- •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
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Chapter 71 / Thoracic Surgery 635 |
What is the treatment in the |
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following cases: |
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Extralobar? |
Surgical resection |
Intralobar? |
Lobectomy |
What is the major danger during surgery for sequestration?
Anomalous blood supply from below the diaphragm (these can be cut and retract into the abdomen resulting in exsanguination!)
Always document blood supply by A-gram or U/S with Doppler flow
DISEASES OF THE MEDIASTINUM
MEDIASTINAL ANATOMY
What structures lie in the following locations:
Superior mediastinum? Aortic arch, great vessels, upper trachea, esophagus
Anterior mediastinum? Thymus, ascending aorta, lymph nodes
Middle mediastinum? Heart, lower trachea and bifurcation, lung hila, phrenic nerves, lymph nodes
Posterior mediastinum? Esophagus, descending aorta, thoracic duct, vagus and intercostal nerves, sympathetic trunks, azygous and hemizygous veins, lymph nodes
What is the major differential diagnosis for tumors of the mediastinum:
Anterior mediastinum? Classic “four Ts”: Thyroid tumor,
Thymoma, Terrible lymphoma, Teratoma; also parathyroid tumor, lipoma, vascular aneurysms
Middle mediastinum? Lymphadenopathy (e.g., lymphoma, sarcoid), teratoma, fat pad, cysts, hernias, extension of esophageal mass, bronchogenic cancer
636 Section III / Subspecialty Surgery |
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Posterior mediastinum? |
Neurogenic tumors, lymphoma, aortic |
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aneurysm, vertebral lesions, hernias |
What is the most common |
Neurogenic (most commonly in posterior |
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type of tumor arising in the |
mediastinum) |
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mediastinum? |
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What is the differential |
Schwannoma (a.k.a. neurolemmoma), |
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diagnosis for a neurogenic |
neurofibroma, neuroblastoma, |
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tumor? |
ganglioneuroma, ganglioneuroblastoma, |
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pheochromocytoma |
PRIMARY MEDIASTINAL TUMORS |
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Thymoma |
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Where are they found in the mediastinum?
How is the diagnosis made?
What is the treatment?
What are the indications for postop radiation therapy?
What are the indications for preop chemotherapy?
What percentage of thymomas are malignant?
How is a malignant thymoma diagnosed?
What is myasthenia gravis?
What percentage of patients with myasthenia gravis have a thymoma?
Anterior
CT scan
All thymomas should be surgically resected via midline sternotomy
Invasive malignant tumor
Tumor 6 cm and CT scan with invasion
25%
At surgery with invasion into surrounding structures (not by histology!)
Autoimmune disease with antibodies against the muscle acetylcholine receptors
15%
What percentage of patients 75%! with thymoma have or will
have myasthenia gravis?
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Chapter 71 / Thoracic Surgery 637 |
Teratomas |
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What are they? |
Tumors of branchial cleft cells; the |
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tumors contain ectoderm, endoderm, and |
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mesoderm |
What is a dermoid cyst?
Which age group is affected?
Where in the mediastinum do they occur?
What are the characteristic x-ray findings?
What percentage are malignant?
What is the treatment of benign dermoid cysts?
What is the treatment of malignant teratoma?
Which tumor markers are associated with malignant teratomas?
Neurogenic Tumors
What is the incidence?
Where in the mediastinum do they occur?
What percentage are malignant?
Teratoma made up of ectodermal derivatives (e.g., teeth, skin, hair)
Usually adolescents, but can occur at any age
Anterior
Calcifications or teeth; tumors may be cystic
15%
Surgical excision
Preoperative chemotherapy until tumor markers are normal, then surgical resection
AFP, CEA
Most common mediastinal tumors in all age groups
Posterior, in the paravertebral gutters
50% in children
10% in adults
638 Section III / Subspecialty Surgery |
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What are the histologic types |
1. |
Neurilemmoma or schwannoma |
(5)? (Note cells of origin and |
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(benign)—arise from Schwann cell |
whether benign or malignant.) |
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sheaths of intercostal nerves |
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2. |
Neurofibroma (benign)—arise from |
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intercostal nerves; may degenerate into: |
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3. |
Neurosarcoma (malignant) |
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4. |
Ganglioneuroma (benign)—from |
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sympathetic chain |
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5. |
Neuroblastoma (malignant)—also |
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from sympathetic chain |
LYMPHOMA |
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Where in the mediastinum |
Anywhere, but most often in the |
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does it occur? |
anterosuperior mediastinum or hilum |
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in the middle mediastinum |
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What percentage of |
50% |
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lymphomas involve |
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mediastinal nodes? |
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What are the symptoms? |
Cough, fever, chest pain, weight loss, |
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SVC syndrome, chylothorax |
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How is the diagnosis made? 1. CXR, CT scan
2.Mediastinoscopy or mediastinotomy with node biopsy
What is the treatment? Nonsurgical (chemotherapy, radiation, or both)
MEDIASTINITIS
Acute Mediastinitis
What is it? |
Acute suppurative mediastinal infection |
Name the six etiologies. 1. Esophageal perforation (Boerhaave’s syndrome)
2.Postoperative wound infection
3.Head and neck infections
4.Lung or pleural infections
5.Rib or vertebral osteomyelitis
6.Distant infections
What are the clinical features?
What is the treatment?
Chronic Mediastinitis
What is it?
What is the most common etiology?
What are the clinical features?
How is the diagnosis made?
What is the treatment?
Chapter 71 / Thoracic Surgery 639
Fever, chest pain, dysphagia (especially with esophageal perforation), respiratory distress, leukocytosis
1.Wide drainage
2.Treatment of primary cause
3.Antibiotics
Mediastinal fibrosis secondary to chronic granulomatous infection
Histoplasma capsulatum
50% are asymptomatic; symptoms are related to compression of adjacent structures: SVC syndrome, bronchial and esophageal strictures, constrictive pericarditis
CXR or CT may be helpful, but surgery/ biopsy often makes the diagnosis
Antibiotics; surgical removal of the granulomas is rarely helpful
SUPERIOR VENA CAVA SYNDROME
What is it? |
Obstruction of the superior vena cava, |
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usually by extrinsic compression |
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What is the #1 cause? |
Malignant tumors cause 90% of cases; |
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lung cancer is by far the most common; |
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other tumors include thymoma, |
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lymphoma, and Hodgkin’s disease |
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What are the clinical |
1. |
Blue discoloration and puffiness of the |
manifestations? |
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face, arms, and shoulders |
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2. |
CNS manifestations may include |
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headache, nausea, vomiting, visual |
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distortion, stupor, and convulsions. |
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3. |
Cough, hoarseness, and dyspnea |