Malignant Lesions Lymphoma

A number of lymphoproliferative disorders can involve the spleen. Hodgkin lymphoma, with the classic multinucleated Reed-Sternberg cells, is a malignant neoplasm originating in a localized nodal group with subsequent progression to other lymph node basins. Treatment of Hodgkin lymphoma is based on accurate staging.3 The disease originates and remains localized to lymph nodes above the diaphragm (stages I and II) in 80 percent of patients however, in those patients with stage III (abdominal...

Central Venous Catheter

The surgical intervention for treatment of an infected central venous catheter is removal of that foreign body. When an infected catheter is suspected, either because of redness at the site, or lack of other source of infection, the catheter should be removed if at all possible. If the skin entry site appears clear of infection, the catheter may be exchanged using Seldinger technique (changing the catheter over a guide wire). If the site is red, or if the catheter is strongly suspected of being...

Nephropathy

The most common indication for kidney transplantation in the United States is renal failure secondary to diabetic nephropathy (types 1 and 2). Kidneys for transplant recipients were generally obtained from deceased donors however, the advent of the laparoscopic donor nephrectomy technique has resulted in living donors supplying greater than 50 percent of kidneys at many transplant centers. Following successful kidney transplantation, diabetics remain at risk for allograft loss due to recurrent...

Keloids and hypertrophic scars

Hypertrophic scars are characteristically elevated but remain within the limits of the initial injury and regress spontaneously. Keloids extend beyond the original wound and do not regress (Fig. 7-6).13 Even though they are Figure 7-6 Typical earlobe keloid after piercing. Notice that the keloid extends well beyond the original wound (ear pierce). Figure 7-6 Typical earlobe keloid after piercing. Notice that the keloid extends well beyond the original wound (ear pierce). most prevalent in...

Reconstruction with Body Tissue

A breast mound can also be created with tissue borrowed from another part of the body. Breasts reconstructed in this fashion are soft and have a natural shape. It is therefore much easier to match the remaining breast with this technique. (Fig. 14-2) Fewer procedures are required to complete the reconstruction Figure 14-2 Left breast reconstruction with implant and final nipple reconstruction to match an augmented right breast for best symmetry. Figure 14-2 Left breast reconstruction with...

Breast Implant Controversies

Breast implants are thin-walled containers made of hard silicone plastic that are filled with saline (salt water) or silicone gel. They have been in use for 30 years and have an excellent safety record. The Institute of Medicine's recent review of breast implants and their safety found saline and silicone gel implants to be similar. Both types of implants were associated with local complications (rupture, scar formation called capsular contracture, and infection) but not with systemic...

Reconstruction with Breast Implants

The most common form of breast reconstruction uses a saline-filled or sili-cone gel implant to rebuild the breast mound. This technique does not add new scars to the body, as the other techniques require. Implant reconstruction also requires less extensive surgery than other techniques, but more procedures are required to complete the reconstructive process.1,2 Not all women are candidates for implant reconstruction. Those with small-to moderate-sized breasts that do not sag are the best...

The Geriatric Patient

The risks of a major procedure in patients over 60 years of age are increased only slightly in the absence of cardiovascular, renal, and other systemic diseases. Changes associated with generalized arteriosclerosis are to be expected, as are limitations of cardiac and renal reserve. The incidence of silent MI increases with age. A thorough comprehensive preoperative evaluation is therefore very critical. Occult cancer is also frequently seen in this age group, and therefore minor...

Esophageal cancer5111214 Epidemiology

More than 99 percent of esophageal tumors are of the malignant variety. However, esophageal cancer is relatively uncommon in the United States, with an annual rate of less than 10 per 100,000. Most are diagnosed between the sixth and the eighth decade of life, and, in general, men are two to four times more likely to be afflicted than females. Nevertheless, it is a lethal problem once diagnosed, the overall 5-year survival rate is typically less than 10 percent, Figure 8-6 The characteristic...

Gluteal Free Flap Reconstruction

Both the upper and lower buttock are another source of skin and fat tissue for breast reconstruction.9 These free flaps can be harvested with muscle based on the superior or inferior gluteal vessels (free superior gluteal flap or free inferior gluteal flap), or as perforator flaps leaving gluteus muscle intact (S-GAP or I-GAP flaps). There is a large scar created across the buttock with mild flattening of the buttock contour but this is imperceptible in normal clothing. The best candidates for...

Anemia And Coagulation Disorders

Patients with hemoglobin of less than 9 g dL can have significant surgical morbidity. A peripheral blood smear may indicate the etiology of the anemia. Macrocytosis or microcytosis suggests significant anemia, target cells are seen in splenic hypofunction, and spherocytes and schistocytes are seen in hemolytic anemias. The usual initial screening coagulation tests include a PT, aPTT, and a platelet count. Qualitative and quantitative defects are seen in platelets in the presence of uremia and...

The Role of Tissue Expanders in Implant Reconstruction

A mastectomy normally removes a variable amount of breast skin with the nipple. The amount removed depends on tumor size and also on the location of the biopsy scar. The skin circulation and its healing ability are also compromised by mastectomy. Both of these factors prevent the immediate placement of a permanent implant at the time of mastectomy in virtually all patients. Tissue expansion is a process that replaces the missing skin in preparation for placement of a permanent implant later. A...

Complications of Implant Reconstruction

The complications associated with breast implant reconstruction are listed in Table 14-1. Of these, scar tissue is perhaps the most problematic for the reconstruction patient as time goes on. The body normally forms a layer of scar tissue around any artificial material implanted beneath the skin. With breast implants, that scar tissue is called a capsule and the process of scarring and subsequent deformation of the breast shape is called capsular contracture. If the capsule which forms remains...

Cystic tumors

A number of cystic neoplasms of the pancreas have been described. The lesions are rare, and associated symptoms and operative management depend on the location.55 Serous cystadenoma is a benign neoplasm that occurs most often in the pancreatic body and tail, but is occasionally found in the head of the gland. Patients usually present with an abdominal pain or an abdominal mass. Patients undergo resection as a means of differentiating the mass from malignant lesions as well as to control...

Hypoxemia

The list of possible causes of hypoxemia in the postsurgical patient is long and complex. For this reason, diagnosis and treatment must proceed systematically. Hypoxemia is defined as PaO2 less than 60 mmHg, and is usually diagnosed by pulse oximetry or less often, arterial blood gas measurement. Clinically, hypoxic patients appear restless, tachycardic, and cyanotic, although cyanosis may not be apparent in severely anemic patients. At more advanced stages, however, patients become somnolent,...

Airway Obstruction

Obstruction of the airway is one of the most urgent complications that can develop in the postoperative patient, and is all the more likely due to the manipulation of the airway that occurs as part of general endotracheal anesthesia. Although the majority of the risk occurs in a highly monitored environment of the PACU, a significant number of cases of airway obstruction occur in delayed settings on surgical wards. This is also becoming a more recognized phenomenon as obstructive sleep apnea...

Elicit a More Thorough History of the Current Complaint

The patient has told you already that his pain started off in the midepigastrium and then moved diffusely all over his abdomen. But how about other symptoms and the timing of events When asked, he reports that the pain initially started after dinner. He states that he had been out with his friends. When asked directly, he reports some drug use and drinking, consisting of a couple of beers, some mixed cocktails, marijuana, and a small amount of crack cocaine. Later in the evening, he noticed...

Physical Examination

The findings of physical examination in the hernia patient, like the history, are different in the chronic setting versus the acute setting. It is important to conduct a thorough physical examination with vital signs, including a cardiovascular and pulmonary assessment. However, the present discussion will focus on the abdominal inguinal examinations. The approach to the abdominal and inguinal examinations consists in inspection, palpation, and auscultation. In the chronic setting, an isolated...

Small Bowel Obstruction

Small bowel obstruction presents with abdominal distention and crampy abdominal pain. Proximal small bowel obstruction can often present with nausea and vomiting. Patients may also have nausea and vomiting with distal small bowel and colonic obstruction, but it presents later in the course of the obstruction. Patients will report minimal flatus, and will describe a history of no bowel movements over a prolonged period of time. Patients will occasionally report small watery or mucus predominant...

Right Lower Quadrant Pain

Right lower quadrant pain is a common complaint. It is also one of the most difficult areas of the abdomen to evaluate because the differential diagnosis is widely varied. The resulting workup is dependent on the age and sex of the patient, as well as the clinical picture. The differential diagnosis can include appendicitis, diverticulitis, inflammatory bowel disease, cecal volvulus, inguinal or femoral hernias, urinary tract infections, renal stones, and pyelonephritis. In females, organs of...

Right Upper Quadrant Pain

Right upper quadrant pain can be caused by gallbladder disease including acute cholecystitis, biliary colic, biliary dyskinesia, cholangitis, and bile duct obstruction. Other sources of right upper quadrant pain include hepatic dysfunction or abscess, leaking duodenal ulcer, as well as processes outside of the peritoneal cavity, such as a right lower lobe pneumonia. Hepatobiliary disease and gallbladder disease, depending on the severity, require different degrees of intervention. Emergent...

Adrenal Cortex

Cushing syndrome results from exogenous steroid administration or excess endogenous cortisol secretion. The clinical manifestations of Cushing syndrome include HTN, edema, muscle weakness, glucose intolerance, osteoporosis, easy bruising, cutaneous striae, and truncal obesity (buffalo hump, moon facies). Women may develop acne, hirsutism, and amenorrhea as a result of adrenal androgen excess. The most common of Cushing syndrome is iatrogenic, resulting from administration of exogenous...

Laboratory and Radiologic Tests

After collecting the medical history and performing the physical examination, the next step will be to decide which blood work and radiologic tests would aid in diagnosis. When ordering blood work, one should begin to think about whether the patient may need to go to the operating room. If so, what laboratory and diagnostic tests should be done to prepare the patient for surgery General blood work should be ordered, including a CBC to allow for assessment of leukocytosis or blood loss. An...

Elicit a Medical History

The patient reports no past medical history. He has not seen a doctor since he was a child and has had no hospitalizations and no history of past surgeries. He reports smoking a half of a pack of cigarettes per day, moderate alcohol use, and occasional drug use, including marijuana and cocaine. He takes no medications except for an over-the-counter multivitamin daily and ibuprofen for the occasional headache and muscle pain. He has no known drug allergies. At the same time that you have been...

Medical Infections In Surgical Patients

Nosocomial infections are those acquired in the hospital setting, and are therefore common in postoperative patients. Nosocomial infections generally involve more virulent and antibiotic-resistant organisms than community acquired infections. Instrumentation of the respiratory tract such as bronchoscopy, tracheostomy or intubation, and mechanical ventilation increases the risk of nosocomial pneumonia. Nasotracheal intubation and to a lesser degree orotracheal intubation increase the risk of...

Endocrine Pancreas Insulin

As previously mentioned, the pancreas secretes a number of hormones that play an integral role in physiologic equilibrium. The most well known of these is insulin, a product of the b cell that is critical for the maintenance of glucose homeostasis. Insulin was discovered by the Canadian surgeon Frederick Banting for which he was awarded the 1923 Nobel Prize in Physiology Medicine.8,9 Beta cells are stimulated to secrete insulin by glucose as well as hormonal and neural activity. The initial...

Primary Aldosteronism

Primary aldosteronism (Conn syndrome) is a syndrome of HTN and hypo-kalemia caused by hypersecretion of the mineralocorticoid aldosterone. This uncommon syndrome previously accounted for less than 1 percent of unse-lected patients with HTN. However, recent data examining routine screening suggest that aldosteronism may be the cause of up to 15 percent of cases of HTN. An aldosterone-producing adrenal adenoma (APA) is the cause of primary aldosteronism in two-thirds of cases and is one of the...

Interventions and operations

Once a diagnosis has been made of liver or biliary tree pathology via clinical examination, laboratory data in combination with radiologic imaging, a care strategy to relieve symptoms and address the pathology is made. Often, this strategy involves radiologic interventions, surgery, or a combination of these two modalities. Careful planning and a clear understanding of the underlying disease must guide the choice of intervention. A thorough discussion of all potential invention strategies is...

Preoperative Management Of Specific Problems

Prophylaxis for Deep Venous Thrombosis and Pulmonary Embolism The morbidity and mortality of deep vein thrombosis and pulmonary embolism make it mandatory to provide prophylaxis against these catastrophes. Patients at high risk include older individuals, those with previous abdominal surgery, varicose veins, increased antithrombin III levels, history of cigarette smoking, and high platelet counts. The risk is increased in patients older than 40 years who undergo general anesthesia for more than...

Diabetes And Endocrine Disorders

Diabetes mellitus is one of the most common metabolic diseases encountered. The prevalence of diabetes mellitus in both adults and children has been steadily rising in the past 20-30 years. Improved glycemic control has a beneficial effect on microvascular and neuropathic complications in type 2 diabetes, but has no effect on the incidence of macrovascular disease. However, light control of blood pressure (with an ACE inhibitor or a beta-blocker) in patients with type 2 diabetes and...

Clinical Manifestations

Clinical manifestations of hyperthyroidism reflect increased catabolism and excessive sympathetic activity caused by excess circulating thyroid hormones. Symptomatic manifestations of hyperthyroidism include weight loss despite normal or increased appetite, heat intolerance, anxiety, irritability, fatigue, muscle weakness, palpitations, and oligomenorrhea. Signs of hyperthyroidism include goiter, tremor, hyperreflexia, fine or thinning hair, thyroid bruit, muscle wasting, and cardiac...

Pathology and dysfunction

The previous paragraphs stressed the normal anatomy and function, and touched on the problems one might encounter with hepatobiliary disease. The systematic review of all liver diseases is beyond the scope of this chapter however, our focus will be on surgical pathologic states and the most commonly encountered problems on clinical rotations. What soon will be apparent is that many diseases converge in common pathways. Infectious diseases such as hepatitis B and C lead to hepatocytes damage and...

Physiology and function

In general, the liver is the biochemical engine of metabolism. The liver receives one-third of the total cardiac output. The hepatic artery carries 25 percent, the portal vein 75 percent, with the liver subsequently receiving 1.5 L of blood per minute.5 All blood traverses the liver via the portal triads and travels via the hepatic sinusoids to ultimately arrive in the hepatic veins and vena cava. Under normal circumstances, pressure in the portal vein is low, 9-12 mmHg however, a pressure...

Manifestations of HPT

The more common manifestations of HPT include nephrolithiasis, osteoporosis, hypertension (HTN), and emotional disturbances. The widespread use of the multichannel autoanalyzer has led to more patients being diagnosed with asymptomatic hypercalcemia or with earlier symptoms, such as muscle weakness, polyuria, anorexia, and nausea. Differential diagnosis of hypercalcemia includes HPT, malignancy, granulomatous disease (e.g., sar-coidosis), immobility, hyperthyroidism, milk-alkali syndrome, and...

TRAM Flap Reconstruction

A patient must have sufficient tissue in the lower abdomen to be a candidate for this procedure. The volume of tissue must also match the volume of tissue in the contralateral breast one is trying to match. Surprisingly, little tissue is needed to match an A-cup breast, and a large amount of tissue may be transferred to match a very large breast. The resultant shape in these two Table 14-1 Complications of Breast Implant Reconstruction Reoperation Breast pain Wrinkling Asymmetry Replacement...

Endocrine and renal systems

Patients with diabetes mellitus, whether taking oral hypoglycemic therapy or insulin, are commonly found among the surgical population and frequently suffer from its complications, including renal insufficiency, widespread atherosclerosis, coronary artery disease, and hypertension. Tight control of hyperglycemia has been shown to improve surgical outcomes, especially in the neurosurgical, cardiac, and intensive care populations. On the morning of elective surgery, according to current...

Thyroiditis

Thyroiditis represents a diverse group of autoimmune and inflammatory disorders characterized by infiltration of the thyroid with inflammatory cells and subsequent fibrosis of the gland. Hashimoto's thyroiditis is a chronic autoimmune disorder characterized by destructive lymphocytic infiltration of the thyroid. The disease is 15 times more common in women, and more than 90 percent of patients have circulating antibodies directed against thyroid microsomes and thyroglobulin. Patients are...

Hypothyroidism

Hypothyroidism is almost always caused by primary hypofunction of the thyroid gland. Clinically, hypothyroid patients should be separated into those without goiter (primary atrophy), those with goitrous hypothyroidism (i.e., Hashimoto's thyroiditis, drug-induced hypothyroidism, iodine deficiency, and congenital causes of dyshormonogenesis), and those with postablative hypothyroidism (after thyroidectomy or treatment with RAI). Postablative hypothyroidism and Hashimoto's thyroiditis are the most...

References

Swaged Needle

An overview of nosocomial infections, including the role of the microbiology laboratory. Clin Microbiol Rev 6(4) 428-442, 1993. 2. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol 20(4) 247-278, 1999. 3. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med 326 281-286, 1992. 4. Bratzler DW, Houck PM,...

Lichtenstein Repair

The most commonly performed method of inguinal hernia repair in the United States is the tension-free mesh repair introduced in the 1980s by Irving Lichtenstein.24'29'30 It involves placing a piece of mesh, typically polypropylene, to fill the space between the conjoint tendon transversalis fascia superiorly, and the inguinal ligament inferiorly. The mesh scars in place, and the scar acts to prevent recurrence. The conjoint tendon transversalis fascia are sutured to the mesh patch superiorly,...

Urethral Catheterization

Urethral catheterization is a useful procedure for the surgical patient. One of the more important indications for this procedure is to accurately measure urine output. Urine output is a critical parameter for the patient's hemody-namic status. Another indication is the relief of urinary retention, which could be due to medications, neurologic injury, or loss of bladder tone. Temporary treatment of urinary incontinence, collecting urine for bacterial culture, and treatment of perineal wounds...

Info

The most common organisms include Escherichia coli, E. faecalis, and E. faecium, but a wide variety of organisms are seen. Unlike more benign outpatient UTIs, catheter-related infections require a longer course of treatment of 10-14 days. Administration of preoperative antibiotics immediately prior to skin incision has recently been shown to decrease the rate of wound infection, although there is no evidence that there is a benefit from continuing them into the postoperative period. The...

Initial Evaluation

The initial evaluation of a patient with abdominal pain is extremely important. The physician's ability to collect a comprehensive medical history and perform a complete physical examination in a timely fashion is now often eclipsed and compromised by the facility of ordering a radiologic or serologic test and expecting that a single test will give the diagnosis. Although the sensitivity and specificity with which many tests can now aid in diagnosis often range in the upper 90th percentile, it...

Special Section on Drugs Anxiolytic of choice

A common anxiolytic that is used is lorazepam (Ativan), a benzodiazepine with rapid onset and moderate duration 0.5-2 mg IV is the recommended dose, but start with 0.5 mg at first and then give additional 0.5 mg doses every 5-10 min until the total dose is reached. Midazolam (versed), which is commonly used for procedures such as colonoscopy, is not ideal because it is too short acting and requires frequent dosing. The maximum dose of 1 percent lidocaine that one can use is 500 mg (based on 70...

Gastric cancer

Gastric cancer, or cancer of the stomach, is the second leading cause of cancer deaths worldwide. However, there are considerable differences in the geographic distributions of gastric cancer.11,12 In fact, in Japan where gastric cancer is a relatively common malignancy, screening for gastric cancer rivals the western practice of screening for colon cancer. The overwhelming majority (90-95 percent) of gastric cancers are adenocarcinomas arising from mucous producing cells of the gastric mucosa...

Midepigastric Pain

Midepigastric pain is associated with early stages of acute appendicitis, acute small bowel obstruction, peptic ulcer disease, and acute pancreatitis. Pancreatitis, depending on the etiology of the inflammation, including gallstones, alcohol or idiopathic causes, requires different types of intervention. Gallstone pancreatitis is one of the few types of pancreatitis that require early surgical intervention. It occurs when gallstones become lodged in the pancreatic duct causing obstruction and...

Myocardial Infarction

The incidence of postoperative MI varies from 0.4 to 12 percent depending on the patient population and the manner studied. Patients at highest risk include those with preoperative congestive heart failure, ischemia, who are over 70 years of age, those with other comorbidities such as diabetes mellitus, renal insufficiency, or other atherosclerotic disease (e.g., carotid artery stenosis and peripheral vascular disease). The most recent data on perioperative MI show that those at the highest...

Treatment

Because there is no cure for chronic pancreatitis, therapeutic options are based on controlling the symptoms. These should include abstinence from alcohol, which has been shown to decrease the degree of pain. Patients require narcotics for relief of abdominal pain, and drug dependence is common in this population. Pancreatic enzyme replacements and dietary fat restriction are used to treat steatorrhea, and diabetes is managed with standard, intermittent insulin injections. The management of...

Hematologic Disorders Affecting the Spleen Hereditary Spherocytosis

Hereditary spherocytosis is an autosomal dominant genetic defect resulting in the absence of spectrin, an RBC membrane protein, which results in the loss of RBC membrane plasticity. The rigid RBCs are unable to pass through the splenic vasculature, resulting in RBC trapping and increased rate of RBC destruction within the spleen. The RBC trapping in the spleen results in massive splenomegaly, as well as anemia and jaundice from increased bilirubin production from hemoglobin breakdown. The...

P

Figure 14-3 TRAM flap breast reconstruction.The dotted line is the tissue carried with the flap which can be used to replace missing breast skin and fat tissues. (1) Internal mammary vessels exposed after rib removal for recipient site for free flap reconstruction. (2) Thoracodorsal vessels also used for recipient vessels. (3) Mastectomy defect awaiting reconstruction. (4) Muscle pedicle used for pedi-cled TRAM flaps based on the superior epigastric system. (5) Deep inferior epigastric vessels...

Des

Nissen Fundopli

Simultaneous (nonperistaltic) contractions Repetitive (at least three peaks) Increased duration (> 6 s) Spontaneous contractions Intermittent normal peristalsis Contractions may be of increased amplitude Nutcracker esophagus Mean peristaltic amplitude (10 wet swallows) in distal esophagus > 180 mmHg Increased duration of contractions (> 6 s) frequent Normal peristaltic sequences Hypertensive LES LES pressure > 45 mmHg but with normal relaxation Nonspecific esophageal motility disorders...

Insulinoma Clinical Features

Patients with insulinoma develop profound hypoglycemia during fasting or after exercise. The clinical picture includes the signs and symptoms of neu-roglycopenia (anxiety, tremor, confusion, and obtundation) and the sympathetic response to hypoglycemia (hunger, sweating, and tachycardia). These bizarre complaints initially may be attributed to malingering or a psychosomatic etiology unless the association with fasting is recognized. Many patients eat excessively to avoid symptoms, causing...

Unusual Islet Cell Tumors

VIPomas secrete vasoactive intestinal peptide and cause profuse secretory diarrhea (fasting stool output greater than 1 L day), hypokalemia, and either achlorhydria or hypochlorhydria (watery diarrhea, hypokalemia, and achlorhydria or Verner-Morrison syndrome). Hyperglycemia, hypercalcemia, and cutaneous flushing may be seen. Other, more common causes of diarrhea and malabsorption must be excluded. A diagnosis of VIPoma is established by the finding of elevated fasting serum vasoactive...

Direct Inguinal Hernia

Direct inguinal hernias are generally acquired in origin, arising as a result of an imbalance between intra-abdominal stresses and the strength of the abdominal wall. The stresses alone cause weakening of the wall, and when the strength of the abdominal wall is exceeded, herniation occurs. The etiologic factors in direct hernia thus relate to conditions with high intra-abdominal pressure and thus, wall stresses , and loss of structural integrity of the abdominal wall. High intra-abdominal...

Cellular system

Various cells have a specific role during wound healing and are briefly described in the following section. Contraction is an active and essential part of the repair process to close the gap in soft tissues. A contracture, on the other hand, is an undesirable result of healing due to contraction, fibrosis, or other type of tissue damage.3 Myofibroblasts are responsible for wound contraction. These cells differ from regular fibroblasts due to their cytoplasmic microfilaments similar to those of...

Hypertension

Hypertension is a minor clinical predictor of increased preoperative cardiovascular risk. Hypertension is classified as primary essential or idiopathic in 95 percent of cases. Secondary hypertension is found in 5 percent of patients. The five most common causes of secondary hypertension include renal artery stenosis, primary hyperaldosteronism, Cushing syndrome, pheochromocytoma, and aortic stenosis. Several studies have suggested that intraoperative blood pressure changes may be greater in...