- Scientific Foundations
Basic Concepts of Anesthesia
By Pooja Pandya, MD; George P. Yang, MD, PhDPurchase PDF
Basic Concepts of AnesthesiaPurchase PDF
It is expected that surgeons have detailed and nuanced knowledge of the procedures they perform. It is equally necessary that surgeons have a working knowledge of anesthesia because it is important in patient selection for surgery, and for intraoperative factors including patient positioning and invasive monitoring. Proper care of the operative patient requires excellent communication and coordination between the surgical and anesthetic team. Providing optimal perioperative care for the patient requires the surgeon to understand the risks and benefits of each anesthetic approach and to relay potential portions of the procedure that may have a profound impact on the patient’s physiology so the anesthesiologist can properly prepare for it. With the increasing complexity of patients and the operations being performed, this ensures the best possible outcome.
This review contains 6 figures, 13 tables, and 142 references.
Key words: Local anesthetic, regional anesthesia, general anesthesia, sedation, cardiovascular risks, preoperative evaluation, difficult airway, perioperative medications, surgical risk calculators
Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health Care
By Laura Stafman, MD; Sushanth Reddy, MD, FACSPurchase PDF
Advance Directives, Do Not Resuscitate Orders, and Power of Attorney for Health CarePurchase PDF
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
Postoperative Pain Management
By Abhishek Parmar, MD, MSPurchase PDF
Postoperative Pain ManagementPurchase PDF
The aim of this review is to provide practical clinical information on modern pain management options to guide the clinician on evidence-based practices, optimizing the treatment of pain and avoiding practices that may lead to potential abuse. Postoperative pain management is an essential component of any surgeon’s practice and has clear implications for surgical outcomes, patient satisfaction, and population health. Understanding options within a multimodal approach to pain management in the acute setting is a key determinant to improving outcomes for our patients. This review discusses multimodal analgesic options, including a variety of pain medications (opiates, antiinflammatory medications, and patient-controlled analgesia) and techniques (epidural catheter placement, regional nerve blocks) to be used in tandem. Lastly, best possible practices to avoid opiate abuse are discussed.
This review contains 4 figures, 5 tables, 1 video and 96 references.
Key words: antiinflammatories, epidural, narcotics, patient-controlled analgesia, postoperative pain, regional nerve block
By Katie C Farmer, PharmD, BCPS; Duraid S Younan, MDPurchase PDF
Clinical PharmacologyPurchase PDF
In addition to multiple procedures and interventions that can produce significant pathophysiologic changes, all critically ill surgical patients require drugs to treat organ dysfunction. However, the pharmacokinetics of these drugs used for therapeutic benefit can be greatly altered in the setting of multiple comorbidities and varied organ function and, combined with polypharmacy, can even result in adverse drug reactions (ADRs). This review aims to describe basic pharmacokinetic principles (absorption, distribution, metabolism, elimination) and changes in these processes due to altered organ function in critically ill surgical patients. This knowledge is a key factor in reducing ADRs.
10 figures; 2 tables; 77 references
Keywords: adverse drug reactions, drug interactions, obesity, pharmacodynamics, pharmacokinetics, plasma protein binding, therapeutic drug monitoring
Clinical Trial Design and Statistics
By Julie Ann Sosa, MA, MD, FACSPurchase PDF
Clinical Trial Design and StatisticsPurchase PDF
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
By Emily R. Winslow, MDPurchase PDF
Evidence-based MedicinePurchase PDF
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
By Jason Primus, MD; Colin Martin, MD; Herbert Chen, MD, FACSPurchase PDF
Acid-base DisordersPurchase PDF
This review is a summary of the acid-base physiology that is essential to understanding acid-base pathophysiology. An acid is defined as a proton donor; a base is defined as a proton acceptor. The body fluids are composed of acids and bases, which are tightly regulated by our organ systems, specifically the respiratory system and kidneys. Derangements in the body’s acid-base homeostatic mechanisms or overloading the capacity of the body’s ability to respond can lead to acid-base disorders. These include acidosis and alkalosis, which can be further classified into respiratory, metabolic, or mixed disorders. The approach to these disorders is to stabilize the patient, focusing on respiratory and circulatory status and treating the underlying cause of the acid-base derangement.
This review contains 4 highly rendered figures, 2 tables, and 26 references.
Key words: acid-base disorders, acid-base homeostasis, acid-base physiology, acidemia, alkalemia, metabolic acidosis, metabolic alkalosis, mixed acid-base disorders, respiratory acidosis, respiratory alkalosis
Disorders of Water and Sodium Balance
By Micah Katz; Herbert Chen, MD, FACSPurchase PDF
Disorders of Water and Sodium BalancePurchase PDF
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.
Nature and Clinical Impact of Physiologic Changes Associated With Aging
By Omeed Moaven, MD; Carlo M Contreras, MD, FACSPurchase PDF
Nature and Clinical Impact of Physiologic Changes Associated With AgingPurchase PDF
This review highlights important age-related changes at the physiologic level and their clinical consequences. Latest societal guidelines and consensus expert opinions on pre- and perioperative management of elderly surgical patients are discussed. Age-related postoperative complications, including precipitating factors and appropriate management, are summarized. The latest advancements in the management of important surgical problems in geriatric populations are outlined.
This review contains 4 figures, 8 tables, and 103 references.
Key words: aging, elderly patient, immunosenescence
Evaluation of Surgical Risk
By Ryan Schmocker, MD; Suresh Agarwal, MD, FACS, FCCMPurchase PDF
Evaluation of Surgical RiskPurchase PDF
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.
Perioperative Antithrombotic Therapy Management and Venous Thromboembolism Prophylaxis
By Irene Lou, MD; Herbert Chen, MD, FACSPurchase PDF
Perioperative Antithrombotic Therapy Management and Venous Thromboembolism ProphylaxisPurchase PDF
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.
Preoperative Evaluation of the Elderly Surgical Patient
By Tracy S. Wang, MD, MPH, FACS; Jennifer Roberts, MD; Nicholas G Berger, MDPurchase PDF
Preoperative Evaluation of the Elderly Surgical PatientPurchase PDF
The elderly population uses a significant portion of health care resources in the United States and poses an increasing challenge to perioperative care. Many reports point to both increasing age and frailty as important risk factors for short-term mortality; cardiovascular, pulmonary, and renal complications; and increased length of stay and hospital costs following operation. To provide the best care for the aging US population, it is important for the clinician to be familiar with the appropriate presurgical workup specific to the comorbidities prevalent to the elderly population. This review discusses the postoperative complications facing elderly surgical patients and the physiologic complications of aging, with a particular emphasis on the concept of frailty as a predictor of major morbidity and mortality. With age and comorbidities in mind, this review discusses the relevant preoperative cardiovascular, respiratory, and renal workup and includes important guidelines for appropriate risk assessment and reduction in the elderly surgical patient.
This review contains 1 figure, 5 tables, and 86 references.
Key words: aging, anesthesia, elderly, frailty, outcomes, preoperative workup, risk assessment
Perioperative Management of Patients on Steroids Requiring Surgery
By Dawn M. Elfenbein, MD, MPH; Alexandra Reiher, MD; Rebecca S. Sippel, MD, FACSPurchase PDF
Perioperative Management of Patients on Steroids Requiring SurgeryPurchase PDF
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.
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, FACSPurchase PDF
Pharmacologic Considerations in the Elderly Surgical PatientPurchase PDF
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
Prevention and Diagnosis of Infection
By Sara M. Demola, MD; Taylor S Riall, MD, PhD, FACSPurchase PDF
Prevention and Diagnosis of InfectionPurchase PDF
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.
Surgical Considerations in Solid-organ Transplant Recipients
By Thomas A. Pham, MD; Marc L. Melcher, MDPurchase PDF
Surgical Considerations in Solid-organ Transplant RecipientsPurchase PDF
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
By Jason A. Castellanos, MD; Nipun B. Merchant, MD, FACSPurchase PDF
Viral InfectionPurchase PDF
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.
By Sara Buckman, MD, PharmD; Luis A. Fernandez, MD, FACSPurchase PDF
Fungal InfectionsPurchase PDF
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.
Prevention of Postoperative Infection
By Rindi Uhlich, MD; Parker Hu, MD; Patrick L Bosarge, MD, FACS, FCCMPurchase PDF
Prevention of Postoperative InfectionPurchase PDF
Surgical site infection remains a preeminent focus of perioperative care given its huge potential to impact outcomes, length of stay, and mortality. Numerous governmental and regulatory bodies have developed recommendations to limit the incidence of surgical site infection. These recommendations continue to evolve at a rapid pace, with all aspects of perioperative care sharing ongoing scrutiny. Implementation of these strategies should remain the focus of all providers to limit the incidence of postoperative infections and optimize outcomes.
This review contains 4 figures, 14 tables, and 109 references.
Key words: antibiotic, complication, infection, preoperative, preparation, postoperative, scrub, surgical site infection
By Michael R. Filbin, MDPurchase PDF
Sepsis accounts for approximately one in three hospital deaths, and is associated with very high health care costs due to prolonged lengths of stay in the intensive care unit and hospital. Sepsis is essentially an immunologic response to infection that is propagated systemically, leading to diffuse cellular and microcirculatory dysfunction, vasodilation, vital organ hypoperfusion, and eventual failure. This review covers the pathophysiology, stabilization/assessment, diagnosis, treatment, and disposition and outcomes of sepsis. Figures show the inflammatory and thrombotic response to infection, the action of nitric oxide on vascular smooth muscle cells, accelerated glycolysis and increased lactate production as a result of the catecholamine surge seen in septic shock, sepsis mortality associated with number of organ failures identified in the emergency department (ED), and protocolized therapy for septic shock. Tables list definitions of sepsis syndromes; frequently cited scoring systems for mortality prediction in emergency department patients with sepsis; Sequential Organ Failure Assessment (SOFA) score; current recommendations regarding treatment bundles at 3 and 6 hours of resuscitation; antibiotic recommendations based on suspected source; and vasopressors used in septic shock with recommended dosing, mechanism of action, and indications.
This review contains 5 figures, 7 tables, and 57 references.
Keywords: Sepsis; Surviving Sepsis Campaign guidelines, definitions, SEP-1 sepsis quality measure, time-to-antibiotics, volume resuscitation, lactated ringers
Infection Control in Surgical Practice
By Elizabeth A Bailey, MD, MEd; Caroline E. Reinke, MD, MSHP; Rachel R. Kelz, MD, MSCE, FACSPurchase PDF
Infection Control in Surgical PracticePurchase PDF
Health care–associated infections (HAIs) are those that are acquired while patients are being treated for another condition in the health care setting. HAIs are associated with substantial morbidity and mortality, with 75,000 deaths attributable to HAIs each year. This review outlines the evolution of HAI as a quality metric and introduces key governmental and professional organization stakeholders. The role of the local infection control program is also discussed. Using the example of surgical site infection, we detail the multitude of factors that contribute to the occurrence of an HAI, evidence-based preventive strategies, and systems-based programs to reduce preventable infections. Specific diagnostic criteria and preventive strategies are also introduced for catheter-associated urinary tract infection, central line–associated bloodstream infection, ventilator-associated pneumonia, Clostridium difficile infection, and various multidrug-resistant organisms.
This review contains 3 figures, 9 tables, and 74 references.
Key words: catheter-associated urinary tract infection, central line–associated bloodstream infection, Clostridium difficile, hospital-acquired infection, infection, quality, surgical site infection, ventilator-associated pneumonia
Minimally Invasive Surgery: Equipment and Troubleshooting
By Luke M. Funk, MD, MPH; Jacob A. Greenberg, MD, EDMPurchase PDF
Minimally Invasive Surgery: Equipment and TroubleshootingPurchase PDF
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.
Technical Aspects of Laparoscopic Surgery
By James G. Bittner IV, MD, FACS; Charlotte Rabl, MD; Guilherme M. Campos, MD, FACSPurchase PDF
Technical Aspects of Laparoscopic SurgeryPurchase PDF
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.
By Alfredo M. Carbonell, DO, FACS, FACOS; Jeremy A Warren, MDPurchase PDF
Robotic SurgeryPurchase PDF
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
Key words: Robotic, surgery, hernia, inguinal, ventral, incisional, fundoplication, paraesophageal hernia, myotomy, gastrectomy, cholecystectomy, pancreatectomy, splenectomy, bariatric, adrenalectomy, colon, colectomy, colorectal
By Rindi Uhlich, MD; Parker Hu, MD; Patrick L Bosarge, MD, FACS, FCCMPurchase PDF
Nutritional SupportPurchase PDF
Nutritional optimization of the surgical patient remains a cornerstone of perioperative care. Significant effort and scrutiny are routinely directed to the field as it has the potential to improve outcomes, limit infectious complications, and decrease hospital length of stay and mortality. As such, previously identified cornerstones of care have been called into question. The timing, route, and intensity of nutritional supplementation remain the subject of controversy in an ever-evolving field. Previous methods of nutritional assessment, such as albumin and transthyretin, have proved unreliable, and their use is no longer recommended. In their place, new scoring systems are available to risk assess patients for malnutrition. We review the most pressing changes and assess the landscape of the field today.
Key words: critical illness, enteral, glutamine, malnutrition, nutrition, outcomes, parenteral, protein
Cancer Epidemiology and Prevention
By Carlo M. Contreras, MDPurchase PDF
Cancer Epidemiology and PreventionPurchase PDF
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
Molecular Genetics of Cancer
By Christina W. Lee, MD; Gregory D. Kennedy, MD, PhDPurchase PDF
Molecular Genetics of CancerPurchase PDF
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.
By Amanda Contreras, BS; Clifford S. Cho, MD, FACSPurchase PDF
Cancer ImmunologyPurchase PDF
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.
Principles of Cancer Treatment
By Rebecca A. Busch, MD; David F. Schneider, MD, MSPurchase PDF
Principles of Cancer TreatmentPurchase PDF
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.
The Skin and the Physiology of Normal Wound Healing
By Sahil K. Kapur, MD; Timothy W. King, MD, PhDPurchase PDF
The Skin and the Physiology of Normal Wound HealingPurchase PDF
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.
Management of Acute Wounds
By Lee D. Faucher, MD, FACS; Angela L. Gibson, MD, PhDPurchase PDF
Management of Acute WoundsPurchase PDF
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.
Management of Chronic Wounds
By Angela L. Gibson, MD, PhD; Dana Henkel, MDPurchase PDF
Management of Chronic WoundsPurchase PDF
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
Postoperative and Adjunctive Wound Care
By Rebecca A. Busch, MD; Lee Faucher, MD, FACSPurchase PDF
Postoperative and Adjunctive Wound CarePurchase PDF
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
Clinical Immunology and Innate Immunity
By Lung-Yi Lee, MD; David P Foley, MDPurchase PDF
Clinical Immunology and Innate ImmunityPurchase PDF
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
Perioperative Management of the Surgical Patient on Suboxone (buprenorphine and Naloxone)
By Vimal N. Desai, MD; Jane C Ahn, MD; Kyle S Ahn, MDPurchase PDF
Perioperative Management of the Surgical Patient on Suboxone (buprenorphine and Naloxone)Purchase PDF
Over the past two decades, the incidence of legal and illegal drug abuse and dependency has increased at alarming levels, resulting in a rise in the number of associated deaths. Multiple resources are available to manage addiction, including the use of buprenorphine with or without naloxone. Consequently, more and more patients are requiring this treatment and are presenting for elective and emergent surgery where treatment of acute postoperative pain in the setting of buprenorphine use becomes challenging due to its unique properties. Buprenorphine has unique properties in which it binds to the opioid (mu) receptor with a higher affinity than other opioids. Buprenorphine is bound for a long period of time (32 hours), but its opioid effects have a ceiling. Since the receptors are occupied, when illegal or prescribed opioids are abused, they cannot activate the occupied receptors, and, in parallel, the effects that lead to addiction, tolerance, and craving are limited. However, in the surgical setting, increased opioid use may be appropriately needed to manage pain, which is hindered and limited by buprenorphine. Using current studies and strategies, we propose an algorithm to effectively manage buprenorphine in the perioperative setting.
By Brett A Melnikoff, MD; René P Myers, MDPurchase PDF
Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all 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 (eg, ventricular assist devices) has increased markedly. With these changes has come an increase in the incidence of serious Candida infections. This review covers the definition and classification, epidemiology and risk factors, and clinical evaluation of candidiasis, as well as management of candidemia, acute disseminated candidiasis, nonhematogenous candidiasis, and peritonitis and intra-abdominal abscess. Figures show Candida endophthalmitis in patients with persistent fungemia and superficial candidiasis in the gastrointestinal tract. Tables list clinical presentation and diagnostic methods for common fungal infections, antimicrobial agents of choice for candidal infections, and the latest guidelines for candidiasis.
This review contains 2 figures, 3 tables and 131 references
Key words: acute disseminated candidiasis, candidemia, candidiasis, candiduria, nonhematogenous candidiasis
Systemic Antifungal Agents
By Brett A Melnikoff, MD; René P Myers, MDPurchase PDF
Systemic Antifungal AgentsPurchase PDF
Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all especially vulnerable. Despite the development of a number of new and useful antifungal agents in the past decade and the noteworthy improvements in therapeutic approaches to fungal infections, physicians’ ability to diagnose these infections in a timely fashion remains limited, and patient outcomes remain poor. Antifungal prophylaxis has emerged as a potential means of reducing the occurrence of serious fungal infections. In patient populations estimated to be at high risk for acquiring a fungal infection, antifungal prophylaxis has reduced infection rates by about 50%; however, it has not been shown to significantly improve mortality. This review discusses both established and newly approved systemic antifungal agents. Tables list characteristics of currently available antifungals and antifungal chemotherapy.
This review contains 2 tables and 32 references
Key words: antifungal chemotherapy, antifungal prophylaxis, antifungals, Candida prophylaxis, systemic antifungal medications
Noncandidal Fungal Infections
By Brett A Melnikoff, MD; René P Myers, MDPurchase PDF
Noncandidal Fungal InfectionsPurchase PDF
Fungal infections remain an important cause of morbidity and mortality in surgical settings, with critically ill patients, transplant recipients, and sick neonates all 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 (eg, ventricular assist devices) has increased markedly. With these changes has come an increase in the incidence of serious fungal infections, including the less common but potentially fatal noncandidal infections caused by Aspergillus and the Zygomycetes Mucor and Rhizopus. This review outlines an approach to the workup and management of the nonneutropenic surgical patient with a suspected noncandidal infection (aspergillosis and zygomycosis). Figures show biopsy samples from an elderly man with chronic progressive disseminated histoplasmosis and thick-walled, broad-based budding yeasts typical for Blastomyces dermatitidis on biopsy material.
This review contains 2 figures and 47 references
Key words: aspergillosis, aspergillosis prophylaxis, blastomycosis, Cryptococcus, histoplasmosis, noncandidal fungal infections
Principles and Techniques of Abdominal Access and Physiology of Pneumoperitoneum
By Jon C. Gould, MD, FACS; Kathleen Simon, MDPurchase PDF
Principles and Techniques of Abdominal Access and Physiology of PneumoperitoneumPurchase PDF
Laparoscopic surgery has gained popularity in recent time. An essential aspect of this technique is production of a pneumoperitoneum with insufflation for adequate visualization and manipulation of abdominal contents. Various techniques have been developed over the years for optimal access with minimization of complications. Some of these complications include vascular injury, visceral injury, and incisional hernia. Furthermore, considerations with regards to the patient’s physical morphology, and the cardiovascular/respiratory effects of increased abdominal pressure and anesthesia must be accounted for. The guidelines to optimize patient care in these regards are discussed in this review.
This review contains 2 videos, 5 figures, 2 tables, and 79 references.
Keywords: trocar insertion, port site hernia, Veress needle, optical trocar, trocar related injuries, Hassan cannula, pneumoperitoneum, air embolism, pneumoperitoneum physiology
- Organ Systems: Anatomy and Physiology
By David C Mauchley, MDPurchase PDF
Cardiac SystemPurchase PDF
The circulatory system, which consists of the heart, arterial system, venous system, and lymphatics, constitutes a complicated network of vessels and ducts that are responsible for the delivery of oxygenated blood to the body and return of deoxygenated blood to the heart and lungs. The heart is at the center of the circulatory system, and its pumping mechanism provides energy and nutrition to all organs in the body. This review focuses on the anatomy and physiology of the heart and describes anatomic details that are important to the planning of many common cardiac operations.
This review contains 28 figures, and 25 references.
Key words: aortic root, aortic valve, atrial septum, atrioventricular node, coronary artery, fibrous skeleton of heart, mitral valve, myocardium, pericardium, pulmonic valve, sinoatrial node, tricuspid valve, ventricular septum
The Renal System
By John T Killian Jr, MD; Jayme E. Locke, MD, MPH, FACSPurchase PDF
The Renal SystemPurchase PDF
This updated review on the renal system provides a concise overview of the topics most important to the general surgeon. Anatomic topics have been expanded to also include variant anatomy and surgical approaches. There is a new focus on the accuracy and utility of equations for estimating the glomerular filtration rate, as well as supplementation and pharmacology for the general surgeon with discussions of vitamin D and erythropoietin. Acute kidney injury is defined; its pathophysiology is discussed; and its management is outlined, highlighting evidence-based practice. Finally, urologic surgery is addressed with a focus on donor nephrectomy and its consequences, as well as the management of iatrogenic ureteral injuries.
Key words: acute kidney injury; contrast nephropathy; erythropoiesis-stimulating agents; estimated glomerular filtration rate; iatrogenic ureteral injury; laparoscopic donor nephrectomy; renal surgical anatomy; vitamin D supplementation
By Michael Frank Gleason, MD; Benjamin Wei, MDPurchase PDF
The EsophagusPurchase PDF
The esophagus is a tubular structure spanning from the posterior pharynx, through the thorax, and terminating in the stomach. It arises from endodermal foregut tissue. Its submucosal muscular layers are initially striated, transitioning to smooth muscle in more distal areas. Due to the distance in the body it traverses, the esophagus derives its blood and nerve supply from several structures. The role as a conduit from mouth to stomach necessitates secretory and barrier functions, as well as sphincters for protection from anterograde flow. Various modalities of esophageal test exist, ranging from fluoroscopy, to invasive endoscopy capable of obtaining tissue samples, to probes that detect pH and muscle tone, all of which play roles in identifying various pathologic processes.
Key words: abdomen, endoscopy, esophagography, esophagus, impedance, lower sphincter, manometry, upper sphincter
The Endocrine System: Thyroid and Parathyroid
By David F. Schneider, MD, MS; Rebecca S. Sippel, MD, FACSPurchase PDF
The Endocrine System: Thyroid and ParathyroidPurchase PDF
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.
The Liver and Portal System
By Jared A White, MD, FACSPurchase PDF
The Liver and Portal SystemPurchase PDF
Understanding of the anatomy and physiology of the liver and techniques for safe anatomic and nonanatomic liver resections has evolved over the past several decades. The liver is composed of a complex arterial and portal venous inflow, which has several important variants that are crucial for the surgeon to understand when planning hepatic resections, both anatomic and nonanatomic. In addition, intra- and extrahepatic biliary configurations may be encountered, and variants must be recognized to prevent complications during common surgical procedures, such as cholecystectomy and liver resection. The liver is responsible for numerous metabolic, homeostatic, and immunologic processes throughout the body. It is crucial for the practicing physician and surgeon to have a fundamental understanding of hepatic anatomy and physiology when treating patients with derangements in liver structure and function.
Key words: bile duct, bilirubin, bilirubin metabolism, hepatic artery, hepatic blood flow, hepatic parenchyma microstructure, liver anatomy, portal hypertension, portal vein
Gallbladder and Biliary Tree
By Stephen Gray, MD, MSPHPurchase PDF
Gallbladder and Biliary TreePurchase PDF
Understanding gallbladder and biliary anatomy is paramount to the surgeon. A comprehensive understanding of the gallbladder and biliary tree is necessary to properly treat a variety of surgical pathologies. Understanding the usual anatomy and the variations will help prevent iatrogenic biliary injuries. Moreover, anatomic consideration dictates oncologic therapies for gallbladder and biliary tract malignancies.
Key words: bile duct, bile salts, biliary tree, cholecystectomy, gallbladder
By Sushanth Reddy, MD, FACS; Adam C Witcher, MDPurchase PDF
The PancreasPurchase PDF
The casual observer might be forgiven for assuming that the pancreas plays an insignificant role given its size, morphology, and location. Indeed, Galen and anatomists for a millennium considered the pancreas a fatty cushion on which the stomach rested. In truth, this largest digestive gland, situated in the center of the body, on either side of the transpyloric (L1) plane, is notable for its complex anatomy and the colocation of exocrine and endocrine organs. The pancreas is an organ of endless fascination, with congenital anomalies giving rise to a range of anatomic variations, anatomic relations challenging the most meticulous surgeons, and wide-ranging pathology of clinical significance. Surgical management of pancreatic disease requires a detailed understanding of the anatomy of the pancreas and its relation to adjacent vital structures, and the management of patients with diseases related to the pancreas requires a detailed understanding of the physiology of both the exocrine and the endocrine pancreas. The functional reserve of the gland is such that over 50% of its acinar tissue must be destroyed before there is marked evidence of an effect on digestion, and more than 70% of insulin secreting beta cells must be destroyed before the endocrine functions of the gland are affected.
This review contains 16 figures, and 16 references.
Key words: chronic pancreatitis, pancreas, pancreatic anatomy, pancreatic cancer, pancreatic pathology, pancreatic physiology, pancreatitis
By Eric A Schinnerer, MD; Jayleen M Grams, MD, PhD,Purchase PDF
The SpleenPurchase PDF
This review focuses on the normal anatomy and physiology of the spleen. The spleen functions as a hematologic organ, filtering blood, metabolizing iron, and acting as a reservoir for blood cells. The spleen, the largest lymphatic organ, also plays a key role in adaptive and innate immunity.
This review contains 7 figures of highly rendered artwork and 26 references.
Key words: immune system, spleen, spleen anatomy, spleen physiology, splenectomy vaccine guidelines
By Vincent E Mortellaro, MDPurchase PDF
Small BowelPurchase PDF
The small intestine is where multiple cell types combine to achieve the complex interaction between our bodies and ingested material from the outside world. As a highly specialized organ, the small intestine has a role in digestion, absorption of nutrients and electrolytes, and innate immunity to thwart exogenous pathogens and as host to a symbiotic environment where our immune system successfully interacts with a resident microbiome. This review covers the embryology, gross and microscopic anatomy, physiology of nutritional absorption, immune function, and advances in examining new discoveries in the interplay between the host and the resident microbiome.
Key words: duodenum, ileum, jejunum, microbiota, midgut, migrating motor complex, nutritional absorption, villi
Human Adult Reproductive System
By Patrick Guthrie, MD; Johanna Von Hofe, MD; Rachael B Lancaster, MDPurchase PDF
Human Adult Reproductive SystemPurchase PDF
The human reproductive system is a unique combination of organs and endocrine components that is extremely complex and adaptive. The reproductive organs are distinct between males and females, and sexual differentiation is a result of genotype, gonadal type, and phenotype. The anatomic and physiologic system of each sex is composed with a set purpose: to propagate the human species. Linked closely to the reproductive system is the endocrine system, which provides the messengers and feedback mechanisms that allow the development, maintenance, and function of the reproductive organs. The gonads have both endocrine and exocrine functions, namely steroidogenesis and gametogenesis. This review focuses on the components of the endocrine system as well as male and female anatomy and physiology to fully grasp the human reproductive system.
Key words: fertility, hypothalamic-pituitary-adrenal axis, reproductive anatomy, sexual aging, sexual physiology
The Colon, Appendix, Rectum, and Anus
By Margaret M Romine, MD, MS; Daniel I. Chu, MDPurchase PDF
The Colon, Appendix, Rectum, and AnusPurchase PDF
The colon, appendix, rectum, and anus have unique anatomic features, both structural and functional, that contribute to normal and pathologic states. Structural features discussed in this review include the layers of the intestinal wall, vascular anatomy, lymphatic drainage, and innervation. Functional features highlighted include the role(s) each organ plays in immunity, nutrient absorption, electrolyte secretion, water absorption, continence, and elimination of waste. A clear understanding of these structural and functional details is the foundation on which surgical techniques and treatment strategies are based when addressing surgical pathology.
Key words: anus, appendix, colon, colorectal pathology, colorectal surgery, rectum
By Courtney J. Balentine, MD, MPH; C Taylor Geraldson, MDPurchase PDF
The ParathyroidsPurchase PDF
Successful surgery of the parathyroid glands depends on a thorough knowledge of their anatomic and developmental relations. This knowledge is crucial for locating ectopic parathyroids or preventing injury to the recurrent laryngeal nerve. In addition, the surgeon should understand the physiology and function of these glands. Unlike other conditions a surgeon might treat, physiology, and not anatomy alone, often dictates the timing and course of parathyroid procedures. This surgeon-oriented, focused review covers the development, histology, anatomy, physiology, and pathophysiology of the parathyroid. Figures show the location and frequencies of ectopic upper and lower parathyroid glands, and regulation of calcium homeostasis.
This review contains 2 highly rendered figures, and 16 references
Key words: calcitonin; hypercalcemia; hyperparathyroidism; multiple endocrine neoplasia; parathyroid; parathyroid hormone; primary hyperparathyroidism; secondary hyperparathyroidism; tertiary hyperparathyroidism
By Carla N Holcomb, MD, MSPH; Britney L Corey, MDPurchase PDF
The StomachPurchase PDF
This review discusses the anatomy and physiology of the stomach. The embryologic origins of the foregut are described, as well as how malformations in development lead to pathology. Color illustrations are included detailing the stomach and its surrounding attachments. The neurohormonal pathways involved in the mechanics of gastric motility and gastric acid secretion are described in detail. The biochemistry involved in the digestion of fats, carbohydrates, and proteins is explained, and a summary table of gut hormones and their source and function has been provided. Additionally, an update on how the knowledge of hormonal pathways governing appetite is being used in pharmaceuticals and bariatric surgery to treat obesity is included.
Key words: acid suppression, digestion, foregut, ghrelin, leptin, motility, obesity, stomach, vagus nerve
By Sean Ronnekleiv-Kelly, MD; Richard A Burkhart, MDPurchase PDF
The DuodenumPurchase PDF
The duodenum is the first part of the small intestine that arises from the embryologic foregut and midgut. With maturation, it lies mostly retroperitoneal and is intimately associated with nearby structures such as the pancreas, hepatoduodenal ligament, and transverse colon mesentery. It is well vascularized with a rich lymphatic network and supports digestive, absorptive, immune, and endocrine functions. The duodenum receives food bolus from the stomach and releases various hormones important for regulating motility and gastric acid secretion. In the duodenum, food content mixes with bile and pancreatic enzymes to continue digestion of and initiate absorption for fats, carbohydrates, proteins, and vitamins and minerals. The duodenum experiences substantial exposure to the external environment and therefore contains an extensive immune barrier, including mucosa-associated lymphoid tissue. Additionally, there is a significant neuroendocrine network within the duodenum and small intestine that possesses a variety of endocrine functions, including regulation of acid secretion, motility, pancreatic function, bile flow, and mucosal cell growth. These enterochromaffin cells are the source duodenal neuroendocrine tumors (carcinoid) and can be classified according to subtype or grade. The duodenum is a diverse component of the small intestine that is uniquely suited to its numerous functions.
Key words: absorption, acid secretion, anatomy, digestion, duodenum, intestinal immune system, microstructure, motility, mucosa-associated lymphoid tissue, neuroendocrine
The Endocrine System: Adrenal Glands
By Abbas Al-Kurd, MD; Haggi Mazeh, MD, FACSPurchase PDF
The Endocrine System: Adrenal GlandsPurchase PDF
The adrenal glands represent an essential component of the endocrine system, and their failure can have catastrophic consequences to several aspects of bodily homeostasis. Each adrenal gland can be divided into two different endocrine components, the cortex and the medulla, each with distinct functions. This in-depth review of normal adrenal embryology, anatomy, and physiology also emphasizes the clinical relevance of various irregularities in adrenal functioning. Every surgeon attempting to manage adrenal diseases is expected to be familiar with the detailed pathophysiology of these conditions because such an understanding is essential for sound preoperative evaluation and perioperative management of this potentially complicated patient group.
This review contains 4 figures, 1 table, and 70 references.
Key words: adrenal, adrenal glands, adrenal pathophysiology, adrenal physiology, anatomy of adrenal glands, cortex, embryology, endocrine system, medulla
The Endocrine System: Pituitary Gland
By Omer Doron, MD; Jose E Cohen, MD; Iddo Paldor, MDPurchase PDF
The Endocrine System: Pituitary GlandPurchase PDF
The pituitary gland is the main point where the neural and endocrine systems function in continuity, maintaining homeostasis of many functional elements of the human body. Located inside the sella turcica, it is separated from the rest of the central nervous system (CNS); however, it plays a crucial part in the regulation of the fundamental endocrine profile, inhibiting or promoting CNS signaling to the rest of the human body. Made up of two distinct tissue subtypes, this gland is fed by a complex vascular network, which enables communication beyond the blood-brain barrier. Lying in close proximity to both important neural and vascular structure, changes in gland size and function result in significant clinical impact. The pituitary gland controls many processes, among which are thermoregulation; metabolism and metabolic rate; glucose, solute, and water balance; growth and development; blood pressure; and sexual drive, pregnancy, childbearing, birth, and breast-feeding. The devastating effects of pituitary dysfunction underscore the importance of the pituitary gland in maintenance of the various functions that underlie normal everyday human activity. This review covers the basic aspects of pituitary gland development, anatomy, and physiologic function.
This review contains 3 figures, and 38 references,
Key words: adenohypophysis, neurohypophysis, pituitary-hypothalamic axis, pituitary portal system, sella turcica
The Respiratory System: Physiology
By John Yerxa, MD; Cory J Vatsaas, MD; Suresh Agarwal, MD, FACS, FCCMPurchase PDF
The Respiratory System: PhysiologyPurchase PDF
Respiratory system uses an elegant physiologic mechanism to support the metabolic demands of the body through oxygenation and ventilation. Oxygen must be absorbed and delivered to the tissues to sustain oxidative metabolism, whereas carbon dioxide must be expelled in a delicate balance to maintain an acid-base equilibrium. Complete understanding of oxygen content, delivery, consumption, and carbon dioxide elimination is essential as a provider caring for the critically ill patient.
This review contains 13 figures and 25 references.
Key Words: oxygenation, respiratory system, ventilation, gas exchange, haemoglobin, respiratory physiology, respiratory anatomy, oxidative metabolism, dead space.
The Respiratory System: Physiologic Assessment and Real-world Application
By Joshua Watson, MD; Cory Vatsaas, MD; Suresh Agarwal, MD, FACS, FCCMPurchase PDF
The Respiratory System: Physiologic Assessment and Real-world ApplicationPurchase PDF
The respiratory system is an elegant physiologic mechanism that provides the most basic support of the body, oxygenation and ventilation. Oxygen must be absorbed and delivered to the tissues to continue with oxidative metabolism while the byproduct of carbon dioxide must be expelled in a delicate balance to maintain an acid/base equilibrium. Complete understanding of oxygen content, delivery, and consumption is essential as a provider caring for the critically ill patient. The respiratory system can be closely monitored through a variety of helpful adjuncts including pulse oximetry, capnometry, and pulmonary function testing. These additional data points are useful for assessing a patient’s clinical condition in conjunction with the patient’s overall pulmonary status, underlying pathology, and environmental factors. A thorough understanding of the respiratory system guided by diagnostic testing and an assessment of patient factors are helpful in mitigating risk of pulmonary complications in the perioperative environment.
This review contains 2 figures, 2 tables, and 54 references.
Key Words: capnometry, pulse oximetry, respiratory system, oxygenation, ventilation pulmonary, pulmonary function testing, pulmonary complications, preoperative pulmonary optimization, smoking cessation
Respiratory System: Physiology of Mechanical Ventilation
By John Yerxa, MD; Cory J Vatsaas, MD; Suresh Agarwal, MD, FACS, FCCMPurchase PDF
Respiratory System: Physiology of Mechanical VentilationPurchase PDF
Airway and ventilatory management are mandatory skills for the critical care surgeon. Identifying and correctly managing a patient’s airway is the first step followed by correcting any oxygenation or ventilation deliver deficits. Mechanical ventilation with positive pressure has multiple physiologic effects that must be completely understood in a complex critically ill patient. Invasive and non-invasive modalities may be used to aid in achieving these goals. Further strategies such as using low tidal volume, adequate PEEP, and rescue strategies are important in patients with ARDS. Weaning from the ventilator as soon as able is an important consideration to improve outcomes, The subsequent chapter reviews airway management and the physiologic aspects of mechanical ventilation to aid in decision-making when caring for the critically ill patient with deficits in oxygenation or ventilation.
This review 5 figures, 2 tables, and 41 references.
Key Words: airway management, mechanical ventilation, invasive ventilation, non-invasive ventilation, tracheostomy, Acute Respiratory Distress Syndrome (ARDS), positive pressure ventilation, oxygenation
- Basic Surgical and Perioperative Considerations
Postoperative Management of the Hospitalized Patient
By Edward Kelly, MD, FACSPurchase PDF
Postoperative Management of the Hospitalized PatientPurchase PDF
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.
Bleeding and Transfusion
By Garth H. Utter, MD, MSc, FACS; Robert C. Gosselin, MT; John T. Owings, MD, FACSPurchase PDF
Bleeding and TransfusionPurchase PDF
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.
Preparation of the Operating Room
By T. Forcht Dagi, MD, MPH, FACS, FCCMPurchase PDF
Preparation of the Operating RoomPurchase PDF
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.
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, MPhilPurchase PDF
Enhanced Recovery Pathways: Organization of Evidence-based, Fast-track Perioperative CarePurchase PDF
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.
- Breast, Skin, and Soft Tissue
Soft Tissue Infection
By Mark A. Malangoni, MD, FACS; Christopher R McHenry, MD, FACSPurchase PDF
Soft Tissue InfectionPurchase PDF
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.
Principles of Wound Management and Soft-tissue Repair
By Jonathan S. Friedstat, MD; Eric G. Halvorson, MD; Joseph J. Disa, MD, FACSPurchase PDF
Principles of Wound Management and Soft-tissue RepairPurchase PDF
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.
By Lindi VanderWalde, MD, FACS; Alyssa D. Throckmorton, MD, FACS; Stephen B Edge, MD, FACS, FASCOPurchase PDF
Breast CancerPurchase PDF
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
Evolving Molecular Therapeutics and Their Applications to Surgical Oncology
By Valerie Francescutti, MD, MSc, FRCSC, FACS; Kelli Bullard Dunn, MD, FACS, FACRSPurchase PDF
Evolving Molecular Therapeutics and Their Applications to Surgical OncologyPurchase PDF
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
Soft Tissue Sarcoma
By Aimee M. Crago, MD; Samuel Singer, MD, FACSPurchase PDF
Soft Tissue SarcomaPurchase PDF
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.
By D. Scott Lind, MD; Julie G Grossman, MD; Melissa DeSouza, MDPurchase PDF
Breast ProceduresPurchase PDF
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.
Surgical Management of Melanoma and Other Skin Cancers
By Jennifer A. Wargo, MD; Kenneth Tenabe, MDPurchase PDF
Surgical Management of Melanoma and Other Skin CancersPurchase PDF
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.
Lymphatic Mapping and Sentinel Node Biopsy
By David W. Ollila, MD, FACS; Karyn B. Stitzenberg, MD, MPH; Kristalyn Gallagher, DO, FACSPurchase PDF
Lymphatic Mapping and Sentinel Node BiopsyPurchase PDF
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.
Principles of Wound Management and Soft Tissue Repair I
By Jonathan S. Friedstat, MD; Michelle R Coriddi, MD; Eric G Halvorson, MD; Joseph J Disa, MD, FACSPurchase PDF
Principles of Wound Management and Soft Tissue Repair IPurchase PDF
Principles of initial wound management include adequate debridement, bacterial contamination assessment, nutritional optimization, and moist wound healing versus the use of negative-pressure wound therapy. The main goals of coverage procedures are to achieve a healed wound and avoid infection. Aside from allowing to heal by secondary intention, options for wound closure include primary closure, skin grafting, local flaps, and free flaps. Each wound should be evaluated on an individual basis to determine which method of coverage is most appropriate.
This review contains 13 figures, 2 tables, and 22 references.
Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps
Principles of Wound Management and Soft Tissue Repair II
By Jonathan S. Friedstat, MD; Michelle R Coriddi, MD; Eric G Halvorson, MD; Joseph J Disa, MD, FACSPurchase PDF
Principles of Wound Management and Soft Tissue Repair IIPurchase PDF
Wound management and soft-tissue repair can vary depending on the location. The head and neck, chest and back, arm and forearm, hand, abdomen, gluteal area and perineum, thigh, knee, lower leg, and foot all have different local options and preferred free flaps to use for reconstruction. Secondary reconstruction requires a detailed analysis of all aspects of the wound including any scars, soft tissue and/or skin deficits, functional defects, contour defects, complex or composite defects, and/or unstable previous wound coverage. Careful monitoring of both the patient and reconstruction is necessary in the postoperative period to ensure long-term success.
This review contains 2 figures and 17 references.
Key Words: free tissue transfer, pedicle flaps, soft-tissue coverage, wound closure, wound healing, wound management, wound reconstruction, tissue flaps
Breast Benign Findings and Disease
By Helen Cappuccino, MD, FACS; Ermelinda Bonaccio, MDPurchase PDF
Breast Benign Findings and DiseasePurchase PDF
Patients often seek the opinion of physicians for benign breast conditions, because of substantial concern about cancer. It is important that general surgeons are armed with the necessary information to thoroughly evaluate and treat benign breast conditions. In this chapter, the more common benign breast complaints and benign breast pathology are reviewed and appropriate management is discussed. The workup and management of masses, cysts, breast pain, nipple discharge, fibrocystic changes, various fibroepithelial lesions (including fibroadenoma) will be reviewed. Borderline lesions including atypical hyperplasias radial scars, and lobular neoplasia will also be discussed with special attention directed to the comparative risks of upgrade to malignancy and the need for surgical excision. Gynecomastia will also be reviewed, along with the various causes, treatments and distinctions from malignancy. Lastly, we will review the management of breast infections and inflammatory conditions, as well as more uncommon breast lesions.
This review contains 11 figures, 6 tables, and 38 references.
Key Words: Breast masses, Breast pain/Mastalgia, Nipple Discharge, Fibrocystic Changes, LCIS, Radial Scar, Atypical Hyperplasia, Lobular neoplasia, Papillomas, gynecomastia
Breast Screening and Evaluation, High Risk Patients
By Helen Cappuccino, MD, FACS; Ermelinda Bonaccio, MDPurchase PDF
Breast Screening and Evaluation, High Risk PatientsPurchase PDF
The fundamental tasks facing surgeons evaluating patients’ breasts are to rule out malignancy, ameliorate breast symptoms, and manage premalignant breast conditions and risk factors to minimize a patient’s chances of developing cancer. Woman presenting to a surgeon should receive thorough and appropriate breast evaluation, breast cancer risk assessment, and treatment, which minimizes risks going forward. In this review, we focus on screening recommendations for (both average and high-risk) patients for breast cancer, Breast Imaging, Reporting and Data System categories, the performance of a thorough breast history and physical examination. We also discuss various breasts imaging modalities and their strengths and weaknesses. We review breast density as a confounding factor and increased risk factor, and the grading of breast density. Finally, different ways of performing breast biopsies are discussed as well as the evaluation of risk for breast cancer with interventions for enhanced screening and risk reduction.
This review contains 12 figures, 7 tables, and 35 references.
Key Words: BI-RADs, breast cancer risk factors, breast cancer risk reduction, breast core biopsy, breast screening, enhanced screening, BRCA, chemoprevention, mammography
- Care in Special Situations
The Elderly Surgical Patient
By Sylvia S. Kim, MD, FACS; Michael E. Zenilman, MD, FACSPurchase PDF
The Elderly Surgical PatientPurchase PDF
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.
The Pediatric Surgical Patient
By Omar Nunez Lopez, MD; Kanika A Bowen-Jallow, MD, MMSPurchase PDF
The Pediatric Surgical PatientPurchase PDF
The surgical care of pediatric patients requires familiarization with the physiologic principles that govern homeostasis in neonates, infants, children, and adolescents. These principles must be taken into consideration in the perioperative management and trauma care of pediatric patients. In addition to surgical problems common to all age groups, there are specific pathologic processes requiring surgery (or treatment by a surgeon) that are seen only in pediatric patients. Here we present an overview of the physiologic considerations important for the surgical care of children and a review of the most commonly encountered pediatric surgical conditions, with an emphasis on the acute management and stabilization of the patient. References to current guidelines are being provided when available.
This review contains 2 figures, 5 tables, and 62 references.
Key words: abdominal wall defects, diaphragmatic hernia, gastroschisis, nonaccidental trauma, nutrition, pediatric surgery, pediatric trauma, perioperative care
Gynecologic Considerations for the General Surgeon
By Magdy P. Milad, MD, MS, FACOG; Eden R. Cardozo, MDPurchase PDF
Gynecologic Considerations for the General SurgeonPurchase PDF
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.
The Pregnant Surgical Patient
By Nina Tamirisa, MD; Mostafa Borahay, MD, FACOG; Sami Kilic, MD, FACOGPurchase PDF
The Pregnant Surgical PatientPurchase PDF
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.
Urologic Considerations for the General Surgeon
By Samuel H. Eaton, MD; Robert B. Nadler, MD, FACSPurchase PDF
Urologic Considerations for the General SurgeonPurchase PDF
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.
Plastic Surgery Considerations for the General Surgeon
By Sonya P Agnew, MD; Gregory A. Dumanian, MD, FACSPurchase PDF
Plastic Surgery Considerations for the General SurgeonPurchase PDF
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.
General Surgery in Patients With End-stage Organ Disease
By Amy R. Evenson, MD; Ramanathan M. Seshadri, MD; Jonathan P. Fryer, MDPurchase PDF
General Surgery in Patients With End-stage Organ DiseasePurchase PDF
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.
The Immunocompromised Surgical Patient
By Rhiannon Deierhoi Reed, MPH; Brittany Shelton, MPH; Jayme E. Locke, MD, MPH, FACSPurchase PDF
The Immunocompromised Surgical PatientPurchase PDF
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.
Substance Use Disorders in the Surgical Patient
By Abdul Q Alarhayem, MD; Natasha Keric, MD; Daniel L. Dent, MDPurchase PDF
Substance Use Disorders in the Surgical PatientPurchase PDF
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.
The Diabetic Surgical Patient
By Cathline Layba, MD; Lance Griffin, MDPurchase PDF
The Diabetic Surgical PatientPurchase PDF
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
The Morbidly Obese Surgical Patient
By Mustafa W Aman, MD; Michael A. Schweitzer, MDPurchase PDF
The Morbidly Obese Surgical PatientPurchase PDF
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
- Competency-based Surgical Care
Bedside Procedures for General Surgeons
By Thomas H. Cogbill, MD; Benjamin T Jarman, MDPurchase PDF
Bedside Procedures for General SurgeonsPurchase PDF
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
Ethical Issues in Surgery
By Jason D. Keune, MD, MBA; Ira J. Kodner, MD, FACS; Mary E. Klingensmith, MD, FACSPurchase PDF
Ethical Issues in SurgeryPurchase PDF
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.
Value-driven Nonemergent Surgical Care
By Peter A Najjar, MD, MBA; Julie Ann Sosa, MA, MD, FACSPurchase PDF
Value-driven Nonemergent Surgical CarePurchase PDF
As healthcare expenditures rise, payers and providers have increasingly recognized the importance of measuring and improving value. Surgical care accounts for a significant percentage of total healthcare expenditures in the United States, and efforts to improve value globally must take into account the unique challenges and opportunities specific to elective surgical care. This situation makes it essential that surgeons have a thorough understanding of surgical value, its measurement, improvement, and incentivization efforts predicated on it. Toward that end, this review (1) explores the fundamental concept of value in healthcare, particularly as applied to surgery, (2) surveys the challenges in measuring surgical cost and quality, (3) describes the framework of value improvement, (4) identifies selected tools to help surgeons improve the value of care provided, and (5) discusses the increasing role that value-based competition is likely to play in the American healthcare industry.
This review contains 5 figures, 3 tables, and 56 references.
Key Words: healthcare costs, quality improvement, surgery, surgical value, value, value-based competition, value improvement
By Benjamin S Brooke, MD, PhD; Karl Y. Bilimoria, MD, MSPurchase PDF
Evidence-based SurgeryPurchase PDF
The practice of surgery has undergone a dramatic evolution over the last century with the availability of new scientific evidence supporting different surgical techniques and management. Evidence-based surgery is defined as the judicious and systematic application of scientific evidence to surgical decision making and the establishment of standards of surgical care. This includes efforts to appraise the strength of scientific evidence and evaluate the quality of research studies or evidence, as well as efforts to interpret and apply evidence to clinical practice. In this review, we discuss important methodology and approaches in surgical health services research to accomplish these goals and improve the quality of care in surgery. By providing this overview, we hope readers will be able to navigate the surgical literature and apply evidence-based science to their own surgical practice.
This review contains 1 figure, 3 tables, and 43 references.
Key words: bias, comparative effectiveness, confounding, evidence, external validity, implementation science, internal validity, pragmatic trials, quality, risk adjustment, surgery
Minimizing Vulnerability to Malpractice Claims
By Janaka Lagoo, MD; William R Berry, MD, MPH, FACSPurchase PDF
Minimizing Vulnerability to Malpractice ClaimsPurchase PDF
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 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 serving as a defendant or witness in a courtroom trial is presented.
This review contains 5 tables, and 23 references.
Key words: claim, communication, defendant, informed consent, lawsuit, malpractice, medical records, negligence, suit
Nontechnical Skills in Surgery
By Steven Yule, MA, MSc, PhD; Douglas S. Smink, MD, MPHPurchase PDF
Nontechnical Skills in SurgeryPurchase PDF
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.
Patient Safety in Surgical Care
By Amir Ghaferi, MD, MS, FACS; Caprice C. Greenberg, MD, MPH, FACSPurchase PDF
Patient Safety in Surgical CarePurchase PDF
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.
Performance Measurement in Surgery
By Justin B. Dimick, MD, MPHPurchase PDF
Performance Measurement in SurgeryPurchase PDF
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
Preoperative Testing and Planning for Safer Surgery
By Valerie Ng, MD, PhD; Sarah Markham, MD; Jill Antoine, MD; Alden H. Harken, MD, FACSPurchase PDF
Preoperative Testing and Planning for Safer SurgeryPurchase PDF
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
Process Improvement in Surgery
By Frederick H Millham, MD, MBAPurchase PDF
Process Improvement in SurgeryPurchase PDF
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.
Professionalism in Surgery
By K. Christopher McMains, MD, PhD, MS; Jo Shapiro, MD, FACSPurchase PDF
Professionalism in SurgeryPurchase PDF
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.
Strategies for Improving Surgical Quality
By Mark A. Healy, MD; Nancy J. O. Birkmeyer, PhDPurchase PDF
Strategies for Improving Surgical QualityPurchase PDF
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.
Surgical Palliative Care
By Emily B. Rivet, MD, MBA, FACS, FASCS; Zara Cooper, MD, MSc, FACSPurchase PDF
Surgical Palliative CarePurchase PDF
Palliative care is a multidisciplinary approach to care that includes relief of suffering and attention to the social, spiritual, physical, and psychological needs of patients and families. The intent of palliative care is to help patients live as well as possible for as long as possible, and relevant domains of palliative care include symptom relief, prognostication, communication with patients, families and clinicians, transitions of care, and end-of-life care. Palliative care is distinct from hospice in many respects including that it can be provided simultaneously with recovery-directed treatments rather than reserved for individuals at end of life. Patients with surgical disease are particularly in need of palliative care due to the common occurrence of severe symptoms such as pain and nausea, complex decision-making, and the often sudden onset of the disease or injury which precludes preparation for the new health state.
This review contains 3 figures, 10 tables, and 61 references.
Key Words: communication, end-of- life, goals of care, high-risk surgery, palliative, palliative care, palliative surgery, patient comfort, surgical decision-making, surgical prognostication
Surgical Practice Management
By Valentine N. Nfonsam, MD, MS; Leigh A. Neumayer, MD, MSPurchase PDF
Surgical Practice ManagementPurchase PDF
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.
The Impaired Surgeon
By David B. Hoyt, MD, FACS; Krista L. Kaups, MD, MSc, FACSPurchase PDF
The Impaired SurgeonPurchase PDF
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
Bedside Procedures for General Surgeons: Part 1
By Basem S Marcos, MD; Thomas H. Cogbill, MDPurchase PDF
Bedside Procedures for General Surgeons: Part 1Purchase PDF
This review focuses on six procedures that are commonly performed by general surgeons in the emergency department, critical care unit, and operating room. Although considered basic procedures, all have their 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 and 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 a 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.
This review contains 19 figures, 7 tables, and 33 references.
Key words: central venous catheter, intraosseous vascular access, needle chest decompression, percutaneous arterial catheter, percutaneous tracheostomy, tracheostomy, venous cutdown
Bedside Procedures for General Surgeons: Part 2
By Thomas H. Cogbill, MD; Basem S Marcos, MDPurchase PDF
Bedside Procedures for General Surgeons: Part 2Purchase PDF
This review focuses on four procedures that are commonly performed by general surgeons in the emergency department and critical care unit and three procedures that are usually performed in the outpatient clinic. Although considered basic procedures, all have their 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 and 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 a 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.
This review contains 24 figures, 9 tables, and 33 references.
Key words: extended focused assessment with sonography for trauma, focused assessment with sonography for trauma, pericardiocentesis for trauma, pigtail tube thoracostomy, skeletal muscle biopsy, superficial abscess drainage, temporal artery biopsy, tube thoracostomy
Understanding Patient Safety in Surgical Care
By Amir Ghaferi, MD, MS, FACSPurchase PDF
Understanding Patient Safety in Surgical CarePurchase PDF
This chapter describes the growing knowledge of factors that affect human performance and how these factors contribute to adverse surgical outcomes. Highlights include factors that affect performance, including teamwork, communication, and environmental and organizational factors. Tables and figures include a schematic depiction of the process by which system failures may lead to injury, accepted definitions of patient safety related terms, hand off coordination and communication objectives, and the Systems Engineering Initiative for Patient Safety model of work system and patient safety.
This review contains 3 figures, 3 tables, and 78 references
Key Words: Patient safety, systems science, medical error, adverse events, systems engineering, teamwork, communication, organizational resilience, high reliability organizations
Improving Patient Safety in Surgical Care
By Amir Ghaferi, MD, MS, FACSPurchase PDF
Improving Patient Safety in Surgical CarePurchase PDF
This chapter 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. Lessons from other high-risk domains are described as are techniques for identifying system flaws. Tables and figures include nonmedical system techniques applicable to medical systems, national patient safety measures, examples of improvement strategies across surgical practice, and contrasting characteristics of medical practice in the twentieth and twenty-first centuries.
This review contains 1 figures, 4 tables, and 84 references
Key Words: human factors, medical error, peer review, patient safety, root cause analysis, systems engineering, teamwork
Health Economics: National Health Expenditures
By Bruce L Hall, MD, PhD, MBA, FACSPurchase PDF
Health Economics: National Health ExpendituresPurchase PDF
A picture of the overall structure of the US health care industry can be garnered by examining national health expenditures. In 2015, US national health expenditures grew to $3.2 trillion (US), outpacing growth in gross domestic product. Valuable insights are found by examining categories of spending, sources of funds, and target areas of spending, raising questions about the logic and performance of the US system. These perspectives can inform deeper consideration of healthcare policy and reform.
This review contains 3 tables and 20 references.
Key Words: health economics, health policy, Medicaid, Medicare, national health expenditures, opportunity cost, projections
Health Economics: Select Concepts of the Health Production Function, Risk, and Insurance
By Bruce L Hall, MD, PhD, MBA, FACSPurchase PDF
Health Economics: Select Concepts of the Health Production Function, Risk, and InsurancePurchase PDF
The production of health as an output of various inputs is a key concept of health care economics and a key influence on health care policy. Similarly, the notion of risk—that an outcome might not turn out as expected or hoped—underpins the entire theory of insurance. Insurance, and the benefits it can provide, cannot be understood without understanding risk, or without understanding how the features of an insurance contract transform risk for the individual, the payer, or society. The health economist, policy maker, leader, expert operator, financier, insurer, clinician of any stripe, patient or family or advocate, or other interested stakeholder must always consider the structural, clinical, and economic anatomy of health care in the context of the underlying physiology of these economic concepts.
This review contains 2 figures, 1 table, and 14 references.
Key Words: health economics, health policy, health production, marginal return (diminishing), utility, inputs, QALY, risk (aversion or tolerance), insurance (contract features)
- Critical Care
By Konstantinos Chouliaras, MD; Kazuhide Matsushima, MD; Heidi L. Frankel, MD, FACS, FCCMPurchase PDF
Cardiac ResuscitationPurchase PDF
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.
By James W. Holcroft, MD, FACS; John T Anderson, MD, FACS; Matthew J. Sena, MD, FACSPurchase PDF
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.
Multiple Organ Dysfunction Syndrome
By Vishal Bansal, MD, FACS; Jay Doucet, MD, FACS, FRCSC, RDMSPurchase PDF
Multiple Organ Dysfunction SyndromePurchase PDF
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.
Pulmonary Insufficiency and Respiratory Failure
By Bruce Chung, MD; J. Jason Hoth, MD, PhD, FACSPurchase PDF
Pulmonary Insufficiency and Respiratory FailurePurchase PDF
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.
By Juan R. Sanabria, MD, MSc, FACSPurchase PDF
Hepatic FailurePurchase PDF
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.
Acute Kidney Injury
By Aileen Ebadat, MD; Eric Bui, MD; Carlos V R Brown, MDPurchase PDF
Acute Kidney InjuryPurchase PDF
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.
Brain Failure and Brain Death
By Sharven Taghavi, MD, MPH; Ali Salim, MDPurchase PDF
Brain Failure and Brain DeathPurchase PDF
Brain failure consists of a wide spectrum of central nervous system pathologies with many different neurologic manifestations. The causes of brain failure include several disease processes that result in decreased supply of blood and oxygen to the brain or metabolic derangements that affect the central nervous system. Brain failure usually results in some altered level of consciousness. Brain failure and brain death result in several pathophysiologic changes. The definition of brain death is controversial and evolving. However, clear guidelines to determine brain death have been established. These guidelines state that three cardinal findings be present to establish brain death: (1) coma or unresponsiveness, (2) absence of brainstem reflexes, and (3) apnea. Several clinical parameters must be met when these findings are made. Adjunctive studies such as four-vessel cerebral angiography, electroencephalography, and nuclear brain scintigraphy can help make a diagnosis of brain death. When brain death is established, suitability for organ transplantation should be evaluated. After obtaining consent, potential organ donation should be optimized for possible donation.
This review contains 2 figures, 3 tables, and 69 references.
Key Words: brain failure, brain death, consciousness, coma, death, delirium, organ donation
Coma, Cognitive Impairment, and Seizures
By Ali Salim, MD; Melissa H Coleman, MDPurchase PDF
Coma, Cognitive Impairment, and SeizuresPurchase PDF
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
Glycemic Control in the Intensive Care Unit
By Eden A. Nohra, MD; Grant V. Bochicchio, MD, MPH, FACSPurchase PDF
Glycemic Control in the Intensive Care UnitPurchase PDF
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.
By Eric M. Campion, MD; Mitchell J. Cohen, MDPurchase PDF
Coagulation DisordersPurchase PDF
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.
Stress Response and Endocrine Deregulation During Critical Illness
By Paul E. Marik, MD, FCCP, FCCMPurchase PDF
Stress Response and Endocrine Deregulation During Critical IllnessPurchase PDF
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.
By E Patchen Dellinger, MD; Erik G. Van Eaton, MD; Heather L. Evans, MD, MSPurchase PDF
Hospital InfectionsPurchase PDF
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.
By Zachary C. Dietch, MD; Puja M. Shah, MD, MS; Robert G. Sawyer, MD, FACS, FIDSA, FCCMPurchase PDF
Intra-abdominal InfectionPurchase PDF
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
By Matthew R Rosengart, MD, MPHPurchase PDF
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.
Metabolic Response to Critical Illness
By Palmer Q. Bessey, MDPurchase PDF
Metabolic Response to Critical IllnessPurchase PDF
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.
Molecular and Cellular Mediators of the Inflammatory Response
By Amy T. Makley, MD; Michael D. Goodman, MD; Timothy A. Pritts, MD, PhDPurchase PDF
Molecular and Cellular Mediators of the Inflammatory ResponsePurchase PDF
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.
Postoperative and Ventilator-associated Pneumonia
By Craig M. Coopersmith, MD, FACS; Marin H. Kollef, MDPurchase PDF
Postoperative and Ventilator-associated PneumoniaPurchase PDF
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.
Severity of Illness Scoring Systems in Critical Care
By Mark T. Keegan, MDPurchase PDF
Severity of Illness Scoring Systems in Critical CarePurchase PDF
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
Quality Improvement in the Surgical Intensive Care Unit
By Mark R. Hemmila, MD; Wendy L Wahl, MDPurchase PDF
Quality Improvement in the Surgical Intensive Care UnitPurchase PDF
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
Principles of Empirical and Therapeutic Antimicrobial Therapy
By Paul Waltz, MD; Matthew R Rosengart, MD, MPH; Brian S. Zuckerbraun, MDPurchase PDF
Principles of Empirical and Therapeutic Antimicrobial TherapyPurchase PDF
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
By Allison Dalton, MD ; Mark Nunnally, MD, FCCMPurchase PDF
Septic ShockPurchase PDF
Sepsis is a leading cause of morbidity and mortality worldwide. Infectious injury leads to inflammation, which leads to additional injury. This cyclical pattern leads to tissue dysfunction, resulting in hypovolemic and vasodilatory shock, hyperdynamic circulatory shock, mitochondrial dysfunction, cellular apoptosis, and immunosuppression. Septic patients are unable to use oxygen effectively, leading to organ dysfunction. The key to management of sepsis is early recognition and treatment. Prompt administration of appropriate antibiotics (preferably but not necessarily following culture) is vital to avoiding the morbidity and mortality associated with sepsis. Aggressive fluid resuscitation resulting in improved blood flow to tissues is the mainstay of initial therapy for septic shock. Balancing the needs for improved preload against the consequences of excessive intravascular volume is paramount. There are many methods (e.g., central venous pressure, mixed/central venous saturation, pulse pressure variation, ultrasonography) to determine when a septic shock patient may no longer respond to fluids and requires vasoconstrictors or inotropes for blood pressure control. Early recognition of sepsis, treatment with appropriate antibiotics, and limiting end-organ damage have led to decreased in-hospital mortality associated with septic shock.
This review contains 5 figures, 5 tables, and 105 references.
Key Words: antibiotic therapy, fluid therapy, resuscitation, sepsis, shock
Signs of Abuse
By Richard Sola Jr, MD; David Juang, MD, FACS, FAAPPurchase PDF
Signs of AbusePurchase PDF
An estimated 3.6 million reports of possible child abuse or neglect, also known as nonaccidental trauma (NAT) or nonaccidental injury, involving approximately 6.6 million children were made to child protective services in the United States in 2014. The annual societal cost of child abuse and neglect is estimated conservatively to be over $103 billion. Understanding the history and physical findings specific to NAT will allow physicians to identify those children at risk and avoid missed injuries and recurrent child abuse. Bruising in particular is a cardinal physical finding for NAT. Certain diagnostic tools, such as skeletal surveys and retinal examinations, are used in evaluating for NAT. Abusive head trauma is the most common and deadliest injury. Although less common, abdominal injuries have a high mortality due to nonspecific symptoms and delayed presentation. Solid-organ abdominal injuries and duodenal hematomas can be managed nonoperatively, with a low failure rate. Up to 25% of skeletal fractures for children less than 1 year old are due to NAT. Tools to help medical personnel identify NAT are vitally important because children with recurrent NAT have a higher mortality compared with those identified at the initial episode. In Europe and the United States, checklists and algorithms have been established to standardize management of children with NAT. NAT carries significant morbidity, mortality, and cost to families and hospital resources. The key to prevention is early identification of children with NAT and early involvement of general or pediatric surgeons.
Key words: abusive head trauma, ATOMAC guidelines, bruising, child abuse, children, nonaccidental injury, nonaccidental trauma, pediatric surgery, skeletal survey
Blunt Cerebrovascular Injuries
By Clay Cothren Burlew, MD, FACSPurchase PDF
Blunt Cerebrovascular InjuriesPurchase PDF
Blunt cerebrovascular injuries (BCVIs) are increasingly recognized in trauma patients, with 1 to 3% of all blunt trauma patients being diagnosed with a carotid artery injury or a vertebral artery injury. Specific injury patterns are associated with BCVI and serve as the trigger for injury screening in asymptomatic patients. Multislice (> 64-slice) computed tomographic angiography is the routine imaging test performed to identify BCVI. Once an injury is identified, antithrombotic treatment almost universally prevents BCVI-related stroke. Endovascular therapy for BCVI is reserved for those patients who are markedly symptomatic or have an enlarging pseudoaneurysm on repeat imaging.
Key Words: blunt cerebrovascular injuries, blunt trauma, carotid artery injury, stroke, vertebral artery injury
End of Life Care and Withdrawal of Life Support
By Craig Chen, MDPurchase PDF
End of Life Care and Withdrawal of Life SupportPurchase PDF
Despite advances in critical care medicine and resuscitation, many patients who are admitted to the intensive care unit (ICU) will ultimately die. Even those who survive the ICU are at risk for readmission. Although outcomes may be better for surgical rather than medical ICU patients, addressing the end of life is a fundamental and necessary aspect of critical care for all patients. Over the last few years, we have increasingly recognized the role of palliative care in the surgical and trauma ICU. Palliative medicine in the surgical ICU setting results in decreased length of stay, improved communication with family and patients, and earlier identification of goals of care. This review covers indications for palliative care consultation, approaching the end of life, withdrawal of artificial nutrition and hydration, withdrawal of mechanical ventilation, practical considerations at the end of life, symptoms and symptom management at the end of life, and time of death. Tables list the American College of Surgeons statement on the principles guiding care at the end of life, guidelines for palliative care consultation in the surgical ICU, ABCDs of dignity-conserving care, palliative care principles on transitioning a patient to comfort measures only, and process of withdrawing ventilatory support.
Key words: comfort measures; end of life; intensive care unit end-of-life care; palliation; palliative care; palliative care consultation; palliative medicine; quality of dying; withdrawal of life support
Disclosure of Error in the Intensive Care Unit
By Leslie Hale, MD; Katrina Kirksey Harper, MD; Anna Bovill Shapiro, MDPurchase PDF
Disclosure of Error in the Intensive Care UnitPurchase PDF
Each year, as many as 98,000 hospital deaths in the United States can be attributed to medical error. Considering that at least half of all medical errors go unreported, the impact they have on mortality, morbidity, prolonged hospital stay, rising hospital costs, and the doctor-patient relationship cannot be overemphasized. At the heart of the dilemma are patients and their family members, who rely on clinicians to provide optimal medical care, devoid of mistakes and error, and want an apology if an error has taken place. In this review, we discuss the moral obligation of hospitals to disclose medical error, no matter what the impact. Whereas in the past, a paternalistic approach to medicine viewed this acknowledgment as weakness, there is now a consensus to advocate for full disclosure, apology, and discussions that facilitate early disclosure of error using teams representing administration, patient care liaisons, and treatment providers. Many institutions now recognize that medical errors are commonly the result of a breakdown of checks and balances, and an increasing number are implementing protocols that target system errors to prevent similar future occurrences. We examine institutions across the United Statesthat take a proactive approach by assembling “communication and resolution” programs to address the concerns of patients and their families through the process of disclosure. We also explore barriers to disclosure, which are attributed to lack of training, fear of litigation, and the “shame and blame culture.” We discuss the benefit, to both patient and provider, of disclosure of accountability as we move toward a culture of strengthening systems and improving patient care and patient-provider relationships.
Key words: apology, culture, disclosure, error, resolution
Invasive Hemodynamic Monitoring in the Intensive Care Unit
By Mary Garland, MD; Michael C Chang, MDPurchase PDF
Invasive Hemodynamic Monitoring in the Intensive Care UnitPurchase PDF
Optimal support of critically ill surgical patients with cardiovascular dysfunction requires that the bedside clinician have both a clear understanding of basic cardiovascular physiology and thorough knowledge of the information available from invasive hemodynamic monitors, including the advantages and pitfalls of each system. Assessment of hemodynamic function in underperfused patients should start with a quantitative assessment of global cardiovascular function. Global variables can be flow derived (e.g., cardiac output), pressure derived (e.g., systolic blood pressure), or both (e.g., ventricular stroke work and power). Any assessment consistent with inadequate global hemodynamic performance should be followed by analysis of the independent determinants of cardiovascular function. These independent determinants include heart rate, preload, afterload, and myocardial contractility. Invasive hemodynamic monitors allow the bedside clinician to measure and quantitate various combinations of global performance and the determinants of cardiac function depending on the monitoring system employed. Central venous lines enable measurement of central venous pressure but limited measure of right ventricular preload. Pulmonary artery catheters offer information pertaining to several global measures and independent determinants. Devices that depend on pulse contour wave analysis, when coupled with a central venous catheter, can measure cardiac output and preload in the context of measurements of stroke volume. However, being invasive, each device carries some degree of risk to the patient, and each monitoring technique employed via these devices carries pitfalls in both measurement and interpretation. It is incumbent upon the bedside clinician to understand the physiologic derangements affecting the patient and the utility and pitfalls of the information available from each device when selecting monitoring systems to be used in any given patient and the supportive therapy that ensues.
This review contains 3 figures, 1 table, and 28 references.
Key words: afterload, cardiac output, central venous catheter, hemodynamic monitor, myocardial contractility, perfusion, preload, pulmonary artery catheter, pulse contour analysis, stroke volume, stroke volume variability, stroke work, ventricular power
Management of Shock in Infants and Children
By Arianne T Train, DO; David H Rothstein, MD, MSPurchase PDF
Management of Shock in Infants and ChildrenPurchase PDF
The definition of shock has seen multiple iterations in the past several decades. In its most recent form, shock is understood to comprise a series of insults to the body resulting in impaired end-organ perfusion and generalized tissue underoxygenation. Causative factors are protean, although a large proportion of recent attention has been placed on infectious etiologies, particularly those in the compromised host. Diagnosis and treatment of pediatric shock are particularly challenging because of inherent difficulties in examining a young patient, early compensation of advanced shock, and, in some cases, a lack of provider familiarity with early signs and symptoms of impaired perfusion. Perhaps the most important advance in the past several years has been the recognition that shock must be identified early and sometimes treated empirically, without a proven etiology. In addition, systems of practice are essential to focus early, aggressive treatment of shock and prevent associated morbidity and mortality. In this review, we discuss key points to the evaluation of a pediatric patient with suspected shock, define what laboratory and radiologic investigations may be of utility in confirming a diagnosis and defining an etiology and direct treatment, and highlight recent advances in the understanding and treatment of shock. We also discuss some of the important advances in integration of treatment pathways and the use of the electronic medical record as a clinical adjunct.
Key words: shock, pediatric, critical care, sepsis
Caustic and Toxic Ingestions
By CDR Thomas Q Gallagher, DO; CDR Robert L Ricca, MDPurchase PDF
Caustic and Toxic IngestionsPurchase PDF
Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion.
Key words: caustic ingestion, endoscopic management, stricture, surgical management
Evaluating the Quality of Evidence
By Zach W Brown, DO, CDR, MC, USN; Herb A. Phelan, MD, MSCSPurchase PDF
Evaluating the Quality of EvidencePurchase PDF
One of the most important skills a medical practitioner must develop is the ability to evaluate the evidence as evidence-based practice is the best way to provide patient care. Critical appraisal of an article requires a systematic approach to identify a clear and novel hypothesis, a relevant topic, valid study methods, and the overall importance of the research. This review identifies how to establish a baseline level of quality per the hierarchy of study designs. It then deconstructs each section of the standard IMRAD format article (Introduction, Methods, Results, Analysis, and Discussion), including a brief discussion of statistical methods. Finally, it shows how to apply some of the evaluation methods of the GRADE guidelines that were devised specifically to provide a process for determining quality of evidence through modifiers reflecting priorities in clinical decision making. In particular, the overall quality can be downgraded based on five criteria: imprecision, inconsistency, indirectness, publication bias, and lack of internal validity. In contrast, quality can be upgraded when the size of the effect seen is very large, when a dose-response relationship exists, or when plausible confounders or other biases paradoxically increase confidence in the direction or magnitude of the signal. Taken together, a final assessment of quality may be applied, and the practitioner may accept the research for inclusion into practice or reject it as low-quality evidence. Both are examples of appropriate evidence-based practice, and both result in better patient care.
Key words: appraisal, evaluate, evidence, grade, statistics
Postoperative Management of Liver Transplant Patients
By Aleah L. Brubaker, MD, PhD; Marianne Chen, MD; Amy Gallo, MDPurchase PDF
Postoperative Management of Liver Transplant PatientsPurchase PDF
Management of the postoperative liver transplant patient can be extremely challenging. The combination of preoperative comorbidities and intraoperative complexity can make for a tenuous postoperative critical care course. Consideration and monitoring of graft function are paramount as poor graft function or primary graft nonfunction will affect every aspect of care. Our goal in this review is to use a systems-based approach to highlight the key tenets for postoperative management of liver transplant patients to help orchestrate integrated care across subspecialties.
This review contains 2 figures, 2 tables, and 94 references.
Key words: critical care, liver transplant, systems-based management
Renal Support Therapy
By Samuel M Galvagno Jr, DO, PhD, FCCM; Anthony E Tannous, MDPurchase PDF
Renal Support TherapyPurchase PDF
Knowledge regarding the practical aspects of managing continuous renal replacement therapy (CRRT) in the surgical intensive care unit is a prerequisite for achieving desired physiologic end points. Familiarity with the initiation, dosing, adjustment, and termination of CRRT is a core skill for surgical intensivists. Modalities, terminology, and components of CRRT are discussed in this review, with an emphasis on the practical aspects of dosing, adjustments, and termination. Filter selection and management of electrolyte and acid-base derangements are emphasized.
Key words: continuous renal replacement therapy, continuous venovenous hemofiltration, continuous venovenous hemofiltration dialysis, dialysis, intensive care unit
Fluid and Electrolyte Considerations for the Pediatric Surgical Patient
By Denise B Klinkner, MD, MEd; Stephanie Polites, MD; TK Pandian, MDPurchase PDF
Fluid and Electrolyte Considerations for the Pediatric Surgical PatientPurchase PDF
Fluid and electrolyte management is critical to successful care of neonatal and pediatric surgical patients. Although infants and toddlers in particular are clearly different from adults in their fluid requirements, recent literature supports a shift away from hypotonic intravenous fluids to isotonic fluids. The importance of glucose regulation and electrolyte management in the development of neonates has been established, and they are essential goals in the care of these patients. Specific surgical diseases included in this review are hypertrophic pyloric stenosis, gastrointestinal atresia and bowel obstructions, ileostomy management, and burns.
Key words: electrolyte replacement; fluid and electrolytes; neonatal surgical critical care; oral rehydration; pediatric hypernatremia; pediatric hyponatremia; pediatric maintenance fluids; pediatric surgical critical care; pediatric total body water
The Immunocompromised Surgical Patient and Opportunistic Infections
By Kiran Gajurel, MD; Aruna K Subramanian, MDPurchase PDF
The Immunocompromised Surgical Patient and Opportunistic InfectionsPurchase PDF
Immunosuppressive medications used to prevent allograft rejection render solid-organ transplant recipients vulnerable to various opportunistic infections. These infections include bacteria, viruses, fungi, and parasites and occur either via reactivation of previously acquired latent infection or de novo acquisition from the donor organ itself or the environment after the transplantation. The type and clinical course of the infection depend on various factors, including the transplanted organ, nature of immunosuppressive regimens, timing of infection relative to the organ transplant, and type and duration of prophylaxis. Proper donor and recipient screening for preventable infections and posttransplantation prophylaxis are instrumental in preventing morbid infections. Posttransplantation infections may present with subtle findings and thus may cause a delay in diagnosis and treatment, resulting in a poor outcome. Appropriate pathogen-specific tests should be requested promptly for early diagnosis. Since these infections may have overlapping clinical and radiologic features, tissue biopsy, if feasible, should be done to establish a definitive diagnosis. Surgical excision or débridement should be attempted in patients presenting with abscesses or invasive fungal sinusitis along with antimicrobial therapy. After the completion of treatment, suppressive therapy may be required in certain infections to prevent a relapse as long as the patient remains immunosuppressed.
This review contains 3 tables, and 82 references.
Key words: allograft, donor, immunocompromised, infection, opportunistic, organ, transplant
Cardiac Support Devices
By Charles C. Hill, MD; Lindsay Raleigh, MDPurchase PDF
Cardiac Support DevicesPurchase PDF
Mechanical circulatory support (MCS) involves the use of intra-aortic balloon pump (IABP), short-term percutaneous ventricular assist devices, long-term surgically implanted continuous-flow ventricular assist devices (cf-LVADs), and extracorporeal membrane oxygenation (ECMO) for the treatment of acute and chronic heart failure and cardiogenic shock. IABP is increasingly recognized as an important adjunct in the postoperative treatment arsenal for those patients with severely reduced left ventricular systolic function. Short-term percutaneous options for the treatment of acute right and left heart failure include both the Impella and Tandem Heart, whereas the Centrimag is often used in the surgical setting for acute cardiogenic shock and heart failure. Long-term surgical MCS options include the total artificial heart and the cf-LVADs HeartWare and Heartmate II. ECMO is frequently used for the treatment of acute cardiogenic shock and may be placed peripherally via a percutaneous approach or with central cannulation. ECMO is also increasingly used in the setting of acute cardiac life support, known as extracorporeal life support.
Key words: cardiac critical care, extracorporeal membrane oxygenation, long-term ventricular assist device, mechanical circulatory support, short-term ventricular assist device
Overview of Enteral Nutrition
By Erin Sisk, MS, RD, LDN, CNSC; Rebecca Lynch, MS, RD, LDN, CNSCPurchase PDF
Overview of Enteral NutritionPurchase PDF
Enteral nutrition (EN) is recognized as a medical nutrition therapy for patients with a functional gastrointestinal tract who are unable to maintain their weight and health by oral intake alone either due to a highly catabolic medical condition or a functional limitation. EN support provides calories and protein to help improve or maintain adequate weight, lean body mass, and overall nutritional status. EN also provides nonnutritive benefits such as maintaining intestinal integrity, supporting the immune system, and preventing infection. EN support can be tailored to a patient’s nutrient needs, and there are various formulas that vary in composition of macronutrients, concentration, and electrolytes for specific disease processes or conditions that may help with tolerance and absorption. EN support complications include issues with access, diarrhea, constipation, electrolyte abnormalities, hyperglycemia, and dehydration/overhydration. Generally, EN is well tolerated. While a patient is on this type of nutrition support, it is important to closely monitor tolerance, weight, laboratory values if indicated, and overall clinical progress, with adjustment to the regimen as needed.
This review contains 1 figure, 4 tables, and 48 references.
Key words: enteral access, enteral formula, enteral nutrition support, gastric residuals, gastrointestinal tract, immunonutrition, malnutrition, medical nutrition therapy, tube feed formula, tube feed tolerance, tube feeding, volume-based feeding
Cardiac Arrhythmias, Acute Coronary Syndromes, and Heart Failure in the Surgical Patient
By Glen Franklin, MD; Amirreza Motameni, MD; Johnson Walker, MDPurchase PDF
Cardiac Arrhythmias, Acute Coronary Syndromes, and Heart Failure in the Surgical PatientPurchase PDF
Cardiac arrhythmias and events, such as acute coronary syndrome and acute decompensated heart failure, are becoming increasingly common with an aging population. Much is written regarding the evaluation and management of these conditions in the cardiac and vascular patient populations; however, there is less literature to discuss the management strategies in the critically ill noncardiac postoperative and polytrauma patients. Factors such as physiologic stress, electrolyte imbalances, neurologic derangement, infection, and massive fluid shifts create an environment that promotes cardiopulmonary instability. Appropriate recognition of cardiac arrhythmias, acute coronary syndromes, and heart failure coupled with accurate and timely intervention can reduce morbidity and mortality in these patients. This review discusses the assessment and management of cardiac tachy- and brady-arrhythmias, acute coronary syndromes, and acute decompensated heart failure in the surgical patient.
This review contains 4 figures, 5 tables and 45 references
Key Words: acute coronary syndrome, angina, arrhythmia, bradycardia, cardiac ischemia, dieresis, fluid overload, heart failure, infarction, tachycardia
Mechanical Ventilation: Respiratory Physiology and Conventional Ventilation
By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCPPurchase PDF
Mechanical Ventilation: Respiratory Physiology and Conventional VentilationPurchase PDF
This three-part review is intended to enable the reader to manage the fundamentals of mechanical ventilation in both the urgent and the nonurgent setting. This first chapter provides a functional understanding of basic pulmonary physiology as a prerequisite knowledge base prior to reviewing the concepts central to basic, traditional, and cyclical ventilation that is regularly employed in the air or ground ambulance, emergency department, operating room, and intensive care unit. Subsequent chapters will review advanced ventilation modes, adjuncts, and special problems encountered in patients with respiratory failure requiring mechanical ventilation. Each segment is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion.
This review contains 5 Figures and 10 references
Key Words: acute respiratory failure, acute respiratory distress syndrome, hypercapnia/therapy, hypoxia/therapy, mechanical ventilation, pulmonary gas exchange
Mechanical Ventilation: Advanced Ventilation and Adjuncts
By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCPPurchase PDF
Mechanical Ventilation: Advanced Ventilation and AdjunctsPurchase PDF
In this chapter, we continue the discussion of mechanical ventilation by reviewing advanced ventilation modes such as airway pressure release ventilation and high-frequency oscillation as well as adjuncts that can be used in patients with respiratory failure. Each segment is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion.
This review contains 6 Figures and 69 references
Key Words: acute respiratory failure, airway pressure–release ventilation, acute respiratory distress syndrome, high-flow nasal cannula, mechanical ventilation, non-invasive ventilation, prone positioning
Mechanical Ventilation: Approaches and Special Considerations
By Adrian A. Maung, MD, FACS, FCCM; Lewis J Kaplan, MD, FACS, FCCM, FCCPPurchase PDF
Mechanical Ventilation: Approaches and Special ConsiderationsPurchase PDF
In this chapter, we complete the discussion of mechanical ventilation by examining approaches to mechanical ventilation for different patient populations and how to assess whether a patient is ready for liberation from mechanical ventilation. Each of the three chapters is intended to build on the preceding one and therefore establishes a functional unit with regard to mechanical ventilation, whether it is provided in an invasive or a noninvasive fashion.
This review contains 1 Figure, 1 Table and 31 references
Key Words: acute respiratory failure, ARDS, mechanical ventilation liberation, spontaneous breathing trial, tracheostomy
- Gastrointestinal Tract and Abdomen
Abdominal Pain and Abdominal Mass
By Blake D. Babcock, MD; Mohammad F. Shaikh, MD; Alexander E. Poor, MD; Wilbur B. Bowne, MDPurchase PDF
Abdominal Pain and Abdominal MassPurchase PDF
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.
By Harry Lengel, BA; Harish Lavu, MD, FACSPurchase PDF
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
By Lilah F Morris-Wiseman, MDPurchase PDF
Intestinal ObstructionPurchase PDF
Bowel obstruction (mechanical and functional) is a common cause of hospitalization for abdominal pain; patients with complaints of abdominal pain, nausea, vomiting, distention, and lack of flatus or bowel movement should be evaluated for obstruction. The surgeon must approach this diagnosis in a stepwise fashion to determine whether the patient has ischemia necessitating emergent operative intervention or whether initial nonoperative management is warranted. Mechanical obstruction in the small bowel is most commonly caused by adhesions from previous surgery, hernia, or mass, whereas mechanical obstruction in the colon is most often caused by volvulus, cancer, and diverticular stricture. Initial evaluation includes a detailed history, physical examination, and biochemical evaluation with initiation of resuscitative efforts as needed. CT with intravenous contrast is often most readily available and most helpful in diagnosing bowel obstruction type; specific CT findings can suggest the need for urgent operative intervention. Water-soluble contrast medium challenge has emerged as an important adjunct in evaluating the likelihood that a patient with nonischemic bowel obstruction will require operative intervention.
This review contains 14 figures, 5 tables and 58 references
Key words: adhesive bowel obstruction, ileus, ischemic bowel obstruction, laparoscopic adhesiolysis, large bowel obstruction, postoperative bowel obstruction, small bowel obstruction, volvulus, water-soluble contrast medium
Upper Gastrointestinal Bleeding
By Matthew B. Singer, MD; Andrew L. Tang, MDPurchase PDF
Upper Gastrointestinal BleedingPurchase PDF
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
Surgical Treatment of Obesity and the Metabolic Syndrome
By Iman Ghaderi, MD, MSc; Nisha Dhanabalsamy, MD; Carlos A Galvani, MDPurchase PDF
Surgical Treatment of Obesity and the Metabolic SyndromePurchase PDF
Obesity and obesity-related comorbid conditions have been steadily increasing in the United States over the past few decades. Despite the availability of several anti-obesity measures such as diet, exercise, pharmacotherapy and behavioral modifications, bariatric surgery is the only effective modality that can provide a sustainable long-term weight loss and improve obesity-associated comorbidities. In this chapter, we discuss perioperative assessment and work-up of morbidly obese patients, minimally invasive approaches to various bariatric surgery procedures including laparoscopic adjustable gastric band, sleeve gastrectomy, gastric bypass and biliopancreatic diversion with duodenal switch, and their short and long term outcomes. We also address revisional bariatric surgery and use of robotic platform and other new procedures and their role in metabolic and bariatric surgery.
Keywords: Obesity, comorbidities, metabolic surgery, bariatric surgery, gastric bypass, adjustable gastric band, sleeve gastrectomy, Biliopancreatic Diversion with Duodenal Switch, revisional surgery
Gastroesophageal Reflux Disease and Hiatal Hernia
By James A Rydlewicz, MD; Matthew R. Pittman, MD; Kyle A. Perry, MDPurchase PDF
Gastroesophageal Reflux Disease and Hiatal HerniaPurchase PDF
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.
Diagnosis and Management of Benign Gastric and Duodenal Disease
By Thomas E. Clancy, MD; Gentian Kristo, MDPurchase PDF
Diagnosis and Management of Benign Gastric and Duodenal DiseasePurchase PDF
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.
Tumors of the Stomach and Small Bowel
By L. Mark Knab, MD; David J. Bentrem, MD, FACS; Jeffrey D. Wayne, MD, FACSPurchase PDF
Tumors of the Stomach and Small BowelPurchase PDF
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
Management of Uncomplicated Gallstones and Benign Gallbladder Disease
By Rebecca C Britt, MD, FACS; Jessica R Burgess, MDPurchase PDF
Management of Uncomplicated Gallstones and Benign Gallbladder DiseasePurchase PDF
Gallbladder disease is one of the most common problems that the general surgeon will encounter. This comprehensive review discusses the management of uncomplicated gallstone disease, functional gallbladder disease, and gallbladder polyps. It provides indications for cholecystectomy in the asymptomatic patient. There is a thorough review of the diagnosis and management of symptomatic cholelithiasis, including special situations such as pregnancy and cirrhosis, and the latest evidence regarding routine versus selective cholangiography during cholecystectomy. This review also discusses the latest updates to the criteria for diagnosing functional gallbladder disease and sphincter of Oddi dysfunction.
This review contains 6 figures, 6 tables, and 99 references.
Key words: asymptomatic gallstones, biliary dyskinesia, cholangiography, gallbladder polyps, laparoscopic cholecystectomy, sphincter of Oddi dysfunction, symptomatic cholelithiasis
Management of Complicated Gallstone Disease
By Carmen L. Mueller, BSc; Amy A. Neville, MD, FRCSC, MSc; Gerald M. Fried, MD, FRCSC, FACS, FCAHSPurchase PDF
Management of Complicated Gallstone DiseasePurchase PDF
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.
Periampullary and Pancreatic Adenocarcinoma
By Jay S Lee, MD; Clifford S. Cho, MD, FACSPurchase PDF
Periampullary and Pancreatic AdenocarcinomaPurchase PDF
Appropriate surgical management of periampullary adenocarcinoma (ampullary adenocarcinoma, duodenal adenocarcinoma, distal cholangiocarcinoma, and pancreatic head 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 30 references.
Key words: American Joint Committee on Cancer staging system, ampullary adenocarcinoma, borderline resectable, distal cholangiocarcinoma, duodenal adenocarcinoma, locally advanced, pancreatic adenocarcinoma, superior mesenteric artery first dissection
Neuroendocrine Tumors of the Pancreas
By Katherine A. Morgan, MD, FACSPurchase PDF
Neuroendocrine Tumors of the PancreasPurchase PDF
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.
Cystic Tumors of the Pancreas
By Nicholas J. Zyromski, MDPurchase PDF
Cystic Tumors of the PancreasPurchase PDF
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.
Tumors of the Liver and Biliary Tract
By Gabriela M. Vargas, MD; Purvi Parikh, MD, FACS; Kimberly M Brown, MD, FACSPurchase PDF
Tumors of the Liver and Biliary TractPurchase PDF
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.
Acute and Chronic Pancreatitis
By Thomas J. Howard, MD, FACSPurchase PDF
Acute and Chronic PancreatitisPurchase PDF
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.
By Patrick S. Kamath, MD; David M. Nagorney, MDPurchase PDF
Portal HypertensionPurchase PDF
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.
Minimally Invasive Approaches in Pancreatic and Liver Surgery
By Brian A. Boone, MD; Stephanie Downs-Canner, MD; Herbert J. Zeh, MD, FACSPurchase PDF
Minimally Invasive Approaches in Pancreatic and Liver SurgeryPurchase PDF
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.
By Bindhu Oommen, MD, MPH; Kent W. Kercher, MD, FACS; B. Todd Heniford, MD, FACS; Ian A. Villanueva, MD, FACSPurchase PDF
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.
Disorders of the Adrenal Glands
By Carolina Martinez, MD; Kelvin Memeh, MD; Beatrice Caballero; Marlon A Guerrero, MDPurchase PDF
Disorders of the Adrenal GlandsPurchase PDF
Adrenal tumors are most commonly identified incidentally during imaging for nonadrenal causes. Others may be identified after a patient presents with symptoms of adrenal hormone excess. Adrenal tumors are categorized as functional or nonfunctional, as well as by their malignant potential. It is important to understand the functionality of adrenal glands and properly diagnose potentially hormonally active adrenal tumors. This review outlines the anatomy and physiology of the adrenal glands and details the management of the diseases that result from adrenal hormone excess.
This review contains 8 figures, 7 tables, and 27 references.
Key words: Addison disease, adrenal, aldosterone, catecholamine, Conn syndrome, cortisol, Cushing syndrome, function, glucocorticoid, malignant, pheochromocytoma
Repair of Ventral Abdominal Wall Hernias
By Clayton C. Petro, MD; Michael J. Rosen, MD, FACSPurchase PDF
Repair of Ventral Abdominal Wall HerniasPurchase PDF
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.
By Bryan K. Richmond, MD, MBA, FACS; Mike Q. Tran, MDPurchase PDF
Inguinal HerniaPurchase PDF
Approximately 700,000 inguinal hernia repairs are performed in the United States annually, making it one of the most commonly performed operations in surgical practice. The anatomy of the inguinal region is quite complex, and a thorough understanding of this region is required to successfully and safely repair these defects. The science of inguinal hernia repair continues to evolve and over the past several years has expanded to include laparoscopic and robotic approaches, as well as time-honored open repairs that still play an essential role in treating this disease process. The following review describes the relevant anatomy, types of groin hernias, the role of different hernia prostheses and meshes, common and evolving repair techniques, and the common complications encountered in hernia surgery, including chronic groin pain after inguinal hernia repair. The text is supplemented with high-quality illustrations and photographs to enhance the reader’s understanding of the material. In addition, instructional videos are provided demonstrating both relevant anatomy and surgical technique.
Upper Gastrointestinal Endoscopy
By Jeffrey Marks, MD, FACS; Hahn Soe-Lin, MDPurchase PDF
Upper Gastrointestinal EndoscopyPurchase PDF
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.
Anatomy, Physiology, and Measurement of Physiologic Function for Colorectal Surgery
By M. Nicole Lamb, MD; Andreas M Kaiser, MD, FACS, FASCRSPurchase PDF
Anatomy, Physiology, and Measurement of Physiologic Function for Colorectal SurgeryPurchase PDF
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.
Lower Gastrointestinal Endoscopy
By Parakkal Deepak, MBBS; David H. Bruining, MDPurchase PDF
Lower Gastrointestinal EndoscopyPurchase PDF
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.
By Neil J. Mortensen, MD, FRCS; Shazad Ashraf, DPhil, FRCSPurchase PDF
Intestinal AnastomosisPurchase PDF
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.
By Robert D. Madoff, MD; Sarah A. Vogler, MDPurchase PDF
Fecal IncontinencePurchase PDF
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.
Pelvic Floor Dysfunction
By Michael A. Valente, DO, FACS, FASCRS; Tracy L. Hull, MD, FACS, FASCRSPurchase PDF
Pelvic Floor DysfunctionPurchase PDF
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.
By John L. Rombeau, MD; Kimberly J. Hwa, MMS, PA-C; George P. Yang, MD, PhDPurchase PDF
Pilonidal DiseasePurchase PDF
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.
Procedures for Rectal Prolapse
By Steven D. Wexner, MD, PhD (Hon), FACS, FRCS, FRCS (ED); Susan M. Cera, MD, FACSPurchase PDF
Procedures for Rectal ProlapsePurchase PDF
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.
By Kevin R. Kasten, MD; Peter W. Marcello, MD; Todd D. Francone, MD, MPHPurchase PDF
Colonic VolvulusPurchase PDF
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.
By John P. Welch, MD, FACS; Jeffrey L. Cohen, MD, FACS, FASCRSPurchase PDF
Diverticular DiseasePurchase PDF
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.
Fissure, Fistula, and Abscesses
By Elisa H. Birnbaum, MD, FACS, FASCRS; Ira J. Kodner, MD, FACSPurchase PDF
Fissure, Fistula, and AbscessesPurchase PDF
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.
Inflammatory Bowel Disease
By Tara M. Connelly, MB, BCh, MSc; Andrew Tinsley, MD, MS; Walter A Koltun, MD, FACS, FASCRSPurchase PDF
Inflammatory Bowel DiseasePurchase PDF
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.
Surgical Management of Ulcerative Colitis
By Robert R. Cima, MD, MA; Amy Lightner, MD; John H. Pemberton, MDPurchase PDF
Surgical Management of Ulcerative ColitisPurchase PDF
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.
By Susan Galandiuk, MD, FACS, FASCRSPurchase PDF
Crohn DiseasePurchase PDF
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.
By Martin D Zielinski, MD, FACSPurchase PDF
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
Hereditary Colorectal Cancer and Polyposis Syndromes
By Jose G. Guillem, MD, MPH, FACS; John B Ammori, MDPurchase PDF
Hereditary Colorectal Cancer and Polyposis SyndromesPurchase PDF
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.
Adenocarcinoma of the Colon and Rectum
By Martin R Weiser, MD; Leonard B Saltz, MDPurchase PDF
Adenocarcinoma of the Colon and RectumPurchase PDF
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.
Adjuvant and Neoadjuvant Management of Colorectal Cancer
By Y. Nancy You, MD, MHSc; Christina E Bailey, MD, MSCI; Eduardo Vilar, MD, PhDPurchase PDF
Adjuvant and Neoadjuvant Management of Colorectal CancerPurchase PDF
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.
Operations for Colon Cancer
By Kevork Kazanjian, MD, FACS; David A. Etzioni, MD, MSHS, FACSPurchase PDF
Operations for Colon CancerPurchase PDF
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.
Procedures for Rectal Cancer
By Bashar Safar, MBBS, MRCS, FACS; Jonathan Efron, MD, FACSPurchase PDF
Procedures for Rectal CancerPurchase PDF
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.
Management of Hepatic Metastases From Colorectal Cancer
By Rory Smoot, MD; David M. Nagorney, MD, FACSPurchase PDF
Management of Hepatic Metastases From Colorectal CancerPurchase PDF
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.
Anal Neoplasms, Presacral Tumors, and Rare Malignancies
By David E. Beck, MD, FACS, FASCRSPurchase PDF
Anal Neoplasms, Presacral Tumors, and Rare MalignanciesPurchase PDF
An understanding of anal anatomy is essential for optimal management. Patients with anal lesions that appear suspicious or fail to respond to conventional therapy within a month should undergo a biopsy. Premalignant perianal lesions are managed with local excision. Epidermoid carcinoma of the anus is usually managed with chemoradiation. Presacral tumors are managed with excision.
This review contains 11 figures, 7 tables, and 53 references.
Key words: anal cancer, anterior sacral meningocele, basal cell carcinoma, chordoma, epidermoid carcinoma, high-grade squamous intraepithelial lesions, retrorectal tumor
Acute and Chronic Radiation Injury to the Lower Gastrointestinal Tract
By Rachel E. Beard, MD; Deborah Nagle, MDPurchase PDF
Acute and Chronic Radiation Injury to the Lower Gastrointestinal TractPurchase PDF
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.
By J Graham Williams, MCh, FRCSPurchase PDF
Intestinal StomasPurchase PDF
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.
Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised Patient
By Amy Lightner, MD; Cindy Kin, MD; Mark Welton, MD, MHCMPurchase PDF
Surgical Management of Benign and Malignant Colorectal Disease in the Immunocompromised PatientPurchase PDF
Patients who are immunosuppressed either due to an underlying disease process or medications to treat a disease require important perioperative considerations. Preoperative evaluation mandates a higher index of suspicion for pathology given that peritoneal and systemic markers of illness may be masked. Intraoperatively, consideration should be given for diversion more frequently than in a nonimmunosuppressed patient. Postoperatively, patients should be managed in a multidisciplinary fashion. This review largely focuses on the immunosuppressive mediations used for the treatment of inflammatory bowel disease, benign colorectal disease in an immunosuppressed patient, and colorectal malignancies in immunosuppressed patients to highlight important considerations for this patient population.
This review contains 4 figures, 5 tables, and 78 references.
Key words: anal squamous cell carcinoma, appendicitis versus typhlitis, biologic therapy, corticosteroids, human papillomavirus, immunosuppression, neutropenic enterocolitis
Reoperative Pelvic Surgery
By Eric J. Dozois, MD, FACS, FASCRS; Daniel I. Chu, MDPurchase PDF
Reoperative Pelvic SurgeryPurchase PDF
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.
Achieving Evidence-based Practices in Colorectal Surgery
By Imran Hassan, MD, FACS, FASCRSPurchase PDF
Achieving Evidence-based Practices in Colorectal SurgeryPurchase PDF
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.
Advanced and Recurrent Rectal Cancer
By Nicole de Rosa, MD; George J Chang, MD, MSPurchase PDF
Advanced and Recurrent Rectal CancerPurchase PDF
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
The LGBT Colorectal PatientPurchase PDF
The LGBT Colorectal PatientPurchase PDF
Lower Gastrointestinal Bleeding
By Jennifer Nayor, MD; John R. Saltzman, MDPurchase PDF
Lower Gastrointestinal BleedingPurchase PDF
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.
Complex Perianal Fistulas
By Amy L Halverson, MD; Massarat Zutshi, MDPurchase PDF
Complex Perianal FistulasPurchase PDF
Recurrent fistulas, fistulas with multiple external openings, those involving more than one third of the anal sphincter complex, and fistulas involving adjacent organs are considered complex. Fistulas occurring in the setting of perianal Crohn disease or following pelvic radiation are also considered complex. Evaluation of a fistula includes a detailed history and physical examination. Imaging with ultrasonography helps delineate the course of a fistula relative to adjacent structures as well as identify occult branching of the fistula tract. The initial step in treating fistulas is resolving associated inflammation. When treating fistulas with multiple branching tracts, the portion of the tracts outside the anal sphincter complex should be unroofed, with the goal of transforming the complex fistula into a simpler fistula with a single internal opening. The selection of the most appropriate treatment for a complex fistula depends on the etiology, anatomy, patient comorbidities, and condition of surrounding tissue.
Key Words: anal fistula, anovaginal fistula, Crohn disease, fistulotomy, rectourethral fistula
Benign Diseases of the Peritoneum and Retroperitoneum
By Amanda K. Arrington, MDPurchase PDF
Benign Diseases of the Peritoneum and RetroperitoneumPurchase PDF
The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for trauma, inflammation, infection, benign neoplasms, and malignancies. To understand the spread of disease in these locations, one must first understand their anatomy, physiology, and relationship. As both the peritoneum and retroperitoneum contain multiple organs, the relationships of the abdominal organs within these spaces are critical. This review defines both the peritoneum and retroperitoneum and then describes the most common disease states and spread of disease within these spaces. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable and can be treated in certain instances with heated intra-abdominal chemotherapy intraoperatively.
This review contains 5 figures, 5 tables, and 37 references.
Key words: ascites, carcinomatosis, desmoid, hyperthermic intra-abdominal chemotherapy, peritoneum, peritonitis, retroperitoneal sarcoma, retroperitoneum
Malignant Diseases of the Peritoneum and Retroperitoneum
By Amanda K. Arrington, MDPurchase PDF
Malignant Diseases of the Peritoneum and RetroperitoneumPurchase PDF
The peritoneum and retroperitoneum, once considered just spaces, are now recognized as primary locations for malignancies. Spread of disease, in particular, spread of malignancy, within the peritoneum is complex but predictable. This review covers the pathophysiology, diagnosis, and treatment of malignant peritoneal tumors such as peritoneal metastases and peritoneal carcinomatosis, pseudomyxoma peritonei, and mesothelioma, including a section on cytoreductive surgery and hyperthermic intraperitoneal chemotherapy. In addition, primary malignant disease of the retroperitoneum is discussed, with particular emphasis on retroperitoneal sarcomas.
This review contains 9 figures, 3 tables, and 33 references.
Key words: hyperthermic intraperitoneal chemotherapy, peritoneal carcinomatosis, peritoneal malignancy, peritoneal mesothelioma, peritoneal metastasis, peritoneal tumors, pseudomyxoma peritonei, retroperitoneal malignancy, retroperitoneal sarcoma
Diet Advancement After Weight Loss Surgery
By Laura Andromalos, MS, RD, CD, CDEPurchase PDF
Diet Advancement After Weight Loss SurgeryPurchase PDF
Diet advancement after bariatric surgery has not been standardized across various bariatric programs. It is generally agreed that patients should advance through a textured progression while the gastrointestinal tract heals; however, the content of each diet stage is open for interpretation. The postoperative diet is intended to promote healing and weight loss while minimizing diet-related complications. This review presents the literature regarding the progression of patients through a postoperative bariatric surgery diet, macro- and micronutrient needs in the early postoperative period, and management of common diet-related complications, including nausea, dumping syndrome, gastroesophageal reflux disease, and defecatory dysfunction.
This review contains 5 tables and 45 references
Key words: Bariatric surgery, bariatric surgery diet, postoperative diet, macro-nutrient needs, micro-nutrient needs, diet-related complications
Constipation: Diagnosis and Investigation
By Charles H Knowles, MBBChir, PhD, FRCSPurchase PDF
Constipation: Diagnosis and InvestigationPurchase PDF
Although constipation is no longer treated primarily with surgery, surgeons continue to regularly see patients with constipation in ward and ambulatory settings. It is therefore critical that surgeons have a practical approach to the patient with constipation in respect of diagnosis, investigation, and management. This review covers background knowledge in terms of the definition, classification, epidemiology, and etiology of constipation. It then addresses the clinical evaluation and investigation of the patient with chronic constipation. A subsequent review follows on to cover medical and surgical management.
This review contains 6 figures, 8 tables and 59 references
Key Words: chronic constipation, constipation, defecation disorder, defecography, dyssynergia, intussusception, manometry, proctography, rectocele, slow-transit
Constipation: Medical and Surgical Treatment
By Charles H Knowles, MBBChir, PhD, FRCSPurchase PDF
Constipation: Medical and Surgical TreatmentPurchase PDF
This review follows the general review entitled “Constipation,” which introduced the definition, classification, epidemiology, etiology, clinical evaluation, and investigation of constipation. This review addresses the medical and surgical management of constipation with a focus on surgical management. The latter is a subject of much controversy, and this review aims to provide a balanced view between those who favor radical surgery for the colon (colectomy) and rectum/pelvic floor (forms of rectopexy, rectal excision, and reinforcement) and those who have concerns that the unpredictable outcomes of such procedures push the risk–benefit analysis against surgical intervention for most patients.
This review contains 5 figures, 2 tables and 80 references
Key Words: chronic constipation, colectomy, constipation, ileorectal, intussusception, pelvic floor, rectocele, rectocele repair, rectopexy, slow-transit, stapled transanal rectal resection
Minimally Invasive Approaches in Liver Surgery
By Waseem Lutfi, BS; Melissa E Hogg, MD, MS, FACSPurchase PDF
Minimally Invasive Approaches in Liver SurgeryPurchase PDF
Minimally invasive approaches for liver surgery are being increasingly used at highly specialized centers. Both laparoscopic and robotic techniques appear to be associated with improved short-term outcomes such as decreased morbidity and shorter hospital stay. However, there are still concerns with regard to cost-effectiveness and technical training that have prevented widespread dissemination of these techniques. Within the realm of liver surgery, laparoscopic approaches have gained acceptance; however, robotic surgery still remains a relatively new technique. This chapter discusses the preoperative considerations and operative techniques of minimally invasive liver surgery, while also reviewing the current literature detailing short-term and long-term outcomes.
This review contains 6 figures, 5 tables and 33 references
Key Words: clinical trials, laparoscopic, liver cancer, minimally invasive, morbidity, mortality, oncologic outcomes, open, robot-assisted,
Minimally Invasive Approaches in Pancreatic Surgery
By Waseem Lutfi, BS; Melissa E Hogg, MD, MS, FACSPurchase PDF
Minimally Invasive Approaches in Pancreatic SurgeryPurchase PDF
Minimally invasive approaches for pancreatic resections are being increasingly utilized at highly specialized centers. Both laparoscopic and robotic techniques appear to be associated with improved short-term outcomes such as decreased morbidity and shorter hospital stay. However, there are still concerns with regards to cost-effectiveness and technical training, which have prevented widespread dissemination of these techniques. For pancreatic surgery, both laparoscopic and robotic techniques have gained acceptance for all pancreatic resections, most notably in distal pancreatectomy where minimally invasive approaches have become the standard of care at high-volume centers. This chapter discusses the preoperative considerations and operative techniques of minimally invasive pancreatic surgery while also reviewing the current literature detailing short-term and long-term outcomes.
This review contains 46 references, 6 figures, 5 tables, and 2 videos.
Key Words: clinical trials, laparoscopic, minimally invasive, morbidity, mortality, oncologic outcomes, open, pancreatic cancer, robot-assisted
By Yesenia Rojas-Khalil, MD; Anthony J. Senagore, MD, MS, MBAPurchase PDF
The management of symptomatic hemorrhoidal disease is based on the severity of symptoms and preexisting medical conditions that may preclude one treatment option over another. The majority of patients can be managed in the office setting with nonexcisional methods including injection sclerotherapy, rubber band ligation, and infrared coagulation. The small percentage of patients that fail this management warrant evaluation for surgical excisional hemorrhoidectomy. In recent years, newer techniques such as advanced energy devices for excision, circular stapled hemorrhoidopexy, and Doppler-guided hemorrhoidal artery ligation have been introduced. The purported advantage of these device-driven surgical options is similar efficacy with less pain. Unfortunately, although there are proponents for each approach, the device costs remain problematic, and the outcome improvement has been limited, especially in terms of long-term efficacy. Surgeons are urged to learn the standard techniques so that they can assess the newer options for themselves.
This review contains 9 figures, 4 tables, and 71 references.
Key Words: bipolar diathermy, direct current electrocautery, Doppler-guided hemorrhoidal artery ligation, excisional hemorrhoidectomy, harmonic, infrared coagulation, LigaSure, rubber band ligation, stapled hemorrhoidopexy
Tumors of the Liver
By Alex C Kim, MD, PhD; Hari Nathan, MD, PhDPurchase PDF
Tumors of the LiverPurchase PDF
Tumors in the liver arise from either the underlying hepatic parenchyma, resulting in benign or malignant lesions, or as metastatic deposit from extrahepatic malignancies. Treatment of these tumors is complex and requires a careful clinical evaluation. Recent improvement in diagnostic imaging techniques and reporting facilitates for appropriate characterization of hepatic tumors. In addition, utilization of genetics allows for careful classification of malignant potential in certain hepatic tumors. This chapter discusses several different types of hepatic tumors and examines the underlying etiologies, clinical presentation, diagnostic studies, staging, treatment, and prognosis. The staging of the malignant lesions is updated to reflect the American Joint Committee on Cancer’s eighth edition system.
This review contains 7 figures, 4 tables and 82 references.
Key Words: Barcelona Clinic Liver Cancer system, CAPOX, future liver remnant volume, FOLFOX, LI-RADS, stereotactic body radiation therapy, transarterial chemoembolization, transarterial radioembolization, β-catenin
Upper Gastrointestinal Endoscopy: Basic Upper Endoscopy
By Jeffrey Marks, MD, FACS; Hahn Soe-Lin, MD; Boxiang Jiang, MDPurchase PDF
Upper Gastrointestinal Endoscopy: Basic Upper EndoscopyPurchase PDF
Since the beginning of the 1970s, flexible endoscopy of the gastrointestinal tract has been the dominant modality for the diagnosis of gastrointestinal disease. Over the same period, developments in technology and methodology have made possible the use of endos-copy to treat a host of conditions that once were considered to be manageable only by means of surgical intervention. The concept of performing endoscopic surgery has become a reality with the advancement of endoscopic therapies to control hemorrhage and perform mucosal ablations, resections, and tissue approximation. In addition, investigation into intra-abdominal interventions has begun with the progression of natural orifice transluminal endoscopic surgery (NOTES). The tools created for both intraluminal and transluminal procedures will allow the endoscopist to continue to supplant surgical therapies for numerous gastrointestinal diseases. The integration of flexible endoscopic techniques into the armamentarium of the gastrointestinal surgeon permits a more multidi-mensional approach to the treatment of digestive system disorders. The modern surgeon must continue to stay abreast of these en-doscopic advances to provide appropriate patient care.
This review contains 12 figures, 2 tables, and 21 references.
Key words: optical biopsy, chromoendoscopy, over the scope clips, endoscopic suturing techniques
Upper Gastrointestinal Endoscopy: Advanced Endoscopic Techniques
By Jeffrey Marks, MD, FACS; Hahn Soe-Lin, MD; Boxiang Jiang, MDPurchase PDF
Upper Gastrointestinal Endoscopy: Advanced Endoscopic TechniquesPurchase PDF
Advanced endoscopy techniques use the same principles as basic upper endoscopy but involve more complex maneuvers and additional imaging modalities. Most endoscopists after mastering basic upper endoscopy will pursue additional training to become adept with advanced endoscopy techniques. This chapter reviews these techniques.
This review contains 9 images, 8 tables, 1 video and 26 references.
Key words: endoscopic submucosal dissection, organ sparing endoscopic surgery, submucosal tunneling endoscopic resection, endoluminal bariatric procedures, over the scope clips, endoscopic suturing techniques, endoluminal lumen apposing metal stents
- Head and Neck
By Neil Bhattacharyya, MD, FACS; Harrison W. Lin, MD; Yarah M Haidar, MDPurchase PDF
Parotid MassPurchase PDF
Major salivary gland tumors constitute 3 to 6% of all tumors of the head and neck in adults, and about 85% of these salivary gland tumors are found in the parotid gland. Approximately 70% of parotid lesions are neoplastic, and roughly 16% of these neoplasms are malignant. The spectrum of histopathologic entities encompassed by the term parotid mass is exceedingly broad and continues to evolve as our understanding of the origin and clinical behavior of the various tumors arising from the parotid gland expands. This review discusses the anatomy, etiology, differential diagnosis, diagnostic workup and imaging, surgical management, and overall prognosis for parotid masses.
This review contains 6 figures, 11 tables, and 72 references.
Key words: facial nerve, fine-needle aspiration, imaging, malignant neoplasm, neck dissection, parotid mass, parotidectomy, pleomorphic adenoma
By Miriam N. Lango, MD, FACS; Bert W. O'Malley Jr, MD, FACS; Ara Chalian, MD, FACSPurchase PDF
Neck DissectionPurchase PDF
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.
Oral Cavity Lesions
By Kiran Kakarala, MD; Sook-Bin Woo, DMD, MMSc; Keith Saxon, MDPurchase PDF
Oral Cavity LesionsPurchase PDF
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.
Head and Neck Diagnostic Procedures
By Donald J. Annino Jr, MD, DMD; Laura A. Goguen, MD, FACSPurchase PDF
Head and Neck Diagnostic ProceduresPurchase PDF
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.
By John A. Ridge, MD, PhD, FACS; Francis Si Wai Zih, MDPurchase PDF
When a patient presents with a mass at the angle of the mandible, a neoplasm within the parotid gland is a strong consideration. The parotid is the largest of the salivary glands. Terminal branches of the facial nerve are found within the gland. Their functional preservation is an important goal of parotid surgery. Risks of facial nerve injury rise in reoperative procedures and resection of cancers. Surgical principles apply in parotidectomy. In addition to facial nerve injury, a numb earlobe, contour deficit, salivary fistula, and gustatory sweating should be discussed with the patient before an operation. Most lesions can be removed after identification of the main trunk of the facial nerve, but a retrograde approach after finding a peripheral branch may be required. No randomized trials support a benefit from nerve monitoring. An intact facial nerve will usually begin to function, but months of recovery time may be needed. Permanent paralysis is rare. Salivary fistulae are usually self-limited. Many methods to ameliorate the cosmetic changes after parotidectomy have been described. None has gained ascendency.
This review contains 6 figures and 61 references.
Key words: facial nerve, facial paralysis, Frey syndrome, gustatory sweating, nerve monitoring, parotid gland, parotid neoplasm, parotidectomy, salivary fistula
By Gerard M. Doherty, MDPurchase PDF
Neck MassPurchase PDF
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
Parathyroid Diseases and Operations
By Daniel T. Ruan, MD; Francis D. Moore Jr, MD; Matthew A. Nehs, MD, FACSPurchase PDF
Parathyroid Diseases and OperationsPurchase PDF
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.
By Karen R. Borman, MD, FACS; Erin A. Felger, MD, FACSPurchase PDF
Thyroid DiseasesPurchase PDF
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.
By H. David Reines, MD, FACS; Elizabeth Franco, MD, FACSPurchase PDF
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.
Oral Cavity Procedures
By Mark E.P. Prince, MD, FRCSC; Carol R. Bradford, MD, FACS; Charles J Krause, MDPurchase PDF
Oral Cavity ProceduresPurchase PDF
The surgical management of lesions of the oral cavity is complex and requires the surgeon to consider multiple factors. Frequently a multidisciplinary team should be included in the decision-making process, particularly when a malignant lesion is being treated. Preoperative evaluation is critical in determining the optimal therapy and often will include radiologic evaluation and flexible endoscopy in addition to physical examination. Surgical decision making includes determining when a transoral approach is possible and appropriate versus a more extensive surgical approach such as a lip split and mandibulotomy. For small lesions, with a cooperative patient, local anesthesia might be adequate, but often, general anesthesia will be required. For malignant lesions, management of possible cervical node metastasis must be included in the treatment plan. Management of the airway during surgery and postoperatively must also be carefully considered. When there is concern for significant postoperative swelling or trismus, which might make reintubation difficult, tracheostomy should be considered. Primary closure can be effective for small defects. In some circumstances, a skin graft or local flaps can be successfully employed. When surgical excision results in larger defects, reconstruction must be included in the surgical plan.
This review contains 13 figures, 7 tables and 32 references
Key Words: glossectomy, lip split, oral cancer, mandibulectomy, mandibulotomy, maxillectomy, ranula, sialendoscopy
Thyroidectomy: Technique, Tips, and Troubleshooting
By Lindsay EY Kuo, MD, MBA; Matthew A. Nehs, MD, FACSPurchase PDF
Thyroidectomy: Technique, Tips, and TroubleshootingPurchase PDF
Historically, thyroidectomy was associated with a high mortality rate, now understood to likely be secondary to postoperative hypocalcemia. In the modern age, perioperative morbidity and mortality rates are extremely low, although some complications, such as recurrent laryngeal nerve injury, can have significant consequences. Understanding the safe approach to total thyroidectomy and thyroid lobectomy is key to minimizing operative morbidity. In particular, the capsular dissection technique facilitates identification and preservation of the recurrent laryngeal nerve and parathyroid glands. The postoperative care of the patient, including diagnosis and management of the more common complications such as hematoma or hypocalcemia, is crucial to optimize patient outcomes. Although novel thyroidectomy techniques have been developed to avoid or minimize the traditional neck incision, these approaches have not become widely used.
This review contains 9 figures, 1 table, and 29 references.
Key Words: capsular dissection, external branch of the superior laryngeal nerve, intraoperative nerve monitoring, minimally invasive thyroidectomy, postoperative hematoma, postoperative hoarseness, postoperative hypocalcemia, recurrent laryngeal nerve, remote access thyroidectomy
Benign and Malignant Thyroid Diseases
By Lindsay EY Kuo, MD, MBA; Matthew A. Nehs, MD, FACSPurchase PDF
Benign and Malignant Thyroid DiseasesPurchase PDF
The thyroid is key to numerous metabolic and homeostatic processes, including thermomodulation, protein synthesis, carbohydrate and lipid metabolism, and adrenergic regulation. A normal thyroid gland weighs 15 to 25 g and is firm, mobile, and smooth to palpation. There are two distinct physiologically active cell types: follicular cells, which synthesize thyroid hormone, and parafollicular or C cells, which produce calcitonin. Surgery is indicated for three broad categories of thyroid disease: (1) a hyperfunctioning gland, (2) an enlarged gland (goiter) causing compressive symptoms, and (3) diagnosing or treating malignancy. These indications may overlap in a patient presenting for surgical consultation. Regardless of the indication, a thorough discussion with the patient about the thyroid disease and other diagnostic or therapeutic options (if any) should be conducted.
This reviews contains 3 figures, 13 tables, and 56 references.
Key Words: anaplastic thyroid cancer, antithyroid medications, Bethesda classification, follicular thyroid cancer, Graves disease, medullary thyroid cancer, nontoxic multinodular goiter, papillary thyroid cancer, radioactive iodine, toxic nodular goiter
By Anna L. McGuire, MD, FRCSC; R. Sudhir Sundaresan, MD, FRCSC, FACSPurchase PDF
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.
Cough and Hemoptysis
By Shahriyour Andaz, MD, FACS, FRCS; Svetlana Danovich, DO, PhDPurchase PDF
Cough and HemoptysisPurchase PDF
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.
Chest Wall Mass
By Erik A. Sylvin, MD; John C. Kucharczuk, MDPurchase PDF
Chest Wall MassPurchase PDF
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.
By Eitan Podgaetz, MD, MPH; Rafael S. Andrade, MD, FACSPurchase PDF
Pleural EffusionPurchase PDF
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.
Solitary Pulmonary Nodule
By Olugbenga T Okusanya, MD; Taine T.V. Pechet, MD, FACSPurchase PDF
Solitary Pulmonary NodulePurchase PDF
The solitary pulmonary nodule is a common finding that is observed in more than 150,000 persons each year in the United States. Factors influencing probability of malignancy are discussed, including age and environmental factors. Investigative studies are described. Imaging includes chest radiography, computed tomography, 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 nonsmallcell lung cancer, small cell lung cancer, pulmonary neuroendocrine tumors, and 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. In this review, the 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 5 figures, 4 tables, and 73 references.
Key Words: bronchoscopy, compute tomography, lung cancer, nodule, positron emission tomography, solitary
Invasive Diagnostic and Therapeutic Techniques in Lung Disease
By Raphael Bueno, MD; Abby White, DOPurchase PDF
Invasive Diagnostic and Therapeutic Techniques in Lung DiseasePurchase PDF
This review encompasses the diagnosis and management of primary lung diseases. Although every encounter with a patient with suspected primary lung disease begins with a history and physical examination, many patients present with imaging abnormalities. It is therefore essential to have a thorough understanding of chest radiography, computed tomography (CT), magnetic resonance imaging (MRI), and ultrasonography (US). Many patients are simply followed with chest CT to monitor disease progression, stability, or regression before proceeding with invasive methods, the subject of this review. This review discusses flexible and rigid bronchoscopies, and open and video-assisted surgeries. Figures include illustrations of the tracheobronchial tree and lung anatomy, as well as procedures and techniques such as endobronchial biopsy, rigid bronchoscopy, and more. Tables list the indications for bronchoscopy and evaluating tools for tissue diagnosis.
21 figures; 2 tables; 41 references.
By Raymond P. Onders, MD, FACS; Philip A. Linden, MD, FACSPurchase PDF
Paralyzed DiaphragmPurchase PDF
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
Open Esophageal Procedures
By Cameron D Wright, MD, FACSPurchase PDF
Open Esophageal ProceduresPurchase PDF
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.
Minimally Invasive Esophageal Procedures
By Jon O. Wee, MD, FACSPurchase PDF
Minimally Invasive Esophageal ProceduresPurchase PDF
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.
Chest Wall Procedures
By Jason L. Muesse, MD; Seth D Force, MDPurchase PDF
Chest Wall ProceduresPurchase PDF
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.
Video-assisted Thoracic Surgery
By Abby White, DO; Scott J. Swanson, MDPurchase PDF
Video-assisted Thoracic SurgeryPurchase PDF
Since the early 1990s, video-assisted thoracoscopic surgery (VATS) has revolutionized surgical care. The era of VATS is sufficiently mature that enough data have accrued to compare the efficacy of VATS with that of open procedures. In this regard, anatomic pulmonary resection by VATS has led to significant reductions in morbidity, mortality, and hospital length of stay, allowing patients a more expeditious return to regular activities. VATS has been used in the treatment of both benign and malignant diseases of the chest. Furthermore, VATS may be used in selected patients with early-stage lung cancer without breaching oncologic surgical principles. This review covers the case for VATS technology; operative planning; basic thoracoscopy operative technique; VATS procedures for pleural disease, pulmonary wedge resection, spontaneous pneumothorax and bullous disease, lung volume reduction surgery, lobectomy, mediastinal lymph node dissection, pericardial window, mediastinal masses, management of thoracic trauma, sympathectomy and splanchnicectomy; and cost considerations. Figures show preoperative evaluation; proper patient position in the operating room, with the patient propped on pontoons; triangulation technique for port placement in relation to intrathoracic structures and targets; thoracoscope and trocar placement; video and monitors; wedge resection with lung compression clamp; tissue-reinforced stapler inserted into the chest; endoleader looped around the superior pulmonary vein; endoleader looped around the truncus anterior and its branch; and division of the upper lobe bronchus. Tables list indications and relative contraindications for VATS procedures, basic instruments and equipment used for VATS procedures, and operative steps for VATS lobectomy.
This review contains 10 highly rendered figures, 3 tables, and 35 references
Key words: Video-assisted thoracoscopic surgery; VATS; Minimally invasive thoracic surgery; Thoracoscopy; Rigid thoracoscope; Flexible thoracoscope; Thoracoport
By Joseph B. Shrager, MD, FACS; Vivek Patel, MBBSPurchase PDF
Mediastinal ProceduresPurchase PDF
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.
By Thomas A. D'Amico, MD; Dawn Emick, MDPurchase PDF
Pericardial ProceduresPurchase PDF
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.
Decortication and Pleurectomy
By Eric S. Lambright, MDPurchase PDF
Decortication and PleurectomyPurchase PDF
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.
Computed Tomographic Screening for Lung Cancer
By Doraid Jarrar, MD, FACS, FCCP; Grace Y. Song, MD; Scott Swanson, MD, FACSPurchase PDF
Computed Tomographic Screening for Lung CancerPurchase PDF
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.
By Rajeev Dhupar, MD; Ara Vaporciyan, MD, FACSPurchase PDF
Pulmonary ResectionPurchase PDF
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.
By Ayesha S. Bryant, MSPH, MD; Benjamin Wei, MD; Robert James Cerfolio, MD, FACS, FCCPPurchase PDF
Diaphragmatic ProceduresPurchase PDF
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.
Thoracic Diagnostic and Staging Procedures
By Farzaneh Banki, MD; Larry R. Kaiser, MD, FACSPurchase PDF
Thoracic Diagnostic and Staging ProceduresPurchase PDF
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.
Thoracic Outlet Syndrome
By Mark W Fugate, MD; Julie A Freischlag, MDPurchase PDF
Thoracic Outlet SyndromePurchase PDF
Thoracic outlet syndrome (TOS) is a condition caused by compression of the neurovascular structures leading to the arm passing through the thoracic outlet. The incidence of TOS is reported as 0.3 to 2% in the general population. There are three distinct types of TOS: neurogenic (95%), venous (4%), and arterial (1%). Treatment algorithms depend on the type of TOS. Arterial and venous TOS often present urgently with arterial or venous thrombosis, which is fairly easily identified by thorough history taking and a physical examination. Diagnosis is also aided by duplex ultrasonography. Restoration of arterial or venous flow can often be readily accomplished by thrombolysis. More important, however, is the diagnosis of the underlying structural component involved in the development of symptoms. Although statistically the most common, neurogenic TOS is often the most difficult to diagnose and treat. There are good data indicating that appropriately selected patients benefit from surgical therapy for neurogenic TOS as well. To prevent recurrence of symptoms, patients must undergo first rib resection and anterior scalenectomy, as well as resection of any rudimentary or cervical ribs. Regardless of the type of TOS encountered, proper therapy requires a thorough diagnostic evaluation and multimodal treatment.
Keywords: thoracic outlet syndrome, arterial thoracic outlet syndrome, neurogenic thoracic outlet syndrome, venous thoracic outlet syndrome, TOS, effort thrombosis, thoracic outlet decompression
Diagnosis and Management of Barrett Esophagus
By Arianna Barbetta, MD; Francisco Schlottmann, MD; Daniela Molena, MDPurchase PDF
Diagnosis and Management of Barrett EsophagusPurchase PDF
Barrett esophagus (BE) is defined by the presence of intestinal metaplasia in the esophageal mucosa. This condition is associated with an increased risk of esophageal adenocarcinoma. BE develops from chronic insult to the esophageal mucosa due to gastroesophageal reflux disease (GERD). Its diagnosis requires endoscopy with multiple biopsies. Numerous image-enhanced modalities have been developed to improve the endoscopic diagnosis of BE and dysplasia. Surveillance has a central role to monitor for progression of metaplastic to dysplastic mucosa and early diagnosis of invasive carcinoma. Whereas nondysplastic BE can benefit from medical or surgical treatment of GERD, today multiple therapies are available to treat dysplastic BE with a low rate of complications.
Key words: Barrett esophagus, biopsy, dysplasia endoscopy, endoscopic mucosal resection, esophageal adenocarcinoma, gastroesophageal reflux metaplasia, proton pump inhibitor, surveillance
Stereotactic Body Radiation and Other Ablative Therapies
By Praveen Sridhar, MD; Hiran C Fernando, MBBS, FRCSPurchase PDF
Stereotactic Body Radiation and Other Ablative TherapiesPurchase PDF
Lung cancer is the leading cause of cancer death in both men and women. This is related to the high prevalence and high mortality particularly when presenting at an advanced stage. Surgical resection remains the standard curative therapy for early-stage lung cancer. However, many patients are not able to tolerate resection secondary to poor respiratory reserve and other comorbid diseases. Stereotactic body radiation therapy (SBRT) and percutaneous thermal ablation are minimally invasive techniques that have been used to treat other solid tumors with curative intent. Over the past decade, there has been an expansion in the roles of both SBRT and thermal ablation in the treatment of early-stage lung tumors. The encouraging results from several studies have led to the incorporation of these therapies, particularly SBRT, as the standard of care for curative-intent treatment of patients with medically inoperable early-stage lung cancer. This chapter presents an overview of the approach to patient selection as well as provides a review of the current evidence for SBRT, percutaneous thermal ablation, and bronchoscopic ablation for early-stage nonsmall cell lung cancers.
This review contains 3 figures, 4 tables, and 28 references
Key Words: stereotactic body radiation therapy, percutaneous thermal ablation, cryoablation, microwave ablation, endoscopic ablation, bronchoscopic ablation, radiofrequency ablation, early stage NSCLC therapy
By Ilaria Gandolfini, MD; Paolo Cravedi, MD, PhDPurchase PDF
Transplantation ImmunobiologyPurchase PDF
The immune system has evolved to clear the host of invading microorganisms and its own cells that have become altered in some way, such as infected cells or mutated tumorigenic cells. The immune system recognizes such cells as “foreign” based on their expression of different molecules (antigens). Similarly, when organs are transplanted between genetically disparate (allogeneic) individuals, the immune system recognizes and reacts against the foreign antigens of the other individual (alloantigens) to cause rejection. The immune response to a transplanted organ is the consequence of a complex interplay between the innate and adaptive immune systems. Early ischemia-reperfusion injury to the allograft triggers an innate immune response and contributes to the activation of recipient T cells that recognize donor major and minor histocompatibility alloantigens.1 Once activated, T cells migrate into the allograft, where they mediate rejection by imposing direct cytotoxicity on allogeneic cells, or by providing help to other cells of the immune system, such as macrophages, natural killer (NK) cells, and B lymphocytes, which differentiate into antibody-producing cells. These effector cells and factors then lead to allograft injury.2 This review outlines the elements involved in the innate and adaptive immune responses to a transplant and the mechanisms of rejection.
Infections Following Transplantation
By Nicholas C Issa, MD; Jessica M. Stempel, MD; Sophia Koo, MDPurchase PDF
Infections Following TransplantationPurchase PDF
Infections following kidney transplantation are an important cause of morbidity and mortality throughout the entire posttransplantation period. Patients become more susceptible to an assortment of diverse infections following transplantation due to ongoing immunosuppression and may present with atypical clinical manifestations. An expeditious microbiologic workup and appropriate management are essential to ensure timely diagnosis and prompt initiation of specific therapy.
Lung Transplantation 1: an Overview - Recipient Evaluation and Procedures
By Hilary J Goldberg, MD, MPHPurchase PDF
Lung Transplantation 1: an Overview - Recipient Evaluation and ProceduresPurchase PDF
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 the progression of disease. Although lung transplantation may confer substantial benefits on recipients, the median survival after lung transplantation according to the most recent registry data is only 5.7 years, substantially shorter than that for other solid-organ transplant cohorts. As a result, the available prognostic data for potential recipients in the absence of lung transplantation, the risks of transplantation, and the potential benefits in terms of survival and quality of life should be reviewed in detail when considering this intervention. This review discusses candidates for lung transplantation, timing of transplantation, organ donors and donor-recipient matching, transplantation procedures, and transplantation outcomes. Figures depict the prevalence and natural history of lung diseases indicated for transplantation, organ transplants 2005 to 2007, bilateral/double lung and single lung transplantations from 1985 to 2013, and the average 5-year survival rates of lung, heart, kidney, and liver recipients between 1997 and 2004. Tables list the contraindications to transplantation, disease-specific guidelines for referral and transplantation, predictors of poor prognosis in cystic fibrosis patients, donor criteria. A sidebar lists internet transplantation resources and registries.
4 figures; 4 tables; 97 references.
Lung Transplantation 2: Care of the Lung Transplant Recipient
By Hilary J Goldberg, MD, MPHPurchase PDF
Lung Transplantation 2: Care of the Lung Transplant RecipientPurchase PDF
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 the progression of disease. Although lung transplantation may confer substantial benefits on recipients, the median survival after lung transplantation according to the most recent registry data is only 5.7 years,1 substantially shorter than that for other solid-organ transplant cohort. This review discusses posttransplantation management, transplantation outcomes, and posttransplanation complications. Figures depict the average 5-year survival rates of lung, heart, kidney, and liver recipients between 1997 and 2004, an example of primary graft dysfunction, an example of airway stenosis, and pathologic manifestations of both acute and chronic rejection after lung transplantation. Tables list the causes of death after lung transplantation, classification and histologic features of allograft rejection, staging system for bronchiolitis obliterans syndrome, and complications of lung transplantation and posttransplantation immunosuppression. A sidebar lists internet transplantation resources and registries.
5 figures; 4 tables; 43 references.
Kidney Transplantation 1: an Overview--recipient Evaluation and Immunosuppression
By Anil Chandraker, MD; Jamil Azzi, MD; Martina M McGrath, MB, BCh; Belinda T. Lee, MDPurchase PDF
Kidney Transplantation 1: an Overview--recipient Evaluation and ImmunosuppressionPurchase PDF
Kidney transplantation remains the optimal renal replacement therapy for patients with end-stage renal disease (ESRD). A timely referral to kidney transplantation and a thorough pretransplantation evaluation ensure improvement in the morbidity and mortality of ESRD patients. Basic knowledge of immune biology and an in-depth understanding of the different induction and maintenance therapies used post kidney transplantation are imperative for optimal patient management. In this review, we discuss the multidisciplinary process of pretransplantation evaluation of kidney transplant recipients. We also discuss state-of–the-art early management post kidney transplantation with the different immunosuppressive therapies currently available.
This review contains 3 figures, 11 tables, and 106 references.
Key words: crossmatch, donor-specific antibody, immunosuppression, human leukocyte antigen, immunosuppression, induction, maintenance, medical evaluation, transplantation
Kidney Transplantation 2: Care of the Kidney Transplant Recipient
By Anil Chandraker, MD; Jamil Azzi, MD; Martina M McGrath, MB, BCh; Belinda T. Lee, MDPurchase PDF
Kidney Transplantation 2: Care of the Kidney Transplant RecipientPurchase PDF
Renal transplantation is the preferred therapy for patients with end-stage kidney disease, leading to increased life expectancy, improved quality of life, and reduced health care resource use. Owing to their preexisting burden of disease, caring for renal transplant recipients is complex. Patient management following successful renal transplantation involves a multifactorial approach to cardiovascular risk factor management, along with titration of immunosuppression, management of complications related to immunosuppression, and active monitoring of allograft function. Recent advances in immunosuppressive management hold promise for improved long-term allograft survival. Finally, immune monitoring of transplant recipients is an area of considerable research, with the ultimate aim of individualized management of immunosuppression and the ability to induce transplant-specific tolerance.
This review contains 7 figures,7 tables, and 117 references.
Key words: cardiovascular disease, drug interactions, immunosuppression, infection, interstitial fibrosis and tubular atrophy, malignancy, rejection, tolerance
Liver and Pancreas Transplantation
By Julie A Thompson, MD; Aleksandra Kukla, MDPurchase PDF
Liver and Pancreas TransplantationPurchase PDF
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.
By Michael M. Givertz, MDPurchase PDF
Heart TransplantationPurchase PDF
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.
By Prosanto Chaudhury, MD, MSc, FRCSC; Talia B. Baker, MD, FACS; Anton I. Skaro, MD, PHD, FRCSC, FACS; Paul Alvord, MD, FACSPurchase PDF
Organ ProcurementPurchase PDF
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.
The Future of Transplant Biology and Surgery
By Marc Colaco, MD, MBA; Anthony Atala, MDPurchase PDF
The Future of Transplant Biology and SurgeryPurchase PDF
Although allograft organs remain the gold standard for transplantation, the availability of donor organs has forced us to search for alternatives. Regenerative medicine and tissue engineering offer a solution for this issue. Through the use of synthetic scaffolds and organic substrates, we have been able to generate neoorgans for a variety of different body systems. Although these neoorgans remain largely in the experimental phase, the results are promising, and recent technological developments have made production a realistic endeavor on the large scale. In this review, we highlight recent advances in the field of regenerative medicine and their application to the future of transplant surgery.
This review contains 6 figures, 2 tables and 42 references
Key Words: bioengineering, biomaterial, bioreactor, decellularized organs, organ scaffolds, regenerative medicine, stem cell, three-dimensional printing
Transplantation Ethics and Policy
By Anji Elizabeth Wall, MD, PhD; J. Michael Millis, MDPurchase PDF
Transplantation Ethics and PolicyPurchase PDF
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.
Small Intestinal and Multivisceral Transplantation
By Bernard J. DuBray, MD; Douglas G. Farmer, MDPurchase PDF
Small Intestinal and Multivisceral TransplantationPurchase PDF
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.
Transplant Immunology: Basic Immunology and Clinical Practice
By David P Foley, MD; Lung-Yi Lee, MDPurchase PDF
Transplant Immunology: Basic Immunology and Clinical PracticePurchase PDF
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.
- Trauma and Thermal Injury
Initial Management of Life-threatening Trauma
By Emily Cantrell, MD; Jay Doucet, MD, FACS, FRCSC, RDMSPurchase PDF
Initial Management of Life-threatening TraumaPurchase PDF
Management of the critically injured patient is optimized by a coordinated team effort in an organized trauma system that allows for rapid assessment and initiation of life-preserving therapies. This initial assessment must proceed systematically and be prioritized according to physiologic necessity for survival. Beginning in the prehospital setting, coordination, preparation, and appropriate triage of the injured are crucial to facilitating rapid resuscitation of the trauma patient. Next, active efforts to support airway, breathing, circulation, and disability are performed with simultaneous intervention to treat life-threatening injuries and restore hemodynamic stability in the primary survey. With ongoing evaluation and continued resuscitation, a secondary survey provides a head-to-toe assessment of the patient allowing for further diagnosis of injuries and triage to more definitive care.
This review contains 12 figures, 8 tables and 63 references
Key Words: advanced trauma life support, definitive airway, FAST/eFAST, field triage, Glasgow coma scale, primary survey, 1:1:1 resuscitation, secondary survey
Injuries to the Central Nervous System
By Krista Keachie, MD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD; Kiarash Shahlaie, MD, PhDPurchase PDF
Injuries to the Central Nervous SystemPurchase PDF
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.
Injuries to the Chest
By Amy N. Hildreth, MD, FACS; J. Jason Hoth, MD, PhD, FACS; J. Wayne Meredith, MD, FACSPurchase PDF
Injuries to the ChestPurchase PDF
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.
Injuries to the Stomach, Small Bowel, Colon, and Rectum
By Jordan A Weinberg, MD, FACS; Timothy C. Fabian, MD, FACSPurchase PDF
Injuries to the Stomach, Small Bowel, Colon, and RectumPurchase PDF
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
Injuries to the Face and Jaw
By Graham G Walmsley, MD, PhD; Michael S Hu, MD, MPH, MS; Richard A. Hopper, MD, MS; H Peter Lorenz, MDPurchase PDF
Injuries to the Face and JawPurchase PDF
The human face is vulnerable to injury most frequently as the target of interpersonal violence or when inadequately restrained within a motor vehicle collision. Injuries to both the soft tissues and skeleton of the face are common reasons of emergency department admissions and consultations. Isolated maxillofacial trauma is rarely life threatening or an immediate cause of death unless associated with airway compromise; however, approximately 20% of all patients with facial soft tissue, dentoalveolar, or facial fracture trauma have associated injury to additional body systems. In particular, motor vehicle crash victims, personal assault, occupational injuries, and motorcycle crash victims may have associated injuries to additional body systems. This review covers the assessment and management of maxillofacial fractures, initial evaluation, comprehensive survey, treatment of soft tissue injuries, and treatment of maxillofacial fractures. Figures show a patient with a combination of blunt and penetrating trauma to the central face; fractured mandible; fractured zygoma; infraorbital fracture; broken nose; soft tissue injuries involving the facial nerve distal to the vertical line, likely too small for primary repair; injuries to the parotid duct repaired by passing a catheter through the Stensen duct and through the area of laceration and then repairing the parotid duct over the catheter; mandibular fracture; Le Fort I, Le Fort II, and Le Fort III fractures; findings in patients with Le Fort III maxillary fractures immediately after injury, before obliterative edema develops; and preoperative and postoperative right-sided orbitozygomatic fracture.
This review contains 12 highly rendered figures, and 29 references
Key words: Jaw injuries; Face injuries; Maxillofacial injuries; Le Fort level; Facial fractures; Orbital fractures; Maxillary fractures;
Injuries to the Liver and Biliary Tract
By Clay Cothren Burlew, MD, FACS; Ernest E. Moore, MD, FACSPurchase PDF
Injuries to the Liver and Biliary TractPurchase PDF
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
Injuries to the Neck
By Joseph M. Galante, MD; Ian E Brown , MD, PhDPurchase PDF
Injuries to the NeckPurchase PDF
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
Operative Exposure of Abdominal Injuries and Closure of the Abdomen
By Christian Minshall, MD, PhD, FACS; Erwin R. Thal, MD, FACS, FRACS(Hon)Purchase PDF
Operative Exposure of Abdominal Injuries and Closure of the AbdomenPurchase PDF
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.
Duodenal and Pancreatic Trauma
By Robert T. Stovall, MD; Erik Peltz, DO; Gregory J. Jurkovich, MD, FACSPurchase PDF
Duodenal and Pancreatic TraumaPurchase PDF
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.
Injuries to Great Vessels of the Abdomen
By David V. Feliciano, MD, FACS; Juan A. Asensio, MDPurchase PDF
Injuries to Great Vessels of the AbdomenPurchase PDF
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
Injuries to the Upper Urogenital Tract
By Alex J. Vanni, MD; Hunter Wessells, MD, FACSPurchase PDF
Injuries to the Upper Urogenital TractPurchase PDF
Traumatic injury to the upper urinary tract usually results from multisystem trauma. The kidney is the most commonly injured urologic organ and accounts for nearly one quarter of all solid-organ traumatic injuries. Ureteral injuries are difficult to diagnose and must be suspected based on the mechanism of injury. These injuries, although rarely fatal, may result in significant morbidity and permanent disability if not promptly evaluated and treated. Modern urologic trauma management with rapid computed tomography and a focus on nonoperative management have dramatically changed the field of urologic trauma. Additionally, improvement in angiography and selective embolization allows treatment of active arterial or delayed renal bleeding. Although fewer injuries require operative management, exploration is still required for hemodynamically unstable patients.
Key words: kidney injury, kidney trauma, upper urinary tract trauma, ureteral injury, ureteral trauma
Injuries to the Pelvis and Extremities
By J.C. Goslings, MD, PhD; K.J. Ponsen, MD, PhD; O.M. van Delden, MD, PhDPurchase PDF
Injuries to the Pelvis and ExtremitiesPurchase PDF
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.
Management of the Patient With Thermal Injuries
By Nicole S. Gibran, MD, FACS; Michael J. Mosier, MD, FACS, FCCMPurchase PDF
Management of the Patient With Thermal InjuriesPurchase PDF
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
Injuries to the Peripheral Blood Vessels
By Charles J. Fox, MD, FACSPurchase PDF
Injuries to the Peripheral Blood VesselsPurchase PDF
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
Miscellaneous Burns and Related Conditions
By David A Brown, MD, PhD; Nicole S. Gibran, MD, FACSPurchase PDF
Miscellaneous Burns and Related ConditionsPurchase PDF
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.
Management of the Burn Wound
By Jose P. Sterling, MD; David M. Heimbach, MD, FACS; Nicole S. Gibran, MD, FACSPurchase PDF
Management of the Burn WoundPurchase PDF
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.
Rehabilitation of the Burn Patient
By Samuel P Mandell, MD, MPH; Nicole S. Gibran, MD, FACSPurchase PDF
Rehabilitation of the Burn PatientPurchase PDF
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.
By Martin L. Gunn, MBChB, FRANZCR; Kathleen R. Fink, MD; Joel A. Gross, MDPurchase PDF
Trauma ImagingPurchase PDF
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.
By Areti Tillou, MD; Sigrid Burruss, MD; Lillian Min, MD, MSHSPurchase PDF
Geriatric TraumaPurchase PDF
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.
Venomous Bites and Stings
By J Patrick Walker, MD, FACSPurchase PDF
Venomous Bites and StingsPurchase PDF
Approximately 8000 persons are bitten by venomous snakes in the US each year. Mortality is low (4 to 6/yr), but morbidity can be significant, treatment costly. Overuse of surgery and antivenom is common. Simply cutting the wound with attempted aspiration is not indicated. Fasciotomy should only be used for patients with elevated compartment pressures. CroFab is a highly effective (but expensive) treatment useful for serious envenomation. Antivenom should be used in patients with life-threatening symptoms (hypotension, clinical coagulopathy) or rapid advancement of local signs, and to reduce compartment pressures to avoid fasciotomy. The most significant morbidity from insect envenomation is secondary to anaphylaxis. A bite from the black widow spider can induce abdominal cramping and pain that can mimics an acute abdomen. Brown recluse envenomation can produce tissue necrosis and long-term complications. Most events are seen rarely by the average physician; this review can be a useful guide in management.
Key words: antivenom, copperhead bite, CroFab, insect bite, rattlesnake bite, snakebite, water moccasin bite
Injuries to the Spleen and Diaphragm
By J. Jason Hoth, MD, PhD, FACS; Andrea M. Long, MD; Preston R Miller, MD, FACSPurchase PDF
Injuries to the Spleen and DiaphragmPurchase PDF
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
Injuries to the Lower Urogenital Tract and Genitalia
By Alex J. Vanni, MDPurchase PDF
Injuries to the Lower Urogenital Tract and GenitaliaPurchase PDF
Injury to the lower urinary tract may involve multiple organs depending on the mechanism of injury, often requiring the collaboration of both trauma and orthopedic surgeons. Although blunt trauma to the lower urogenital tract and genitalia is much more common than penetrating trauma, both mechanisms of injury can produce life-altering injury. Prompt diagnosis is imperative for optimal outcomes and may require computed tomography, ultrasonography, and urethrography to delineate the extent of injury. The nature and variety of injuries require a combination of minimally invasive, open, and plastic surgical techniques for optimal management. Particular attention is required for possible female reproductive organ injury, particularly in the setting of sexual assault.
Key words: bladder injury, penile amputation, penile fracture, penile injury, scrotal trauma, urethral injury, urogenital trauma
New Techniques in Hemorrhage Control
By Megan Brenner, MD, MS, RPVI, FACS; Joseph DuBose, MD, RPVI, FCCM, FACSPurchase PDF
New Techniques in Hemorrhage ControlPurchase PDF
The use of interventional procedures in trauma has increased steadily over the past 10 years. With advancements in both imaging and device technology, endovascular techniques have become part of the treatment algorithm for both large and small vessel injury. Endovascular therapy in trauma involves a minimally invasive, catheter-based approach, which can be used as a temporizing measure in patients in extremis or as definitive therapy in a wide variety of diagnoses. Sheaths, catheters, and guide wires are universal instruments, regardless of procedure. Devices passed over guide wires form the basis of diagnosis and treatment. Using this technology provides many advantages to traditional open surgical therapy, namely the avoidance of large and potentially morbid incisions. Angioembolization, stent grafting, and resuscitative endovascular balloon occlusion of the aorta (REBOA) are being used with increasing frequency in trauma centers, with established algorithms, multiinstitutional trials, and more published data available, particularly for solid-organ and pelvic hemorrhage.
Key words: angiography, embolization, hemorrhage, resuscitative endovascular balloon occlusion of the aorta, stent graft
Cerebral Metabolism and Blood Flow Following Traumatic Brain Injury
By Ryan Martin, MD; Lara Zimmermann, MD; Marike Zwienenberg-Lee, MD; Kee D Kim, MD; Kiarash Shahlaie, MD, PhDPurchase PDF
Cerebral Metabolism and Blood Flow Following Traumatic Brain InjuryPurchase PDF
The management of traumatic brain injury focuses on the prevention of second insults, which most often occur because of a supply/demand mismatch of the cerebral metabolism. The healthy brain has mechanisms of autoregulation to match the cerebral blood flow to the cerebral metabolic demand. After trauma, these mechanisms are disrupted, leaving the patient susceptible to episodes of hypotension, hypoxemia, and elevated intracranial pressure. Understanding the normal and pathologic states of the cerebral blood flow is critical for understanding the treatment choices for a patient with traumatic brain injury. In this chapter, we discuss the underlying physiologic principles that govern our approach to the treatment of traumatic brain injury.
This review contains 3 figures, 1 table and 12 references
Key Words: cerebral autoregulation, cerebral blood flow, cerebral metabolic rate, intracranial pressure, ischemia, reactivity, vasoconstriction, vasodilation, viscosity
Traumatic Spinal Cord Injury
By Ryan Martin, MD; Lara Zimmermann, MD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD; Kiarash Shahlaie, MD, PhDPurchase PDF
Traumatic Spinal Cord InjuryPurchase PDF
Traumatic spinal cord injury currently affects approximately 285,000 persons in the United States and carries with it significant morbidity and cost. Early management focuses on adequate ventilation and hemodynamic resuscitation of the patient and limiting motion of the spine to prevent a second injury. Medical management targets maintenance of adequate blood flow to the spinal cord, whereas surgical management focuses on decompression, realignment, and stabilization of the vertebral column. In this chapter, we discuss the approach to the patient with traumatic spinal cord injury, injury types, and medical and surgical management.
This review contains 9 figures, 4 tables and 30 references
Key Words: American Spinal Injury Association score, burst fracture, Chance fracture, compression fracture, hangman, mean arterial pressure therapy, odontoid fracture, spinal cord injury, traction
Severe Traumatic Brain Injury
By Ryan Martin, MD; Lara Zimmermann, MD; Kee D. Kim, MD; Marike Zwienenberg-Lee, MD; Kiarash Shahlaie, MD, PhDPurchase PDF
Severe Traumatic Brain InjuryPurchase PDF
Traumatic brain injury remains a leading cause of death and disability worldwide. Patients with severe traumatic brain injury are best treated with a multidisciplinary, evidence-based, protocol-directed approach, which has been shown to decrease mortality and improve functional outcomes. Therapy is directed at the prevention of secondary brain injury through optimizing cerebral blood flow and the delivery of metabolic fuel (ie, oxygen and glucose). This is accomplished through the measurement and treatment of elevated intracranial pressure (ICP), the strict avoidance of hypotension and hypoxemia, and in some instances, surgical management. The treatment of elevated ICP is approached in a protocolized, tiered manner, with escalation of care occurring in the setting of refractory intracranial hypertension, culminating in either decompressive surgery or barbiturate coma. With such an approach, the rates of mortality secondary to traumatic brain injury are declining despite an increasing incidence of traumatic brain injury.
This review contains 3 figures, 5 tables and 69 reference
Key Words: blast traumatic brain injury, brain oxygenation, cerebral perfusion pressure, decompressive craniectomy, hyperosmolar therapy, intracranial pressure, neurocritical care, penetrating traumatic brain injury, severe traumatic brain injury
Principles of Initial Trauma Management and Evaluation
By Shelby Resnick, MD; Brian Smith, MD; Patrick Reilly, MD, FCCP, FACSPurchase PDF
Principles of Initial Trauma Management and EvaluationPurchase PDF
Trauma accounts for almost 10% of deaths worldwide and is the fourth most common cause of death in the United States. Treatment of the injured patient requires multiple unique resources, including multidisciplinary teams, surgical subspecialties, and dedicated resuscitation areas. Evaluation and initial management of the trauma patient is performed systematically to quickly identify and treat life-threatening injuries. This review serves as an introduction to care for the critically injured patient. It covers the initial steps for evaluation, resuscitation, diagnosis and treatment of the trauma patient and provides a brief overview of various injury patterns resulting from both blunt and penetrating trauma.
This review contains 6 figures, 6 tables and 49 references
Key Words: blunt trauma, damage control resuscitation, FAST exam, lateral canthotomy, penetrating trauma, primary survey, rapid sequence intubation, secondary survey, trauma systems
- Vascular System
Medical Management of Vascular Disease
By Deepak G. Nair, MD, MS, MHA, FACS, RVT; Russell H. Samson, MD, FACS, RVTPurchase PDF
Medical Management of Vascular DiseasePurchase PDF
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.
Acute Limb Ischemia
By Jovan N. Markovic, MD; Cynthia K. Shortell, MD, FACSPurchase PDF
Acute Limb IschemiaPurchase PDF
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.
Lower Extremity Ulcers
By Robert D. Galiano, MD; Richard F. Neville, MDPurchase PDF
Lower Extremity UlcersPurchase PDF
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.
Symptomatic Carotid Stenosis: Stroke and Transient Ischemic Attack
By Kenneth R. Ziegler, MD, RPVI; Thomas C. Naslund, MDPurchase PDF
Symptomatic Carotid Stenosis: Stroke and Transient Ischemic AttackPurchase PDF
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.
Surgical Treatment of Carotid Artery Disease
By Wesley S. Moore, MD, FACSPurchase PDF
Surgical Treatment of Carotid Artery DiseasePurchase PDF
The rationale for operating on patients with carotid artery disease is to prevent stroke. It has been estimated that in 50 to 80% of patients who experience an ischemic stroke, the underlying cause is a lesion in the distribution of the carotid artery, usually in the vicinity of the carotid bifurcation. Appropriate identification and intervention could significantly reduce the incidence of ischemic stroke. Carotid endarterectomy for both symptomatic and asymptomatic carotid artery stenosis has been extensively evaluated in prospective, randomized trials. Surgical reconstruction of the carotid artery yields the greatest benefits when done by surgeons who can keep complication rates to an absolute minimum. The majority of complications associated with carotid arterial procedures are either technical or judgmental; accordingly, this review emphasizes the procedural considered to be particularly important for deriving the best short- and long-term results from surgical intervention. Specifically, this review covers preoperative evaluation, operative planning, operative technique, postoperative care, follow-up, and alternatives to direct carotid reconstruction. Figures show carotid arterial procedures including recommended patient positioning, the commonly used vertical incision, the alternative transverse incision, mobilization of the sternocleidomastoid muscle to identify the jugular vein, palpation of the internal carotid artery, division of the structures between the internal and external carotid arteries to allow the carotid bifurcation to drop down, division of the posterior belly of the digastric muscle to yield additional exposure of the internal carotid artery, a graphic representation of the measurement of internal carotid artery back-pressure, a central infarct zone surrounded by an ischemic zone, shunt placement, open endarterectomy, eversion endarterectomy, repair of fibromuscular dysplasia, and repair of coiling or kinking of the internal carotid artery.
This review contains 17 highly rendered figures, and 21 references
Key words: Carotid artery disease; Carotid endarterectomy; Carotid angioplasty with stenting; Eversion endarterectomy; Open endarterectomy; Carotid plaque
Pulsatile Abdominal Mass
By Robert J.T. Perry, MD, FACS; Gilbert R Upchurch Jr, MD, FACSPurchase PDF
Pulsatile Abdominal MassPurchase PDF
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
Asymptomatic Carotid Bruit/carotid Artery Stenosis
By Ali F Aburahma, MD; Patrick A. Stone, MDPurchase PDF
Asymptomatic Carotid Bruit/carotid Artery StenosisPurchase PDF
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
Infrainguinal Arterial Procedures
By Amy B. Reed, MD, FACSPurchase PDF
Infrainguinal Arterial ProceduresPurchase PDF
Even in the endovascular era, infrainguinal arterial bypass remains a mainstay in a vascular surgeon’s armamentarium for treating patients with claudication or critical limb ischemia. New techniques include hybrid endovascular and open options to treat those patients with limited autogenous conduit or to simply decrease graft length to help minimize risk of stenosis long term. Over time, the perceived notions of distal vein cuffs and use of prosthetic below the knee have been modified with extensive registry and literature reviews, making lower extremity bypass an ever-changing treatment modality.
Key words: duplex mapping, femoral tibial artery exposure, hybrid, vein harvest
This review contains 17 figures, and 77 references.
By Mark K. Eskandari, MD; Michael J Nooromid, MDPurchase PDF
Aortoiliac ReconstructionPurchase PDF
This review outlines the preoperative evaluation, clinical decision making, and surgical treatment options for patients with aortoiliac occlusive disease. It also details the open surgical techniques for the treatment of aortoiliac occlusive disease and reviews endovascular treatment options. The discussion of treatment options includes the potential complications and expected outcomes, as well as steps that can be taken to optimize surgical results.
Key words: aortobifemoral bypass, aortoiliac reconstruction, atherosclerotic occlusive disease, endovascular reconstruction, femoral endarterectomy, iliac angioplasty, iliac stenting, peripheral vascular disease