surgery, Robert C. Byrd Health Sciences Center, West Virginia University, Charleston, WV
      • PATRICK A. STONE, MDAssistant Professor of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, Robert C. Byrd Sciences Center, West Virginia University, Charleston, WV

      Stroke used to be the third leading cause of death in the United States, behind coronary artery disease and cancer. However, a 2011 report states that stroke has now dropped to the fourth leading cause of death. Nearly 80% of strokes are ischemic, but only 15% of stroke patients have warning transient ischemic attacks. The management of patients with asymptomatic carotid stenosis is controversial; in this review, a stepwise approach to the management of asymptomatic carotid bruit/extracranial carotid artery stenosis is provided. Specifically, this review covers clinical evaluation, carotid bruits, vascular risk evaluation, imaging modalities, natural history of asymptomatic carotid artery disease, carotid plaque progression, natural history of asymptomatic carotid stenosis with evidence of clinically silent cerebral emboli, recommendations for carotid intervention/medical therapy, level 1 evidence supporting carotid endarterectomy in asymptomatic patients, and decision making for medical therapy alone versus intervention. Figures show color Doppler image with Doppler sampling from the right common carotid artery (CCA) and internal carotid artery (ICA), color duplex image with Doppler sampling of the distal left CCA and proximal ICA, color duplex ultrasound image of a plaque at the carotid bifurcation, magnetic resonance angiography showing severe stenosis of the right ICA and occluded left ICA, computed tomographic angiography showing severe stenosis of the left ICA with calcification, diagram for management of patients with both carotid stenosis and coronary artery disease, and protocol of management of asymptomatic bruit/carotid artery stenosis. Tables list the annual risk of stroke, prevalence of carotid stenosis in patients with bruits and in healthy volunteers, duplex velocity criteria for carotid stenosis, consensus criteria, validation of consensus criteria: duplex ultrasonography versus angiographic stenosis, risk factors for stroke, ranking of modifiable stroke risk factors, asymptomatic randomized trials comparing medical with medical and surgical treatment (stenosis > 60%), and a summary of specialty/societal guidelines.

       

      This review contains 7 highly rendered figures, 9 tables, and 91 references

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    • 8

      Infrainguinal Arterial Procedures

      By Stefano J. Bordoli, MD; John W. York, MD
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      Infrainguinal Arterial Procedures

      • STEFANO J. BORDOLI, MDVascular Surgery Fellow, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC
      • JOHN W. YORK, MDAssociate Professor, Department of Surgery, University of South Carolina School of Medicine, Greenville, SC

      Patients with limbs threatened by distal tibial occlusive disease present an ongoing challenge to the vascular surgeon. Provided that careful attention is paid to obtaining high-quality preoperative angiograms and that the surgeon is willing to consider alternative approaches, it is generally possible to achieve good results from limb salvage procedures. Only patients with threatened limbs—manifested by rest pain, frank gangrene, or nonhealing ulcers—should be considered candidates for infrainguinal bypass. The authors discuss preoperative evaluation, femoropopliteal bypass, infrapopliteal bypass, plantar bypass, and alternative bypasses using more distal inflow vessels.

      This review contains 17 figures, and 69 references.

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    • 9

      Aortoiliac Reconstruction

      By Andrew W. Hoel, MD; Mark K. Eskandari, MD
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      Aortoiliac Reconstruction

      • ANDREW W. HOEL, MDAssistant Professor, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL
      • MARK K. ESKANDARI, MDProfessor, Division of Vascular Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL

      There are multiple techniques for aortoiliac reconstruction that vary both in the physiologic stress to the patient and in long-term durability. These treatment options should be individualized based on a patient’s anatomy and comorbidities. In this chapter, the authors focus on open surgical intervention for the treatment of aortoiliac occlusive disease. Endovascular procedures have expanded the treatment options for peripheral arterial occlusive disease and are discussed in detail. This authors detail the preoperative evaluation, clinical decision making, and open surgical treatment options for patients with aortoiliac occlusive disease. The discussion of treatment options will include the potential complications and expected outcomes as well as steps that can be taken to optimize surgical results. This review is richly illustrated with 10 figures, and contains 40 references.

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    • 10

      Acute Mesenteric Ischemia

      By Mohammad H. Eslami, MD, MPH
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      Acute Mesenteric Ischemia

      • MOHAMMAD H. ESLAMI, MD, MPHAssociate Professor, Department of Surgery, Associate Professor, Department of Radiology, Boston University School of Medicine, Boston, MA

      Acute mesenteric ischemia (AMI) is an uncommon life-threatening clinical entity with a reported incidence rate of 0.09 to 0.2% per patient-year at tertiary referral centers. Diagnosis is challenging: the initial presentation of abdominal pain is vague, varied, and similar to other, more common, pathologic abdominal conditions. This review covers clinical evaluation, investigative studies, management, intraoperative consultation, determination of bowel viability, mesenteric ischemia and reperfusion, and outcome after surgical treatment of AMI. Figures show computed tomographic (CT) scan of mesenteric vessels, CT scan of a partially occluding thrombus in the superior mesenteric vein, contrast-enhanced three-dimensional magnetic resonance angiography images of aorta and mesenteric vessels, a schematic drawing demonstrating the usual site for superior mesenteric artery (SMA) thrombosis versus that for SMA embolus, selective angiogram of the SMA in anterior projection demonstrating embolus within the vessel at the typical location, lateral contrast angiogram demonstrating near-occlusion of the celiac artery and total occlusion of the SMA, contrast angiograms of the aorta and mesenteric arteries in a patient with nonocclusive mesenteric ischemia, selective angiogram of the SMA demonstrating a partially occluding embolus in the distal vessel, selective angiogram showing a clot beyond the orifice of the SMA, lodged in the SMA of smaller caliber, algorithm illustrating intraoperative determination of bowel salvageability, evaluation of SMA pulses, and assessment of bowel viability after revascularization, and an intraoperative photograph of diffuse bowel ischemia with classic sparing of the proximal jejunum and transverse colon due to embolus of the SMA.

       

      This review contains 11 highly rendered figures and 65 references

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    • 11

      Anterior Retroperitoneal Spine Exposure

      By Theodore H. Teruya, MD; Ahmed M. Abou-Zamzam Jr, MD
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      Anterior Retroperitoneal Spine Exposure

      • THEODORE H. TERUYA, MDAssociate Professor, Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA
      • AHMED M. ABOU-ZAMZAM JR, MDAssociate Professor, Division of Vascular Surgery, Loma Linda University Medical Center, Loma Linda, CA

      This chapter covers the aspects of anterior surgical exposure of the spine, including a review of the background, pathophysiology, and clinical presentation of lumbar spine disease. Treatment options and preoperative evaluation are discussed. The technical aspects, including the relevant anatomy, exposure techniques, and conduct of the operation, are presented. The routine postoperative management of these patients and frequently encountered complications (including vascular injuries, deep vein thrombosis, lymphoceles, nerve dysfunction, and bowel and genitourinary injuries) are reviewed. Important but rare situations, such as redo anterior approaches, are discussed. The various exposure options are presented, including a conventional retroperitoneal approach, a mini-open approach, a laparoscopic approach, and a transperitoneal approach. Figures show the important anatomic relations of the disk spaces to the aorta, vena cava, and iliac arteries and veins; intraoperative incision planning; and the use of fluoroscopy to confirm the appropriate level and identify the midline. This chapter contains 34 references.

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    • 12

      Repair of Infrarenal Abdominal Aortic Aneurysms

      By James Sampson, MD; William D. Jordan Jr, MD
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      Repair of Infrarenal Abdominal Aortic Aneurysms

      • JAMES SAMPSON, MDFellow, Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, AL
      • WILLIAM D. JORDAN JR, MDProfessor, Chief, Section of Vascular Surgery and Endovascular Therapy, University of Alabama Medical Center, Birmingham, AL

      An arterial aneurysm is a permanent localized dilation of an artery having at least a 50% increase in diameter compared to the expected normal diameter of the reference artery. Aneurysms may be classified by location, morphology, and etiology. The most common cause is atherosclerotic degeneration of the arterial wall. The pathogenesis is multifactorial, involving genetic predisposition, aging, atherosclerosis, inflammation, and localized activation of proteolytic enzymes. Aneurysms of the infrarenal aorta are by far the most common arterial aneurysms encountered in clinical practice today. Such aneurysms must be recognized and treated before they rupture. There is a relationship between aneurysm size and risk of rupture; however, the exact size at which an asymptomatic abdominal aortic aneurysm (AAA) should be treated remains unsettled. The authors outline the endovascular approach to AAA repair, describing preoperative preparation, the surgical technique with IVUS images and angiographs for each step, and outcome evaluation. They also discuss open repair by describing preoperative evaluation and optimization (risk factors, assessment of AAA size, classification for urgent or elective repair), operative planning, operative technique, special considerations, and outcome evaluation.
      This chapter is richly illustrated with 33 Figures, 32 References, 5 Board-styled MCQs, and 1 Teaching Slide Set.

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    • 13

      Repair of Femoral and Popliteal Artery Aneurysms

      By Patrick J. O'Hara, MD, FACS
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      Repair of Femoral and Popliteal Artery Aneurysms

      • PATRICK J. O'HARA, MD, FACSProfessor of Surgery, Cleveland Clinic Lerner College of Medicine, Cleveland, OH

      Femoral and popliteal artery aneurysms constitute most peripheral aneurysms. In general, with both femoral and popliteal artery aneurysms, elective repair and reconstruction tend to be associated with significantly better postoperative outcomes than emergency repair undertaken after a limb-threatening complication. Specific treatment decisions may be influenced by the presence or absence of symptoms of aneurysmal disease. For femoral artery aneurysms, this chapter presents the preoperative evaluation, operative planning, operative technique (endovascular repair, ultrasound-guided compression, and open surgical repair), and outcome evaluation. For popliteal aneurysms, this chapter discusses the preoperative evaluation, operative planning (indications for repair and preoperative arterial thrombolysis), operative technique (open vs. endovascular repair), and outcome evaluation (dependent on whether surgical or endovascular). More than one dozen figures show artheroembolization to the foot, various imaging results, and detailed repairs of femoral artery aneurysms and popliteal artery aneurysms. This chapter contains 43 references.

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    • 14

      Compartment Syndrome

      By Neha D. Shah, MD; Joseph R. Durham, MD, FACS
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      Compartment Syndrome

      • NEHA D. SHAH, MDResident, Department of General Surgery, Rush University Medical Center, Chicago, IL
      • JOSEPH R. DURHAM, MD, FACSChief, Division of Vascular Surgery, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL

      Compartment syndrome can develop anywhere skeletal muscle or abdominal organs are enveloped by a rigid, unyielding fascial layer. This chapter describes the epidemiology, pathophysiology, and diagnosis of compartment syndrome. Thereafter, the anatomy and surgical techniques are provided for the leg, the thigh and buttocks, the forearm, and the arm. Postoperative care and wound closure is addressed. Chronic exertional compartment syndrome is defined, as is abdominal compartment syndrome. Figures depict various fasciotomies and an algorithmic approach to management. Tables show the contents and function of the compartments of the leg and forearm. This chapter contains 32 references.

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    • 15

      Lower-extremity Amputation for Ischemia

      By William C. Pevec, MD, FACS
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      Lower-extremity Amputation for Ischemia

      • WILLIAM C. PEVEC, MD, FACSProfessor and Chief, Vascular and Endovascular, Surgery, University of California, Davis, Sacramento, CA

      Amputation procedure should be considered reconstructive and restorative for patients with infected, painful, or necrotic lower extremities. Amputations across the toe, the forefoot, the leg, and the thigh are discussed by operative planning, operative technique, complications, and outcomes. General preoperative planning includes selection of appropriate level of amputation below or above the knee, careful medical assessment, and optimal timing of elective amputation.
      It is advisable to obtain consent for possible above-the-knee amputation beforehand in case unexpected muscle necrosis is encountered below the knee. As with any amputation, the surgeon's preoperative interaction with the patient should be as positive as possible. A constructive perspective to convey is that the amputation, although regrettably necessary, is the first step toward rehabilitation. Although many patients with critical limb ischemia fail to achieve fully independent, community ambulation after below–the-knee amputation, a well-motivated patient whose cardiopulmonary status is not too greatly compromised can generally be expected to achieve some degree of function with a prosthetic limb. In this regard, a preoperative discussion with a physiatrist can be very helpful.
      This chapter includes 5 Procedures; 10 Figures; 13 References; 5 Board-Styled Questions; 1 Teaching Slide Set.

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    • 16

      Strategies of Hemodialysis Access

      By Robyn A. Macsata, MD, FACS; Anton N. Sidawy, MD, MPH, FACS
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      Strategies of Hemodialysis Access

      • ROBYN A. MACSATA, MD, FACSChief, Vascular Surgery, Veterans Affairs Medical Center, Assistant Professor of Surgery, Georgetown University Hospital
      • ANTON N. SIDAWY, MD, MPH, FACSChief, Surgery, Veterans Affairs Medical Center, Professor of Surgery, Georgetown University Hospital, Professor of Surgery, George Washington University Hospital

      Chronic kidney disease and end-stage renal disease (ESRD) have become common diagnoses in the United States; in response, several clinical practice guidelines for the surgical placement and maintenance of arteriovenous (AV) hemodialysis access have been published. This review examines temporary hemodialysis access, permanent hemodialysis accesses, and the Hemodialysis Reliable Outflow (HeRO) graft. Figures show trends in the number of incident cases of ESRD, in thousands, by modality, in the US population, 1980 to 2012, Medicare ESRD expenditures, algorithm for access location selection, autogenous posterior radial branch-cephalic wrist direct access (snuff-box fistula),  autogenous radial-cephalic wrist direct access (Brescia-Cimino-Appel fistula), autogenous radial-basilic forearm transposition, prosthetic radial-antecubital forearm straight access, prosthetic brachial (or proximal radial) antecubital forearm looped access, autogenous brachial (or proximal radial) cephalic upper arm direct access,  autogenous brachial (or proximal radial) basilic upper arm transposition, prosthetic brachial (or proximal radial) axillary (or brachial) upper arm straight access, prosthetic superficial femoral-femoral (vein) lower extremity straight access and looped access, prosthetic axillary-axillary (vein) chest looped access,  straight access, and body wall straight access,  HeRO graft, banding of the outflow access tract, distal revascularization with interval ligation, upper extremity edema and varicosities associated with venous hypertension, internal jugular to subclavian venous bypass, and puncture-site pseudoaneurysms of an AV access. Tables list AV access configuration, autogenous AV access patency rates, and prosthetic AV access patency rates.

       

       

      This review contains 19 highly rendered figures, 3 tables, and 67 references

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    • 17

      Diabetic Foot

      By Andy Lee, MD; Richard C. Hsu, MD, PhD; Allen D. Hamdan, MD, FACS
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      Diabetic Foot

      • ANDY LEE, MDResident, Clinical Research Fellow, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School. Boston, MA
      • RICHARD C. HSU, MD, PHDAttending Surgeon, Vascular and Endovascular Surgery, Danbury Hospital Department of Surgery, Danbury, CT
      • ALLEN D. HAMDAN, MD, FACSAssociate Professor, Harvard Medical School, Clinical Director, Vascular and Endovascular Surgery, Vice Chairman, Department of Surgery (Communication), Beth Israel Deaconess Medical Center, Boston, MA

      Surgeons caring for diabetic patients are faced with a diverse spectrum of foot disease. This review describes the thorough history and examination that is required and the assessment of clinical findings to determine the presence and severity of infection, the salvageability of the limb, and the presence of ischemia. A discussion of management is presented, in the context of management of the whole patient, as diabetes affects every organ system in the body. Steps for revascularization are described, as the goal of arterial reconstruction is to restore maximal perfusion to the foot. Continued wound care is emphasized. Secondary procedures on the foot are described with the aim of maximal foot salvage, and can include removing infected bone (if present), restoring functional stability, and reducing the risk of subsequent ulceration. The authors discuss the increasing literature comparing outcomes of open bypass surgery to endovascular intervention in treatment of critical limb ischemia. With diabetic wound care, the negative pressure system using the Vacuum Assisted Closure (V.A.C.) Therapy System has gained increasing popularity for the treatment of chronic and complex wounds compared to traditional moist dressing changes. The review concludes with patient education, focusing on general hygiene and daily inspection. Various figures are presented of the diabetic foot in various conditions, including a foot with wet and dry gangrene.

      This review contains 1 management algorithm, 11 figures, and 39 references.

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    • 18

      Varicose Vein Surgery

      By Jovan N. Markovic, MD; Cynthia K. Shortell, MD, FACS
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      Varicose Vein Surgery

      • JOVAN N. MARKOVIC, MDGeneral Surgery Resident, Post-doctorate, Department of Surgery, Duke University School of Medicine, Durham, NC
      • CYNTHIA K. SHORTELL, MD, FACSChief of Vascular Surgery, Vascular Fellowship Program Director, Professor of Surgery, Duke University School of Medicine, Durham, NC

      Chronic venous insufficiency (CVI) is a common vascular disorder that affects a significant proportion of the population in the United States and other developed countries. In its advanced stages, CVI significantly reduces patients’ quality of life and imposes a high economic burden on society due to increased direct health care costs and reduced productivity. Favorable clinical results associated with endovascular ablation techniques and patient preference for minimally invasive procedures has led to a shift in which treatment of vein disease is moving from the hospital to the office, allowing a more diverse group of physicians to enter a field that had typically been the domain of surgeons. This chapter reviews the terminology associated with venous disease, indications for varicose vein surgery, preoperative evaluation, procedural planning, endovenous procedures (endovenous laser ablation, radiofrequency ablation), surgical vein stripping techniques, and foam sclerotherapy. Tables include Clinical severity, Etiology or Cause, Anatomy, Pathophysiology classification; summary of nomenclature changes for the lower extremity venous system; indications for varicose vein surgery; interrogation points in the venous reflux examination; complications associated with treatment modalities used in the management of CVI; and methods of variceal ablation. Figures show an ultrasonographic image of a saphenous eye, placement of a quartz fiber for laser ablation of the great saphenous vein, a typical saphenofemoral junction, surgical stripping  of the great saphenous vein, and microfoam sclerotherapy.

      This review contains 9 figures, 6 tables and 73 references.

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    • 19

      Sclerotherapy

      By Melissa L. Kirkwood, MD
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      Sclerotherapy

      • MELISSA L. KIRKWOOD, MDAssistant Professor of Surgery, Division of Vascular and Endovascular Surgery, The University of Texas Southwestern Medical Center, Dallas, TX

      Sclerotherapy involves the injection of a caustic solution into an abnormal vein so as to cause localized destruction of the venous intima and obliteration of the vessel. Over the past 50 years, improvements in the technology have greatly enhanced the results achievable with sclerotherapy. To ensure optimal results, it is essential to have a thorough knowledge not only of the technique but also of the indications, expected outcomes, and possible complications associated with the procedure. This review covers preoperative evaluation, operative planning, technique and complications associated with sclerotherapy. Figures show a 63-year-old woman before and after two treatments with 0.2% sodium tetradecyl sulfate, a 52-year-old woman  before and after two treatments with 0.5% sodium tetradecyl sulfate, a 36-year-old woman before and after four treatments with a combination of 0.5% and 0.2% sodium tetradecyl sulfate, the standard hand position for sclerotherapy, skin necrosis on the left posterior calf of a 48-year-old woman after ultrasound-guided sclerotherapy,  a 56-year-old woman before treatment and with residual hyperpigmentation after treatment with 0.2% sodium tetradecyl sulfate, and telangiectatic matting in a 43-year-old woman after treatment with 0.2% sodium tetradecyl sulfate. Tables list complications of sclerotherapy, suggested polidocanol (POL) and sodium tetradecyl sulfate (STS) concentrations for liquid and foam sclerotherapy, materials needed for sclerotherapy, and absolute and relative contraindications for sclerotherapy for varicose veins.

       

      This review contains 7 highly rendered figures, 4 tables, and 29 references.

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    • 20

      Venous Thromboembolism

      By Guillermo A. Escobar, MD; Thomas W. Wakefield, MD; Peter K. Henke, MD, FACS
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      Venous Thromboembolism

      • GUILLERMO A. ESCOBAR, MDAssistant Professor of Surgery, Vascular Surgery, University of Michigan, Ann Arbor, MI
      • THOMAS W. WAKEFIELD, MDStanley Professor of Vascular Surgery, Department of Surgery, Section of Vascular Surgery, Conrad Jobst Vascular Research Laboratories, University of Michigan, Ann Arbor, MI
      • PETER K. HENKE, MD, FACSProfessor of Surgery, Vascular Surgery, University of Michigan, Ann Arbor, MI

      Deep vein thrombosis (DVT) and pulmonary embolism (PE) comprise venous thromboembolism (VTE). Together, they comprise a serious health problem. Risk factors for VTE are described, and can be irreversible (e.g., due to age, malignancy, or inherited thrombophilia) or acquired (e.g., from immobilization, surgery and trauma, or intravenous catheters). Management depends on whether the indications are for immediate intervention (pulmonary embolus, phlegmasia cerulea dolens, or phlegmasia alba dolens), urgent intervention (primary axillary-subclavian vein DVT or iliofemoral DVT/May-Thurner syndrome) or nonemergent intervention (uncomplicated lower and upper extremity VTE, superficial vein thrombosis, and pylephlebitis). Figures show the modified Caprini score questionnaire, phlegmasia cerulea dolens, and a venogram showing May-Thurner syndrome. Tables include the recommended VTE prophylaxis stratified by surgical procedure and associated VTE risk factors according to the 8th ACCP Consensus Statement. This review contains 145 references.

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    • 21

      Peritoneal Dialysis Access

      By Min C. Yoo, MD; Ramesh Saxena, MD, PhD; Ingemar J.A. Davidson, MD, PhD, FACS
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      Peritoneal Dialysis Access

      • MIN C. YOO, MDTransplant Surgery Fellow, University of Tennessee/Methodist Transplant Institute, Memphis, TN
      • RAMESH SAXENA, MD, PHDAssociate Professor, Division of Nephrology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
      • INGEMAR J.A. DAVIDSON, MD, PHD, FACSProfessor, Division of Surgical Transplantation, Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX

      Peritoneal dialysis remains an underused modality for renal replacement, despite ample evidence of improved survival and quality of life when compared with hemodialysis. This review provides an overview of the preoperative and operative planning for peritoneal dialysis. Both open and laparoscopic surgical techniques are described as is closure, postoperative care, and catheter removal. Complications including hernias, leakage, mechanical problems, and infection are discussed. More than one dozen figures show the placement of a peritoneal dialysis catheter in the open technique. Tables show both indications and contraindication for peritoneal dialysis. This review contains 44 references.

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    • 22

      Carotid Artery Stenting

      By Carlos H. Timaran, MD
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      Carotid Artery Stenting

      • CARLOS H. TIMARAN, MD

      Carotid angioplasty and stenting (CAS) is gaining ground as an alternative to endarterectomy. Extensive study results putting carotid endarterectomy (CEA) in favor in recent years are discussed, as are the studies underway for CAS (CREST; CAVATAS-II; ACT I). The basic indications for CAS are given. Additionally, use of an embolic protection device (EPD) in conjunction with the procedure for protection against ischemic stroke is strongly advocated, and the three types of devices are described: distal balloon occlusion; distal filter protection; and proximal balloon occlusion with or without flow reversal. The operative technique of CAS has evolved but is currently performed in the following steps, with few exceptions: securing of arterial access; selective carotid catheterization and arteriography; advancement of sheath and dilator into the common carotid artery; removal of guide wire and dilator and selective arteriography of carotid bifurcation; measurement of activated clotting time; delivery of the EPD across the target lesion; predilation of lesion; deployment of stent; postdilation of lesion; EPD retrieval; completion arteriography; and access-site hemostasis. The short-term results of CAS depend largely on the presence or absence of cerebral embolization. Figures show various aortograms and angiograms of the procedure as well as the use of the “buddy wire” technique to deliver an EPD. Tables show inclusion and exclusion criteria for endarterectomy; indications for carotid angioplasty and stenting in high-risk patients; and limitations of and contraindications to CAS.

      This review contains 11 figures, 3 tables, and 50 references.

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    • 23

      Endovascular Procedures for Lower Extremity Vascular Disease

      By Mark G. Davies, MD, PhD, MBA, FACS
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      Endovascular Procedures for Lower Extremity Vascular Disease

      • MARK G. DAVIES, MD, PHD, MBA, FACSMethodist DeBakey Heart & Vascular Center, The Methodist Hospital, Houston, TX

      The application of endovascular procedures to lower extremity vascular disease is now established as the first-line intervention and has supplanted conventional open surgical approaches for most common vascular diseases. This new review details several common endovascular techniques and therapies used in the lower extremity arterial and venous systems by vascular surgery providers. The author's comprehensive approach to each procedure includes preprocedure “basics,” technical steps, adjunct therapies, troubleshooting, and postprocedure outcomes and considerations. There are three treatment algorithms, six figures, and 78 references in this chapter. As endovascular therapy for patients with lower extremity disease evolves, the algorithms for patient treatment are likely to evolve in concert.

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    • 24

      Fundamentals of Endovascular Surgery

      By Jon S. Matsumura, MD, FACS; Brian G. Peterson, MD, FACS
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      Fundamentals of Endovascular Surgery

      • JON S. MATSUMURA, MD, FACSUniversity of Wisconsin School of Medicine and Public Health, Madison, WI
      • BRIAN G. PETERSON, MD, FACSSaint Louis University Health Sciences Center, St. Louis, MO

      Endovascular techniques are an important part of vascular surgery. The initial step in endovascular surgery is selection of the vascular access site and how to choose the ideal access site is described. Thereafter, the general technical principles of artery puncture (femoral, brachial, and axillary artery puncture as well as translumbar puncture) are described along with troubleshooting principles for each procedure. Once vascular access has been obtained through arterial puncture, it is maintained through placement of a guide wire. The placement of a sheath or guide is typically placed over the guide wire to maintain a stable pathway for catheter exchange or for placement of a device. Insertion of catheters and placement of vascular stents are discussed in detail, including troubleshooting techniques. Type of stents are discussed and include balloon expandable, self-expanding, and covered stents. Postprocedural management of the arterial access site is described. The need for large sheath access during aortic interventions is also presented. The review concludes with a numerical listing of the more than two dozen steps of the basic steps in endovascular procedures, and more than a dozen figures represent the aforementioned procedures. This review contains 21 references.

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    • 25

      Preoperative Evaluation of the Vascular Patient

      By Issam Koleilat, MD; Christopher G. Carsten, MD
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      Preoperative Evaluation of the Vascular Patient

      • ISSAM KOLEILAT, MDVascular Surgery Fellow, Greenville Health Systems, Greenville, SC
      • CHRISTOPHER G. CARSTEN, MDChief, Division of Vascular Surgery, Greenville Health Systems, Greenville, SC

      Almost as critical as an operation itself is the preparation of the patient. Although this often includes psychosocial concerns such as expectations of recovery, inpatient stay, and other patient-centered issues, the discussion prior to surgery should not be limited to these factors. A medical assessment of the patient’s fitness and physiologic preparedness for the planned procedure must be performed by the surgeon and the resultant findings and plan reviewed with the patient. Although vascular disease affects multiple organ systems requiring a thorough general preoperative patient assessment, the focus of preoperative risk reduction strategies center on cardiac outcomes. Therefore, this review focuses on cardiac-related interventions with added coverage of preoperative strategies regarding diabetes, pulmonary and renal risk assessment, and infection reduction. Lastly, the perioperative management of anticoagulation/antiplatelet medications and cerebrovascular disease are discussed Techniques and treatments to optimize patients for surgery are integrated into the respective sections, allowing for a primer to guide this critical phase in a patient’s journey through surgery. Tables outline the Revised Cardiac Risk Index, assessment of functional capacity from patient self-reported activities, optimal delay in elective surgery after percutaneous coronary revascularization according to the 2014 American College of Cardiology/American Heart Association clinical practice guidelines, Respiratory Failure Risk Index, Szilagyi classification of vascular surgical site infection, and recommendations regarding perioperative management of anticoagulants and antiplatelet agents. A suggested algorithm for preoperative cardiac workup and the Cockcroff-Gault equation are provided.

       

      This review contains 2 figures, 6 tables, and 115 references.

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  • Normal Lab Values

Welcome to SAS!

Scientific American Surgery (SAS) is the only continuously-updated online resource teaching principles and practice. SAS offers packages tailored to all different levels of lifelong learning: Core Clerkship for undergrads; Weekly Curriculum™ and Board Prep for trainees; and CME/MOC for practitioners. Our brand new, totally responsive website and app has your covered wherever and whenever, on all devices and screens.

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Developed to encourage reflection and extrapolations to be drawn between diseases/problems within larger pathophysiologic topics thus informing students about specific diseases they may clinically encounter during their Core Surgery Clerkship.

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Whether you are in private practice, full-time faculty or attending, SAS offers CME/MOC for surgeons in all circumstances! All CME/MOC exercises are post-tests associated with the monthly SAS updates. All exercises are comprised of case-based MCQs, assessing new material and knowledge gaps. All exercises are 'Board-styled', helping physicians prepare for re-certification! 

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