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(BQ) Part 2 book The mont reid surgical handbook presents the following contents: Benign and malignant liver lesions, renal transplantation, liver transplantation, pancreas transplantation, malignant skin lesions, diseases of the breast, breast reconstruction, gastric tumors, malignant pancreas disease, colorectal cancer,... and other content.
Benign and Malignant Liver Lesions Andreas Karachristos, MD, PhD The presence of solid asymptomatic liver lesions is increasingly recognized because of the availability of sophisticated imaging Management depends on knowledge of the pathology, radiologic appearance, and clinical behavior of each lesion Generally, liver lesions can be morphologically differentiated into solid and cystic The most common diagnosis of each category is described in this chapter, and a common clinical problem for each is discussed 48 briefly I SOLID LIVER LESIONS Most importantly, one must differentiate between malignant and benign disease, and if benign (which is far more common), whether the patient needs any further follow-up or treatment A BENIGN Hemangioma a This is the most common benign tumor; prevalence rate is 7% to 20% in ultrasound and autopsy series Female/male ratio is 3:1 b Vascular malformation that enlarges by ectasia c Generally remains stable over time but occasionally may demonstrate growth Rapid expansion may cause symptoms by stretching of Glisson’s capsule or pressure on neighboring organs d In contrast-enhancing computed tomography (CT), during the arterial phase, the tumor appears as a sharply defined mass with sequential globular opacification from “outside in.” In magnetic resonance imaging (MRI), the tumor appears higher in signal density on T2-weighted images e Technetium-99m pertechnate-labeled red blood cell scan can usually provide definitive diagnosis f The majority of patients can be managed by observation alone g Resection or enucleation is indicated in symptomatic patients or inability to exclude malignancy Usually hemangiomas smaller than 10 cm not produce symptoms h Kasabach-Merritt syndrome is a rare entity of giant hemangioma associated with diffuse intravascular coagulopathy Patients need urgent therapy including embolization or resection with concomitant treatment of coagulopathy Focal nodular hyperplasia (FNH) a FNH is the second most common benign liver tumor Autopsy series show a prevalence rate of 0.31% Occurs in male and female individuals but more common in female sex 531 532 Hepatobiliary Surgery b Developmental vascular malformation that induces a vascular hyperplastic process Unclear relation with oral contraceptives c Majority of patients are and remain asymptomatic; however, symptoms occur in up to 10% of patients d In contrast-enhanced CT, it appears as homogenous hyperattenuating in arterial phase with central scar and radiating bands In MRI, T1-weighted images appear isointense or slightly hypointense, and T2-weighted images appear isointense or slightly hyperintense e Technetium-99m–labeled sulfur colloid scan may be useful in confirming diagnosis f The lesion that resembles FNH is fibrolamellar carcinoma g The majority of patients can be managed by observation alone In asymptomatic patients, if definite diagnosis is provided by imaging, no further follow-up is necessary Hepatocellular adenoma (HA) a Rare, benign proliferation of hepatocytes b The annual incidence is approximately in 1,000,000 people in noncontraceptive users, and the risk is increased 500-fold in women who are long-term users c Female/male ratio is up to 11:1 d Documented link with long-term oral contraceptive use e More patients with HA are symptomatic than with FNH Up to one third can present with acute rupture f HAs can undergo malignant transformation, although the exact risk is not well defined g Usually are solitary but can be multiple in up to 30% of cases h In contrast-enhanced CT, adenomas often demonstrate moderate enhancement during the arterial phase that tends to be less than that seen in FNH In MRI, the majority of adenomas are hyperintense in T1-weighted images and isointense or hyperintense on T2-weighted images There is overlap with FNH, and it sometimes is difficult to differentiate the tumor i Most HAs should be resected Discontinuation of oral contraceptives should be advised j Behavior of HAs during pregnancy is unpredictable; therefore, it may be advisable to resect them before pregnancy k Ruptured adenomas are often surgical emergencies Embolization may be helpful to stabilize the patient B MALIGNANT Metastatic lesions to the liver a Metastatic lesions are the most common malignant lesions to the liver, mainly from colorectal, lung, pancreas, breast, carcinoid, neuroendocrine, and urogenital cancer Metastasis from colorectal cancer is the most common form, and resection in selected patients provides a survival advantage Benign and Malignant Liver Lesions 533 BENIGN AND MALIGNANT LIVER LESIONS b The liver is the second most common site of colorectal metastases after the lymph nodes: 25% of all patients with colorectal cancer will have hepatic metastases at presentation, and 50% will experience development of them in the future c Nearly 10% of these patients will be amenable to aggressive surgical treatment d Keep in mind that in a patient with known malignancy, the likelihood of a solitary liver mass Յ1 cm being a metastasis is less than 20% e Most metastases, including colorectal, are hypovascular and appear to be hypoattenuating on portal venous CT images During the arterial phase, they most commonly appear with a ringlike peripheral enhancement 48 f Hypervascular metastases are renal cell carcinoma, carcinoid tumors, adrenal tumors, thyroid carcinoma, pancreatic islet cell tumors, and neuroendocrine tumors g Colorectal liver metastases are associated with elevated carcinoembryonic antigen h Previously, colorectal liver metastases were considered resectable under the following circumstances: four or fewer lesions occupying one lobe, with a margin of at least cm i Recently, improved combination chemotherapy has significantly improved survival j Criteria for resection include: (1) Patient is fit for surgery (2) All detectable liver tumors can be removed, leaving adequate liver parenchyma, as long as a clear margin can be achieved (3) At the University of Cincinnati, the following algorithm is applied: (a) For patients with resectable metachronous metastases, immediate surgical resection is an attractive option (b) For patients with questionably resectable lesions or in whom negative margins may be difficult to achieve, as well as in those patients with synchronous metastases or recurrent disease, neoadjuvant chemotherapy followed by restaging and resection, if possible, is a better option (c) For patients who are surgically resectable but not have adequate hepatic reserve, portal vein embolization (which is thought to increase the size of the remaining liver) is an attractive adjunct before resection (d) Finally, in those patients who remain unresectable despite all these measures, radiofrequency ablation should be strongly considered Primary hepatocellular carcinoma (HCC) a This is one of the most common cancers worldwide Its incidence in the United States is relatively low: approximately cases (of liver and intrahepatic biliary cancers) per 100,000 people Male/female ratio is 3:1 Consensus exists among experts that the incidence is increasing 534 Hepatobiliary Surgery b The most common causative factor is the presence of cirrhosis Hepatocellular injuries related to alcohol, hepatitis C infection, hepatitis B infection, and fatty liver disease (nonalcoholic steatohepatitis) are the leading causes in the United States Other causes are hemochromatosis, Wilson’s disease, tyrosinemia, ␣-1-antitrypsin deficiency, and BuddChiari syndrome c Symptoms of malignancy are common at the time of presentation and may include anorexia, weight loss, lethargy, nausea, right upper quadrant pain, and symptoms related to cirrhosis, such as ascites, jaundice, and encephalopathy d The radiologic appearance of HCC is quite variable In contrastenhanced CT, it most commonly appears as a transiently heterogeneously hyperattenuating mass in the arterial phase Vascular invasion or vein thrombosis may be present e ␣-Fetoprotein level is increased in approximately 75% of HCCs, but it is nonspecific and related to size Percutaneous biopsy of a suspicious lesion should be performed with caution because of the risk for needle seeding (approximately 2%) ␣-Fetoprotein level Ͼ200 ng/ml together with an imaging study showing a hypervascular mass is considered diagnostic of HCC f Options that improve survival include liver resection or liver transplantation Management depends on the extent of the disease Important preoperative determinants are presence of vascular invasion, multiple tumors, and presence of hepatic fibrosis, as well as the general condition of the patient In general, Child A and early B (Child–Pugh–Turcotte score Յ8) patients are offered resection, and late B and C patients are best treated by transplantation The best outcomes in liver transplantation are achieved when there is one tumor less than cm or no more than three tumors, none of them more than cm, without vascular invasion (Milan criteria) g Recently, radiofrequency ablation has been shown to have comparable results with resection for small HCCs Other treatment options for inoperable patients used at the University of Cincinnati are transarterial chemoembolization and transarterial yttrium-90 theraspheres h Fibrolamellar carcinoma is a variant of HCC that is more common in young women ␣-Fetoprotein is usually normal, is not associated with liver disease, and has better prognosis than HCC Therapy is complete surgical resection Must be differentiated from FNH Intrahepatic cholangiocarcinoma a This is the second most common liver cancer after HCC Originates from intrahepatic bile ducts b In most patients, the tumor is discovered incidentally c Most patients not have underlying liver disease d On CT, usually appears as a large hypovascular tumor with central necrosis It is important to identify before surgery the extent of the portal or hepatic artery involvement Benign and Malignant Liver Lesions 535 e Resection with negative margins remains the only viable therapy Chemotherapy or radiotherapy has not been shown to improve survival II CYSTIC LESIONS Cystic lesions of the liver are also quite common Most are benign Cystic neoplasms are complex lesions and rare Following is an outline of the most common cystic lesions A BENIGN Pyogenic hepatic abscess a Results from bacterial infection of the liver parenchyma b Most common cause is ascending cholangitis (caused by lithiasis, cancer, or manipulation), followed by pyelophlebitis (complicated appendicitis, diverticulitis, pancreatitis, inflammatory bowel disease) or any other cause of intraabdominal sepsis, septicemia, direct extension, or trauma c No clear causative factor can be identified in 20% to 45% of cases d Most common organisms are aerobic gram-negative (Escherichia coli, Klebsiella spp, Enterococcus spp), Streptococcus spp, Staphylococcus aureus, and anaerobes (Bacteroides sp, Clostridia) Fungal abscesses are common in immunocompromised patients e Blood cultures are positive in only 50% of patients at presentation 48 BENIGN AND MALIGNANT LIVER LESIONS Clinical scenario: A 39-year-old woman after injury during exercise had persistent right upper quadrant pain Her primary care physician ordered an ultrasound that showed a 4-cm solid mass in the right lobe of the liver The patient was referred for further management In differentiating between the above entities, one must consider the age of the patient, history or clinical signs of liver disease, or any history of malignancy A breast examination, liver palpation for presence of hepatomegaly, and rectal examination are of paramount importance Laboratory tests are in order: a complete blood cell count, liver function tests, and serology for hepatitis B and C viruses, as well as tumor markers ␣-fetoprotein, carcinoembryonic antigen, and CA 19-9 In one study, all patients with asymptomatic liver lesion and age older than 55, with increased alkaline phosphatase level and hepatomegaly, had cancer An imaging study should be ordered next At the University of Cincinnati, a triple-phase liver CT is the modality of choice and provides helpful insight If malignancy cannot be excluded by imaging, then one should proceed with laparoscopic or open biopsy and/or resection Percutaneous biopsy of benign lesions often gives indeterminate results In addition, when HCC is suspected, percutaneous biopsy should be avoided because of the risk for seeding This particular patient had no history of liver disease, normal laboratory tests, and a CT suggestive of FNH An MRI scan confirmed the result The patient will be managed with another MRI in months, and if the lesion is unchanged, no further follow-up is necessary She was advised to avoid oral contraceptives, and the pain resolved with symptomatic therapy 536 Hepatobiliary Surgery f Clinical presentation is often subacute, and mild symptoms may precede admission Fever, right upper quadrant pain, and hepatomegaly are common symptoms and signs g Characteristic contrast CT appearance is that of a round or irregularly shaped hypoattenuating mass with a peripheral capsule that shows enhancement h Once the diagnosis has been made, broad-spectrum antibiotics (piperacillin/tazobactam) should be started and modified according to available cultures i Antibiotic therapy is not enough Percutaneous catheter drainage is the usual treatment modality If lithiasis or biliary strictures are present, they should be treated with ERCP or surgery The underlying source, if present, should be treated j Surgical drainage is indicated when percutaneous drainage has failed (48 hours after percutaneous drainage without improvement), location inaccessible to percutaneous drainage, multiloculated abscesses, or concomitant pathology that requires surgery k Mortality rate has significantly declined since the late 1980s, reaching 2% to 6% in many recent series Ruptured hepatic abscess carries a high mortality rate of 30% to 43% Amebic hepatic abscess a Caused by entamoeba histolytica Travels to the liver from the intestines via the portal blood b A concomitant hepatic abscess is found in only one third of patients with amebic colitis Male/female ratio is 10:1 Usually patients have a history of traveling to a tropical area c Typically, the onset of the illness is abrupt with right upper quadrant pain, fever, anorexia, and acute colitis d Diagnosis is made by serum indirect hemagglutination assay e Findings in CT are nonspecific and usually appear as solitary, round, hypoattenuating mass with an enhancing ring; 70% to 80% of the abscesses occur exclusively in the right lobe f Usually therapy with metronidazole (750 mg three times daily for 5–10 days) is effective, with a 95% success rate Echinococcal cysts a Hydatid disease is caused by the dog tapeworm Echinococcus granulosus, with sheep being the usual intermediate host b Humans ingest ova shed in the feces of the host The ova penetrate the intestinal wall, pass the portal circulation, enter the liver, and from there the lungs, brain, and bones c E granulosus has an active cyst wall consisting of a germinal layer and a laminar layer A reactive fibrous layer surrounds the active cyst, called the pericyst, which becomes calcified in 50% of liver cases The germinal layer produces the daughter cysts d Liver cells undergo liquefaction necrosis and produce a cavity filled with pus appearing as “anchovy paste.” Benign and Malignant Liver Lesions 537 BENIGN AND MALIGNANT LIVER LESIONS e Diagnosis is made by enzyme-linked immunosorbent assay or indirect hemagglutination tests Eosinophilia is present in 40% of cases f Classic ultrasonographic or CT findings are a thick wall, often with calcifications and with daughter cysts g Most cysts are asymptomatic at presentation Patients with complicated conditions present with cholangitis from rupture into a bile duct or with acute abdomen and anaphylaxis from rupture into the peritoneal cavity h Medical therapy with albendazole (the best regimen) has a less than 30% success rate i Definitive therapy includes complete excision of living parasites j Extreme caution should be used to avoid spillage, and all surrounding tis- 48 sues should be packed with 20% normal saline–soaked gauze Open cyst evacuation with aspiration of the contents and removal of the active cyst lining, complete pericystectomy, or liver resection are acceptable options k If the patient presents with jaundice or cholangitis, then ERCP with sphincterotomy should precede surgery Simple hepatic cyst a Prevalence rate of asymptomatic liver cysts in ultrasound or CT series is approximately 3% in adults Equal distribution among sexes, although symptomatic cysts are more common in female individuals b Adult polycystic kidney disease is associated with liver cysts in approximately 60% of patients c In general, these cysts grow slowly, lack septa, and not have malignant potential In most cases, they are asymptomatic and only large cysts produce symptoms Therefore, any patient with abdominal pain and simple liver cysts should be evaluated for other pertinent pathology d Most patients not require any treatment In symptomatic patients, laparoscopic or open fenestration and rarely partial liver resection are acceptable treatments Hepatic cystadenoma a Uncommon single, usually large tumor b Abdominal pain or discomfort is common presenting symptom because of size c Ultrasonography is probably the best modality and shows a single large fluid-filled cyst with irregular margins, septations, and mural nodules d Must be differentiated from hydatid cyst and simple cyst e Treatment is complete surgical resection B MALIGNANT Cystic subtypes of primary liver neoplasms These lesions are rare and usually are the result of central necrosis or systemic or local treatment The two most common neoplasms that can present as cystic lesions are HCC and giant hemangioma Characteristic CT features of the mass and liver parenchyma will help identify the nature of these lesions 538 Hepatobiliary Surgery Cystic metastases Cystic metastases may be seen in mucinous adenocarcinomas from colorectal or ovarian origin Also, hypervascular metastases, such as carcinoid, neuroendocrine, sarcoma, and melanoma, may have cystic appearance because of central necrosis Clinical scenario: A 42-year-old man presents to the emergency department with a 1-week history of malaise and currently fever up to 102°F, upper abdominal discomfort, diaphoresis, and tachycardia An upper abdominal ultrasound showed at least two separate large (7 and cm) cystic lesions in the right lobe of the liver Again, history and physical examination are of paramount importance History of recent travel to tropical areas, pathology related to the liver, and recent therapeutic interventions to the liver and bile ducts, as well as recent history of intraabdominal infections, should be defined in detail A triple-phase CT should be ordered to better delineate the lesion At the same time, serology for hydatic and amebic disease should be ordered Our patient was resuscitated, and intravenous broad-spectrum antibiotics were started immediately CT showed lesions compatible with pyogenic abscesses that were subsequently percutaneously drained His condition did not improve and a new CT scan 30 hours later showed that the abscesses were enlarged He underwent a formal right lobectomy Gallbladder was significantly inflamed He had an uneventful postoperative course RECOMMENDED READING Blumgart LH (ed): Surgery of the Liver and Biliary Tract, 4th ed Saunders, 2007, Philadelphia Cameron JL (ed): Current Surgical Therapy, 9th ed Mosby, 2004, St Louis Lee JKT, Sagel SS, Stanley RJ, Heiken JP (eds): Computed Body Tomography with MRI Correlation, 4th ed Lippincott Williams & Wilkins, 2006 Renal Transplantation Dong-Sik Kim, MD I A a b a b c d a b c d e EVALUATION OF CANDIDATES FOR TRANSPLANTATION QUALIFICATIONS Criteria End-stage renal disease from a variety of causes Patient life expectancy longer than graft half-life Absolute contraindications Malignancy Current infection Hepatitis Human immunodeficiency syndrome Relative contraindications History of noncompliance Malnutrition Severe cardiovascular disease Substance abuse High likelihood of recurrent renal disease (e.g., primary oxalosis) B a b c d a PATIENT EVALUATION Detailed history and physical examination with special emphasis on: Underlying renal disease Estimated urine output Cardiovascular history History of infectious disease Routine pretransplant studies Routine screening laboratory studies; renal panel, liver function tests, complete blood cell count, coagulation screen, urinalysis, calcium, phosphorus, magnesium Hepatitis screen, human immunodeficiency syndrome, Venereal Disease Research Laboratory, viral titers (cytomegalovirus, Epstein–Barr virus, varicella), throat and urine cultures, tuberculin skin test Chest radiograph, electrocardiogram Blood typing, human leukocyte antigen (HLA), panel-reactive antibodies Indication for pretransplantation native nephrectomy Chronic renal parenchymal infection Infected stones Heavy proteinuria Intractable hypertension Polycystic kidney disease that is massive, recurrently infected, or bleeding Acquired renal cystic disease with suspicion of adenocarcinoma Infected reflux b c d a b c d e f g 49 541 542 Transplant Surgery II IMMUNOLOGY OF RENAL TRANSPLANTATION A ABO ANTIGENS The ABO blood group antigens behave as strong transplantation antigens, and transplantation across ABO barriers usually leads to irreversible hyperacute rejection Disproportionate percentage of waiting patients who are type O or B generally mandates that ABO identity (same blood type) rather than ABO compatibility (B → B or O) determines the distribution of deceased donor kidneys For living-related donor transplantation, ABO compatibility is adequate A2 kidneys can be safely transplanted into O or B recipients with low preoperative titers of isoagglutinin ABO-incompatible transplants may be performed if isoagglutinins are removed by splenectomy and plasmapheresis B HLA MATCHING IN TRANSPLANTATION Class I antigens consist of A, B, or C loci antigens located on the surface membranes of all nucleated cells Class II antigens consist of DP, DQ, and DR loci found primarily on immune, dendritic, and endothelial cells In clinical transplantation, the most important major histocompatibility genes are HLA-A, -B, and -DR HLA-DR matching provides a greater benefit than class I antigen matching C PANEL-REACTIVE ANTIBODY The patient’s serum is incubated separately with B and T cells from a panel of donors selected to represent the HLA antigens commonly found in the local population The results are usually expressed as the percentage of panel cells that are killed by the serum The anti-HLA antibodies that are detected are called panel-reactive antibodies The finding of 60% of panel-reactive antibodies suggests that 60% of donors will be unacceptable for the patient because there are circulating antibodies that react with one or more of the donor’s HLA antigens D CROSS-MATCH The cross-match test is the final pretransplant immunologic screening step The presence of cytotoxic IgG antidonor HLA antibodies is a strong contraindication to transplantation Preliminary cross-match is performed by testing donor lymphocytes with stored sera of patients at the time of donor HLA typing Postoperative care (Cont’d) pulmonary, 50 renal, 51 Postoperative fever, 455 Postoperative nausea and vomiting (PONV) for general anesthesia, 181 risk factors of, 191 treatment of, 191 Postpericardiotomy syndrome, 456 Postthrombotic syndrome, 365 Potassium, basic physiology of, 60 Poupart’s ligament, 229 Povidone-iodine-(Betadine), 844 PP-cells, 323 Precautions, standard See Standard precautions Preeclampsia, pregnancy-related complications, 354 Pregnancy appendicitis and, 213 breast cancer and, 588 gallstone disease in, 523 management of, 701 operative treatment of, 700 trauma and, 681 Preload, in shock, 107 Preoperative care antibiotics in, 47 general, 46–50 operation, need for, 39 operative risk, assessment of age, 39 cardiovascular risk, 40 endocrine risk, 42 hematologic risk, 43 hepatic risk, 42 nutritional-immunologic risk, 43 operation, urgency of, 39 renal risk, 42 operative risk, intervention to reduce emergent operations, 43 endocrine, 46 hematologic, 46 hepatic, 45 nutrition, 46 renal, 45 respiratory, 45 Preperitoneal repair, on femoral hernias, 236 Preperitoneal space bleeding in, 237 inguinal anatomy in, 239f Preperitoneal space, anatomy of, in hernia repair, 238 Presentation, 782 Present illness, Pressure, arterial, 122 Pressure therapy, 94 Pressure ventilation, noninvasive positive, 128 Primary tumor, 621 Procaine, injectable agents, 167 Procedures, FDA approval of, on robotic surgery, 810t Process neuropathic, 255 retroperitoneal, 255 Proctocolectomy, 304 Progesterone, 570 Prolactin, 570 Prophylactic antibiotics, indications for, 47 Prophylaxis bacterial endocarditis, 47 caused by wild animals, 830 with proton-pump inhibitors, 250 Propofol metabolism of, 187 side effects, 187 uses of, 187 Propofol (Diprivan), 179 Propylthiouracil and methimazole, 639 Proteins, rapid-turnover, in malnutrition, 74 Prothrombin time, 182 Protocols, postexposure, 97 Proton-pump inhibitors (PPIS), 249 Proton-pump inhibitors, prophylaxis with, 250 Pruritus ani causes of, 316 diagnosis of, 317 treatment for, 317 Pruritus, jaundice and, 509 Pseudocyst, 333 spleen and, 349 933 INDEX Index 934 Index Pseudohyperkalemia, 61 Pseudomonas, multidrug-resistant organisms, 160 Psoas sign, 208 Psyllium seed (Metamucil), 78 Puestow procedure, for chronic pancreatitis, 340 Pulmonary artery catheterization, in shock, 108, 110 occlusion pressure, 124 Pulmonary artery catheter, 120 Pulmonary aspiration, recommendations to reduce risk for, 177t Pulmonary care, postoperative, 50 Pulmonary contusions, 710 Pulmonary disease, 354 Pulmonary embolism (PE), 363, 368–369 Pulmonary risk, in preoperative care, 41 Pulsation, 32 Pulse in acute abdomen, 199 in gastrointestinal bleeding, 244 Pulse oximetry, 119 conscious sedation and, 177 in surgical patients, 22 Punch biopsy, 566 Puncture arterial, 873 arterial versus venous, 874 Purkinje fibers, bupivacaine for, 168 PVD See Peripheral vascular disease Pyelophlebitis, 535 Pyoderma gangrenosum, 163, 289 Pyogenic hepatic abscess, 535 Pyrazinamide, antituberculosis agents, 150t Pyridostigmine, 188 R Rabies, caused by rabies virus, 830 Rabies immunization, 91 Raccoon eyes, 24 Radial nerve block, 172 Radial segmentectomy, 598 Radiation arteritis, 417 Radiation therapy for basal cell carcinoma, 563 gallbladder and, 530 for gastric lymphoma, 607 surgical excision with, 94 Radiography abdominal, 145 chest, 145 for jaundice, 511 of lumbar spine, 319 mesenteric venous thrombosis and, 428 for mucous gland adenoma, 459 of pelvis, 319 preoperative, 47 for surgical infection, 145 for thoracic trauma, 704 in wound closure, 829 Radioiodine ablative therapy, 639 Radiology, for lung carcinoma, 470 Radionucleotide imaging, in renal transplantation, 546 Radionuclide HIDA scan, gallstone and, 218 Radiotherapy chemotherapy and, 486 to chest/breast disease, 586 malignant esophagus and, 486 Ransohoff’s sign, 200t Ranson’s criteria, 332, 333t Rapamycin inhibitors, 543 RBC count, autologous, 137 RBC disorders, splenectomy and, 344 Rectal bleeding, hemorrhoids as cause of, 309 Rectal cancer diagnosis and treatment of, 625 operative approach, 625 postoperative follow-up, 625–626 stage-specific therapy, 624 Rectal prolapse, depiction of, 319f Rectal sling (Ripstein procedure), 320 Rectovaginal fistula, 305 Rectus diastasis, 231 Red blood cells blood component therapy and, 136–137 Red blood cells (Cont’d) indications, 137 specifics of transfusion, 136–137 Red cell aplasia, autoimmune disorders, 476 Refeeding syndrome, 84 Referred pain, diagram of, 196f Regional lymph nodes, 621 Renal artery and vein, 545 Renal artery bypass, 435 Renal artery disease consequence of, 392 developmental, 431 diagnosis of, 393 epidemiology of, 392 history of, 392 pathophysiology of, 392 Renal artery stenosis, 546 Renal artery thrombosis, 761 Renal biopsy, in renal transplantation, 546 Renal failure, 77 in cardiac surgery, 454 hypercatabolism of, 80 Renal formulation, in parenteral nutrition, 82 Renal laceration, depiction of grades of, 762f, 763f Renal risk, in preoperative care, 42 Renal transplantation complications of, 546–547 immunology of, 542–543 medical complications of, 547 postoperative considerations, 545–546 statistics of, 547 survival benefit of, 547 Renin-angiotensin-aldosterone system (RAS), 158, 392 Renin-angiotensin system, 657 to prevent renal parenchymal injury, 429 Renin secretion, 657 Renin, 429 Renovascular hypertension additional features, 430 arterial studies contrast angiography, 433 magnetic resonance angiography, 433–434 Renovascular hypertension (Cont’d) spiral computed tomography with angiography, 434 atherosclerosis, 430 background of, 429 causes of, 431 clinical findings of abdominal bruit, 432 hypertension, 432 renal function, 432 endovascular therapy transluminal renal angioplasty, percutaneous/ stent placement, 435 fibromuscular dysplasia, 430–431 functional studies ACE inhibitors, 433 captopril renal scan, 433 renal vein renin assay, 433 intimal fibrodysplasia, 431 medial fibroplasia, 431 medical therapy, 434 nephrectomy, 436 pharmacologic management of, 434 renal artery disease, developmental, 431 renin-dependent disease, 430 screening studies duplex ultrasound, 432 intravenous pyelogram, 433 laboratory, 432 specific functions ACE, 429 aldosterone, 430 angiotensin II, 429 renin, 429 surgical outcomes of, 436 surgical therapy hepatorenal, 435 renal artery revascularization, 435 renal endarterectomy, 435 splenorenal bypass, 435 volume-dependent disease, 430 Repaglinide (Prandin), 371 Replacement therapy, of parenteral fluids, 67t 935 INDEX Index 936 Index Residency Review Committee (RRC), on surgical education, Respiratory acidosis causative factor of, 70 diagnosis of, 70 treatment of, 70 Respiratory alkalosis causative factor of, 71 diagnosis of, 71 treatment of, 71 Respiratory, catastrophes and, 185 Respiratory disorders, primary, 70 Respiratory failure, in cardiac surgery, 454 Respiratory muscle fatigue, mechanical ventilation and, 130 Respiratory rate, in acute abdomen, 199 Resuscitation calculations of, 728t esophageal rupture and, 275 goals of, 728 interventions during, 705 Retinoblastoma protein (pRB), 627 Retinopathy, pancreas transplantation and, 555 Retrograde urethrogram (RUG), 759 Retroperitoneal process, 255 Revascularization therapy, 387 Reynolds’ pentad, 224, 506, 521 Rheumatoid arthritis, 173 Richter’s hernias, 232, 233f Rifampin, antituberculosis agents, 149t Right lower quadrant (RLQ), 208 Right ventricular end-diastolic volume (RVEDV), 124 Ringer’s solution, 112 Ringer’s solution, lactated, 66 Risk cardiovascular, 40 endocrine, 42 hematologic, 43 hepatic, 42 nutritional-immunologic, 43 pulmonary, 41 renal, 42 Risk group analysis, 646t Robinson catheter, 840 Robotic surgery, 810–811 Rocuronium, 188 Ropivacaine, local anesthetics, 189 Rotter’s nodes, 569 Rovsing’s sign, 201t Rovsing’s sign with palpation, 208 Rubber band ligation, 309 S SAH See Subarachnoid hemorrhage Saphenous vein, 435 SBO See Small-bowel obstruction SBTs See Spontaneous breathing trials Scarpa’s fascia, 228 Scars, hypertrophic, 94 Schatzki’s ring, 270 Schistosomiasis, in sub-Saharan Africa, 492 Schwann cells, 460 Sciatic hernias, 232 Scintigraphy, for adrenal gland, 659 Scleroderma, 268 Sclerosant injection, 499 Sclerosing cholangitis, in chronic pancreatitis, 338 Sclerosing hemangioma, 459 Sclerotherapy for benign colorectal disease, 309 for gastrointestinal bleeding, 249 SDH See Subdural hematoma Secretin stimulation test, 668 Sedation, 174t conscious See Conscious sedation Seizures, carotid disease and, 420 Semiopen techniques, 859, 869 Sengstaken-Blakemore tube, 250, 499, 854 Sentinel acute pancreatitis event (SAPE) hypothesis, 327 Sentinel lymph node biopsy, 585 Sepsis bradycardia in, 199 catheter-related, 159t fever and, 210 management of, 156f–157f with mucosal hypoperfusion, 221 Sepsis (Cont’d) organ-based pathophysiology, 155 pancreas transplantation and, 557 and septic shock, 155 thrombocytopenia with, 201 Septic shock acalculous cholecystitis and, 522 gram-negative, 112 gram-positive, 112 treatment of, 112 Sequestration, pulmonary diagnosis of, 793 pathophysiology of, 792 prognosis of, 793 treatment for, 793 types of, 792 Serologic test, 282 Seronegative-type myasthenia gravis, 478 Serum bilirubin, 222 Serum osmolality formula for, 55 and tonicity, 55 Seton, use of, in high fistula, 315f Sevoflurane, complications of, 189 Shave biopsy, 566 Shock airway and, 819 cardiogenic, 678 hemodynamic considerations afterload, 108 myocardial contractility, 108 preload, 107 relationships in, 107 vasoactive agents, 108 hemodynamic profiles in, 110t hypovolemic, 678 multiorgan dysfunction syndrome, 118 organ response to inflammatory response, 117 microvascular dysfunction, 116 neuroendocrine response, 117 pulmonary, 117 renal, 118 pathophysiology of, 107 Shock (Cont’d) states of cardiogenic shock, 114 hypoadrenal shock, 116 hypovolemic shock, 109 neurogenic shock, 114 septic shock, 112 Shock wave lithotripsy, extracorporeal, 525 Short-bowel syndrome causative factors, 780 clinical syndrome, 780 Shouldice repair, on hernias, 236 Shunt central splenorenal, 502 distal splenorenal, 502 Shunts, portosystemic, 501f Sibutramine, appetite suppressant, 354 Sickle cell disease, 344 Sigmoidoscopy, for gastrointestinal bleeding, 248 Sigmoid volvulus, 258 Silica, malignant esophagus and, 481 Silicone band, 357 Silver sulfadiazine, 731 Sipple syndrome, 674 Sister Mary-Joseph’s node, 603 Sjögren’s syndrome, 338 Skeletonization, 552 Skin carcinomas, 563 Skin glues, suturing techniques, 833 Skin lesions, malignant, 563–567 Skull fractures, 746 Sleep apnea, obstructive, airway abnormalities, 173 Sliding hernias, 232, 234f Small bowel intubation, 261–262 loops of dilated, 260f Small-bowel obstruction (SBO), 234, 253 Sodium, 58–60 Sodium bicarbonate, 438 Sodium reduction, calculation of, 58 Soft-tissue wounds, management of, 91–92 Soft tubes, small-bore, for nasogastric or nasointestinal feedings, 76 937 INDEX Index 938 Index Solid liver lesions benign, 531–532 malignant, 532–535 Solitary pulmonary nodule (SPN), 465–466 Solu-Medrol, 553 Somatostatinoma demographics of, 672 diagnosis of, 672 management of, 672 presentation of, 672 Somatostatin receptor scintigraphy, 671 Specimen collection, for surgical infection, 146 Spectrin, abnormality in, 344 Spermatic cord, ilioinguinal nerve in, 229 Spherocytes, diagnosis of, 344 Sphincter external, 307 internal, 307 Sphincters, 266 Sphygmomanometer, 119 Spider angiomata, with cirrhosis, 244 Spigelian hernias, 232 Spinal cord injury, 751 Spinal cord ischemia, 409 SPINK1 gene mutation, 338 Spirometry, for respiratory care, before surgery, 48 Spironolactone, for adrenal gland, 659 Spleens accessory, 343 anatomy of, 343–344 average adult, 343 blood supply, 343 function of filtration, 344 host defense, 344 immunologic function, 344 hand-assisted technique, 348 postsplenectomy considerations, 348–349 splenectomy, general indications for, 344–347 surgical techniques, 347–348 Splenectomy, 337 for acute sequestration crisis, 344 indications for, 344–347 laparoscopic, 347 open, 347 Splenic abscesses, 346 Splenic artery aneurysm, 324, 347 Splenic artery embolization, 695 Splenic cysts, 346 Splenic mobilization, 688 Splenic puncture, thoracentesis and, 838 Splenic vein thrombosis, as splenic disorders, 337, 347 Splenomegaly, definition of, 343 Splenorenal bypass, 435 SPN See Solitary pulmonary nodule Spontaneous breathing trials, 130 Sputum cytology, for lung carcinoma, 470 Squamous cell carcinoma adenocarcinoma and, 317, 481 development of, 481 diagnosis, 564 general, 564 non–small-cell lung cancer and, 469 Stab wounds, 708 Staging, 621 Stamm gastrostomy tube, 853 Standard central formula, 82 Standard precautions, for body fluids, 95 Stanford classification, in aortic dissection, 450 Staples, suturing techniques, 833 Stellate cells, 491 Stenosis atresia and, 774 bilateral, 392 unilateral, 392 Stenting after dilation, 487 carotid, 442 in peripheral vascular disease, 387 Sternocleidomastoid muscle (SCM), 25 Steroids acute abdomen and, 198 for autoimmune pancreatitis, 340 cortisol output of, 46 guide to cover, 46 indications of, 46 surgical excision with, 94 Stewart-Treves syndrome, 585 Stomach, nasogastric tubes, 849 Stomas, digital examination of, 201 Stone and ductal obstruction hypothesis, 327 Stones, removal of, 224 Stoppa repair, on hernias, 236 Straight cath, 839 Streptozocin for gastrinoma, 670 for glucagonoma, 671 in tumor biology, 632 Stress nutritional requirements in, 74–76 basic concepts, 74 caloric need, determination of, 75 Stricturoplasty, 304 Stroke abdominal aortic aneurysm and, 408 carotid disease and, 420 causative factors, 413 risk factors, 413 Subarachnoid hemorrhage causative factors, 753 clinical, 753–754 surgical management, 755 Subdural hematoma, 745 Subxiphoid pericardiotomy, 709 Succinylcholine, side effects of, 187 Sulfasalazine, 295 Sulfonamides, trimethoprim and, 148t Sulfonylureas, 371 Summer’s sign, 201t Superior mesenteric artery (SMA) celiac artery and, 421 embolization of, 423 IMA and, 421 thrombosis of, 423 Supralevator abscess, 312 Suprapubic catheter, 848 Suprasphincteric fistula, 313 Supraventricular tachycardia, 453 Surgery bariatric See Bariatric surgery coagulopathy in, 99–104 endovascular See Endovascular surgery endovascular intervention catheter-directed thrombolysis, 440 preoperative considerations, 439 hyperglycemic response to, 375 new technology in biomedical engineering, 807 biosurgery, 811 biotechnology and, 807 gene surgery, 809 genomic information, 807 modern biology, 807 robotic surgery, 810 pediatric, 773–778 Surgery/radioiodine ablative therapy, 642 Surgical bypass therapy, in peripheral vascular disease, 388 Surgical education, 3–4 Surgical infection definitions nonoperative-associated infections, 143 postoperative infections, 143 source control, 143 determinants of host defense, 144 microbial features, 143 diagnosis of history of, 162 laboratory values, 153, 163 physical examination, 153, 162 source control, 153 empiric therapy, 154 follow-up care, 154 principles of therapy antibiotic therapy, 146 source control, 146 wound management, 146 sepsis, 154–158 939 INDEX Index 940 Index Surgical infection (Cont’d) skin and soft-tissue infections diffuse nonnecrotizing infections, 163 focal infections, 163 in surgical patient common sources of, 158 postoperative fever/infection, 158 Surgical therapy for bleeding, 283 in peripheral vascular disease, 389 Sutures deep, 832 fast absorbing, 832 mattress, 833 skin, 832 Suturing techniques, 832 Swan-Ganz catheters, 108, 407, 881–887 Swelling, scrotal, 238 Syndromes celiac artery compression, 427 compartment, 716–719 juvenile polyposis, 619 median arcuate ligament, 427 nonadenomatous polyposis, 619 nonpolyposis, 619 Paget-Schroetter, 365 Peutz-Jeghers, 619 postthrombotic, 365 Systemic inflammatory response (SIRS), 117, 327 definition of, 154 Systemic vascular resistance (SVR), calculating, 108 T Tachycardia, 678 in fever, 199 with hypovolemic shock, 21 in intestinal obstruction, 257 Tachypnea, 58 Takayasu’s arteritis, 417 Tamoxifen alternatives to, 588 versus aromatase inhibitors, 587 benign breast disease, 576 hormonal agents, 632 Tamoxifen (Cont’d) for premenopausal patients, 587 TAPP See Transabdominal preperitoneal approach Taxis, process of reducing hernia, 235 TBW See Total body water Technetium-99m-labeled sulfur colloid scan, 532 Technetium-labeled red blood cell scan, for gastrointestinal bleeding, 249 Techniques, suturing, 832 Telangiectasia, in neuroendocrine tumors, 665 Temperature, in gastrointestinal bleeding, 244 Tensilon, an acetylcholinesterase inhibitor, 478 Tensilon test, 478 Tension pneumothorax, 115–116, 681 TEF See Tracheoesophageal fistula TEP See Total extraperitoneal laparoscopic repair Teratoma, 462 Tertiary healing, 90 Testicular trauma general, 768 imaging for, 768 management of, 768 signs of, 768 Tetanus, 829 Tetanus immunization, 91 Tetanus prophylaxis, 729 Tetracaine, injectable agents, 167 Tetracycline and doxycycline, 148t TGF-beta See Transforming growth factor-beta Therapy endovascular, 387 revascularization, 387 Thiamine deficiency, 742 Thiazide, in acute pancreatitis, 329 Thiersch procedure, 320 Thoracentesis complications of, 838 differential diagnosis of, 837 indications of, 835 interpretation and complications of, 837 Thoracentesis (Cont’d) materials and preparation of, 835 position of, 835 procedure for, 836 Thoracic and neck cystic hygroma, 791 esophagus, 800 fluid and electrolyte requirements acid-base balance, 787 fluid balance, 786 maintenance electrolytes, 786 resuscitation fluids, 786 foreign bodies, 799 general considerations, 785 thermoregulation, 785 venous access, 785 lesions of brachial cleft anomalies, 790 general, 788 lymphadenopathy, 789 thyroglossal duct remnants, 789 parenteral nutrition, total, 787–788 complications, 788 general, 787 requirements, 788 thoracic disorders, 792–799 torticollis, 792 Thoracic aorta, abdominal aortic aneurysm and, 404 Thoracic trauma brief history, 703 chest, physical examination of, 704 dull versus resonant percussion, 704 flail chest, 704 point tenderness, 704 seatbelt signs, 704 subcutaneous emphysema, 704 complications of, 710–711 epidemiology of, 703–704 mediastinum, 704 pathophysiology of, 704–709 procedures in, 709 Thoracodorsal nerve, 570 Thoracolumbar fractures, classification of, 753f Thoracolumbar spine fractures, McAfee classification of, 754t Thoracoscopy, 709 Thrombocytopenia acquired, 102 in coagulopathy, 245 heparin-induced, 102 with sepsis, 201 Thromboembolic disease, 43 Thromboembolic events, risk for, 44t Thromboembolic phenomena, 349 Thromboembolism, prevention of, 51 Thrombolysis, 399 Thrombolytics, anticoagulation versus, 369 Thrombosis grafting, 546, 557 primary, 365 secondary, 365 tumor, 365 vein See Deep vein thrombosis Thrombotic disease, history of, 544 Thrombotic thrombocytopenic purpura, 346 Thymoma differential diagnosis of, 476 epidemiology of, 475 Masaoka clinical staging of, 476 primary thymic tumor, 475 staging of, 476 surgical treatment of, 476 symptoms of, 475–476 Thymus glands anatomy and embryology of, 475 pathology of, 475–479 Thyroglossal duct remnants, 637 causative factors of, 789 differential diagnosis of, 789 presentation of, 789 treatment of, 790 Thyroid anatomy of deep cervical fascia, 637 941 INDEX Index 942 Index Thyroid (Cont’d) nerves, 637 venous drainage, 637 embryology of, 637 enlarged, 642 hyperthyroidism signs/symptoms of, 638 thyrotoxicosis, 638 toxic multinodular goiter, 641 hypothyroidism Hashimoto’s thyroiditis, 641 signs/symptoms of, 638 incidentaloma neoplasm, 645 nodules, 643 physiology of diiodotyrosine, 638 iodine, 638 iodine metabolism, 638 TSH, 638 tyrosine residue, 638 Thyroid cancer classification of, 642t, 645 risk groups for welldifferentiated, 646t staging of, 645t Thyroidectomy, 640 Thyroid lymphoma, 651 Thyroid peroxidase catalysts, 638 Timing, 593 Tinzaparin, low-molecular-weight heparin, 366 Tissue cultures, deep, 378 Tissue hypoxia, 376 Tissue plasminogen activator, 367 Tissue sample, for surgical infection, 146 Tissue transfer, autologous, 594–595 TNM staging system, 565 Tobacco, malignant esophagus and, 481 Tolazamide, sulfonylureas, 371 Tolbutamide, sulfonylureas, 371 Tonicity definition of, 55 serum osmolality and, 55 Tortuous aorta, 405 Total body water (TBW), 55 Total extraperitoneal laparoscopic repair (TEP) Total extraperitoneal laparoscopic repair (TEP) (Cont’d) advantages of, 240 disadvantages of, 240 operative procedure of, 240 Toupet, 271 Toxic colitis, with megacolon, 293 Toxicity cardiac, 168 central nervous system, 168 local anesthesia and, 168 Toxic megacolon, 302 Toxic-metabolic hypothesis, 327 Toxic multinodular goiter, 641 Toxin production, 143 Toxins, production and release of, 282 Tracheal malacia, airway and, 825 Tracheal stenosis, 131 airway and, 825 Tracheoesophageal fistulas, types of, 801f Tracheoesophageal fistula (TEF), esophageal atresia and, 800 Tracheostomy basics of, 823 need for, in mechanical ventilation, 131 technique of, 824 TRAM See Transverse rectus abdominis musculocutaneous flap Transabdominal preperitoneal approach (TAPP), 236 advantages of, 239 disadvantages of, 240 operative procedure of, 238 Transaminases, 493–494 Transferrin, in malnutrition, 74 Transforming growth factor (TGF)-beta, 87 Transfusion rate, 348 Transhiatal esophagectomy, indications for, 485 Transitional cell, 317 Transmural necrosis, 207 Transplantation evaluation for, 541 patient, 541 qualifications, 541 liver, 551–554 Transplantation (Cont’d) pancreas, 555–559 renal, 541–550 Trans-sphincteric fistula, 313 Transthoracic esophagectomy advantages of, 485 disadvantages of, 485 Transthoracic needle biopsy, 461 Transverse rectus abdominis musculocutaneous flap (TRAM), 594–595 Trash foot, 408 Trastuzumab (Herceptin), 633 Trauma abdominal See Abdominal trauma in acute pancreatitis, 328 airway and, 819 assessment with sonography in advantages, 862 complicating factors, 862 CT scan, 863 disadvantages, 862 indications, 862 technique, 862 blood transfusion and, 137 in history of medical illness, 10 penetrating, 707 splenectomy and, 344 thoracic See Thoracic trauma urologic, 759–769 Trauma, overview epidemiology of mechanisms of injury, 677 mortality, 677 management of evaluation and transfer, 679 primary survey, 677 secondary survey, 679 and pregnancy anatomic and physiologic changes during, 681 epidemiology of, 681 fetal assessment, 682 maternal evaluation, 681 Traumatic brain injury, prognosis of, 746 Traumatic shock, 110 Traumatic wounds, preparation of, 91 Treacher Collins syndromes, 176 Treatment, negative-pressure, 90 Trendelenburg test, of valve competence, 29 Triad of splenomegaly, 347 Trimethoprim and sulfonamides, 148t Trimodal distribution, 685 Trinkle procedure, 709 Triple therapy, 282 Truncal vagotomy, 285 T-tube extraction, postoperative, 223 Tube feedings, 77 Tubes feeding, 851–853 orogastric, 850 Tumbling ileus, 524 Tumor ablation, local, 487 Tumor biology chemotherapeutic agents alkylating agents, 632 antimetabolites, 632 hormonal agents, 632 mitotic inhibitors, 632 genetic instability, 629–630 pharmacotherapy drug mechanisms and therapeutics, 631–632 tumor growth and kinetics, 630–631 programmed cell death, evasion of, 628 replicative potential, 628 sustained angiogenesis, 628–629 tissue invasion and metastasis, 629 Tumor necrosis factor-alpha, 155 Tumors appendiceal, 213–214 benign, 251 chondroma, 462 endobronchial, 457 fibroma, 461 gastric, 601–610 hamartoma, 461 Klatskin’s, 507 lipoma, 462 location of primary, 466 malignant, 251 943 INDEX Index 944 Index Tumors (Cont’d) miscellaneous, 461–462 neuroendocrine, 665–674 Tumor suppressor proteins (p53 and pRB), loss of, 628 Tumor thrombosis, 365 Turcot syndrome, 619 Typing, blood component therapy and, 135 U UC See Ulcerative colitis Ulcerative colitis (UC), 289 causative factors, 291 clinical manifestations of, 292 complications of, 293 diagnosis of, 292 epidemiology of, 291 medical management of, 295 pathophysiology of, 291 prognosis of, 298 surgical management of, 297 Ulcerative colitis vs Crohn’s disease, 290t Ulcer, decubitus, 23 Ulcer, gastric, biopsy for, 250 Ulcerogenic agents, 244 Ulcer prophylaxis, 729 Ulcers arterial, 378 diabetic foot, 377–380 venous, 378 Ulnar nerve block, 171 Ultrasound in acalculous cholecystitis, 523 in acute pancreatitis, 330 in cirrhosis and portal hypertension, 494 in diagnosis of acute cholecystitis, 518 gallstone and, 218 in renal transplantation, 546 renovascular hypertension and, 432 for surgical infection, 145 for thoracentesis, 835 Umbilical hernias, 231 Uncinate process, 324 Unconscious patient approach to causative factors, 739 Unconscious patient (Cont’d) comprehensive neurologic examination, 740 history of, 739 physical examination, 740 Unfractionated heparin, 103, 366 Unilateral stenosis, 392 United Network for Organ Sharing, 551 Universal precautions See Standard precautions Urea breath test, 282 Ureteral stenosis, 546 Ureteral trauma complications of, 764 delayed repair of, 764 general, 761 management of, 762 symptoms of, 762–763 workup, 763 Ureteroneocystostomy, 545 Urethral catheterization in female patient, 846f in male patient, 843f–845f Urethral catheters, 840f Urethral injury anterior, 766 general, 766 management of, 766 posterior, 766 Urinalysis in appendicitis, 209 in intestinal obstruction, 258 surgical infection and, 153 Urinary bladder, diversion to, 556 Urinary catheter, complications of indwelling, 839 Urinary retention, after catheterization, 848 Urinary tract infection, 143, 839 Urinary tract infections, in surgical patient, 158 Urobilinogen, 510 Urologic trauma overview of, 759 procedures for, 759 renal trauma complications, 761 general, 759 management of, 760 Urologic trauma (Cont’d) renal artery thrombosis, 761 surgical approach, 761 V V.A.C dressings, to open wounds, 92 Vacuum-assisted closure, 90 for traumatic wounds, 833 Vagotomy antrectomy and, 285 diarrhea after, 285 and drainage, 285 truncal, 285 Valacyclovir, 151t Valproic acid, in acute pancreatitis, 329 Valve competence, Trendelenburg test of, 29 Vancomycin antibacterial agents, 149t for surgical treatment, 161 Varicose veins, risk factors for, 397 Vascular anastomoses, 545 Vascular beds, diagnostics in, 441 Vascular disease, peripheral See Peripheral vascular disease Vascular endothelial growth factor (VEGF), 88 during epithelialization, 88 for wound healing, 88 Vascular lesion, neurologic impairment with, 414t Vascular thrombosis, 556 Vasoactive agents, 108 Vasodilatation, 368 Vasodilators, in shock, 109 Vasopressin infusion, 249 in shock, 109, 117 Vasopressors afterload and, 108 in shock, 113 VATS lobectomy advantages of, 473 contraindications to, 473 Vecuronium, 188 Veins, varicose, 398, 400 Vena cava interruption, 443 Venography, 399 Venography, portal, during mesenteric arteriography, 495 Veno-occlusive disease, 493 Venous disease anatomy of coagulation cascade, 397 main lower extremity veins, 397 main upper extremity veins, 397 causative factors deep venous thrombosis prophylaxis, 399 mechanical, 399 medical, 399 diagnosis of, 398–399 hypercoagulable workup, 398 imaging, 399 presentation of, 398 history, 398 physical examination, 398 treatment of, 399–400 CVI, 400 DVT, 399 pulmonary embolism, 400 varicose veins, 400 Venous drainage, 343, 515, 556 Venous insufficiency, 29 chronic, risk factors for, 397 Venous lines, central background of, 867 techniques of infraclavicular subclavian vein approach, 870 supraclavicular subclavian vein approach, 870 Venous pressure, central, 122 Venous thrombosis prophylaxis, deep, 399 Venous ulcers, 378, 383 Ventilation mechanical See Mechanical ventilation minute, 127 versus oxygenation, 127–128 purpose of, 127 Ventilator settings, standard, in mechanical ventilation, 132 Ventral hernias, 231 Ventricular drain, external, 815–818 945 INDEX Index 946 Index Ventricular ectopy, after cardiac surgery, 453 Ventriculostomy contraindications of coagulopathy, 815 thrombocytopenia, 815 indications of acute hydrocephalus, 815 head injury, 815 shunt infection, 815 materials, 815 procedure for computed tomography, review, 816 magnetic resonance imaging, review, 816 position and, 816 technique, 816 Vestibuloocular reflex, 37 Vicryl (polyglycolic acid), 832 Video-assisted thoracic surgery (VATS) for lung carcinoma, 471 with wedge biopsy, for tissue diagnosis, 466 Vinblastine, mitotic inhibitors, 632 Vincristine, mitotic inhibitors, 632 Viral hepatitis, 506 Viral, sepsis and, 158 Viral specimens, for surgical infection, 146 Virchow’s node, 603 Virulence of organism, 143 Visceral angiography, 670 Visceral artery, angiography of, 435 Vital signs, assessment of, in cardiopulmonary monitoring, 119 Vitamin A, wound healing and, 89 Vitamin C, 85t wound healing and, 89 Vitamin D, 63 Vitamin K deficiency, acquired bleeding disorders, 101 Vomiting acute abdomen and, 197 acute pancreatitis and, 329 carotid disease and, 414 in endovascular surgery, 438 in intestinal obstruction, 256 Vomiting (Cont’d) jaundice and, 509 ulcerative colitis and, 292 von Hippel-Lindau disease, 662 von Willebrand disease, 101, 139 W Warfarin (Coumadin), 366, 399 coagulopathy and, 99 Warren-Zeppa shunt, 502 Water intoxication, 59 Water-soluble vitamins, 85t WBC disorders, 345 Weight loss bariatric surgery and, 358 chronic pancreatitis and, 338 in history of medical illness, 10 malignant pancreas disease and, 611 Wermer syndrome, 673 Westermark’s sign, 365 Wheezing in neuroendocrine tumors, 667 in surgical patients, 27 Whipple procedure, 613 for chronic pancreatitis, 340–341 Whipple’s triad, 669 White blood cell (WBC), 135–136 in appendicitis, 209 Wilms’ tumor, 782 Wilson’s disease, 493 Wood’s lamp, ultraviolet lamp, 425 World Health Organization, on malignant epithelial lung tumors, 466 Wound closure, 91, 829–833 Wound, closure, classifications of, 831 Wound closure, types of, 90 primary, 90 Wound complications management of dehiscence, 93 hematoma, 93 infection, 92 seroma, 93 Wound contraction, 88 Wound debridement, phagocytosis and, 87 Index Wound management, in surgical infection, 146 Wound sepsis, pathogenesis of, 734 Wound, traumatic evaluation and closure of, 829 basic principles, 829 Wound treatment, with chromic gut suture, 310 X Xenograft, 732 X-ray abdominal, in acute pancreatitis, 330 abdominal, in chronic pancreatitis, 339f chest, in acute pancreatitis, 330 Z Zenker’s diverticulum, 267, 269 Zollinger-Ellison syndrome, 280–281, 608, 665 Zygomaticotemporal and zygomaticofacial block, 170 Zymogen granules, 323 INDEX Wound dehiscence factors of, 54 treatment for, 54 Wound dressings, 92 Wound healing choreographers of, 87 factors affecting age, 89 chemotherapy, 89 diabetes mellitus, 90 edema, 89 foreign bodies, 89 general health, 90 infection, 89 nutrition, 89 oxygenation, 89 radiation, 90 smoking, 89 steroids, 89 impairment to, 90 and management, 87–94 phases of inflammatory, 87 maturation, 88 proliferative, 87–88 risk for infection and slow, 376 Wound hematomas cause of, 54 risk factors, 54 Wound hypoxia, cause of wound infection, 89 Wound infection, 349, 861 airway and, 825 cause of, 89 incidence of, 54, 212 management of, 54 in surgical infection, 146 prevention of, 54 risk factors of, 54 surgical infection and, 143 947 ... transplant 4.00 3.75 3.50 3 .25 3.00 2. 75 2. 50 2. 25 2. 00 1.75 1.50 1 .25 1.00 0.75 0.50 0 .25 Compared to WLD IDK 549 MDK Time to equal risk (ER) 122 d Time to equal survival (ES) 25 6d 185d 531d Marginal... caused by the dog tapeworm Echinococcus granulosus, with sheep being the usual intermediate host b Humans ingest ova shed in the feces of the host The ova penetrate the intestinal wall, pass the portal... 4-cm solid mass in the right lobe of the liver The patient was referred for further management In differentiating between the above entities, one must consider the age of the patient, history