Contents

1. Basic Physiology 1

Mary B. Carter and William R. Wrightson

Fluids and Electrolytes 1

Mary B. Carter

Water Balance 1

Extracellular Volume Loss 1

Electrolyte Abnormalities 1

Hormones 3

Mary B. Carter

Hormones Secreted from the Anterior Pituitary 3

Hormones Secreted by the Posterior Pituitary Gland 4

Peripherally Secreted Hormones 4

Acid-Base Abnormalities 7

William R. Wrightson

Background 7

Respiratory Acidosis 7

Respiratory Alkalosis 7

Metabolic Acidosis 8

Metabolic Acidosis with Normal Anion Gap 8

Metabolic Acidosis with Increased Anion Gap 8

Metabolic Alkalosis 8

2. Surgical Immunology 9

Phillip T. Burch

Immunology 9

Innate Immunity 9

Complement Cascade 9

Cells of the Innate Immune System 12

Acquired Immunity 14

Functional Proteins of the Acquired Immune System 14

Cell-Mediated Immune Responses 18

Humoral Immune Responses 19

3. Hemostasis 24

William R. Wrightson

Management of Coagulation in the Surgical Patient ... 24

History 24

Platelets 24

Coagulation Cascade 24

Fibrinolysis 25

Diagnosis of Coagulation Disorders 25

Defects in Hemostasis 26

Hypercoaguable States 28

Correction of Anticoagulation in Surgical Patients 28

Medications 29

Fibrin Sealants and Hemostatic Agents in Surgery 29

Fibrin Glue Components 29

Viral Transmission 30

Physiology 30

Hemostasis 30

Tissue Sealant 30

Other Hemostatic Agents 30

Blood Products 31

Packed Red Blood Cells (PRBC) 31

Complications of Blood Transfusion 31

Platelets 31

Fresh Frozen Plasma (FFP) 32

Cryoprecipitate 32

Erythropoesis 32

Red Blood Cell Substitutes 32

4. Anesthesia 33

Brian R. Davis

Physiology and Mechanism of Anesthetic Agents 33

Background 33

Physiology 33

General Anesthesia 34

Background 34

Anesthetic Agents Used in Induction and Maintenance 35

Muscle Relaxants 36

Malignant Hyperthermia 37

Regional and Epidural Anesthesia 38

Regional Anesthesia 38

Side Effects and Toxicity 38

Local Infiltration and Nerve Blocks 39

Epidural Anesthesia 40

Conscious Sedation 40

5. Statistics 42

Robert C. Kanard

Basic Medical Statistics 42

Background 42

Types of Studies 45

6. Wound Healing 48

Robert I. Oliver, Jr.

Physiology ofWound Healing 48

Background 48

Inflammation 48

Proliferation and Fibroplasia 49

Epithelialization/Contraction 49

7. Critical Care 57

William R. Wrightson

Sepsis and Management 57

Background 57

Etiology 57

Pathophysiology 57

Role of Protein C in Severe Sepsis (Xigris® and Prowess Trial) 57

Other Research and Treatment Strategies 58

Pneumonia in the ICU 59

Background 59

Epidemiology 59

Diagnosis 59

Microbiology 60

Management 60

Adult Respiratory Distress Syndrome (ARDS) 60

Background 60

Etiology 61

Pathophysiology 61

Diagnosis 61

Management 62

8. Surgical Oncology 64

William R. Wrightson

Surgical Oncology Principals 64

Background 64

Epidemiology 64

Tumor Biology 64

Pathology 64

Genetic Alterations 65

Treatment Principles 65

Molecular Staging 65

Background 65

Molecular Staging 66

Sentinel Node Biopsy 66

Background 66

Technique 67

Intradermal Radiocolloid Injection 67

Pathology 69

9. Breast 7G

Sara Elizabeth Snell

Breast Cancer Screening and Diagnosis 70

Screening 70

Diagnosis 70

Metastasis 71

Breast Cancer: Benign Breast Disease 72

Anatomy 72

Benign Breast Disease 72

Management 72

Breast Cancer 75

Risk Factors and Genetics 75

Pathology 75

Staging 76

Management of Breast Cancer: Surgical Therapy 78

History 78

Surgical Options 78

Breast Cancer: Adjuvant Therapy 79

10. Esophagus 81

William R. Wrightson

Barrett's Esophagus 81

History 81

Background 81

Etiology 81

Presentation 82

Management 82

Motility Disorders 82

Achalasia 83

Esophageal Spasm Syndromes 84

Management 85

Esophageal Carcinoma 86

Anatomy 86

Surgical History 86

Background 86

Etiology 86

Pathophysiology 86

Presentation 86

Diagnosis 87

Staging 87

Surgical Managemnt 87

Adjuvant Therapy 88

11. Stomach and Duodenum 89

Steven M. Girard

Gastric Hormones 89

Gastrin 89

Somatostatin 89

Acid Secretion 89

Upper Gastrointestinal Hemorrhage 90

Etiology 90

Presentation 90

Diagnosis 90

Treatment 91

Surgical Management 91

Helicobacter pylori 92

Background 92

Diagnosis 92

Management 92

Peptic Ulcer Disease and Complications of Management 93

Background 93

Pathophysiology 93

Helicobacter pylori 93

Presentation 94

Diagnosis 94

Medical Therapy 95

Surgical Therapy 96

Complications of Peptic Ulcer Disease 97

Postgastrectomy Syndromes 98

Gastric Adenocarcinoma and Lymphoma 99

Background 99

Etiology 99

Premalignant Conditions 100

Presentation 100

Pathology 100

Gastric Lymphoma 103

Gastrinoma and the Zollinger-Ellison Syndrome 104

Background 104

Presentation 104

Diagnosis 104

Management 105

Surgical Management 105

12. Small and Large Intestines 107

Steven R. Casos and William R. Wrightson

Appendicitis 107

Steven R. Casos

Background 107

Epidemiology 107

Pathophysiology 107

Anatomy 107

Diagnosis 107

Radiology 108

Management 108

Treatment 108

Antibiotics 109

Prognosis and Outcomes 110

Colon and Rectal Cancer 111

William R. Wrightson

Background 111

Genetics 111

Etiology 111

Screening 111

Diagnostic Studies 112

Management 112

Obstructive Lesions and One Stage Operations 113

No Touch 113

Adjuvant Therapy 113

Current Research 114

Follow-Up 114

Fistulas and Their Management 114

William R. Wrightson

Background 114

Etiology 114

Fistula Classification 115

Complications of Fistulas 115

Diagnosis 116

Management 116

Medical Management 116

Percutaneous Drainage 117

Surgery 117

Outcome 117

13. Liver 119

Dan N. Tran and William R. Wrightson

Primary Liver Anatomy and Physiology 119

Dan N. Tran

Anatomy 119

Portal Vein 119

Hepatic Artery 119

Hepatic Veins 119

Metabolism and Primary Hepatic Function 119

Carbohydrate Metabolism 120

Bilirubin Metabolism 120

Protein Metabolism 120

Lipid Metabolism 120

Vitamin Metabolism 120

Metabolism of Drugs and Toxins 121

Cirrhosis and Portal Hypertension 121

Dan N. Tran

Background 121

Etiology 121

Complications of Cirrhosis and Portal Hypertension 122

Prevention of Recurrent Hemorrhage 123

Portosystemic Shunts 123

Ascites 123

Liver Abscesses 124

Dan N. Tran

Background 124

Pyogenic 124

Presentation 124

Amebic Liver Abscess 125

Incidence 125

Etiology 125

Pathology 125

Presentation 125

Diagnosis 125

Management 125

Benign and Malignant Hepatic Neoplasms 125

Dan N. Tran

Hemangiomas 125

Cysts 126

Malignant Cancer of the Liver 126

Metastatic Tumors 127

Liver Resection 128

Liver Tumor Ablation 128

William R. Wrightson

Cryosurgery 129

Radiofrequency Ablation (RFA) 129

Technique 129

Application 129

14. Biliary System 130

Alina D. Sholar and William R. Wrightson

Cholelithiasis: Presentation, Complications and Management 130

Alina D. Sholar

Background 130

Epidemiology 130

Pathophysiology 130

Complications of Cholecystitis 131

Diagnosis and Radiologic Findings 132

Management 132

Acalculous Cholecystitis 133

Alina D. Sholar

Background 133

Epidemiology 133

Diagnosis and Radiology Findings 133

Management 133

Cholangitis 134

Alina D. Sholar

Background 134

Pathophysiology 134

Diagnosis and Radiologic Findings 134

Management 134

Primary Sclerosing Cholangitis 135

Primary Biliary Cirrhosis 135

Choledocholithiasis 136

Alina D. Sholar

Background 136

Pathophysiology 136

Diagnosis 136

Radiology Findings 136

Management 136

Choledochal Cysts 137

Management 137

Caroli's Disease 138

Presentation 138

Diagnosis 138

Management 138

Prognosis 138

Common Bile Duct Injury 138

William R. Wrightson

Background 138

Etiology 138

Presentation 139

Management 139

Diagnosis 139

Management 139

Cholangiocarcinoma and Gall Bladder Adenocarcinoma 140

Alina D. Sholar

Background 140

Epidemiology 140

Presentation 140

Diagnosis 141

Radiology Findings 141

Management 141

Prognosis 141

Gallbladder Cancer 141

About Pathophysiology 142

Presentation 142

Diagnosis 142

Management 142

Prognosis 142

15. Pancreas 143

William R. Wrightson

Clinical Focus on Pancreatic Disease and ERCP 143

Background 143

Etiology 143

Endoscopic Retrograde Cholangiopancreatography (ERCP) 143

The Role of ERCP in the Management of Acute Pancreatitis 143

Sphincter of Oddi Dysfunction and Acute Idiopathic Pancreatitis 144

Pancreatic Pseudocysts 144

Thoracoscopic Splanchnicectomy for Pancreatic Pain 144

Anatomy 145

Thoracoscopic Splanchnicectomy 145

Results 145

16. Hernias 146

Timothy K. Bullock

Surgical History 146

Background 146

Etiology 146

Pathophysiology 147

Diagnosis 147

Management 147

Operative Techniques 147

Results and Complications 148

Other Hernias 150

17. Minimally Invasive Surgery (MIS) 152

Vincent C. Lusco III Minimally Invasive Surgery and Physiologic Principals 152

Surgical History 152

Principles 153

Economics 153

Physiology of Pneumoperitoneum 153

Laparoscopy during Pregnancy 155

Complications 155

Common Laparoscopic Procedures and Indications 156

Cholecystectomy 156

Anti-Reflux Procedures 157

Ideal Patient 157

Workup 157

Complications 157

Splenectomy 157

Complications 158

Inguinal Herniorrhapy 158

Indications 158

18. Vascular Surgery 160

William R. Wrightson

Carotid Endarterectomy 160

Background 160

Presentation 160

Pathophysiology 160

Diagnosis 160

Management 161

Abdominal Aortic Aneurysms 162

Background 162

Epidemiology 162

Anatomy 162

Pathophysiology 162

Presentation 162

Diagnosis 162

Rupture 163

Management 163

Complications 164

Endovascular and Noninvasive Vascular Surgery 165

Background 165

Abdominal Aortic Aneurysm Repair 165

Technique 165

Tube Graft 165

Outcomes 165

Angioplasty and Stenting 166

19. Cardiothoracic Surgery 167

William R. Wrightson

Lung Cancer 167

Surgical History 167

Background 167

Etiology 167

Pathophysiology 167

Nonsmall Cell Lung Cancer 168

Small Cell Carcinoma 168

Other 168

Genetic Factors 168

Screening Issues 168

Clinical Presentation 168

Diagnosis 169

Management 170

Preoperative Evaluation 170

Questions 172

Minimally Invasive Coronary Artery

Bypass Grafting 173

History 173

Indications for Coronary Artery Bypass Grafting (CABG) 174

Complications of CABG and CPB 174

Off-Pump Coronary Artery Bypass (OPCAB) 174

Indications 175

Current Problems 175

MIDCAB Grafting 175

Extrathoracic MIDCAB 176

Results 176

20. Endoscopy 177

C. Adam Conn and William R. Wrightson

Endoscopy 177

Background 177

Upper Endoscopy 177

Endoscopic Retrograde Pancreatography (ERCP) 178

Other Uses 179

21. Orthopaedic Trauma 181

James C. Dodds and S. Matthew Rose

Orthopaedic Trauma 181

Evaluation 181

Pelvic Trauma 182

Evaluation 182

Classification 182

Treatment 183

Open Fractures 183

Compartment Syndrome 184

Dislocations 185

22. Head and Neck Surgery 187

Steven L. Goudy

Cancer of the Larynx 187

Background 187

Epidemiology 187

Pathology 187

Anatomy 187

Treatment 187

Prognosis 187

Cancer of the Nasopharynx 188

Background 188

Epidemiology 188

Histopathology 188

Management 188

Prognosis 188

Cancer of the Oral Cavity 188

Background 188

Epidemiology 188

Premalignant Lesions 188

Pathology 189

Predictors of Nodal Metastasis 189

Survival 189

Cancer of the Oropharynx 189

Cancer of the Upper Aerodigestive Tract 189

Presentation 189

Etiology 189

Exam 189

Biopsy 189

Imaging 190

Staging 190

Neck Nodal Staging 190

Salivary Gland Neoplasms 190

Background 190

Incidence 190

Salivary Gland Tumor Staging 190

Tumor-Like Conditions 191

Parotid Gland 191

Benign Tumors 191

Carcinoma of the Parotid 192

23. Pediatric Surgery 194

Monica S. Hall

Pediatric Surgery Overview 194

Management of Fluids and Electrolytes 194

Lesions of the Neck 194

Chest Lesions 195

Lesions of the Abdomen/GI Tract 197

Neoplasms 201

Index 203

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