- •Dedication
- •Editors and Contributors
- •Foreword
- •Preface
- •Contents
- •PREPARING FOR THE SURGERY CLERKSHIP
- •SURGICAL NOTES
- •COMMON ABBREVIATIONS YOU SHOULD KNOW
- •RETRACTORS (YOU WILL GET TO KNOW THEM WELL!)
- •SUTURE MATERIALS
- •WOUND CLOSURE
- •KNOTS AND EARS
- •INSTRUMENT TIE
- •TWO-HAND TIE
- •COMMON PROCEDURES
- •NASOGASTRIC TUBE (NGT) PROCEDURES
- •CHEST TUBES
- •NASOGASTRIC TUBES (NGT)
- •FOLEY CATHETER
- •CENTRAL LINES
- •MISCELLANEOUS
- •THIRD SPACING
- •COMMON IV REPLACEMENT FLUIDS (ALL VALUES ARE PER LITER)
- •CALCULATION OF MAINTENANCE FLUIDS
- •ELECTROLYTE IMBALANCES
- •ANTIBIOTICS
- •STEROIDS
- •HEPARIN
- •WARFARIN (COUMADIN®)
- •MISCELLANEOUS AGENTS
- •NARCOTICS
- •MISCELLANEOUS
- •ATELECTASIS
- •POSTOPERATIVE RESPIRATORY FAILURE
- •PULMONARY EMBOLISM
- •ASPIRATION PNEUMONIA
- •GASTROINTESTINAL COMPLICATIONS
- •ENDOCRINE COMPLICATIONS
- •CARDIOVASCULAR COMPLICATIONS
- •MISCELLANEOUS
- •HYPOVOLEMIC SHOCK
- •SEPTIC SHOCK
- •CARDIOGENIC SHOCK
- •NEUROGENIC SHOCK
- •MISCELLANEOUS
- •URINARY TRACT INFECTION (UTI)
- •CENTRAL LINE INFECTIONS
- •WOUND INFECTION (SURGICAL SITE INFECTION)
- •NECROTIZING FASCIITIS
- •CLOSTRIDIAL MYOSITIS
- •SUPPURATIVE HIDRADENITIS
- •PSEUDOMEMBRANOUS COLITIS
- •PROPHYLACTIC ANTIBIOTICS
- •PAROTITIS
- •MISCELLANEOUS
- •CHEST
- •ABDOMEN
- •MALIGNANT HYPERTHERMIA
- •MISCELLANEOUS
- •OVERVIEW
- •CHOLECYSTOKININ (CCK)
- •SECRETIN
- •GASTRIN
- •SOMATOSTATIN
- •MISCELLANEOUS
- •GROIN HERNIAS
- •HERNIA REVIEW QUESTIONS
- •ESOPHAGEAL HIATAL HERNIAS
- •PRIMARY SURVEY
- •SECONDARY SURVEY
- •TRAUMA STUDIES
- •PENETRATING NECK INJURIES
- •MISCELLANEOUS TRAUMA FACTS
- •PEPTIC ULCER DISEASE (PUD)
- •DUODENAL ULCERS
- •GASTRIC ULCERS
- •PERFORATED PEPTIC ULCER
- •TYPES OF SURGERIES
- •STRESS GASTRITIS
- •MALLORY-WEISS SYNDROME
- •ESOPHAGEAL VARICEAL BLEEDING
- •BOERHAAVE’S SYNDROME
- •ANATOMY
- •GASTRIC PHYSIOLOGY
- •GASTROESOPHAGEAL REFLUX DISEASE (GERD)
- •GASTRIC CANCER
- •GIST
- •MALTOMA
- •GASTRIC VOLVULUS
- •SMALL BOWEL
- •APPENDICITIS
- •CLASSIC INTRAOPERATIVE QUESTIONS
- •APPENDICEAL TUMORS
- •SPECIFIC TYPES OF FISTULAS
- •ANATOMY
- •COLORECTAL CARCINOMA
- •COLONIC AND RECTAL POLYPS
- •POLYPOSIS SYNDROMES
- •DIVERTICULAR DISEASE OF THE COLON
- •ANATOMY
- •ANAL CANCER
- •ANATOMY
- •TUMORS OF THE LIVER
- •ABSCESSES OF THE LIVER
- •HEMOBILIA
- •ANATOMY
- •PHYSIOLOGY
- •PATHOPHYSIOLOGY
- •DIAGNOSTIC STUDIES
- •BILIARY SURGERY
- •OBSTRUCTIVE JAUNDICE
- •CHOLELITHIASIS
- •ACUTE CHOLECYSTITIS
- •ACUTE ACALCULOUS CHOLECYSTITIS
- •CHOLANGITIS
- •SCLEROSING CHOLANGITIS
- •GALLSTONE ILEUS
- •CARCINOMA OF THE GALLBLADDER
- •CHOLANGIOCARCINOMA
- •MISCELLANEOUS CONDITIONS
- •PANCREATITIS
- •PANCREATIC ABSCESS
- •PANCREATIC NECROSIS
- •PANCREATIC PSEUDOCYST
- •PANCREATIC CARCINOMA
- •MISCELLANEOUS
- •ANATOMY OF THE BREAST AND AXILLA
- •BREAST CANCER
- •DCIS
- •LCIS
- •MISCELLANEOUS
- •MALE BREAST CANCER
- •BENIGN BREAST DISEASE
- •CYSTOSARCOMA PHYLLODES
- •FIBROADENOMA
- •FIBROCYSTIC DISEASE
- •MASTITIS
- •BREAST ABSCESS
- •MALE GYNECOMASTIA
- •ADRENAL GLAND
- •ADDISON’S DISEASE
- •INSULINOMA
- •GLUCAGONOMA
- •SOMATOSTATINOMA
- •ZOLLINGER-ELLISON SYNDROME (ZES)
- •MULTIPLE ENDOCRINE NEOPLASIA
- •THYROID DISEASE
- •ANATOMY
- •PHYSIOLOGY
- •HYPERPARATHYROIDISM (HPTH)
- •PARATHYROID CARCINOMA
- •SOFT TISSUE SARCOMAS
- •LYMPHOMA
- •SQUAMOUS CELL CARCINOMA
- •BASAL CELL CARCINOMA
- •MISCELLANEOUS SKIN LESIONS
- •STAGING
- •INTENSIVE CARE UNIT (ICU) BASICS
- •INTENSIVE CARE UNIT FORMULAS AND TERMS YOU SHOULD KNOW
- •SICU DRUGS
- •INTENSIVE CARE PHYSIOLOGY
- •HEMODYNAMIC MONITORING
- •MECHANICAL VENTILATION
- •PERIPHERAL VASCULAR DISEASE
- •LOWER EXTREMITY AMPUTATIONS
- •ACUTE ARTERIAL OCCLUSION
- •ABDOMINAL AORTIC ANEURYSMS
- •MESENTERIC ISCHEMIA
- •MEDIAN ARCUATE LIGAMENT SYNDROME
- •CAROTID VASCULAR DISEASE
- •CLASSIC CEA INTRAOP QUESTIONS
- •SUBCLAVIAN STEAL SYNDROME
- •RENAL ARTERY STENOSIS
- •SPLENIC ARTERY ANEURYSM
- •POPLITEAL ARTERY ANEURYSM
- •MISCELLANEOUS
- •PEDIATRIC IV FLUIDS AND NUTRITION
- •PEDIATRIC BLOOD VOLUMES
- •FETAL CIRCULATION
- •ECMO
- •NECK
- •ASPIRATED FOREIGN BODY (FB)
- •CHEST
- •PULMONARY SEQUESTRATION
- •ABDOMEN
- •INGUINAL HERNIA
- •UMBILICAL HERNIA
- •GERD
- •CONGENITAL PYLORIC STENOSIS
- •DUODENAL ATRESIA
- •MECONIUM ILEUS
- •MECONIUM PERITONITIS
- •MECONIUM PLUG SYNDROME
- •ANORECTAL MALFORMATIONS
- •HIRSCHSPRUNG’S DISEASE
- •MALROTATION AND MIDGUT VOLVULUS
- •OMPHALOCELE
- •GASTROSCHISIS
- •POWER REVIEW OF OMPHALOCELE AND GASTROSCHISIS
- •APPENDICITIS
- •INTUSSUSCEPTION
- •MECKEL’S DIVERTICULUM
- •NECROTIZING ENTEROCOLITIS
- •BILIARY TRACT
- •TUMORS
- •PEDIATRIC TRAUMA
- •OTHER PEDIATRIC SURGERY QUESTIONS
- •POWER REVIEW
- •WOUND HEALING
- •SKIN GRAFTS
- •FLAPS
- •SENSORY SUPPLY TO THE HAND
- •CARPAL TUNNEL SYNDROME
- •ANATOMY
- •MISCELLANEOUS
- •NOSE AND PARANASAL SINUSES
- •ORAL CAVITY AND PHARYNX
- •FACIAL FRACTURES
- •ENT WARD QUESTIONS
- •RAPID-FIRE REVIEW OF MOST COMMON CAUSES OF ENT INFECTIONS
- •THORACIC OUTLET SYNDROME (TOS)
- •CHEST WALL TUMORS
- •DISEASES OF THE PLEURA
- •DISEASES OF THE LUNGS
- •DISEASES OF THE MEDIASTINUM
- •DISEASES OF THE ESOPHAGUS
- •ACQUIRED HEART DISEASE
- •CONGENITAL HEART DISEASE
- •CARDIAC TUMORS
- •DISEASES OF THE GREAT VESSELS
- •MISCELLANEOUS
- •BASIC IMMUNOLOGY
- •CELLS
- •IMMUNOSUPPRESSION
- •OVERVIEW OF IMMUNOSUPPRESSION MECHANISMS
- •MATCHING OF DONOR AND RECIPIENT
- •REJECTION
- •ORGAN PRESERVATION
- •KIDNEY TRANSPLANT
- •LIVER TRANSPLANT
- •PANCREAS TRANSPLANT
- •HEART TRANSPLANT
- •INTESTINAL TRANSPLANTATION
- •LUNG TRANSPLANT
- •TRANSPLANT COMPLICATIONS
- •ORTHOPAEDIC TERMS
- •TRAUMA GENERAL PRINCIPLES
- •FRACTURES
- •ORTHOPAEDIC TRAUMA
- •DISLOCATIONS
- •THE KNEE
- •ACHILLES TENDON RUPTURE
- •ROTATOR CUFF
- •MISCELLANEOUS
- •ORTHOPAEDIC INFECTIONS
- •ORTHOPAEDIC TUMORS
- •ARTHRITIS
- •PEDIATRIC ORTHOPAEDICS
- •HEAD TRAUMA
- •SPINAL CORD TRAUMA
- •TUMORS
- •VASCULAR NEUROSURGERY
- •SPINE
- •PEDIATRIC NEUROSURGERY
- •SCROTAL ANATOMY
- •UROLOGIC DIFFERENTIAL DIAGNOSIS
- •RENAL CELL CARCINOMA (RCC)
- •BLADDER CANCER
- •PROSTATE CANCER
- •BENIGN PROSTATIC HYPERPLASIA
- •TESTICULAR CANCER
- •TESTICULAR TORSION
- •EPIDIDYMITIS
- •PRIAPISM
- •ERECTILE DYSFUNCTION
- •CALCULUS DISEASE
- •INCONTINENCE
- •URINARY TRACT INFECTION (UTI)
- •MISCELLANEOUS UROLOGY QUESTIONS
- •Rapid Fire Power Review
- •TOP 100 CLINICAL SURGICAL MICROVIGNETTES
- •Figure Credits
- •Index
What is the gross appearance?
What is the treatment?
What is the prognosis?
DISEASES OF THE LUNGS
Chapter 71 / Thoracic Surgery 627
Pedunculated “broccoli or cauliflower” tumor on a stalk coming off of the lung
Surgical resection with at least 1 cm clear margin
In contrast to malignant mesothelioma, the benign mesothelioma has an excellent prognosis with cure in the vast majority of cases
BRONCHOGENIC CARCINOMA
What is the annual incidence 170,000 new cases/year of lung cancer in the United
States?
What is the number of annual deaths from lung cancer?
What is the #1 risk factor?
Does asbestos exposure increase the risk in patients who smoke?
150,000; most common cancer death in the United States in men and women
Smoking (85%!)
Yes
What type of lung cancer arises in nonsmoking?
Cancer arises more often in which lung?
What are the signs/ symptoms?
Adenocarcinoma
Right left; upper lobes lower lobes
Change in a chronic cough Hemoptysis, chest pain, dyspnea Pleural effusion (suggests chest wall
involvement)
Hoarseness (recurrent laryngeal nerve involvement)
Superior vena cava syndrome Diaphragmatic paralysis (phrenic nerve
involvement)
Symptoms of metastasis/paraneoplastic syndrome
Finger clubbing
628 Section III / Subspecialty Surgery
What is Pancoast’s tumor? Tumor at the apex of the lung or superior sulcus that may involve the brachial plexus, sympathetic ganglia, and vertebral bodies, leading to pain, upper extremity weakness, and Horner’s syndrome
What is Horner’s syndrome? Injury to the cervical sympathetic chain; Think: “MAP”
1. Miosis (small pupil)
2. Anhydrosis of ipsilateral face
3. Ptosis
What are the four most common sites of extrathoracic metastases?
What are paraneoplastic syndromes?
1.Bone
2.Liver
3.Adrenals
4.Kidney
Syndromes that are associated with tumors but may affect distant parts of the body; they may be caused by hormones released from endocrinologically active tumors or may be of uncertain etiology
Name five general types of |
1. Metabolic: Cushing’s, SIADH, |
|
paraneoplastic syndromes. |
|
hypercalcemia |
|
2. |
Neuromuscular: Eaton-Lambert, |
|
|
cerebellar ataxia |
|
3. |
Skeletal: hypertrophic osteoarthropathy |
|
4. |
Dermatologic: acanthosis nigricans |
|
5. |
Vascular: thrombophlebitis |
What are the associated |
CXR, CT scan, PET scan |
|
radiographic tests? |
|
|
How is the tumor |
1. Sputum cytology |
|
diagnosed? |
2. Needle biopsy (CT or fluoro guidance) |
|
|
3. |
Bronchoscopy with brushings, biopsies, |
|
|
or both |
|
4. |
With or without mediastinoscopy, |
|
|
mediastinotomy, scalene node biopsy, |
|
|
or open lung biopsy for definitive |
|
|
diagnosis |
For each tumor listed, recall its usual site in the lung and its natural course:
Squamous cell?
Chapter 71 / Thoracic Surgery 629
66% occur centrally in lung hilus; may also be a Pancoast’s tumor; slow growth, late metastasis; associated with smoking (Think: Squamous Sentral)
Adenocarcinoma? |
Peripheral, rapid growth with |
|
hematogenous/nodal metastasis, |
|
associated with lung scarring |
Small (oat) cell?
Large cell?
What are the AJCC stages of carcinoma of the lungs:
Stage Ia?
Stage Ib?
Stage IIa?
Central, highly malignant, usually not operable
Usually peripheral, very malignant
Tumor 3 cm, no nodes, no metastases
Tumor 3–5 cm, no nodes, no metastases
1.Tumor 5 cm and positive nodes to lung or ipsilateral hilum; no metastases, or
2.Tumor 5–7 cm, no nodes, no metastases
Stage IIb? |
1. |
Tumor 5–7 cm and positive nodes in |
|
|
lung or ipsilateral hilum, or |
|
2. |
Tumor that invades chest wall, |
|
|
diaphragm, mediastinal pleura, |
|
|
phrenic nerve, pericardial sac, or |
|
|
bronchus (not carina) and no nodes, |
|
|
no metastases |
630 Section III / Subspecialty Surgery
Stage IIIa?
1.Tumor 7 cm and nodes in ipsilateral mediastinum or subcarina with no metastases
2.Tumor 7 cm or extends into chest wall, parietal pleura, diaphragm, phrenic nerve, or pericardium and
lymph node metastases to ipsilateral, mediastinal, or subcarinal nodes
3.Any size tumor that invades heart, great vessels, trachea, esophagus, carina, or ipsalateral lobe, or nodes peribronchial and/or ipsilateral hilum, or intrapulmonary nodes
Stage IIIb? |
Any tumor, lymph node metastases to |
|
contralateral hilum or mediastinum |
|
Supraclavicular/scalene nodes, NO |
|
distant metastases |
Stage IV?
What are the surgical contraindications for NON-small cell carcinoma?
What is the treatment by stage for NON-small cell lung carcinoma:
Stage I?
Stage II?
Stage IIIa?
Stage IIIb?
Stage IV?
What is the treatment for isolated brain metastasis?
Distant metastases
Stage IV, Stage IIIb, poor lung function (FEV1 0.8L)
Surgical resection
Surgical resection
Chemotherapy and XRT surgical resection
Chemotherapy and XRT
Chemotherapy XRT
Surgical resection
What is the approximate prognosis (5-year survival) after treatment of NON-small cell lung carcinoma by stage:
Stage I?
Stage II?
Stage III?
Stage IV?
How is small cell carcinoma treated?
What are the contraindications to surgery for lung cancer?
Chapter 71 / Thoracic Surgery 631
50%
30%
10%
1%
Chemotherapy XRT (very small isolated lesions can be surgically resected)
Think: “STOP IT”
Superior vena cava syndrome, Supraclavicular node metastasis, Scalene node metastasis Tracheal carina involvement Oat cell carcinoma (treat with
chemotherapy radiation) Pulmonary function tests show
FEV1 0.8L
Infarction (myocardial); a.k.a. cardiac cripple
Tumor elsewhere (metastatic disease)
What postoperative FEV1 |
FEV1 800 cc; thus, a preoperative |
must you have? |
FEV1 2L is usually needed for a |
|
pneumonectomy |
|
If FEV1 is 2L, a ventilation perfusion |
|
scan should be performed |
What is hypertrophic |
Periosteal proliferation and new bone |
pulmonary |
formation at the end of long bones and |
osteoarthropathy? |
in the bones of the hand (seen in 10% |
|
of patients with lung cancer) |
SOLITARY PULMONARY NODULES (COIN LESIONS) |
|
|
|
What are they? |
Peripheral circumscribed pulmonary |
|
lesions |
632 Section III / Subspecialty Surgery
What is the differential diagnosis?
What percentage are malignant?
Is there a gender risk?
Granulomatous disease, benign neoplasms, malignancy
Overall, 5% to 10% (but 50% are malignant in smokers 50 years)
Yes; the incidence of coin lesions is 3 to 9 higher and malignancy is nearly twice as common in men as in women
What are the symptoms? |
Usually asymptomatic with solitary |
|
nodules, but may include coughing, |
|
weight loss, chest pain, and hemoptysis |
What are the signs? |
Physical findings are uncommon; clubbing |
|
is rare; hypertrophic osteoarthropathy |
|
implies 80% chance of malignancy |
How is the diagnosis made?
What is the significance of “popcorn” calcification?
What are the risk factors for malignancy?
CXR, chest CT
Most likely benign (i.e., hamartoma)
1.Size: lesions 1 cm have a significant chance of malignancy, and those 4 cm are very likely to be malignant
2.Indistinct margins (corona radiata)
3.Documented growth on follow-up x-ray (if no change in 2 years, most likely benign)
4.Increasing age
What are the associated lab |
1. |
TB skin tests, etc. |
tests? |
2. |
Sputum cultures |
|
3. |
Sputum cytology is diagnostic in 5% to |
|
|
20% of cases |
Which method of tissue |
Chest CT scan with needle biopsy, |
|
diagnosis is used? |
bronchoscopy ( transtracheal biopsy), |
|
|
excisional biopsy (open or thoracoscopic) |
|
|
Chapter 71 / Thoracic Surgery 633 |
What is the treatment? |
Surgical excision is the mainstay of |
|
treatment |
|
Excisional biopsy is therapeutic for |
|
benign lesions, solitary metastasis, and |
|
for primary cancer in patients who are |
|
poor risks for more extensive surgery |
|
Lobectomy for centrally placed lesions |
|
Lobectomy with node dissection for |
|
primary cancer (if resectable by |
|
preop evaluations) |
Which solitary nodule can |
Popcorn calcifications |
be followed without a tissue |
Mass unchanged for 2 years on previous |
diagnosis? |
CXR |
What is the prognosis? |
For malignant coin lesions 2 cm, 5-year |
|
survival is 70% |
What if the patient |
75% chance of carcinoma |
has an SPN and |
|
pulmonary hypertrophic |
|
osteoarthropathy? |
|
What is hypertrophic |
Periosteal proliferation and new bone |
pulmonary osteoarthropathy? |
formation at the end of long bones and in |
|
bones of the hand |
What is its incidence? |
7% of patients with lung cancer |
|
(2%–12%) |
What are the signs? |
Associated with clubbing of the fingers; |
|
diagnosed by x-ray of long bones, |
|
revealing periosteal bone hypertrophy |
CARCINOID TUMOR |
|
|
|
What is it? |
APUD (Amine-Precursor Uptake and |
|
Decarboxylation) cell tumor of the bronchus |
What is its natural course in |
Slow growing (but may be malignant) |
the lung? |
|
What are the primary local |
Wheezing and atelectasis caused by |
findings? |
bronchial obstruction/stenosis |
634 Section III / Subspecialty Surgery |
|
What condition can it be |
Asthma |
confused with? |
|
How is the diagnosis made? |
Bronchoscopy reveals round red-yellow- |
|
purple mass covered by epithelium that |
|
protrudes into bronchial lumen |
What is the treatment? |
Surgical resection (lobectomy with lymph |
|
node dissection) |
|
Sleeve resection is also an option for |
|
proximal bronchial lesions |
What is a sleeve resection? |
Resection of a ring segment of bronchus |
|
(with tumor inside) and then end-to-end |
|
anastomosis of the remaining ends, |
|
allowing salvage of lower lobe |
What is the prognosis |
|
(5-year survival) after |
|
complete surgical resection |
|
of carcinoid: |
|
Negative nodes? |
90% alive at 5 years |
Positive nodes? |
66% alive at 5 years |
What is the most common |
Hamartoma (normal cells in a weird |
benign lung tumor? |
configuration) |
PULMONARY SEQUESTRATION |
|
|
|
What is it? |
Abnormal benign lung tissue with |
|
separate blood supply that DOES NOT |
|
communicate with the normal |
|
tracheobronchial airway |
Define the following terms: Interlobar
Extralobar
What are the signs/symptoms?
How is the diagnosis made?
Sequestration in normal lung tissue covered by normal visceral pleura
Sequestration not in normal lung covered by its own pleura
Asymptomatic, recurrent pneumonia
CXR, chest CT, A-gram, U/S with Doppler flow to ascertain blood supply